Health Literacy

Literacy is a set of reading, writing, basic mathematics, speech, and speech comprehension skills(3). There are
three types of literacy(4):

• Prose literacy: The knowledge and skills needed to perform tasks (i.e., to search, comprehend, and use
  continuous texts). Examples include editorials, news stories, brochures, and instructional materials.
• Document literacy: The knowledge and skills needed to perform document tasks, (i.e., to search,
  comprehend, and use non-continuous texts in various formats). Examples include job applications,
  payroll forms, transportation schedules, maps, tables, and drug or food labels.
• Quantitative literacy: The knowledge and skills required to perform quantitative tasks, (i.e., to identify
  and perform computations, either alone or sequentially, using number embedded in print materials).
  This is also known as numeracy. Examples include balancing a checkbook, figuring out a tip, completing
  an order form, or determining the amount.

Health literacy incorporates literacy skills within the context of the healthcare system and includes
understanding facts and key concepts in science, health, medicine, and technology. Examples include(2):

• Finding, reading, and comprehending valid and reliable health information on the internet or in journal
  articles and books.
• Correctly taking a prescription or over-the-counter medication.
• Following pre-operation instructions.
• Understanding air quality reports and modifying behavior as needed.
• Accurately measuring a serving size of food or counting calories.
• Filling out forms correctly (i.e., medical history, informed consent, and health insurance enrollment).

(2) Nielsen-Bohlman, L., Panzer, A.M., Kindig, D.A. Health Literacy: A Prescription to End Confusion. National Academy of Sciences. Committee on
Health Literacy. Washington, D.C. 2004.

(3) Kirsch IS (2001). The framework used in developing and interpreting the International Adult Literacy Survey (IALS). European Journal of Psychology of Education, 16(3): 335-361.

(4) National Assessment of Adult Literacy (NAAL). U.S. National Center for Education Statistics. 2003. https://nces.ed.gov/naal/literacytypes.asp

The burden of not systematically addressing health literacy costs the U.S. healthcare system $438-$938 billion
a year(5). Inadequate health literacy has been associated with(6):

• Reduced ability to understand labels and health messages
• Limited ability to follow medication instructions
• Lower likelihood of accessing or receiving preventive care
• More hospitalizations
• Greater use of emergency departments
• Worse overall health status
• Higher mortality in the elderly
• Shorter life expectancy
• Worse physical and mental health
• Low satisfaction with health care(7), all of which are avoidable.

(5) Vernon, J.A., Trujillo, A., Rosenbaum, S., and DeBuono, B. (2007). Low Health Literacy: Implications for National Health Policy. *2008 update using
assumptions and methods in Vernon et al (2007), for 2018 direct medical costs and census population data.

(6) Berkman, N.S., Sheridan, S.L., Donahue, K.E., Halpern, D.J., and Cotty, K. (2011). Low health literacy and health outcomes: updated systematic
review. Annals of Internal Medicine, 155(2): 97-107.

(7) MacLeod, S., Musich, S., Glyas, S., Cheng, Y., Tkatch, R., Cempellin, D.,Bhattarai, G.R., Hawkins, K., and Yeh, C.S. (2017). The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults. Geriatric Nurse, 38(4): 334-341.

Nine in ten U.S. adults have insufficient health literacy skills to care for their health and the health of their
family. This statistic comes from the 2003 National Assessment of Adult Literacy (NAAL) – the first and only
large-scale assessment of the nation’s health literacy. The U.S. Department of Education surveyed more than
19,000 adults aged 16-74 years residing in households and prisons. The NAAL directly measured literacy
(prose, document, quantitative) and health literacy through completion of tasks(8). Health literacy was assessed
with 28 health literacy tasks in three domains(8):

• Clinical: activities associated with the health care provider-patient interaction, clinical encounters,
  diagnosis and treatment of illness, and medication. Examples include filling out a patient information
  form for an office visit, understanding dosing instructions for medication, and following a health care
  provider’s recommendation for a diagnostic test.
• Prevention: activities associated with maintaining and improving health, preventing disease,
  intervening early in emerging health problems, and engaging in self-care and self-management of
  illness. Examples include following guidelines for age-appropriate preventive health services,
  identifying signs and symptoms of health problems that should be addressed with a health
  professional, and understanding how eating and exercise habits decrease risk for developing serious
  illness.
• Navigation of the health care system: activities related to understanding how the health care system
  works and individual rights and responsibilities. Examples are understanding what health insurance
  plan will and will not pay for, determining eligibility for public insurance or assistance programs, and
  being able to give informed consent for a health care service.

Starting in 2012, this survey instrument was replaced by the Program for the International Assessment of
Adult Competencies (PIACC), a cyclical, large-scale study of adult cognitive skills and life experiences
developed by the Organization for Economic Cooperation and Development (OECD) and carried out in 40
participating countries. The National Center for Education Statistics conducted the PIACC in the United States
in 2012, 2014 and 2017 and measured three core domains: literacy, numeracy, and digital problem-solving
skills.

Average scores out of a total of 500 points for each domain were reported for working U.S. adult participants
aged 16-65 years in 2017:

• Literacy: 271
• Numeracy: 255
• Digital problem-solving: 274

There were no statistically significant changes between 2012-2017.

In 2012-2015, the United States scored higher than the international average in literacy (U.S. = 272,
International = 267), but not in numeracy (U.S. = 257, International = 263) or digital problem-solving skills (U.S.
= 274, International = 278). Compared to higher performing countries such as Japan and Finland, the United
States falls behind in all three domains.

(8) Kutner M, Greenberg E, Jin Y, and Paulsen C. (2006). The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006 – 483). U.S. Department of Education. Washington, DC: National Center for Education Statistics.

Studies show a higher prevalence of inadequate health literacy skills among older adults, individuals with chronic and severe health conditions, adults with Limited English Proficiency, individuals enrolled in public healthcare programs or are uninsured, those with lower educational attainment, lower household income, and Black, Indigenous, and People of Color (BIPOC) communities(9).

However, anyone can have difficulty with health literacy, even those with higher educational attainment and
higher literacy skills. This is due to the following:

• Health literacy is not routinely taught in K-12 public schools(10).
• Health literacy and clear communication are not routinely taught in schools of medicine, nursing,
  pharmacy, dental, social work, or public health(11).
• Proficient knowledge of facts and concepts in science, medicine, and health, coupled with information
  on insurance and hospital systems necessary to navigate the complex healthcare system require a
  graduate or professional degree in health and medicine.

(9) Weiss MD, B., et al. Health Literacy and Patient Safety: Helping Patients Understand. American Medical Association, 2007.

(10) Auld, M.E., Allen, M.P., Hampton, C., Montes, J.H., Sherry, C., Mickalide, A.D., Logan, R.A., Alvarado-Little, W., and Parson, K. (2020). Health
Literacy and Health Education in Schools. Collaboration for Action. NAM Perspectives.

(11) Suanders, C., Palesy, D., and Lewis, J. (2019). Systematic Review and Conceptual Framework for Health Literacy Training in Health Professions
Education. Health Professionals Education, 5: 13-29.

Addressing health literacy can:

• Reduce healthcare costs,
• Improve access to health information,
• Increase consumer satisfaction with government agencies, healthcare systems, and the health
  insurance industry, and
• Improve the overall health, safety, and quality of life for millions of Americans.

Widespread and consistent use of health literacy best practices and communication techniques, including the
“teach-back” or “show me” method, Ask Me 3®, accessibility (508-compliance), plain language, and easy-to-
read, culturally and linguistically appropriate written materials is one way to prevent communication-related
adverse health outcomes and health inequities. Another, is fully integrating health literacy into our nation’s:

• K-12 public schools health education curricula,
• Accredited graduate and professional school curricula,
• Health professional continuing education,
• Adult literacy programs for second language learners, and
• Federal, state, and organizational policies and practices.