comm 3201 - the abcs of health literacy

Downloaded from http://journals.lww.com/familyandcommunityhealth by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/17/2022 LWW/FCH lwwj138-07 August 23, 2005 20:8 Char Count= 0 Fam Community Health Vol. 28, No. 4, pp. 351–357 c ⃝ 2005 Lippincott Williams & Wilkins, Inc. The ABCs of Health Literacy Virginia S. Mika, MPH; Patricia J. Kelly, PhD; Michelle A. Price, MEd; Maria Franquiz, PhD; Roberto Villarreal, MD, MPH A significant portion of the US population has serious problems with both literacy and understand- ing how to effectively use and understand health-related information. An understanding of the breadth and significance of this problem and its impact on health outcomes is now clear. Interven- tions and strategies for effectively working with patients with limited literacy must be developed and evaluated. An agenda for medical and public health workers, health educators, and researchers is suggested. Key words: health education , health literacy , patient education D ESPITE almost one century of compul- sory education for children aged 6 to 14, many adults in the United States have sig- nificant problems with literacy. The National Adult Literacy Survey (NALS), conducted by the US Department of Education, showed that 45% of the adult population in the United States has limited literacy skills and almost one quarter is functionally illiterate. 1 Illiter- acy statistics translate into millions of peo- ple challenged in their daily lives, especially when addressing new situations or negotiat- ing the complex institutions necessary to re- ceive even minimal healthcare services. The NALS finding that 75% of respondents with a chronic disease also had limited literacy skills is directly relevant to healthcare providers, health educators, and policy analysts. 1 From South Texas Health Research Center, University of Texas Health Science Center (Mss Mika and Dr Villarreal); Department of Surgery, University of Texas (Mss Price) and Bilingual Bicultural Studies, University of Texas (Dr Frenquiz), San Antonio; and the School of Nursing/Medicine, University of Missouri – Kansas City (Dr Kelly). The authors thank Leah Trevino for her help in format- ting the document and verifying references. Corresponding author: Virginia S. Mika, MPH, South Texas Health Research Center, University of Texas Health Science Center, 7703 Floyd Curl (MSC 7791), San Antonio, TX 78229 (e-mail: seguin@uthscsa.edu). People with limited literacy skills have problems accessing services and have worse health outcomes than patients with full literacy. 2 The US healthcare system is intri- cate, disjointed, and specialized, and patients must be able to access information, get health services, communicate with healthcare pro- fessionals about their illness, sign consent forms, understand treatment options, and fol- low through on treatment plans. 3 Patients who have low literacy, do not speak English, or have limited English fluency are challenged as they access health services for themselves and their families. A public health approach to health liter- acy involves 4 steps: surveillance (what is the problem?), risk factor identification (what is the cause?), intervention evaluation (what works?), and implementation (how do we do it?). Knowledge about the 2 initial steps is available. We know that poor health literacy exists and the extent that it affects people. We know that there are several reasons for it, such as lack of education and high reading- level expectations in the medical setting. It is important to find more information about the “what” and “how” of addressing health liter- acy problems to affect current level of people with health disparities in the United States. This article reviews definitions of health lit- eracy, the association between health literacy and health outcomes, and the interventions 351

LWW/FCH lwwj138-07 August 23, 2005 20:8 Char Count= 0 352 F AMILY & C OMMUNITY H EALTH /O CTOBER –D ECEMBER 2005 that have been used to improve health liter- acy, and offers an interdisciplinary model for improving health literacy. HEALTH LITERACY DEFINITIONS The dictionary definition of literacy is “the ability to read and write” and the “quality of being knowledgeable in a particular subject or field.” 4 Health literacy is considered a vari- ant of functional literacy. For example, the Center for Health Care Strategies’ 5(p1) defini- tion of health literacy is, “the ability to read, understand and act on health information.” Their inclusion of the concepts of understand- ing and action significantly extends the defini- tion. Healthy People 2010 , in its public health goals for the nation, defines health literacy even more comprehensively as “the degree to which individuals have the capacity to obtain, process and understand basic health informa- tion and services needed to make appropriate health decisions.” 6(pp11–19) This definition also includes numeracy, the skill to use basic nu- merical information, such as “Let’s set a goal of losing 10% of your body weight,” or “Give 1 / 2 teaspoon 4 times a day.”Because this defini- tion includes the individual ability to acquire both health information and services, some critics find it overly broad, suggesting that ac- quisition of services is more a function of re- sources than of literacy. 7 The World Health Organization (WHO) has proposed an even broader definition of health literacy: Health literacy represents the cognitive and social skills which determine the motivation and abil- ity of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy means more than being able to read pamphlets and success- fully make appointments. By improving people’s access to health information and their capacity to use it effectively, health literacy is critical to empowerment. 8(p357) In addition to information, access to health resources is explicit in this definition. How- ever, this definition emphasizes that it is not enough for people to have information. The relationship between health literacy and em- powerment is explicit: people must also have access to healthcare. They must move from passive subjects to active participants in their healthcare and effectively use the healthcare system. The WHO definition moves health educators beyond providing information to also initiating the process of empowerment. Kickbusch 9 proposes the WHO’s definition of health literacy as a working goal for all educa- tors because it encompasses the concept of “potential,”thus including capability and mo- tivation into preventive and health promotion behaviors. The continuum of health literacy skills pro- posed by Nutbeam 10 can be useful for im- plementing literacy programs and moving to- ward the personal empowerment goals of the WHO definition. This continuum of health lit- eracy begins with functional health literacy , moves to communicative/interactive health literacy , and then to critical health literacy . Functional health literacy includes the ba- sic skills needed to navigate the health sys- tem. Communicative/interactive health liter- acy combines functional health literacy with the ability to apply new information to dif- ferent situations. Critical health literacy com- bines functional health literacy with both interactive health literacy and personal and community empowerment. Cancer screening provides an example of the continuum. People must have knowledge about what screening tests are important, why and when in their lives the tests should be performed, and where they are available. However, they also need access to the ser- vices, the ability and the means to make an appointment, arrive at the appointment, and follow through on any instructions. If the ser- vices are not available, people ideally should be able to voice the need for more screening services. Health literacy classes might begin with interactive materials that provide infor- mation that teaches functional health literacy, and then work with that knowledge through a visit to a clinic and a walk-through of the appointment, testing, and follow-up process. Finally, the class might provide specific strate- gies for increasing or improving services, such