The relationship between poor literacy skills and health status is now well recognized and better understood. Interest in this relationship has led to the emergence of the concept of health literacy. The concept has emerged from two different roots – in clinical care and in public health. This paper describes the two distinctive concepts that reflect health literacy, respectively, as a clinical “risk”, or a personal “asset”. In the former case a strong science is developing to support screening for poor literacy skills in clinical care and this is leading to a range of changes to clinical practice and organization. The conceptualization of health literacy as an asset has its roots in educational research into literacy, concepts of adult learning, and health promotion. The science to support this conceptualization is less well developed and is focused on the development of skills and capacities intended to enable people to exert greater control over their health and the factors that shape health.
Characteristics
There
are many factors that determine the health literacy level of health education
materials or other health interventions. Reading level, numeracy level,
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.
History
The
young and multidisciplinary field of health literacy emerged from two
expert groups; physicians and 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 cor-relational studies.
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.
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 socioeconomic 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 . 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. 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 multidimensional
model of health literacy built around four central domains:
- fundamental literacy,
- scientific literacy,
- civic literacy, and
- cultural literacy.
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. These patients 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, and are more ill when they seek medical
care.
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. 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. 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.
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. Several tests of health literacy have
been developed to validate research studies, but a practical, three-minute
assessment can be completed in a doctor's office. 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."
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. A program called "Ask Me 3"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.
Health
Illiterate-Related Diabetes Prevalence in Vietnamese-American Populations
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.
Diabetes
disproportionately affects undeserved 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. 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. 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. 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. 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.
ow health literate
would you say you are?
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. The eHealth literacy model is also referred
to as the Lily model, which incorporates the following literacies, each of
which are instrumental to the overall understanding and measurement of eHealth
literacy.
- Basic or traditional literacy
- Computer literacy
- Information literacy
- Media literacy
- Science literacy
- Health literacy
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