Health Literacy

What is health literacy?

The term “health literacy” can be confusing, partly because the term is used in different ways, and partly because experts disagree about the correct definition. A common definition, cited by the Institute of Medicine (IOM) in their 2004 landmark report Health Literacy: A Prescription to End Confusion, is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

The IOM also noted in the report that health literacy is contextual – it depends both on the individual’s skills and the cultural, social, and economic environment in which the individual lives.

Usually, the term is used in one of two ways. It may refer to:

  1. The literacy skills of an individual or group in a health context – the abilities to read, write, understand, and use health information. Health literacy also includes oral skills, such as the ability to give and get information in a medical visit. Some definitions include numeracy, important to tasks such as understanding food labels and medical risks.

    Example: Anna doesn’t understand how to use her asthma inhaler because she has limited health literacy—she can’t read and use the directions correctly.

    Example: Seniors age 65+ demonstrated the lowest levels of health literacy among all groups in the 2003 National Assessment of Adult Literacy.

  2. A policy issue – a key variable in a host of factors affecting the health of the nation. Health literacy cross-cuts and underlies both public health and medical care, including patient safety and quality of care, disease prevention and management, health disparities, disaster preparedness, rising costs, and more.

    Example: Low health literacy contributes to health disparities and poor health outcomes.

Newer considerations and definitions are emerging. Some researchers suggest that the definition of health literacy should recognize functional skills that may not depend on literacy skills. For example, adults may learn how to use a medical device, such as a thermometer or glucometer, from hands-on experience after watching others, rather than from reading and following written instructions.

Other researchers suggest that the definition of health literacy recognize cognitive and meta-cognitive abilities that underlie basic reading skills, leading to a “health learning” capacity. These abilities may include attention span, information processing speed, short- and long-term memory capabilities, and reasoning. (Wolf M et al. Literacy and Learning in Health Care. Pediatrics, 2009. 124:S275-S281.)

Still other researchers are exploring the contextual aspects of health literacy – the role played by our complex care environment. Studies examine the communication systems and skills demonstrated by health brokers (insurance and advocacy groups), as well as government, non-profit, and clinical care organizations.

As the field develops and our understanding grows, the term “health literacy” will no doubt broaden. However, limited literacy skills will continue to have a major impact on individuals’ lives and the health of the nation.

What are the overall health literacy skills of American adults?

The 2003 National Assessment of Adult Literacy (NAAL) measured the health literacy skills of a representative sample of American adults. Results were recorded in 4 levels: Below Basic, Basic, Intermediate, and Proficient. Only 12% of adults demonstrated Proficient health literacy skills. Seniors, who use the most health services, demonstrated the lowest levels of ability. 59% had Below Basic or Basic health literacy skills, and just 3% were able to complete tasks at a Proficient level. Independent research studies reinforced NAAL findings that millions of adults struggle with even basic health tasks, such as using medicines correctly.

How well do health literacy skills match the demands of managing health?

Hundreds of research studies show the dramatic gap between the demands of our health care system and the individual’s ability to meet these demands. We are expected to choose and use insurance plans and navigate complex care systems. To stay healthy and prevent disease, we need skills ranging from reading food and medicine labels to understanding and getting appropriate check-ups and tests. If we have a complex condition such as diabetes, we may see many providers for care and have to follow instructions from all of them.

Health information is hard to read. The difficulty and complexity of most print and web health information pose an additional barrier. Most materials are written at high school reading levels or higher. Below Basic and Basic health literacy skills are definitely not adequate, and Intermediate skills might not suffice, to understand and use information written at these levels.

Health literacy affects everyone. Research studies have shown that adults with limited literacy skills pay a high price in terms of poorer health and health outcomes. Even adults with Intermediate or Proficient skills may find themselves overwhelmed in the health system when fear, stress, fatigue, or illness impair their usual abilities.

What will be the impact of growing populations with limited health literacy skills?

Groups growing most rapidly. Groups growing most rapidly in the United States, including seniors and Hispanic/Latino populations, demonstrated the lowest literacy and health literacy skills on the NAAL.

  • By 2030, almost 1 out of every 5 Americans—some 72 million people—will be 65 years or older. The age group 85 and older is now the fastest growing.
  • The Latino population, already the nation’s largest minority group, will triple in size and will account for most of the nation’s population growth through 2050. Hispanics/Latinos will make up 29% of the U.S. population in 2050, compared with 14% in 2005.

The need to act. Demographic trends highlight the need to prioritize health literacy as a core policy issue across social, educational, and health organizations. As the Institute of Medicine pointed out in the 2004 report referenced above, addressing the problem will require efforts from multiple sectors of society.

It’s time to act. The education system can work to improve literacy skills. Health and social service organizations can work to improve their communication methods and tools and train their workforce to use them. Health profession education programs can strive to better prepare the future health workforce. The federal government and foundations can develop model policies and fund research.

The cost of inaction. The cost of addressing low health literacy across institutions and across the nation is high, but the cost of doing nothing will be higher. As we retool health systems to meet 21st-century challenges, let’s be sure that communication challenges receive high priority along with the resources needed to address them.

For more information about health literacy, check the websites below.

www.health.gov/communication

www.hsph.harvard.edu/healthliteracy

www.healthliteracy.worlded.org

www.nces.ed.gov/naal/health.asp