Health Literacy: A Review of the Literature
The PubMed and Medline databases were searched using the terms ‗health literacy‘ and
‗health literacy + a review of the literature‘. After reviewing the title and abstracts of all retrieved articles, 21 were utilized.
What is Health Literacy?
The ability to obtain, understand, and use the information needed to make wise health choices is known as health literacy (DHHS, 2005). Low literacy among members of such populations as older adults, people with poor reading skills, those with limited mastery of the English language, members of ethnic and cultural minorities, and immigrants is likely a major contributor to health disparities in this country, according to Healthy People 2010. ―Closing the
gap in health literacy is an issue of fundamental fairness and equity and is essential to reduce health disparities,‖ according to Healthy People 2010.
People with low health literacy often lack not only the ability to read well but also the knowledge about the body, its functioning, and the nature and causes of different types of disease (DHHS 2005). This will compromise their ability to manage their disease (Villaire & Mayer, 2007).
Beyond reading and other communication skills, as well as knowledge of relevant health topics, making sense of health information and the healthcare system also requires numerical skills, such as disease risk or the normal range of values such as blood pressure or cholesterol (DHHS 2005).
In a study conducted by Kalichman and Rompa, it was found that ‗HIV-infected people
with lower health literacy had lower CD4 cell counts, higher viral loads, were less likely to be taking antiretroviral medications, reported a greater number of hospitalizations, and reported poorer health than those with higher health literacy‘ (Kalichman and Rompa, 2000).
The term health literacy has been used in the health literaturefor at least 30 years (Ad
Hoc Committee on Health Literacy,1999). In the United States in particular the term is used to
describe and explain the relationship between patient literacylevels and their ability to comply
with prescribed therapeuticregimens (Ad Hoc Committee on Health Literacy, 1999). This
approachinfers that ‗adequate functional health literacy meansbeing able to apply literacy skills
to health related materialssuch as prescriptions, appointment cards, medicine labels, and
directions for home health care‘ (Parker et al., 1995).Research based on this definition has
shown, e.g. that poorfunctional health literacy poses a major barrier to educatingpatients with
chronic diseases (Williams et al., 1998), andmay represent a major cost to the health care
industry throughinadequate or inappropriate use of medicines (National Academyon an Aging
Society-Center for Health Care Strategies, 1998).
It is important to add that medication non-adherence hinders the improvement of the health of patients with chronic diseases. Such patients must have self-efficacy characterized in their confidence in making correct health decisions, in this case taking their medications appropriately (Pleasant & Kuruvilla, 2008). This will not take place without comprehensive measures through clinical and public health approaches to improve health literacy through research, education and effective provider-patient communications (Villaire & Mayer, 2007).
health literacy misses However, this fundamental but somewhat narrow definition of
much of the deeper meaning and purposeof literacy for people; the field of literacy studies is
alivewith debate about different ‗types‘ of literacyand their practical application in everyday life
(Nutbeam 2000). One approachto classification simply identifies types of literacy not as
measures of achievement in reading and writing, but more interms of what it is that literacy
enables us to do (Freebodyand Luke, 1990).
; Basic/functional literacy—sufficient basic skills in readingand writing to be able to function effectively in everyday situations,broadly compatible with the narrow definition of ‗healthliteracy‘ referred to above. ; Communicative/interactiveliteracy—more advanced cognitiveand literacy skills which, together with social skills, canbe used to actively participatein everyday activities, to extractinformation and derive meaningfrom different forms of communication,and to apply new informationto changing circumstances. ; Critical literacy—more advancedcognitive skills which,together with social skills, can beapplied to critically analyzeinformation, and to use this informationto exert greater controlover life events and situations.
Barriers to Health Literacy/Identification of Patient’s with Low Health Literacy
Many barriers—including poverty, limited education, low reading levels, low self-
efficacy, and inadequate English-language skills—stand in the way of developing health literacy
(DHHS 2005). Beyond gaps in the education and reading skills of Americans, however, additional barriers arise because healthcare professionals often inadvertently make it difficult for lay people to understand what to do (DHHS 2005). Throughout their professional education and training, healthcare providers are taught to use precise technical language to discuss body parts and processes, disorders, and treatments—a habit that usually continues throughout their
professional careers (DHHS 2005). While improving the health literacy of patients through
education and patient skill development, it is important to provide special training to healthcare
providers in order to deliver appropriate and sensitive care to patients with different health literacy levels (Primack, Bui, & Fertman, 2007).
An individual‘s health literacy may be worse than his or her general literacy (Ad Hoc
Committee on Health Literacy, 1999). The authors of a study which looked at health literacy in
relation to cancer screenings/treatment noted that ‗functional literacy is context specific;it is
therefore likely that many individuals at all literacylevels lack a clear understanding of cancer
control guidelinesand screening recommendations‘ (Davis et al., 2002). Individuals who have
been screenedfor cancer may lack basic understanding of test results; likewise,cancer patients
may lack adequate knowledge of treatment recommendationsand clinical trial options (Davis et
al., 2002). Here we see an example of how it is possible for literacy and health literacy not to be correlated.
Previous studies found that67 percent of patients with low literacy had not told their
spouse, over half had not told their children and 19 percenthad never told anyone (Parikh et al.,
1996). While testssuch as the Rapid Estimate of Adult Literacy in Medicine (REALM)and the
Test of Functional Health Literacy in Adults (TOFHLA)can identify patients with low literacy
skills, it is recommendedthat these instruments not be used clinically unless the providersand
clinics are willing to specifically tailor their cancercommunication and education for patients
with low health literacy (Davis et al., 1998). Table 1 graphs the available health literacy assessment tools (Artinian 2003).
Table 1: Popular literacy tests
In addition to patient age and education level (less than ahigh school diploma or GED),
practical clues to limited literacyinclude patients claiming they have forgotten their reading
glasses, bringing in family members, or filling out intake formsor clinical research
questionnaires incompletely or inaccurately (Davis et al., In press).
Beyond the problems of technical jargon, patients whose cultural background differ from that of the healthcare provider may bring to the interaction their own beliefs about the body or health, which may be at odds with common conceptions in American health care (DHHS 2005). For example, patients may attribute a disease to different causes and seek relief from different sources than medical science, which makes communicating about their health especially problematic (DHHS 2005). In addition, the prestige and power of the provider, especially physicians, may discourage patients from asking questions that could clear up misunderstandings
or elicit important information because they may feel ashamed of their lack of understanding or their poor English (DHHS 2005).
Literacy among cultural and ethnic groups may vary and many times healthcare delivery is not culturally competent nor linguistically sensitive to patients whose general and health literacy may be limited. This creates various difficulties for such diverse communities to understand and manage their diseases (Poureslami et al. 2007).
Improving Health Literacy
Steps to improving the health of millions of Americans by addressing health literacy barriers (DHHS 2005):
; Make health literacy barriers a national priority
; Collaboration between professional societies, government agencies, and the
; Healthcare administrators must be held accountable and hold organizations
; Healthcare providers must develop the skills of listening and giving explanations
and directions that patients comprehend
; Healthcare providers must get in the habit of checking with patients to make sure
they know what to do
; Health professionals and administrators must work to ensure that written materials
provided to patients and their families are clear and understandable
; Steps must be taken to upgrade the public‘s understanding of health and the
; Increase the public‘s access to accurate and understandable health information
through the mass media, the development of culturally and linguistically
appropriate materials, and the collaboration of professional groups
; Assess and measure patient self-efficacy and health literacy as it relates to disease
Health literacy is clearly dependent upon levels of fundamental literacy and associated cognitive development. Individuals with undeveloped skills in reading or writing will not only have less exposure to traditional health education, but also less developed skills to act upon the information received; for these reasons, strategies to promote health literacy will remain inextricably tied to more general strategies to promote literacy (Nutbeam 2000).
The conceptual frameworkpresents an opportunity for health literacy application, linking
medical terminology of primary, secondary and tertiary preventionwith determinants of health,
i.e. social, physical and environmental,education and income, and vulnerability/risk factors. It
translatesfor the public into: (1) staying healthy, (2) getting betterand (3) living with disease
(Ratzan 2001). Figure 1, adapted from Evans et al., graphs the determinants of health based on
this framework model, shows that education is a ‗principal area in where individual and collective communication emphasis can influence health‘ (Evans et al., 1990).
st Fig. 1: Determinants of health: the 21 century health model
Health Literacy as an Outcome of Health Promotion
Recently, considerable attention has been given to analyzing the determinants of health, and to the definition of outcomes associated with health promotion activity, which has led to the development hierarchies of ‗outcomes‘ from health interventions, which illustrate and explain the linkages between health promotion actions, the determinants of health, and subsequent health outcomes (Nutbeam 2000). Figure 2 provides a summary outcome model for health promotion (Nutbeam 1996).
Fig. 2: An outcome model for health promotion
Healthliteracy problems have grown as the health system has becomemore complex:
diagnostic and treatment options have skyrocketedand people are asked to assume more
responsibility for self-care (Ratzan 2001). Health literacy can be described as both a goal and an
outcome,becoming the currency and capital needed to develop and sustainhealth (Nutbeam
2000). In his essay, Ratzan ‗elucidates that communication is notjust message repetition;
effective communication must also enablean environment for community involvement to
espouse common valuesof humankind: promulgation of life by promoting health (Ratzan 2001).
Many patients find that the majority of their time is spent with a nurse or nurse practitioner instead of an actual medical doctor. Therefore, it is vital that nursing staffs are trained on and aware of the health literacy issue when treating patients as patient-provider
communication is directly associated with health literacy (Hironaka & Paasche-Orlow, 2007).
Literacy assessment is an important component of effective advanced practice nurse-patient communication, enabling a nurse practitioner or clinical nurse specialist to elicit a better medical history, explain a treatment plan in understandable terms, assist the patient to integrate treatment recommendations into their usual daily routine, be sensitive to other psychosocial issues the patient may be dealing with, and convey empathy (Artinian 2003). ―The Self-efficacy
for Appropriate Medication Use (SEAMS) is a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management, and appears to
? be appropriate for use in patients with low literacy skills.‖ (Risser, Jacobson & Kripalani, 2007)
All of these factors may lead to increased patient satisfaction with care, an important health care outcome and indicator of quality of care that is valued by patients, payers, and health care administrators (Artinian 2003).
As mentioned previously, Nutbeam (2001) suggested categorizing health literacy into three domains: functional health literacy, interactive health literacy, and critical health literacy.
A set of indicators or scales should be developed for each domainin order to circumscribe broad
health literacy levels; one couldthen compare differences in health literacy between gender,
population and age groups, and relate it to levels of educationand income (Kickbusch 2001).
Important issues will be: (i) to separate clearlyeducation, general literacy and health literacy; (ii)
to lookparticularly closely at how these three factors interrelate;and (iii) to distinguish what
reinforcing mechanisms might beat work (Kickbusch 2001). Measuring health literacy could be