According to Healthy People 2010, health literacy 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 (HHS, 2000, page 11-20). A number of landmark health literacy pieces published over the past decade have been crucial in describing the state of health literacy, shaping recent and ongoing research on the topic, and creating the primary strategies that research has shown to be successful in helping to improve health literacy rates. These include the Institute of Medicines (IOM) Health Literacy: A Prescription to End Confusion; Healthy People 2010s section on Health Literacy; and Kutner, Greenberg, Jin, and Paulsens 2006 report, The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Much of this work has focused on the ability of individuals to understand the consequences of various medical treatments. However, there is also interest in helping individuals recognize the consequences of choosing different health insurance plans for example, whether a plan covers certain conditions, and what are the varying financial risks associated with high-deductible plans, compared with plans with higher premiums but lower out-of-pocket costs.
Low levels of health literacy are a significant problem for U.S. adults. According to the 2003 National Assessment of Adult Literacy, only 12% of U.S. adults are at a proficient level of health literacy (Kutner et al., 2006). Fifty-three percent of U.S. adults are at an intermediate level of health literacy; 22% have a basic level of health literacy; and 14% have less than basic health literacy (Kutner et al., 2006). Similarly, a systematic review by Sudore and Schillinger in 2009 found that approximately half the U.S. adult population has low health literacy. This is particularly alarming because low levels of health literacy are associated with poorer health outcomes for individuals (Berkman, DeWalt, Pignone, Sheridan, Lohr et al., 2004; Kutner et al., 2006; IOM, 2004; HHS, National Institutes of Health [NIH], 2006; HHS, Office of Disease Prevention and Health Promotion [ODPHP], n.d.; Sudore & Schillinger, 2009). Those with low health literacy are at greater risk of hospitalization (HHS, 2000) than those with high health literacy. In addition, individuals with low health literacy have annual health care costs more than four times as great as those of the general population, and 75% of individuals diagnosed with chronic conditions fall into the limited (general) literacy group (HHS, 2000). Low health literacy is also associated with obtaining fewer preventive procedures, such as flu shots; waiting longer to see a doctor (until individuals are sicker) compared to individuals with higher levels of health literacy; and having poorly control chronic conditions (HHS, ODPHP, n.d.).
Although individuals across all demographic groups may have low levels of health literacy, individuals with low educational levels and adults living below the poverty line are more likely to have low levels of health literacy (Kutner et al., 2006). An expert panel report from 2009 on improving the health literacy of older adults also found that a majority of U.S. adults do not have the health literacy skills to understand what they are reading when they see health materials (HHS, Centers for Disease Control and Prevention [CDC], 2009a). Improving the health literacy of persons with inadequate or insufficient skills is one of the health-promotion objectives in Healthy People 2010.
It will be necessary to overcome multiple barriers in order to improve health literacy; these include, but are not limited, to stigma around health issues, language and cultural barriers, differing cultural and educational backgrounds of the providers and the patients, and fear and emotional barriers (IOM, 2004). Certain strategies are helpful in surmounting these obstacles. Healthy People 2010 notes that it is important to target a specific audience in order to frame information for individual use and make that information easily understandable. Many individuals with low health literacy are also those who are not native English speakers or who have lower educational levels (IOM, 2004; Kutner et al., 2006). Clear communication is therefore an important strategy in reaching these individuals and improving their health literacy. This includes the concept of plain language a method of writing and speaking designed to improve the accessibility of information for individuals who have low health literacy skills (HHS, ODPHP, 2005b). Specific strategies for clear communication include organizing information to list key messages first, segmenting the information into easy to understand portions, using white space, and simplifying language and avoiding technical jargon (HHS, ODPHP, n.d.). The use of plain language has been steadily moving into health care to help individuals better understand their health care diagnoses (HHS, ODPHP, 2005b). There is still work to do; more than 300 studies show that the majority of health materials currently in existence exceed the reading level of the average U.S. adult (IOM, 2004). When addressing health issues, it is imperative to consider all aspects of communication, including the source, message, channel, and receiver (HHS, NIH, 2006). Clearly communicating health information also extends beyond the use of linguistic terms into the realm of culture. To increase health literacy, it is important for providers and those who deliver interventions to be able to understand the best way to access individuals in terms of their own cultures (HHS, ODPHP, n.d).
Another barrier relates to current interest in using evidence-based health care to inform decision making. A qualitative and quantitative study found that few consumers understood terms such as medical evidence or quality guidelines (Carman et al., 2010). Many participants believed that higher utilization of care and of the newest technologies meant higher quality care. A third of the participants perceived that treatments that are more expensive were superior to less costly ones. These attitudes and beliefs are likely to present a barrier to developing initiatives for evidence-based decision making.
Another communication issue is the use of the internet and other electronic forms to disseminate health information (HHS, 2000). Electronic information has the capability to increase the dissemination of health resources and information, and thereby promote health literacy. However, it also has the disadvantage of widening the gap between those with enough income to have access to the internet and those who do not (HHS, 2000). This issue relates conversely to the goal of making information easily accessible to target audiences, including older persons, for whom low health literacy is a serious concern. Limited health literacy in older adults may be a function of reduced cognitive functioning, but this may be compensated for through training (HHS, CDC, 2009a). The best ways to present information to older adults include keeping the information focused, repeating the message, allowing time for processing, using face-to-face communication, emphasizing short-term benefits, and following up with individuals (HHS, CDC, 2009a). It is particularly important to work with older patients in translating information they receive into actions they can perform (HHS, CDC, 2009a). Recommendations that came out of CDCs Expert Panel on Improving Health Literacy for Older Adults (2009a) included:
- Using plain language
- Trying to simplify or bundle messages so that patients do not get overwhelmed
- Using multiple channels to disseminate information
- Working on finding ways to bridge the technological gap for older adults
- Improving websites to make them more user friendly
- Examining data for populations with special needs
While literature on how health literacy interventions might improve health outcomes is relatively scarce, studies that exist show promising results in improving health knowledge and/or outcomes (Berkman et al., 2004). Interventions designed to mitigate the effects of lower health literacy often improve outcomes more for those with lower health literacy than those with higher health literacy (HHS, NIH, 2006). Interventions for health literacy can be applied in a number of contexts, such as schools, workplaces, health care settings, and community settings (HHS, 2000). There are also multiple levels of interaction to consider when attempting to intervene in health literacy: the clinicianpatient level, which can include clear communication, teach-to-goal methods, and reinforcement; the health care organizationpatient level, in which clear health education materials, visual aids, and medication labeling are important; and the communitypatient level, in which lay health educators, adult education referrals, and the mass media are important (Sudore & Schillinger, 2009). Effective health programs also must target a communitys needs and take into account diverse populations (HHS, 2000).
Improving health literacy in the future will require approaching the issue from two different sides: the demand side, or what the health care system needs patients to understand and perform to improve the patients health, and the skill side, or what patients need to do to respond to the health care system (HHS, NIH, 2006). It will be necessary to overcome barriers, including the stigma that individuals with low health literacy can feel, the language and cultural barriers hindering effective communication, the complexity of health care systems preventing dialogue between providers and patients, the demands for literacy skills mismatched with individuals actual literacy skills, and fear and emotional barriers (IOM, 2004). Older adults may also feel embarrassed by their lack of knowledge about technology, although trainings on how to navigate web-sites have been successful (HHS, CDC, 2009a).
Various sources have made a number of recommendations for ongoing improvements in health literacy (HHS, ODPHP, 2005a; IOM, 2004; Rudd, 2004; HHS, ODPHP, n.d.). In general terms, these recommendations include (1) Implementing programs in schools and other adult education programs already in existence; (2) Having health care systems look into the most effective approaches to increasing health literacy; and (3)Exploring ways to better communicate health information.