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Overview of Health Literacy and Clear Health Communication
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, whereas Clear 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):
| Author | Title | Journal | Citation | Brief synopsis | Category | Year |
| DeWalt DA, et al. | Low health literacy: epidemiology and interventions | NC Med J | 2007 Sep-Oct;68(5):327-30 | no abstract | HL interventions | 2007 |
| DeWalt DA, et al. | Literacy and its relatiohnship with self-efficacy, trust, and participation in medical decision making | Am J Health Behav | 2007 Sep-Oct:31 Suppl 1:S27-35 | Examination of the relationship between literacy, trust, self-efficacy, and participation in medical decision making in adults with diabetes | HL and outcomes | 2007 |
| Osborn CY, et al. | Measuring adult literacy in health care: performance of the newest vital sign | Am J Health Behav | 2007 Sep-Oct:31 Suppl 1:S36-46 | Evaluation of the Newest Vital Sign compared to existing literacy measures | HL and measurement | 2007 |
| Paasche-Orlow MK, et al. | The causal pathways linking health literacy to health outcomes | Am J Health Behav | 2007 Sep-Oct;31 Suppl 1:S19-26 | Provides and evidence-based review of plausible causal pathways that could best explain well-established associations between limited health literacy and health outcomes | HL and outcomes | 2007 |
| Peters E, et al. | Numeracy skill and the communication, comprehension, and use of risk-benefit information | Health Aff (Millwood) | 2007 May-Jun;26(3):741-8 | Review of the literature supporting the association between innumeracy and comprehension and use of health information | HL and outcomes | 2007 |
| Villaire M, et al. | Chronic illness management and health literacy: an overview | J Med Pract Manage | 2007 Nov-Dec;23(3):177-81 | Summary of shared techniques and practice aids to improve provider-patient communication and help improve outcomes among patients with chronic illnesses | HL and outcomes | 2007 |
| Yin HS, et al. | Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing | Ambul Pediatr | 2007 Jul-Aug;7(4):292-8 | Cross-sectional analysis exploring the association between low caregiver health literacy, use of nonstandardized dosing instruments, and knowledge of weight-based medication dosing | HL and outcomes | 2007 |
| Author | Title | Journal | Citation | Brief synopsis | Category | Year |
| Bastian H, et al. | Health literacy and patient information: developing the methodology for a national evidence-based health website | Patient Educ Couns | 2008 Dec;73(3):551-6 | Description of the political and methodological processes involved in the development of a national, evidence-based health information website in Germany | HL and communication | 2008 |
| Byrd J, et al. | "it's safe to ask":promoting patient safety through health literacy | Healthc Q | 2008;11 (3 Spec No.):91-4 | Description of phase 1 of a health liteacy-based communication intervention aimed at improving communication between patients and providers surrounding patient safety | HL and outcomes | 2008 |
| Cho YI, et al. | Effects of health literacy on health status and helath service utilization amongst the elderly | Soc Sci Med | 2008 Apr;66(8):1809-16 | Evaluation of the association between health literacy, health status, and health service utilization among a sample of Medicare enrollees | HL and outcomes | 2008 |
| Kreps GL, et al. | Meeting the helath literacy needs of immigrant populations | Patient Educ Couns | 2008 Jun;71(3):328-32 | Review of the evidence supporting the challenges in communicating health information and risks to vulnerable immigrant populations with suggestion of strategies to overcome these barriers. | HL and disparities | 2008 |
| Levinthal BR, et al. | Cognition and health literacy in patients with hypertension | J Gen Intern Med | 2008 Aug;23(8):1172-6 | Examination of the role of cognitive and sensory abilities as mediators of age and eduation in determining functional health literacy among patients with hypertension | HL and outcomes | 2008 |
| Manganello JA | Health literacy and adolescents: a framework and agenda for future research | Health Educ Res | 2008 Oct;23(5):840-7 | Provides a summary of issues justifying the importance of studying health literacy as it relates to adolescents and gives a framework for future research | HL and outcomes | 2008 |
| Rothman RL, et al. | Perspective: the role of numeracy in health care | J Health Commun | 2008 Sep;13(6):583-95 | Editorial commentary on the potentially unique role and impact of numeracy on health outcomes | HL and outcomes | 2008 |
| Author | Title | Journal | Citation | Brief synopsis | Category | Year |
| Chin MH, et al. | Health care quality-improvement approaches to reducing child health disparities | Pediatrics | 2009 Nov;124 Suppl 3:S224-36 | Review of lessons learned from adult literature and recommendations to guide future research into how quality-improvment efforts can improve disparities in child health and outcomes | HL interventions | 2009 |
| Clement S, et al. | Complex interventions to improve the health of people with limited literacy: A systematic review | Patient Educ Couns | 2009 Jun;75(3):340-51 | Review of multi-faceted interventions designed to improve health-related outcomes of individuals with limited literacy or numeracy | HL interventions/systematic review | 2009 |
| DeWalt DA, Hink A | Health literacy and child health outcomes: a systematic review of the literature | Pediatrics | 2009 Nov;124 Suppl 3:S265-74 | Review of the relationship between parent and child literacy and child health outcomes and interventions designed to improve child health outcomes for children or parents with low literacy skills. | HL review | 2009 |
| Eichler K, et al. | The costs of limited health literacy: a systematic review | Int J Public Health | 2009 Jul;54:313-324 | Summary of observational and interventional studies that reported on health litearacy outcomes and contained relevant cost data. Out of 2,340 retreived articles, 10 met criteria. Additional costs of health liteacy range from 3-5% of total annual health care costs per year. | HL systematic review | 2009 |
| Elliott RA, et al. | Standardised assessment of patients' capacity to manage medications: a systematic review of published instruments | BMC Geriatr | 2009 Jul 13;9:27 | Review of published instruments designed to assess patients' capacity to self-administer medications | HL review | 2009 |
| Lipkus IM, et al. | Understanding the role of numeracy in health: proposed theoretical framework and practical insights | Health Educ Behav | 2009 Dec;36(6):1065-81 | Proposal of six critical funtions of health numeracy with examination of their practical underpinnings for targeted interventions research | HL interventions | 2009 |
| Mancuso JM | Assessment and measurement of health literacy: an integrative review of the literature | Nurs Health Sci | 2009 Mar;11(1):77-89 | Review of current health literacy assesssment tools including their psychometric properties, advantages, and limitations. | HL and measurement/review | 2009 |
| Rothman RL, et al. | Health literacy and quality: focus on chronic illness care and patient safety | Pediatrics | 2009 Nov;124 Suppl 3:S315-26 | Editorial review of health literacy and its association with health outcomes with emphasis on its role in pediatric quality of care and safety | HL and outcomes | 2009 |
| Sanders LM, et al. | Literacy and child health: a systematic review | Arch Pediatr Adolesc med | 2009 Feb;163(2):131-40 | Review of the prevalence of low health literacy among adolescents, young adults, and child caregivers in the US, the readability of common child-health information, and the relationship between literacy and child health. | HL review | 2009 |
| Shaw SJ, et al. | The role of culture in health literacy and chronic disease screening and management | J Immigr Minor Health | 2009 Dec;11(6):460-7 | Review of cultural influences on health literacy, cancer screening, and chronic disease outcomes | HL and outcomes | 2009 |
| Sudore RL, et al. | Interventions to Improve Care for Patients with Limited Health Literacy | J Clin Outcomes Manag | 2009 Jan 1;16(1):20-29 | Literature review of evidence supporting provider level, system level, and community level interventions to improve health outcomes for patients with limited health literacy | HL review | 2009 |
| Wolff MS, et al. | Literacy and learning in health care | Pediatrics | 2009 Nov;124 Suppl 3:S275-81 | Review of current health literacy definitions and provision of an additional conceptual framework and research agenda that considers an individuals "health-learining capacity" as a means to guide future intervention research. | HL interventions | 2009 |
| Author | Title | Journal | Citation | Brief synopsis | Category | Year |
| Easton P, et al. | Health in the 'hidden population' of people with low literacy. A systematic review of the literature | BMC Public Health | 2010; 10:459 | Review of published research to investigate relationships between low funcitonal or health literacy and health in working age adults. Lower funtional or health literacy was found to be associated with worse health status. Greater research is need to further explore causality and develop appropriate responses. | HL systematic review | 2010 |
| Evangelista LS, et al. | Health literacy and the patient with heart failure--implications for patient care and research: a consensus statement of the Heart Failure Society of America | J Card Fail | 2010 Jan;16(1):9-16 | Summary of current definitions, assessment and impact of health litearacy in patients with heart failure. Provides direction for future research and clinical practice | HL review | 2010 |
| Finne RK, et al. | Beyond reading level: a systematic review of the suitability of cancer education print and Web-based materials. | J Cancer Edu | 2010 Dec;25(4):497-505 | Describes intruments used to evaluate categories of suitability in cancer education materials | HL systematic review | 2010 |
| Galliher JM, et al. | Patients' question-asking behavior during primary care visits: a report from the AAFP National Research Network | Ann Fam Med | 2010 Mar-Apr;8(2):151-9 | RCT of the Ask Me 3 health communication program among 20 practices from the AAFP National Research Network | HL intervenitons | 2010 |
| Hawkins AO, et al. | Health Literacy: a potential barrier in caring for underserved populations | Dis Mon | 2010 Dec;56(12):734-740 | Brief review of prevelence estimates, cost burdern, associated health outcomes and methods to improve health communication with patients with limited health literacy. | HL review | 2010 |
| Lubetkin El, et al. | Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes | J Health Care Poor Underserved | 2010 Aug;21(3):796-808 | Cross-sectional analysis of performance of the Patient Activation Measure (PAM) among a minority population with comparisions to the general U.S. population | HL and outcomes | 2010 |
| McCaffery KJ, et al. | The challenge of shared decision making among patients with lower literacy: a framework for research and development | Med Decis Making | 2010 Jan-Feb;30(1):35-44 | Review of current research in decision making and proposal of a framework for improving the ability of patients with lower literacy to participate in the process. | HL and outcomes | 2010 |
| Paasche-Orlow MK, et al. | Promoting health literacy research to reduce health disparities | J Health Commun | 2010; 15 Suppl 2:34-41 | Recommendations for a research agenda that focuses on how health literacy research can promote the effort to eliminate health disparities. | HL and disparities | 2010 |
| Powers BJ, et al. | Can This Patient Read and Understand Written Health Information? | JAMA | 2010 Jul;304(1):76-84 | Systematic review of the accuracy of brief instruments for identifying patients with limited health literacy. Literature search from 1969-2010. Ten studies met criteria; the Newest Vital Sign demonstrated moderate performance in identifying limited health literate patients | HL systematic review | 2010 |
| Sampson UKA, Mensah GA | Initial Clinical Encounter with the Patient with Established Hypertension | Cardiology Clinics | 2010 Nov;28(4):587-95 | Provides and overview of steps providers should take in the initial evluation of the hypertensive patient including highlighting the importance of health literacy assessment. | HL and measurement | 2010 |
| Schnipper JL, et al. | Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study | Circ Cardiovasc Qual Outcomes | 2010 Mar;3(2):212-9 | Design of an RCT of a pharmacist intervention at 2 academic medical centers aimed at reducing serious medication errors. | HL intervenitons | 2010 |
| VanGeest JB, et al. | Patients' perceptions of screening for health literacy: reactions to the Newest Vital Sign | J Health Commun | 2010 Jun;15(4):402-12 | Report of patient's reactions to administration of the Newest Vital Sign in a primary care setting by literacy status. | HL and measurement | 2010 |
| Wolf MS, et al. | In search of 'low health literacy': threshold vs. gradient effect of literacy on health status and mortality | Soc Sci Med | 2010 May;70(9):1335-41 | Explores the relationship between health literacy, physical and mental health, and all-cause mortality with emphasis on a threshold vs. gradient effect of health literacy on outcomes. | HL and outcomes | 2010 |
| Wynia MK, et al. | Validation of an organizational communication climate assessment toolkit | Am J Med Qual | 2010 Nov-Dec;25(6):436-43 | Prospective multisite validation study of an organizational communication climate assessment tool in 13 geographically and ethnically diverse heath care organizations | HL intervenitons | 2010 |
| Author | Title | Journal | Citation | Brief synopsis | Category | Year |
| Berkman ND, et al. | Low health literacy and health outcomes: an updated systematic review | Ann Intern Med | 2011 Jul 19;155(2):97-107 | HL is associated with differential use of certain health care services, poor medication and health message comprehension, and among the elderly, poorer overall health status and higher mortality. There is emerging evidence that low HL may explain racial disparities | HL and outcomes/systematic review | 2011 |
| Clark B | Using law to fight a silent epidemic: the role of health literacy in health care acces, quality, & cost | Ann Health Law | 2011 Summer;20(2):253-327 | Discussion of the role of law and policy in bringing about necessary health literacy reform and its potential impact on healthcare quality and cost. | HL and policy | 2011 |
| Coleman C | Teaching health care professionals about health literacy: A review of the literature | Nurs Outlook | 2011 Apr;59(2):70-78 | Review of the literature on teaching health liteacy principles to health professionals and presents a menu of teaching options for health professions educators. | HL and education/review | 2011 |
| DeWalt DA, et al. | Developing and testing the health literacy universal precautions toolkit | Nurs Outlook | 2011 Apr;59(2):85-94 | Review of the development of the Health Literacy Universal Precautions Toolkit (HLUP) geared toward helping practices restructure their delivery of care. | HL tools | 2011 |
| Goldberg JP, Sliwa SA | Communicating actionable nutrition messages: challenges and oportunities | Proc Nutr Soc | 2011 Feb;70(1):26-37 | Review of the challenges of communicating accurate and actionable health behavior information given the evolution of nutrition sciences. | HL and communication | 2011 |
| Herdon JB, et al. | Health Literacy and Emergency Department Outcomes: A Systematic Review | Ann Emerg Med | 2011 Apr;57(4):334-345 | Compilation of articles published 1980-2010 reporting a health literacy measure in ED patients, readability of ED materials, or the association between health literacy and ED-related outcomes. | HL and outcomes/systematic review | 2011 |
| Hendren S, et al. | Patients' barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator | J Natl Med Assoc | 2011 Aug;103(8):701-710 | Secondary analysis of a RCT of a patient navigation intervention in which newly diagnosed breast and colorectal cancer patients were assisnged to a community health worker who collected information of barriers to care. | HL interventions | 2011 |
| Jordan JE, et al. | Critical appraisal of health literacy indices revealed variable underlying constructs, narrow content and psychometric weaknesses | J Clin Epidemiol | 2011 Apr;64(4):366-79 | Critical appraisal of existing health literacy measurement tools developed from 1990-2008. 19 instruments identified; Most rely on testing of individual abiliites, self-report, or use population-based proxy measures. | HL and measurement | 2011 |
| Lora CM, et al. | Progression of CKD in Hispanics: Potential Roles of Health Literacy, Acculturation, and Social Support | Am J Kidney Dis | 2011 Aug;58(2):282-290 | Examination of the potential role of patient-centered characteristics in the disparate development and progression of chronic kidney disease in Hispanics. | HL and disparities | 2011 |
| Marvanova M, et al. | Health literacy and medication understanding among hospitalized adults | J Hosp Med | 2011 Nov;6(9):488-93 | Evaluated the association between health literacy and pre-admission understanding of medications among hospitalized adults. | HL and outcomes | 2011 |
| Osborn CY, et al. | Health literacy explains racial disparities in diabetes medication adherence | J Health Commun | 2011;16 Suppl 3:268-78 | This study explored whether health literacy and/or numeracy were related to diabtes medication adherence and whether either factor explained racial differences in adherence. | HL and disparities | 2011 |
| Sarkar U, et al. | Validation of self-reported health literacy questions among diverse English and Spanish-speaking populations | J Gen Intern Med | 2011 Mar;26(3):265-71 | Validation of simple self-reported health liteacy screening questions for distinguishing patients with adequate and inadequate health literacy. | HL and measurement | 2011 |
| Sheridan SL, et al. | Interventions for individuals with low health literacy: a systematic review | J Health Commun | 2011; 16 Suppl 3:30-54 | Review of the literatrue on interventions designed to mitigate the effects of low health literacy | HL interventions | 2011 |
| Welch VL, et al. | Time, costs, and clinical utilization of screening for health liteacy: a case study using the Newest Vital Sign (NVS) instrument | J Am Board Fam Med | 2011 May-Jun;24(3):281-9 | Cost and utility analysis of using the NVS in a primary care setting | HL measurement | 2011 |
| Zamora H, Clingerman EM | Health literacy among older adults: a systematic literature review | J Gerontol Nurs | 2011 Oct;37(10):41-51 | Review of published literature on the prevalence of health literacy deficits in adults 65 and older | HL and disparities | 2011 |
Important reports for researchers and policy stakeholders