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Health literacy is the ability to obtain, read, understand and use healthcare information to make appropriate health decisions and follow instructions for treatment.[1] There are multiple definitions of health literacy,[2] 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 (Rudd, Moeykens, & Colton, 1999). Studies reveal that only 12 percent of the adults in the U.S. have proficient health literacy. This means 77 million adults have basic or below basic health literacy. These individuals have difficulty with common health tasks including reading the label of a prescribed drug.[3] Low health literacy reduces the success of treatment and increases the risk of medical error. Health literacy is essential to promote healthy individuals and communities.

Various interventions, such as simplified information and illustrations, avoiding jargon, "teach back" methods and encouraging patients' questions, have improved health behaviors in persons with low health literacy. Health literacy is of continued and increasing concern for health professionals, as it is a primary factor behind health disparities. 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%.[4] This number increased 1% from 2007 to 2010.[4] The Healthy People 2020 initiative of the United States Department of Health and Human Services has included it as a pressing new topic, with objectives for addressing it in the decade to come.[5]

Society as a whole is responsible for improving health literacy, but most importantly the healthcare, public health professionals, and the public health systems.

Characteristics

Plain language

In order to have a population that understands health terms and can make proper health decisions, the language used by health professionals has to be a level that others who are not in the medical field can understand. Health professionals must know their audience in order to better serve their patient. The language used by these professionals should be plain language. Plain language is a strategy for making written and oral information easier to understand; it is communication that users can understand the first time they read or hear it.[6]

Some key elements of plain language include:[7]

  • Organizing information so most important points come first
  • Breaking complex information into understandable chunks
  • Using simple language and defining technical terms
  • Using active voice
  • Using lists and tables to make complex material easier to understand

If health practitioners use plain language and ask their patients to teach back what they were told, individuals will be better able to take action, protect their health and wellness, and the health system will have better health outcomes.

Factors

Many factors determine the health literacy level of health education materials or other health interventions: reading level, numeracy level, current state of health, language barriers, cultural appropriateness, format and style, sentence structure, use of illustrations, interactiveness of intervention, and numerous other factors will affect how easily health information is understood and followed.

A study of 2,600 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 or basic health care materials.[8]

History

The young and multidisciplinary field of health literacy emerged from two expert groups; physicians, other health providers, and health educators, and Adult Basic Education (ABE) and English as a Second Language (ESL) practitioners. Physicians are a source of groundbreaking patient comprehension and compliance studies. Adult Basic Education / English for Speakers of Languages Other Than English (ABE/ESOL) specialists study and design interventions to help people develop reading, writing, and conversation skills and increasingly infuse curricula with health information to promote better health literacy. A range of approaches to adult education brings health literacy skills to people in traditional classroom settings, as well as where they work and live.

Biomedical approach

The biomedical approach to health literacy that became dominant (in the U.S.) during the 1980s and 1990s often depicted individuals as lacking, or "suffering" from, low health literacy, assumed that recipients are passive in their possession and reception of health literacy, and believed that models of literacy and health literacy are politically neutral and universally applicable. This approach is found lacking when placed in the context of broader ecological, critical, and cultural approaches to health. This approach has produced, and continues to reproduce, numerous correlational studies.[9]

Where there are adequate levels of health literacy, that is where the population has sufficient knowledge and skills and where members of a community have the confidence to guide their own health, people are able to stay healthy, recover from illness and live with disease or disability.[10]

McMurray states that health literacy is important in a community as it addresses health inequities, as those at the lower levels of health literacy are often the ones who live in lower socio-economic communities. Being aware of information relevant to improving their health, or how to access health resources creates higher levels of disadvantage. For some people, a lack of education and health literacy that would flow from education prevents them from becoming empowered at any time in their lives.

A more robust 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 complex systems of health care and governance; and knowledge and use of community capital and resources, as well as using cultural and indigenous knowledge in health decision making (Nutbeam, 2000; Ratzan, 2001; Zarcadoolas, Pleasant, & Greer, 2002). This view sees health literacy as a social determinant of health that offers a powerful opportunity to reduce inequities in health.

This perspective defines health literacy as the 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 (Zarcadoolas, Pleasant, & Greer, 2006). While definitions vary in wording, they all fall within the conceptual framework offered in this definition.

Defining health literacy in that manner builds the foundation for a multi-dimensional model of health literacy built around four central domains:[11]

  • fundamental literacy,
  • scientific literacy,
  • civic literacy, and
  • cultural literacy.

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.[12] The METER includes many words from the Rapid Estimate of Adult Literacy in Medicine (REALM) test.[12] 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.[12] The CHC-Test is a test used to measure critical health competencies, which consists of 72 items and is designed to test a person's understanding of medical concepts, literature searching, basic statistics and design of experiments and samples.[12]

Patient safety and outcomes

According to an Institute of Medicine (2004) report, low health literacy negatively affects the treatment outcome and safety of care delivery.[13] The lack of health literacy affects all segments of the population. Although it is disproportionate in certain demographic groups, such as the elderly, ethnic minorities, recent immigrants and persons with low general literacy,[14] it does not only affect the; it is an issue for all racial and ethnic groups. Anyone can face health literacy challenges including people with strong literacy skills. Nevertheless, elderlies, ethnic minorities, recent immigrants and people with low general literacy, have a higher risk of hospitalization and longer hospital stays, are less likely to comply with treatment, are more likely to make errors with medication,[15] and are more ill when they seek medical care.[16][17]

The mismatch between a clinician's level of communication and a patient's ability to understand can lead to medication errors and adverse medical outcomes. Health literacy skills are not only a problem in the public. Health care professionals (doctors, nurses, public health workers) can also have poor health literacy skills, such as a reduced ability to clearly explain health issues to patients and the public.[18][19] A well arranged layout, pertinent illustrations, and intuitive format can improve the usability of health care literature. This in turn can help in effective communication between health care providers and patients and their families.[20]

Risk identification

Identifying patients at risk due to low health literacy is productive. Health behaviors such as correct medication use, taking advantage of health screening and effective preventive measures such as exercise and smoking cessation improved when low literacy patients were given visual aids, easy readability brochures or videotapes.[21] Several tests of health literacy have been developed to validate research studies,[17] but a practical, three-minute assessment can be completed in a doctor's office.[22][23] A recent review on health literacy in the Journal of the American Medical Association's "Rational Clinical Examination Series" showed that single-item questions can be useful. The simple inquiry, "How confident are you in filling out medical forms by yourself?" gives a likelihood ratio (LR) for limited literacy of 5.0 (95% confidence interval [CI], 3.8-6.4) for an answer of "a little confident" or "not at all confident"; an LR of 2.2 (95% CI, 1.5-3.3) for "somewhat confident"; and an LR of 0.44 (95% CI, 0.24-0.82) for "quite a bit" or "extremely confident."[24]

Intervention

Once identified, low health literacy patients benefit from providing limited but clear information at each visit, avoidance of medical jargon, using illustrations of important concepts and confirming information by a "teach back" method.[25] A program called "Ask Me 3"[26] is designed to bring public and physician attention to this issue, by letting patients know that they should ask three questions each time they talk to a doctor, nurse, or pharmacist:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

A public information program by the US Department of Health and Human Services encourages patients to improve healthcare quality and avoid errors by asking questions about health conditions and treatment.[27]

The book Decoding Medical Gobbleddygook - Health Literacy Puts Patients First[28] offers many resources on improving health literacy and is available free online.

The IROHLA (Intervention Research on Health Literacy of the Ageing population) project, funded by the EU, seeks to develop evidence based guidelines for policy and practice for approaches to improve health literacy of the ageing population in EU member states.[29] The project has developed a framework, identified and validated interventions which together constitute a comprehensive approach of addressing health literacy needs of the older people. In November 2015 the IROHLA project will present its findings in an interactive web-portal informing professionals and local, regional and national policy makers.

Diabetes is a rapidly growing health problem among immigrants—affecting approximately 10 percent of Asian-Americans. It is the fifth-leading cause of death in Asian-Americans between the ages of 45 and 64. In addition, type 2 diabetes is the most common form of the disease. Those who are diagnosed with type 2 diabetes have high levels of blood glucose because the body does not effectively respond to insulin. It is a lifelong disease with no known cure. Diabetes is a chronic, debilitating, and costly social burden—costing healthcare systems about $100 billion annually.[30]

Diabetes disproportionately affects underserved and ethnically diverse populations, such as Vietnamese-American communities. The relationship between the disease and health literacy level is in part because of an individual's ability to read English, evaluate blood glucose levels, and communicate with medical professionals. Other studies also suggest lack in knowledge of diabetes symptoms and complications.[31] According to an observational cross-sectional study conducted, many Vietnamese-American diabetic patients show signs of poor blood glucose control and adherence due to inadequate self-management knowledge and experience.[32] Diabetes health literacy research is needed to fully understand the burden of the chronic disease in Vietnamese-American communities, with respect to language and culture, health literacy, and immigrant status. Ethnic minority groups and immigrant communities have less knowledge of health promoting behavior, face considerable obstacles to health services, and experience poor communication with medical professionals.[33] According to a recent review, studies has supported an independent relationship between literacy and knowledge of diabetes management and glucose control, but its impact on patients has not been sufficiently described.[34][35] With the demand of chronic disease self-management (e.g., diabetic diet, glucose monitoring, etc.), a call for cultural-specific patient education is needed to achieve the control of diabetes and its adverse health outcomes in low- to middle-income Vietnamese-American immigrant communities.

eHealth literacy

eHealth literacy is a term that describes the relatively modern concept of an individual's ability to search for, successfully access, comprehend, and appraise desired health information from electronic sources and to then use such information to attempt to address a particular health problem.[36] Due to the increasing influence of the internet for information-seeking and health information distribution purposes, eHealth literacy has become an important topic of research in recent years. Stellefson (2011) states, "8 out of 10 Internet users report that they have at least once looked online for health information, making it the third most popular Web activity next to checking email and using search engines in terms of activities that almost everybody has done."[37] Though in recent years, individuals may have gained access to a multitude of health information via the Internet, access alone does not ensure that proper search skills and techniques are being used to find the most relevant online and electronic resources. The lines between a reputable medical source and an amateur opinion from a so-called expert can often be blurred; however the ability to differentiate between the two is becoming increasing important.

Health literacy requires a combination of several different literacy skills in order to facilitate eHealth promotion and care. Six core skills are delineated by an eHealth literacy model referred to as the Lily model. The Lily Model's six literacies are organized into two central types: analytic and context-specific. Analytic type literacies are those skills that can be applied to a broad range of sources, regardless of topic or content (i.e., skills that can also be applied to shopping or researching a term paper in addition to health) whereas context-specific skills are those that are contextualized within a specific problem domain (can solely be applied to health). The six literacies are listed below, the first three of the analytic type and the latter three of the context-specific:

  • Traditional literacy
  • Media literacy
  • Information literacy
  • Computer literacy
  • Scientific literacy
  • Health literacy

According to Norman (2006), both analytical and context-specific literacy skills are "required to fully engage with electronic health resources." As the World Wide Web and technological innovations are more and more becoming a part of the health care environment, it is important for information technology to be properly utilized to promote health and deliver health care effectively.

Improvement

Incorporate information through the university level

The United States Department of Health and Human Services created a National Action Plan to Improve Health Literacy.[38] One of its goals is to incorporate health and science information in childcare and education through the university level. The target is to educate people at an early stage; that way individuals are raised with health literacy and will have a better quality of life. The earlier an individual is exposed to health literacy skills the better for the person and the community.

Programs such as Head Start[39] and Women, Infants, and Children (WIC)[40] have impacted our society and the low income population. Head Start provides low-income children and their families early childhood education, nutrition, and health. Health literacy is integrated in the program for both children and parents through the education they give the individuals. WIC serves low-income pregnant and after pregnancy mothers by supplementing them food, health care referrals, and nutrition education. Programs like these help both, the parent and the child with health literacy creating a more knowledgeable community with health education.

Although programs like Head Start and WIC have been working with the health literacy of a specific population, much more can be done with the education of children and young adults. Now, more and more adolescents are getting involved with their health care. Due to this, it is crucial to educate these individuals in order for them to make informed decisions.

Many schools in the country incorporate a health class in their curriculum. These classes provided an excellent opportunity to facilitate and develop health literacy in today's children and adolescents. The skills of how to read food labels, the meaning of common medical terms, the structure of the human body, and education on the most prevalent disease in the United States should be taught in both private and public schools. This way new generations will grow with health literacy and would hopefully make knowledgeable health decisions.

Framework and potential intervention points

The National Library of Medicine defines health literacy as:[41]

"The degree to which individuals have the capacity to obtain, process, and understand basic health literacy information and services needed to make appropriate health decisions."

Based on this clinical definition, health literacy gives individuals the skills that they need to both understand and effectively communicate information and concerns. Bridging that gap between literacy skills and the ability of the individual in health contexts, the Health Literacy Framework highlights the health outcomes and costs associated with health contexts including cognitive abilities, social skills, emotional state, and physical conditions such as visual and auditory contributions.

Potential Intervention Points are illustrated in reflection of the Health Literacy Framework. Outlining interactions such as those of individuals and the education systems that they are engaged with, their health systems, and societal factors as they relate to health literacy, these potential intervention points are not however, components of a casual model. The three potential intervention points are culture and society, the health system, and the education system. Health outcomes and costs are the products of the health literacy developed during diversity of exposure to these three potential intervention points.

Referring to shared ideas, meanings, and values that influence an individual's beliefs and attitudes, cultural and societal influences are a significant intervention point for health literacy development. As interactions with healthcare systems often first occur at the family level, deeply rooted beliefs and values can shape the significance of the experience. Included components that reflect the development of health literacy both culturally and societally are native language, socioeconomic status, gender, race, and ethnicity, as well as mass media exposure. These are pathways to understanding American life paralleling conquests for a health literate America.

The health system is an intervention point in the Health Literary Framework. For the purposes of this framework, health literacy refers to an individual's interaction with people performing health-related activities in settings such as hospitals, clinics, physician's offices, home health care, public health agencies, and insurers.

In the United States, the education system consists of K-12 curricula. In addition to this standard educational setting, adult education programs are also environments in which individuals can develop traditional literacy skills founded in comprehension and real-world application of knowledge via reading and writing. Tools for educational development provided by these systems impact an individual's capacity to obtain specific knowledge regarding health. Reflecting components of traditional literacy such as cultural and conceptual knowledge, oral literacy (listening and speaking,) print literacy (reading and writing,) and numeracy, education systems are also potential intervention points for health literacy development.

Skills needed for development

Health Related Goals[41]

  • Promoting and protect health and prevent disease
  • Understand, interpret, and analyze health information
  • Apply health information over a variety of life events and situations
  • Navigate the health-care system
  • Actively participate in encounters with health-care professionals and workers
  • Understand and give consent
  • Understand and advocate for rights

See also

Citations

  1. ^ Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine (10 February 2012). Facilitating State Health Exchange Communication Through the Use of Health Literate Practices: Workshop Summary. National Academies Press. p. 1. ISBN 978-0-309-22029-3.
  2. ^ A. Pleasant; J. McKinney (2011). "Coming to consensus on health literacy measurement: An online discussion and consensus-gauging process". Nursing Outlook. 59 (2): 95–106.e1. doi:10.1016/j.outlook.2010.12.006. Retrieved 2013-12-26.
  3. ^ "America's Health Literacy: Why We Need Accessible Health Information". health.gov. Retrieved 2015-11-20.
  4. ^ a b "Health Communication and Health Information Technology - Healthy People 2020".
  5. ^ "Health Communication and Health Information Technology - Healthy People 2020".
  6. ^ "Health Literacy - Fact Sheet: Health Literacy Basics". health.gov. Retrieved 2015-11-20.
  7. ^ "Federal Plain Language Guidelines: Table of Contents". www.plainlanguage.gov. Retrieved 2016-03-30.
  8. ^ M. V. Williams; et al. (1995). "Inadequate functional health literacy among patients at two public hospitals". JAMA. 274 (21): 677–82. doi:10.1001/jama.274.21.1677. PMID 7474271. Retrieved 2006-06-30.
  9. ^ Pleasant & Kuruvilla, 2008
  10. ^ Anne McMurray (2007). Community Health and Wellness: A Sociological Approach (3rd ed.). Brisbane: Elsevier. ISBN 978-0-7295-3788-9.
  11. ^ Zarcadoolas et al. 2005, 2006
  12. ^ a b c d Altin, Sibel; Finke, Isabelle; Kautz-Freimuth, Sibylle; Stock, Stephanie (2014). "The evolution of health literacy assessment tools: a systematic review". BMC Public Health. 14 (1): 1207. doi:10.1186/1471-2458-14-1207. PMC 4289240. PMID 25418011.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  13. ^ The Institute of Medicine: Health Literacy: A Prescription to End Confusion (2004)
  14. ^ 2003 National Assessment of Adult Literacy The Health Literacy of America's Adults Retrieved 9 September 2006
  15. ^ Terry C. Davis; Michael S. Wolf, MPH; Pat F. Bass III, MD; Jason A. Thompson, BA; Hugh H. Tilson, MD, DrPH; Marolee Neuberger, MS; and Ruth M. Parker, MD (2006). "Literacy and Misunderstanding Prescription Drug Labels". Annals of Internal Medicine. 145 (12): 887–94. doi:10.7326/0003-4819-145-12-200612190-00144. PMID 17135578. Retrieved 2006-11-30.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ U.S. Department of Health and Human Services: Quick Guide to Health Literacy
  17. ^ a b M. V. Williams; et al. (1995). "The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills". J Gen Intern Med. 10 (10): 537–41. doi:10.1007/BF02599568. PMID 8576769.
  18. ^ American Society of Anesthesiology abstracts (October 25, 2005), Aaron M. Fields, M.D., Kirk H. Shelley, M.D., Ph.D., Craig Freiberg, M.D. (Department of Anesthesiology, Yale University School of Medicine)Patients and Jargon: Are We Speaking the Same Language?, retrieved 2008-10-18
  19. ^ The Center for Advancement of Health (March 2003): Talking the Talk: Improving Patient-Provider Communication, retrieved 2008-10-18
  20. ^ Gill, P.S.; Gill, T.S.; Kamath, A.; whisnant, B. (2012). "Readability Assessment of Concussion and Traumatic Brain Injury Publications by Centers for Disease Control and Prevention". International Journal of General Medicine. 5: 923–933. doi:10.2147/IJGM.S37110.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  21. ^ Agency for Healthcare Research and Quality: Evidence Report/Technology Assessment: Number 87 Literacy and Health Outcomes
  22. ^ Barry D. Weiss, MD; et al. (2005). "Quick Assessment of Literacy in Primary Care: The Newest Vital Sign". Annals of Family Medicine. 3 (6): 514–522. doi:10.1370/afm.405. PMC 1466931. PMID 16338915. Retrieved 2006-06-30.
  23. ^ The Newest Vital Sign: a Health Literacy Assessment Tool
  24. ^ Powers, BJ; Trinh, JV; Bosworth, HB. (Jul 2010). "Can this patient read and understand written health information?". JAMA. 304 (1): 76–84. doi:10.1001/jama.2010.896. PMID 20606152. {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  25. ^ "A Conversation on Cultural Competence With Cindy Brach, Senior Health Policy Researcher, AHRQ". Agency for Healthcare Research and Quality. 2013-04-17. Retrieved 2013-08-22.
  26. ^ "National Patient Safety Foundation".
  27. ^ Agency for Healthcare Research and Quality:Questions Are the Answer, retrieved 2008-10-18
  28. ^ "404 - Error: 404". {{cite web}}: Cite uses generic title (help)
  29. ^ "Home".
  30. ^ Cabiglio, Josie. Diabetes on the rise among Asians. Nguoi Viet 2. Web. 7 Dec 2010. http://nguoi-viet.com/absolutenm/anmviewer.asp?a=41207&z=126
  31. ^ Glazier, R.H. "Neighborhood recent immigration and hospitalization in Toronto, Canada." Canadian Journal of Public Health 95 (2004): 130-134.
  32. ^ Mull, Dorothy S. et al. "Vietnamese diabetic patients and their physicians." Western Journal of Medicine 175 (2001): 307-311. Print.
  33. ^ Simich, Laura. "Health Literacy and Immigrant Populations." Public Health Agency of Canada and Metropolis Canada (2009): 1-18. Print.
  34. ^ Schillinger, Dean et al. "Association of Health Literacy With Diabetes Outcomes." Journal of American Medical Association 288 (2002): 475-481. Print.
  35. ^ Schillinger, Dean et al. "Does Literacy Mediate the Relationship Between Education and Health Outcomes? A Study of a Low-Income Population with Diabetes." Public Health Reports 121 (2006): 245-254. Print.
  36. ^ Norman, Cameron D; Skinner, Harvey A (1 January 2006). "eHealth Literacy: Essential Skills for Consumer Health in a Networked World". 8 (2). doi:10.2196/jmir.8.2.e9. {{cite journal}}: Cite journal requires |journal= (help)CS1 maint: unflagged free DOI (link)
  37. ^ Stellefson, Michael; Hanik, Bruce; Chaney, Beth; Chaney, Don; Tennant, Bethany; Chavarria, Enmanuel Antonio (1 January 2011). "eHealth Literacy Among College Students: A Systematic Review With Implications for eHealth Education". 13 (4). doi:10.2196/jmir.1703. {{cite journal}}: Cite journal requires |journal= (help)CS1 maint: unflagged free DOI (link)
  38. ^ "National Action Plan to Improve Health Literacy" (PDF).
  39. ^ "Home - Office of Head Start - Administration for Children and Families".
  40. ^ "Women, Infants, and Children (WIC) - Food and Nutrition Service".
  41. ^ a b Nielsen-Bohlmn, Lynn (2004). "Health Literacy: A Prescription to End Confustion". Institute of Medicine.

Sources

  • Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267.
  • Pleasant, A.; Kuruvilla, S. (2008), A tale of two health literacies? Public health and clinical approaches to health literacy, Health Promotion International, retrieved Feb 28, 2008
  • Ratzan, S. C. (2001). Health literacy: Communication for the public good. Health Promotion International, 16(2), 207–214.
  • Rootman, I., & Wharf-Higgins, J. (2007), Literacy and Health: Implications for Active Living, WellSpring, p. 4{{citation}}: CS1 maint: multiple names: authors list (link)
  • . May 2011 http://www.health.gov/communication/literacy/. {{cite web}}: Missing or empty |title= (help); Unknown parameter |dead-url= ignored (|url-status= suggested) (help)
  • Rudd, R., Moeykens, B. Colton, TC. (1999) Health and literacy: A review of medical and public health literature. In J. Comings, B. Garners, & C. Smith, eds. Annual Review of Adult Learning and Literacy, Volume I. New York, NY: Jossey-Bass.
  • Zarcadoolas, C., Pleasant, A., & Greer, D. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20, 195–203.
  • Zarcadoolas, C., Pleasant, A., & Greer, D. (2006). Advancing health literacy: A framework for understanding and action. Jossey-Bass: San Francisco, CA.
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