A. Health Literacy

Reduced health literacy is one of the key obstacles to effective delivery of health care and outcomes.^{Reference Huber, Shapiro and Gillaspy13} Health literacy is at the intersection of consumers' coping strategies and health providers' orientation.^{Reference Adkins and Corus14} Health literacy involves the use of a range of social and cultural resources by consumers to cope with illness, and it requires health providers' recognition, cooperation and support. If patients exercise coping strategies similar to those seen in subsistence marketplaces, and health providers understand and reinforce those coping strategies, patients and providers might effectively communicate about health and health care in ways to improve patient experiences and outcomes.

As a large number of low-income individuals are also low-literate,^{Reference Cree, Kay and Steward15} the mode of information delivery is critical for effective communication. Oral literacy relating to health is relatively easier to achieve than reading/written literacy.^{Reference Baker16} A significant portion of the U.S. population experiences difficulties reading drug labels and prescription instructions.^{Reference Parker, Baker, Williams, Nurss, Berkman, Sheridan, Donahue, Halpern and Crotty17} Although patients in general have become more active with increased access to medical information through the internet and direct-to-consumer advertising,^{Reference Boyer and Lutfey18} many low-income patients lack access to modern modes of communication.^{Reference Cullen19} The reasons for this include poor communication infrastructure in poverty settings, low penetration of internet due to cost factors, and low technology awareness to use modern communication devices.

As important as the medium of communication is, so is the nature of the health message itself. The complex nature of health information communicated through generic channels compounds lack of information access, leading to poor reach of relevant information. Pictures can improve comprehension and increase adherence to health instructions when they show relationships among ideas or when they show spatial relationships.^{Reference Viswanathan, Hastak, Gau, Houts, Doak, Doak and Loscalzo20} Linking pictures closely to the written or spoken text increases attention and recall. Furthermore, emotional responses to the visual tone and complexity of pictures are an important determinant of outcomes in terms of increasing or decreasing relevant behaviors.^{Reference Norris, Bailey, Bolls and Wise21} In the sections that follow, we review research on the cognitive, affective, behavioral, and social aspects of communications in subsistence marketplaces and draw lessons for improving health literacy in the United States for low-income populations.

B. Cognitive Elements of and Low Literacy — The Thinking Dimension

A lack of literacy leads to difficulty with abstractions. Luria, a Russian psychologist, studied low-income workers in farms in Central Asia in the early 1900s. When shown objects like a hammer or an axe, they responded, not in terms of the higher-level concept of “tools,” but in terms of how these objects could be used to serve a particular need.^{Reference Luria22} A low-literacy consumer today may look at one attribute, price, and then buy the cheapest item available. This tendency to focus on one aspect of an item or transaction is termed concrete thinking (Figure 1).²³ The purchasing decision is not only because of lack of income but the correlated lack of literacy and difficulty with abstractions. Individual constraints from low literacy can also become accentuated by the situational urgency of low income and meeting basic needs.

Successfully navigating the health arena involves substantial abstract thinking. For example, evaluating attributes such as nutrient levels in a product, and reaching a higher-level judgment about their impact and value to one's health, is an abstraction. Advice from a health practitioner may help patients focus more concretely on nutritional information — for example, by isolating one specific nutrient, such as sugar, and urging patients to look for the product with the lowest levels. But even this approach is beset with issues, as concepts such as “minimum daily requirement” may be difficult to comprehend. Not only may there be difficulties in combining pieces of information to reach broader abstract judgments, but important component pieces may themselves be abstractions. Macro or micro-nutrients such as carbohydrates or magnesium are abstractions that cannot be seen and sensed when compared to foods that are tasted and consumed. Low literacy can lead to thinking in the immediate, the visual, the tactile and the world of how something can be used. Health or healthiness is itself an abstraction, eliciting extreme scenarios from somebody who is low-literate, such as meaning something as concrete and extreme as “not being in the hospital.”^{Reference Saltonstall24}

Concrete thinking impacts what information is gathered, how pieces of information are processed, how information can be combined, how cause and effect is inferred, knowing how versus why something is done a particular way, and how goals are set. Primary health considerations, however, are characterized by complex, hierarchical causalities. For instance, what causes diabetes? How can it be controlled? What are the factors involved? What is the role of diet or blood pressure or cardiac health or exercise? What behavioral changes are necessary? How do the medications act or interact? How are physiological functions related to sensory perceptions?

It is important for practitioners to understand the kind and degree of concrete thinking their patients engage in. A symptom, for instance, can be reported as a singular, isolated event (say, numbness in a limb), rather than being understood and thus reported as an underlying indicator of a greater problem (say, a mini stroke!). Causal inferences by low-literacy patients can often be flat, as hierarchical causality involves different degrees of abstraction. Yet, understanding cause and effect in the health arena is crucial. For instance, patients need to understand indicators such as blood pressure and factors contributing to conditions of high blood pressure, or specific medicines and behavioral changes necessary for prevention and cure. Thus, knowing “why,” as opposed to merely “what” or “how” is another crucial aspect of patients' decision making in nutrition and health. Knowing “why” may solidify understanding and enable patients to customize and apply their health regimen as circumstances change. But low income coupled with low literacy can constrain development of the “know-why.”

Pictographic thinking is a coping strategy of low-literacy individuals that can help them navigate the health arena (Figure 1). Pictographic thinking involves not just a reliance on pictures that occurs irrespective of income and literacy level; it is also a fundamentally different way of thinking. Pictographic thinking may allow a person to rely on images to “read,” infer comparative size, and compute a difference.^{Reference Viswanathan, Torelli, Xia and Gau25} In picto-graphic thinking, a person who cannot read may rely on an image or an object to identify a product or concept. Some people describe this as sight-reading; they just look at a word and remember it as an image.^{Reference Viswanathan, Rosa and Harris26} For instance, words can be “sight-read,” brand names, or public bus numbers are pattern-matched, rather than read in a conventional sense. A health-related example is to pattern-match the first letters of a medicine with a prescription in order to confirm proper purchase. Amounts can also be visualized in terms of usage situations — say, imagining baking a cake. In turn, this visualization is used to buy the appropriate volumetric amount of sugar rather than processing the amount and unit of measurement to purchase. Even computation can be accomplished in approximate ways by visualizing a total set of dollar bills and adding or subtracting, i.e., mentally or actually adding or removing bills, as products are bought.

Health providers can use what is known about pictorial thinking to improve health communications. Icons can be used to convey both health conditions and benefits of nutritious alternatives. Unseen and sometimes unfelt influences from a sensory perspective, such as certain health conditions like blood pressure, need to be brought alive through picto-graphic communications. Images can be adopted to help patients visualize diseases, causation, and cure. Nutrient deficiencies, blood pressure and a variety of health conditions need to be made more concrete and sensorily relatable. Physiological functions enabled by specific nutrients need to be picturized and then linked to benefits that can be perceived by the senses — for instance, steady heart rate and good sleep. This involves picturizing both cause and effect.

C. Affect and Decision-Making

Low income and associated low literacy have implications for affect and decision making as well (Figure 1).²⁷ What are mundane shopping encounters for most individuals may involve high anxiety levels in low-literate consumers. Not knowing something in a setting that assumes a certain level of literacy means the possibility of being exposed for one's own low literacy, which in turn is the perceived cause of low income. Being short of money at the counter may be cause for embarrassment, even despair. Individuals may be willing to pay a little more if they are treated kindly, even trading off higher expenses for a positive (or less negative) shopping experience. Low-income consumers may avoid formal banking or healthcare services, fearing the need to have a minimum level of literacy for the required paperwork. Emotional factors can also lead to a cognitive focus on the immediate to the detriment of longer-term goals and considerations. Thus, self-esteem, self-confidence, and other affective issues are highly relevant.

In the health arena, low-income patients may resist asking questions of health care providers, because they fear being unable to answer questions in return.^{Reference Viswanathan28} In fact, irrespective of income and literacy, the affective aspect is accentuated in the health arena with the inherently stressful nature of illnesses overlaid with the lack of medical knowledge. The stark difference in knowledge between the health provider and middle or high-income patients is all the more so for low-literate, low-income patients. There is the further stress and intimidation experienced when dealing with large institutions, such as hospitals and insurance companies.

D. Coping Behaviors

Low-income individuals engage in a variety of coping behaviors to overcome the cognitive and affective constraints of low literacy (Figure 1),²⁹ such as buying one thing at a time at a restaurant or depending on others for basic tasks. Shopping at familiar stores is another way to cope, as a new store may cause anxiety, emphasizing how relationships may take precedence over transactions. In developing contexts, low-income consumers build enduring relationships with shopkeepers, and when possible, doctors. The importance of health-affirming coping behaviors is magnified in the health arena, given the stress inherent in addressing medical needs as well as the need to deal with abstract knowledge and large institutions along with the financial burdens of illness and health care.

E. Materially Poor but Relationally (Socially) Rich?

Our work and the broader literature also points to how low-income settings can be materially poor but relationally or socially rich.^{Reference Viswanathan, Sridharan, Ritchie, Venugopal and Jung30} In many low-income settings in developing countries, we see a marketplace in which people interact one-on-one in a socially intensive environment, where exchanges are fluid, constantly customized, and responsive.³¹ Relationships can be enduring and characterized by interactional empathy, based on oral communications and pervasive interdependence. In the health care arena, a patient may take a prescription from a doctor, buy the medicine and pattern-match the first letters, and then even take it back to show to the doctor to confirm. Thus, the person-to-person interactional social setting can be a stepping stone to learn and improve skills and self-confidence as a customer and patient. Word-of-mouth becomes particularly paramount in the health arena as doctors, elders and others are seen as trusted sources within the individual's social circle. Local pharmacy shopkeepers, clinic/hospital employees and individual family members become primary sources of information in the social milieu. In this regard, the marketplace is socially rich with myriad and diverse group influences.^{Reference Viswanathan, Seth, Gau and Chaturvedi32} In subsistence marketplaces and related health arenas, the ability to relate socially is not contingent on literacy or income.

Ironically, marketplace literacy — as in functional literacy in the marketplace — can actually be lower for low-literate, low-income individuals in an advanced economy. Low-literate, low-income individuals in the U.S. are often isolated in dealing with large institutions such as chain stores and hospitals, rather than small shops and individual providers. Technology is an integral part of interactions now, as shopping totals are computed, or pharmaceuticals requests are processed, whereas direct communications and counting out money is characteristic of developing contexts. Information displays and disclosures assume a certain level of literacy in the U.S. Moreover, whereas in subsistence marketplaces, an individual is often both a seller and a buyer — absorbing the lessons of both roles — this avenue of learning is very limited in the US for low-income individuals who are employed by a large entity. One-to-one personal interactions are further reduced in the health arena, where reliance on institutions instead is the norm.