Health Literacy —Identification and Response
SCOTT C. RATZAN
Johnson & Johnson, St.Stevens-Woluwe, Belgium
RUTH M. PARKER
Emory University School of Medicine, Atlanta, Georgia, USA
The term ‘‘health literacy ’’has now
permeated the public health lexicon. The 2006 U.S. National Assessment
of Adult Literacy (NAAL) is the first national survey to employ assessment
tasks conducted specifically to measure the health literacy of adults
living in the United States.These landmark data provide results on the
scope of overall literacy and health literacy in America with a survey
of over 19,000 U.S.adults.
The health literacy scale and health literacy tasks were
guided by the definition of health literacy accepted by the U.S.Institute
of Medicine and Healthy People 2010 that states that health literacy
is: ‘‘The degree to which individuals have the capacity to
obtain, process, and understand basic health information and services
needed to make appropriate health decisions (HHS, 2000; Ratzan &
Parker, 2000; Institute of Medicine, 2004).
Similarly, across the Atlantic, the UK government also
embraced the U.S.definition.The UK Committee on Safety of Medicines
highlighted this concept is a useful tool in identifying problems in
communicating health information and enabling people to use that information
to make health decisions.They further emphasized a component they called
medication literacy, referring to the range of skills needed to access,
understand and act on medicines information (Medicines and Healthcare
Products Regulatory Agency, 2005).
The most recent U.S.study employed a scale of 0 to 500
for overall literacy and for health literacy, and categorized skills
in four performance levels:Below Basic, Basic, Intermediate, and Proficient.
Official reports of the health literacy survey emphasized that the majority
of adults (53%) had Intermediate health literacy. About 22% had Basic
and 14% had Below Basic health literacy.The complete report is available
at http://nces.ed.gov/pubs2006/2006483.pdf. Additionally, adults in
the oldest age group — 65 and older — had lower average health
literacy than adults in younger age groups.Adults ages 25 to 39 had
higher average health literacy than adults in other age groups. A closer
examination of the recent survey reveals that the average score for
health literacy skills (245, Intermediate range)was significantly lower
than the aver- age overall literacy scores (271 and 275, Intermediate
range for document and prose; 283 for quantitative, Intermediate range).
Literacy experts have long noted that lit- eracy skills are context
and content specific, and thus these results should not be surprising.
Someone can have adequate literacy skills in one domain, and significantly
worse skills in another. The literacy demands of health tasks are daunting
for many.
What does it mean that 53% of Americans have Intermediate
health literacy? Over one-third of American adults, over half of the
elderly, three-fourths of high school drop outs and over half of those
with public or no health insurance cannot figure out what time to take
a medication based on label instructions. They also cannot identify
three substances that may interact with an OTC medication to cause a
side effect based on the information on the label, or use a CDC vaccine
information chart to find the appropriate age range for a child to receive
a vaccine. When looking at a graph that relates height and weight to
body mass index, they cannot figure out a healthy weight range.
Over one-third of Americans — or 36% — with
Below Basic or Basic health literacy were less likely than adults with
higher health literacy to get information about health issues from written
sources (newspapers, magazines, books, brochures, or the Internet) and
more likely than adults with higher health literacy to get a lot of
information about health issues from radio and television.This applied
to a variety of health literacy tasks that were organized around three
domains of health and health care information and services:clinical,
prevention, and navigation of the health care system.
So What Does All This Mean?
The results of NAAL have many implications that will be
digested and discussed in various arenas. Unfortunately, results show
that literacy skills of American adults have not changed dramatically
over the last decade. The average skills of U.S. adults are not adequate
for understanding and using the health system. Data from the survey
will provide for a baseline for the Healthy People 2010 objective,
but the survey instrument and data are owned by the U.S. Department
of Education, and there is no ability to access the raw data or survey
questions. Although health literacy has gained growing attention in
the U.S., there is no on-going population based survey of health literacy
within the health sector, and the only population based effort to measure
health literacy captures only individuals ’skills of print materials.
There remains a pressing need to advance population-based measures and
indicators of a health literate public for national and international
use (Parker &Kindig, 2006).
Health literacy skills are needed for dialogue and discussion,
reading health information, interpreting charts, making decisions about
participating in research studies, using medical tools for personal
or family health care —such as a peak flow meter or thermometer
—calculating timing or dosage of medicine, or voting on health
or environment issues (Institute of Medicine, 2004).As the Committee
on Health Literacy of the Institute of Medicine wrote:
Health literacy is of concern to everyone involved in health promotion
and protection, disease prevention and early screening, health care
maintenance, and policy making.
In short, it reminds health communicators of the need
to tailor information, messages and advice while choosing the appropriate
media to enhance quality decision-making.This includes addressing the
challenge to communicate complex health information to different groups
in the population, addressing the comprehension of risk, benefits and
safety while providing practical support for those of all literacy levels.
The ideas for addressing limited health literacy —
perhaps reframing this as a health competence all should aspire to —
requires health communicators to employ all the available means of persuasion
to support the provision of the right information available at the right
time with the support people need to use it to make appropriate health
decisions.
This will require a Health Information strategy to address
disparities, disadvantaged groups, linguistic and cultural sensitivity
and other areas. Further, a commitment to be innovative — promulgating
a policy of empowerment as a way of enabling people to access and use
health information will be a challenge for all stakeholders in society
(Parker, Ratzan, & Lurie, 2003).
The articles in the Journal continue to challenge us to
extract the ideal evidence base to advance health prudently.In our quest
for optimal influence, it is incumbent upon all of us to consider the
health literacy level in the development of health campaigns, messages,
health professional relationships and in the communication of health
policy and moral imperatives of the 21st Century.
References
Institute of Medicine.(2004). Health Literacy:A Prescription
to End Confusion. Washington, DC: Institute of Medicine, Board on
Neuroscience and Behavioral Health, Committee on Health Literacy.
Medicines and Healthcare Products Regulatory Agency.(2005). Always
Read the Leaflet — Getting the Best Information with Every Medicine.
Report of the Committee on Safety and Medicines Working Group on Patient
Information.London: The Stationery Office, 2005.
Parker, R.M.&Kindig, D.A. (2006). Beyond the Institute of Medicine
Health Literacy Report: Are the Recommendations Being Taken Seriously.
Journal of General Internal Medicine, 21 (8), 891.
Parker, R.M., Ratzan, S.C., & Lurie, N. 2003. Health literacy: A
policy challenge for advancing high-quality health care. Health Affairs,
22(4), 147.
Ratzan, S.C.& Parker, R.M. (2000). Introduction. In C.R. Selden,
M. Zorn, S.C. Ratzan, R.M. Parker, (Eds.), National library of medicine
current bibliographies in medicine: Health literacy. NLM Pub.No.CBM
2000-1. Bethesda, MD:National Institutes of Health, U.S.Department of
Health and Human Services.
U.S. Department of Health and Human Services (HHS). (2000). Healthy
People 2010: Understanding and Improving Health. Washington, D.C.:
Author.
_____
Scott C. Ratzan MD, MPA, MA is Editor-in-Chief of the Journal of
Health Communication: International Perspectives. He also is Vice
President, Government Affairs, Europe for Johnson & Johnson with
academic appointments at George Washington University School of Public
Health, Tufts University School of Medicine, Yale University School
of Medicine, The College of Europe, and University of Cambridge.
