Abstract
We welcome the recent work of Milner and colleagues (Milner et al., 2019) in examining the influence of masculinity norms and depression on men’s health literacy (HL) and appreciate their acknowledgment of our work in calling for greater attention to the role of masculinity in HL (Peerson & Saunders, 2006; 2009).
We note that their paper reflects several of the questions and controversies that inevitably arise, given the ongoing research into men’s health as a gendered concept as well as the numerous definitions and measurements of HL.
The authors’ definition of HL is deliberately broad, encompassing the ability to access, understand, and use health information to “promote and maintain good health.” This extends the definition beyond health-care settings, suggesting HL applies to the management of “wellness” and illness (Kickbusch et al., 2006). This is important because HL outside of health-care settings has the potential to prevent or limit ill-health (Sørensen et al., 2012) and is relevant to men’s health promotion (Oliffe, Rossnagel, Bottorff, et al. 2019; Oliffe, Rossnagel, Kelly, et al., 2019). Other definitions take a similarly broad view, referring to HL as including “knowledge of health topics” and the ability to make “appropriate health decisions” (USDHHS, undated), including “in everyday life concerning health care, disease prevention and health promotion” (Sørensen et al., 2012). However, the authors’ chosen measures of HL reflect a narrow concept of HL, with two measures focusing exclusively on the health system (engaging with health-care providers and feeling understood and supported by health-care providers).
Even given the reciprocal relationships between HL and interaction with the health system, this approach understates the importance of key HL competencies relevant to health-care settings and everyday life, that is, the ability to (a) seek, find, and obtain health information; (b) comprehend health information; (c) interpret, filter, judge, and evaluate health information; and (d) communicate and use information to make decisions to maintain and improve health (Sørensen et al., 2012). Only the first of these is included in the present study, and its measurement is based on self-assessment.
Reliance on self-assessments rather than on objective measures is a particular concern due to discrepancies between perceptions and performance: There is no way to know how a person’s responses relate to his or her actual skill or knowledge level (Nguyen et al., 2017). Self-assessments have been questioned on the grounds that they more accurately measure self-efficacy (SE; belief in one’s capacity to achieve a goal or outcome) instead of HL, even where broad definitions of HL are used (Pleasant, 2014; Woudsdtra et al., 2019). Respondents may not admit to experiencing difficulties, or respondents with a high level of SE may overestimate their skills and knowledge (Xu et al., 2018). Comparisons of objective testing and self-reporting have not revealed consistently strong correlations (Altin et al., 2014). Responses may reflect diverse views about what constitutes “good” health information.
Despite these concerns, the work of Milner and colleagues suggests important directions for further research. More insights are needed into contextual factors (e.g., engaging in protective behaviors vs. experiencing symptoms), which may determine whether men regard health information seeking as a form of help seeking or as an act of autonomy and an alternative to seeking health care. Confusing or contradictory health information may also result in men rejecting information and choosing to make up their own minds rather than relinquishing autonomy or control over health decisions (Richardson, 2010).
If the process of male socialization creates within many men some difficulties in viewing health and healthy living as a masculine way of life (White & Johnson, 2000), then these issues are crucial in advancing our understanding of how “feeling like a man” might be congruent with health-promoting beliefs and behaviors (Gerdes & Levant, 2018).
