Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. There are multiple definitions of health literacy, in part because health literacy involves both the context (or setting) in which health literacy demands are made (e.g., health care, media, internet or fitness facility) and the skills that people bring to that situation.
Since health literacy is a primary contributing factor to health disparities, it is a continued and increasing concern for health professionals. The 2003 National Assessment of Adult Literacy (NAAL) conducted by the US Department of Education found that 36% of participants scored as either "basic" or "below basic" in terms of their health literacy and concluded that approximately 80 million Americans have limited health literacy. These individuals have difficulty with common health tasks including reading the label of a prescribed drug.
Several factors may influence health literacy. The following factors have been shown to strongly increase this risk: age (especially patients 65 years and older), limited English language proficiency or English as a second language, chronic conditions, less education, and lower socioeconomic status. Patients with low health literacy understand less about their medical conditions and treatments and overall report worse health status. Patients who struggle with substantial health literacy challenges often forego important health care such as vaccinations or annual screenings, and are more likely to miss appointments, misuse medication, prepare improperly for procedures, and even die prematurely.DupréAthena. Communicating about Health : Current Issues and Perspectives. Seventh Edition ed., New York, Oxford University Press, 2014, p. Chapter 4, page 63.
Various interventions, such as simplifying information and illustrations, avoiding jargon, using "teach-back" methods, and encouraging patients' questions, have improved health behaviors in persons with low health literacy. The proportion of adults aged 18 and over in the U.S., in the year 2010, who reported that their health care providers always explained things so they could understand them was about 60.6%. This number increased 1% from 2007 to 2010. The Healthy People 2020 initiative of the United States Department of Health and Human Services (HHS) has included health literacy as a pressing new topic, with objectives for improving it in the decade to come.
In planning for Healthy People 2030 (the fifth edition of Healthy People), HHS issued a "Solicitation for Written Comments on an Updated Health Literacy Definition for Healthy People". Several proposals address the fact that "health literacy is multidimensional", being the result of a concerted effort that involves the individual seeking care or information, providers and caregivers, the complexity and demands of the system, and the use of plain language for communication.
Definition
The National Library of Medicine defined health literacy as:
Health literacy encompasses a wide range of skills, and competencies that people develop over their lifetimes to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life.
Another view of health literacy includes the ability to understand scientific concepts, content, and health research; skills in spoken, written, and online communication; critical interpretation of mass media messages; navigating systems of health care and governance; knowledge and use of community capital and resources; and using cultural and indigenous knowledge in health decision making. This view sees health literacy as one of the social determinants of health which can reduce inequities in health.
Impact Health literacy influences individuals' ability to obtain, understand, and use health information, which in turn affects their ability to make informed to make health decisions, and thus directly addresses health inequalities. Individuals with lower levels of health literacy live, disproportionately, in communities with lower socio-economic standing. A barrier to achieving adequate health literacy for these individuals is a lack of awareness, or understanding of, information and resources relevant to improving their health. This knowledge gap arises from both people being unable to understand information presented to them and clinical sources providing inadequate resources to address these literacy gaps. Inadequate health literacy can lead to misunderstanding medical instructions, medication errors, missed appointments, and other adverse health outcomes.
The levels of health literacy are considered adequate when the population has sufficient knowledge, skills, and confidence to guide their own health, and people are able to stay healthy, recover from illness, and live with disability or disease.
Lower literacy
Health literacy influences a person's ability to understand medical information, such as prescription instructions and treatment recommendations, which can directly affect their ability to follow medical advice and manage their health effectively.
Research shows that people with low health literacy may not understand medication instructions or dosage information, which can lead to medication errors and poor treatment outcomes. People with lower health literacy are also more likely to use emergency healthcare services and experience difficulties navigating healthcare systems — this means more emergency room visits, more hospitalizations, and higher healthcare costs.
Health literacy also affects communication between people and healthcare providers, not only when it comes to prescription and treatments, but in the ability of people needing care to ask questions, participate in decision-making, and understand medical advice, which in turn influence health outcomes. Further, limited health literacy is associated with lower participation in preventive healthcare behaviors, including cancer screening, vaccinations, and early medical consultation. These lower rates of preventive behaviors and delayed medical care can negatively affect health outcomes.
Higher literacy
People with higher health literacy are more likely to understand their medical conditions and engage in self-management behaviors, such as medication adherence, healthy lifestyle choices, and monitoring symptoms. Higher health literacy has also been associated with better quality of life, especially among people with chronic illnesses because it supports better self-management and use of healthcare.
Higher health literacy improves medication adherence, lifestyle changes (i.e., diet, exercise) and maintaining mental and physical well-being, symptom monitoring and management, disease knowledge, and access to healthcare resources.
Characteristics
Factors that contribute to health literacy Many factors determine the health literacy level of health education materials or interventions: readability of the text, the patient's current state of health, language barriers between the clinician and patient, cultural appropriateness of the materials, format and style, sentence structure, use of illustrations, and numerous other factors.
A study of 69,000 patients conducted in 1995 by two US hospitals found that between 26% and 60% of patients could not understand medication directions, a standard informed consent form, or materials about scheduling an appointment. The 2003 National Assessment of Adult Literacy (NAAL) conducted by the US Department of Education found that 36% of participants scored as either "basic" or "below basic" in terms of their health literacy and concluded that approximately 80 million Americans have limited health literacy.
Results of a systematic review of the literature found that when limited English proficient (LEP) patients receive care from physicians who are fluent in the patients' preferred language, referred to as having language concordance, generally improves outcomes. These outcomes are consistent across patient-reported measures, such as patient satisfaction, and also more such as blood pressure for patients with diabetes.
Plain language Plain language refers to the use of writing strategies that help readers find, understand, and apply information to fulfill their needs. It has a vital role to play in improving health literacy. In conjunction with readers education, provider cultural training, and system design, plain language helps people make more informed health choices.
Plain language is defined by the International Plain Language Federation as writing whose "wording, structure, and design are so clear that the intended readers can easily find what they need, understand what they find, and use that information."
Some key elements of plain language include: Organizing information so most important points come first Breaking complex information into understandable chunks Using simple language or language familiar to the reader Defining technical terms and acronyms Using active voice in subject-verb-object (SVO) sentences when subject/agent/topic coincide Varying sentence length and structure to avoid monotony Using lists and tables to make complex material easier to understand
The National Institute of Health (NIH) recommends that patient education materials be written at a 6th–7th grade reading level. The UK's National Institute for Health and Care Research (NIHR) recommends involving patients and non-academic members of the public in writing plain language summaries of research articles.
Assessment There are several tests, which have verified reliability in the academic literature that can be administered in order to test one's health literacy. Some of these tests include the Medical Term Recognition Test (METER), which was developed in the United States (2 minute administration time) for the clinical setting. The METER includes many words from the Rapid Estimate of Adult Literacy in Medicine (REALM) test. The Short Assessment of Health Literacy in Spanish and English populations (SAHL-S&E) uses word recognition and multiple choice questions to test a person's comprehension. The CHC-Test measures Critical Health Competencies and consists of 72 items designed to test a person's understanding of medical concepts, literature searching, basic statistics, and design of experiments and samples.
Standardized measures of health literacy are the Newest Vital Sign (NVS), which asks people about a nutrition label, and the Test of Functional Health Literacy (TOFHLA), which asks test-takers to fill in 36 blanks in patient instructions for X-rays and a Medicaid application, from multiple choices, and 4 numbers in medicine dosage forms.
The European Health Literacy Population Survey
Following studies in a number of European countries demonstrating that health literacy is limited in a large proportion of the general population, and the publication of WHO's report Health Literacy: The solid facts (2013), WHO/Europe initiated the Action Network on Measuring Population and Organizational Health Literacy (M-POHL). 28 European countries are involved in M-POHL and measure health literacy in the population regularly. In the Health Literacy Survey 2019 (HLS19) 17 countries were involved. To measure general health literacy the instrument HLS-EU-Q12 - a short form of the original HLS-EU-Q47 instrument was used in this survey.
Patient safety and outcomes