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Definition of terms
Health Literacy—Health literacy is defined as the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate decisions regarding their health (Health People—2010).
NAAL - According to the most recent National Assessment of Adult Literacy (NAAL), a national survey conducted by the U.S. Department of Education & National Center for Education Statistics in 2003, over 90 million Americans have trouble understanding fairly basic health information. This not only includes interpreting print information but incorporates tasks such as following medication instructions, identifying signs and symptoms of illness, and engaging in self-care behaviors. The report identifies four separate health literacy categories with examples of a health task relevant to each literacy level and the proportion of the population at each level as follows (Source—NAAL Report 2003):
- Below Basic: Being able to identify and correctly circle the date of a medical appointment on a hospital appointment slip. 14% of the population was in this category.
- Basic: Can give two reasons a person with no symptoms of a specific disease should be tested for that disease based on information contained in a clearly written pamphlet. 22% of the population was in this category.
- Intermediate: Ability to accurately interpret and understand a prescription drug label. 53% of the population was in this category.
- Proficient: Can calculate an employee’s share of health insurance costs for a year using a table that shows how the employee’s monthly cost varies depending on income and family size. 12% of the population was in this category.
It is clear from this report that low health literacy is present across all races, ethnicities, and insurance types; however, two additional and interesting findings from the report were the disproportionate levels of low health literacy among ethnic/racial minorities and those with no or limited sources of insurance. Specifically the NAAL found that 28% of Whites had basic or below basic health literacy skills compared to 58% of Blacks and 66% of Hispanics. Ethnic minorities as well as the economically disadvantaged, rural populations, women, elderly, and children have all been identified by the Agency for Healthcare Research and Quality as research “priority groups” in that they often experience a disproportionate burden of disease and disparities in healthcare access and quality. Interestingly, we are in fact seeing a growing amount of research activity involving the potential contribution of low health literacy to healthcare disparities both in the U.S. and internationally.
Source: Kutner MA, United States. Dept. of Education., National Center for Education Statistics.: The health literacy of America's adults : results from the 2003 National Assessment of Adult Literacy. Washington, DC., United States Department of Education ; National Center for Education Statistics, 2006
Clear Health Communication - As noted above, the definition of health literacy emphasizes individual skills and abilities, whereasClear Health Communication refers to effective communication within the broader and often complex healthcare environment that individuals are required to navigate. Here, the individual health consumer is joined by the healthcare professional, clinic or hospital staff, insurance provider, managed care organization, and others, all of whom play important roles in ensuring that the individual patient receives health information that is both clear and actionable. For researchers and policy-makers, emphasizing the importance of clear health communication should be our goal as we seek to describe, understand, and intervene upon the current healthcare environment.
Define the scope and impact of health literacy deficits
In terms of health outcomes: A growing body of evidence supports the association between deficits in health literacy and various health related outcomes such as:
- Lower reported health status
- Greater mortality
- Less disease-specific knowledge and ability to recognize common signs and symptoms of illness
- Greater utilization of hospital services
- Less self-confidence and skills needed for self-care and chronic disease management
- Lower receipt of important screening procedures (e.g. colonoscopy) and vaccinations
- Poorer understanding of medication and food labels
A comprehensive review lead by the Agency for Healthcare Research and Quality in 2011 sought to summarize the current science supporting these associations, and they found that for many outcomes the quality/strength of the literature was limited in many areas due to a number of smaller, observational study designs. For example, the collective evidence was limited among studies that identified worse diabetes self-management among low health literate patients. Similar results held true for access to care, asthma severity and control, and certain screening practices (e.g. colon cancer, STD). Moderate evidence does support the association between low health literacy and increased ER visits, hospitalizations, lower influenza vaccination rates, decreased ability to interpret health messages, less mammography screening, worse medication adherence, and higher mortality among the elderly. Dewalt and Hink similarly reviewed the impact of health literacy on child health outcomes and found that children with low literacy had worse health behaviors and parents with low literacy had less health knowledge and behaviors that are advantageous for their children’s health.
In terms of health costs: It is challenging to assign a precise dollar amount to the overall impact of low health literacy on healthcare costs. This is in part due to significant heterogeneity in how health literacy is measured as well as a relative lack of economic evaluations. A recent and rigorous systematic review of health literacy associated costs conducted by Eichler et al. identified 10 studies that addressed this issue. These studies suggested that the additional costs of limited health literacy on the health system level range from 3% to 5% of the total health care costs per year. Using estimates from the National Health Expenditure Report in 2009 would therefore equate the overall economic burden of low health literacy to around $75-125 billion dollars annually. Future research will define this more precisely. Research is also needed to better describe the cost-effectiveness of health literacy targeted interventions.
Materials and Sentinel Reports
Update of Selected Research Bibliography (2007—present):
Important reports for researchers and policy stakeholders
- IOM Report Brief (2004)—this report provides an overview of health literacy and its impact on health and healthcare with emphasis on the role of health systems and policy-makers in addressing low health literacy.
- AHRQ Evidence Report Health Literacy Interventions and Outcomes (2011)—this report systematically reviewed the evidence supporting the association between low health literacy and health outcomes and interventions aimed at mitigating the effect of low health literacy.
- Surgeon General’s Workshop on Improving Health Literacy (2007)—this workshop explored the current science behind health literacy research and made practical recommendations for how we can improve health literacy and particularly translate research into action.
- IOM Innovations in Health Literacy (2011)—summary of a workshop that explored the link between health literacy and health disparities and highlighted the role of research and policy in implementing the National Action Plan to Improve Health Literacy.
- IOM Health Literacy Implications for Health Care Reform (2011)—this roundtable explored opportunities to improve health literacy within the context of recent national policy changes related to the Patient Protection and Affordable Care Act.