Health Literacy Overview

What is health literacy?

“The ability to obtain, process, and understand health information and services to make appropriate health decisions.” (Healthy People 2010)

Health literacy is not simply the ability to read. Health literacy requires a complex group of reading, listening, analytical, and decision-making skills and the ability to apply these skills to health situations.

Patients with adequate health literacy can:

read consent forms, medicine labels and inserts and other written health care information
understand written and oral information given by physicians, nurses, pharmacists and insurers
act upon necessary procedures and directions such as medication and appointment schedules.

Patients are often required to carry out specific tasks when they faced with complex information and treatment decisions. These tasks includes evaluating information for credibility and quality, analyzing relative risks and benefits, calculating dosages, interpreting test results, or locating health information. In order to accomplish these tasks, individuals may need to be:

visually literate, able to understand graphs or other visual information
computer literate, able to operate a computer
information literate, able to obtain and apply relevant information, and
numerically or computationally literate, able to calculate or reason numerically

Oral language skills are important as well. Patients need to articulate their health concerns and describe their symptoms accurately. With increasing needs for shared decision-making between clinician and patient for health care, patients need strong decision-making skills. Health literacy may also include the ability to search the Internet and evaluate web sites since the Internet becomes important source of health information.

What is low health literacy?

Health literacy is measured in terms of grade level-the average reading skill achieved at each year of schooling in the American public school system. A person who can read at the 5 th grade level or higher is considered literate. A person who can read at less than 6 th grade level is sometimes referred to as functionally illiterate ( Doak, Doak & Root, 1996).

An alternative method of defining literacy skills is functional competency levels. This method measures people’s ability to perform literacy tasks needed to fully participate in society. Functional competency is assessed through reading, writing, and computing tests which are then grouped into levels, with level 1 being the lowest functioning and level 5 being the highest. Functional competency levels are used in U.S. government literacy surveys (e.g. National Assessment of Adult Literacy, NAAL) and are becoming more popular than traditional "grade levels" for assessing health literacy.

These two literacy measures, grade level and functional competency, use different criteria and there is no conversion between them. However, as a rough approximation, those who read below 5 th-grade level correspond with those whose literacy skills fall in level 1 in terms of functional competency in literacy tasks.

The Overall Picture of Illiteracy in America

According to the 1992 National Adult Literacy Survey (NALS), some 40 to 44 million of the 191 million adults in the country are functionally illiterate. They read at or below a fifth-grade level, or cannot read at all. Another 50 million are marginally illiterate. They are generally able to locate and assimilate information in a simple text, but are unable to perform tasks that require them to assimilate or synthesize information from complex and lengthy texts ( Kirsch, Jungebut, Jenkins & Kolstad, 1993 )

In average adult patient population ( Doak, Doak, & Root, 1996)

The average reading level is at the eighth- to ninth-grade level (between levels 2 and 3 in functional competency measures
About one in five read at the fifth-grade level and below (in functional competency terms, at about level 1).
For older American (65 and over) and for inner-city minorities almost two out of five read below the fifth-grade level (at level 1)

In community-dwelling Medicare enrollees in a managed care organization (Gazmararian, Baker, Williams, et al., 1999)

Overall 33.9% of English-speaking respondents had inadequate or marginal health literacy,
53.9% of Spanish-speaking respondents had low health literacy
Health literacy declined dramatically with age, even after researchers made adjustments for years of school completed and cognitive impairment.

In a 1995 study of two public hospitals (Williams, Parker, Baker et al., 1995)

33% of patients at two did not understand instructions for a common radiographic procedure written at the 4th grade level,
From 24.3% to 58.2% of patients did not understand directions to take medication on an empty stomach,
20% of patients answered questions incorrectly regarding information on an appointment slip, and
40.7% to 74.5% of patients surveyed did not understand the standard informed consent document. The inability to understand informed consent documents is especially troubling because of the implied legal and ethical implications.

According to the Center for Health Care Strategies, although the population most affected by literacy comprises native-born, White Americans, a disproportionate number of minorities and immigrants are also estimated to have literacy problems (Potter & Martin, 2005)

50% of Hispanics
40% of Blacks
33% of Asians

The Impact of Low Health Literacy on Health Care

Health Consequences

The relationship between literacy and health is complex. Literacy impacts health knowledge, health status, and access to health services. The results of the 1992 Adult Literacy Survey (National Center for Education Statistics, US Department of Education) indicate that adults with low literacy were more likely than those with higher literacy levels to be poor and to have health conditions which limit their activities. There are both direct and indirect consequences of low health literacy. The direct effects include non-compliance or medication errors. The indirect effects are harder to measure, but may include insurance issues, accessibility to healthcare, and poor health behavior choices.

People with low literacy:

Make more medication or treatment errors (Baker, Parker, Williams, et al., 1996: Williams, Baker, Honig, Lee & Nowlan, 1998) PubMed Abstract
Are less able to comply with treatments ( Doak, Doak & Root, 1996)
Lack the skills needed to successfully negotiate the health care system (Baker, Parker, Williams & Clark, 1998) PubMed Abstract
Are at higher risk for hospitalization than people with adequate literacy skills Baker, Parker, Williams & Clark, 1998) PubMed Abstract
Feel shame further hampering their access to care ( Baker, Parker, Williams, et al., 1996). PubMed Abstract

Economic Consequences

Low health literacy is an enormous cost burden on the American health care system, estimated to cost tens of billions of dollars annually. Annual health care costs for individuals with low health literacy skills are four times higher than for those with higher health literacy skills (Hohn, 1998).

The National Academy on an Aging Society estimated that additional health care costs due to low health literacy were about $73 billion in 1998 dollars. This includes an estimated $30 billion for the population that is functionally illiterate, plus $43 billion for the population that is marginally literate. (Health Literacy Fact Sheet, National Academy on an Aging Society). The findings of their study showed that:

In adults who stayed overnight in a hospital in 1994, those with low health literacy skills averaged 6 percent more hospital visits and stayed in the hospital 2 days longer than adults with higher health literacy.
In adults with at least one doctor visit in 1994, those with low health literacy had, on average, one more doctor visit than adults with higher health literacy skills.