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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.1
Health literacy is generally agreed upon as the means to find, understand, analyze and use information to make better decisions about health and to ultimately reduce inequities in health.2 The definitions used by Healthy People 20103 and the Institute of Medicine (IOM)4 are similar: ‘‘The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.’’ These definitions present health literacy as a set of individual capacities that allow the person to acquire and use new information.5 Health literacy is not determined solely by an individual’s capacity to read, understand, process and act on health information.6 It is the product of individuals’ capacities and the demands the health information places on individuals to decode, interpret and assimilate health messages. Furthermore, health literacy is not constant, but is a dynamic state that may change with the situation.6
Health Literacy and the General Population
According to the National Assessment of Adult Literacy, only 12 percent of adults have “proficient” health literacy. Therefore, approximately nine out of 10 adults may lack the skills needed to manage their health and prevent disease. Fourteen percent of adults (30 million people) have “below basic” health literacy. These adults were more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with proficient health literacy.7
The individuals who risk low health literacy are older adults, racial and ethnic minorities, people with less than a high school degree or GED certificate, people with low income levels, non-native speakers of English, and people with compromised health status.8
Why Is Health Literacy Important for Dental Patients?
Limited health literacy has been associated with a range of adverse health outcomes, including decreased use of preventive health services, poorer disease-specific outcomes for certain chronic conditions, and increased risk of hospitalization and mortality.9 Literacy may affect the cost of health care because of its effect on the level and/or effectiveness of health care services used and the cost of interventions.10 Low literacy is a pervasive and under-recognized problem in health care. Affected patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms or health surveys.11
Health information is an important resource for patients trying to understand and engage in the management of their health conditions.12 People typically initiate medical care when they have a medical need. However, people with limited health literacy may delay seeking care because they do not understand prevention and/or know the signs and symptoms of disease that should motivate people to action.13 The health literacy literature has documented that patients with limited literacy may avoid health care settings for fear of being embarrassed,14 which results in decreased health care utilization. As much of routine prevention depends on patients coming in for primary care, it is not surprising that people with limited health literacy receive less primary prevention.15 Literacy skills may also have a strong impact on a patient’s awareness of the importance of oral health and its relation to general health and knowledge of specific health-promoting behaviors.16
Health Literacy Assessment
Historically, the average reading level of patient materials related to health care has been 11th to 14th grade, but the average person’s reading level is much lower. Additionally, even patients who read at the college level have been found to prefer medical information written at the seventh-grade level.17 For written educational material to be effective, the target audience must be able to read and understand it. Health care providers must evaluate the readability of written materials. Several approaches have been developed to measure “readability.” Readability assessment often uses formulas such as the Fry graph,18 the Flesch-Kincaid formula (Microscoft Word®) or others that take into account length of sentences and the number of syllables in the words.10
Evidence indicating that clinicians tend to overestimate their patients’ reading abilities argues for the use of an assessment tool.19 Several instruments are currently available to measure an individual’s literacy level. The instruments used in the health care setting have measured the patient’s ability to read and, in some cases, to use numbers. Two of these instruments that focus on health are the Rapid Estimate of Adult Literacy in Medicine (REALM);20 TOHFLA is the Test of Functional Health Literacy in Adults;21 and the Newest Vital Sign (NVS), a bilingual (English and Spanish) screening tool that identifies patients at risk for low health literacy. The test result provides information about the patient that will allow providers to appropriately adapt their communication practices in an effort to achieve better health outcomes.22 Another health literacy tool is the Adult Basic Learning Examination (ABLE), which can be used to evaluate comprehension of written text (prose literacy), capacity to use and understand tables and forms (document literacy), and arithmetic skills (numeracy).23
Literacy assessment should therefore go hand-in-hand with assessments of culture and language24 to better meet the needs of patients. Health care professionals are encouraged to learn about patients’ health beliefs by asking, for example, the Kleinman Questions:25 “What do you think has caused the illness?” “What do you think the illness does?” “How does it work?” “What kind of treatment do you think you should receive?” “What are the most important results you hope you receive from this treatment?” It is through this cross-cultural exploration that the clinician and patient reach agreement about the appropriate course of action.24 Clinicians may choose to adopt less formal assessment strategies, such as asking a single question; for example, “How confident are you filling out medical forms by yourself?”26 Watching out for low-literacy red flags, such as when a patient says, “I forgot my reading glasses,”27 and letting patients use their own words to describe their culture and language rather than using pre-established categories (Table 1).28
How Can Health Professionals Assist Their Patients?
Too often, there exists a chasm between what professionals know and what consumers and patients understand. Basic literacy is fundamental to the success of each interaction between health care professionals and patients—every prescription, every treatment and every recovery. Basic health literacy is fundamental to putting sound public health guidance into practice and helping people follow recommendations.29
Providers tend to be unaware of their patients’ limited literacy.30 Clinicians need information about the level of oral and written English proficiency to inform their decisions about using interpreter services and translated materials.24 However, a sensitive approach must be applied during the collection of the patient’s literacy, cultural and language data, in order to increase the patient’s comfort level and minimize any embarrassment due to limited English proficiency or literacy.31 To do so, the health care professional will need to learn how to communicate in plain terms to confirm important items in a patient’s history and evaluate patient comprehension of important action items.32 An option is not to screen patients but to take “universal precautions” to avoid miscommunication,6,33 as it is better to assume that all patients experience some degree of difficulty in understanding health information.
Several strategies to assist in achieving clear communication with patients involve limiting the number of messages delivered at one time; using simplified, jargon-free language; and using the teach-back or teach-to-goal method of having patients explain what they have been told and repeating the information until it is clear the patient understands. Although these approaches serve culturally diverse and limited English proficiency patients as well, the emphasis is on improving the way clinicians give instructions. Health care organizations need to use the full array of health care professionals to reinforce and augment clinician-patient communications.24
The health care team should include receptionists as the first people seen by patients; receptionists can allay confusion, fear, or uncertainty, as well as assist in completing paperwork and arrange for interpreters.34 In addition, receptionists can address any concerns after the clinical treatment, which can help ensure the patient understands the post-treatment self-care instructions.
For health care professionals to be prepared with skills required to assist their patients, it is essential that they receive health literacy training. Training could include how to collect assessment data, when and how to use interpreters, and how to engage in cross-cultural and clear communication.24 Without better tools and provider training, screening alone is unlikely to be beneficial.6
Conclusion
Effective patient-provider interactions are fundamental to achieving successful clinical outcomes. Assuring that interactions are effective with diverse patients requires that clinicians learn about their patients’ health literacy, culture and language, and use that information to improve communication and self-management support.24 Clinicians and health care staff have an important role to play, but the responsibility for achieving real progress for patients facing challenges related to literacy, culture and language must extend to organizations that support them. We are still at an early stage of understanding the scope of literacy, cultural and language challenges patients face and developing remedies to address them. The relationship between health literacy and health disparities is only beginning to be explored.35
Su-yan L. Barrow, RDH, MA, MPH
Senior Lecturer
Bachelor Oral Health Program
Melbourne Dental School
The University of Melbourne
Australia
Health Literacy Resources
Health Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF, April 2010. Rockville, Md.: Agency for Healthcare Research and Quality. Available at: www.ahrq.gov/qual/literacy/index.html
Toolkit for Making Written Material Clear and Effective. Centers for Medicare & :Medicaid Services. U.S. Health and Human Services. Available at: www.cms.gov/WrittenMaterialsToolkit/
Health Literacy and Cultural Competency. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ). Available at: http://www.ahrq.gov/browse/hlitix.htm
Office of Disease Prevention and Health Promotion. U.S. Department of Health and Human Services Health Communication, Health Literacy and e-Health. Available at: www.health.gov/communication/Default.asp
The Council of State Governments: Health Literacy Tool Kit: A Comprehensive Resource for Policy-Makers. Available at: www.csg.org/knowledgecenter/docs/ToolKit03HealthLiteracy.pdf
HHS Quick Guide to Health Literacy. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Available at: www.health.gov/communication/literacy/quickguide/about.htm
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, D.C.: Available at: www.health.gov/healthliteracyonline/index.htm
America’s Health Literacy: Why We Need Accessible Health Information. An Issue Brief from the U.S. Department of Health and Human Services. Available at: www.health.gov/communication/literacy/issuebrief/
Online Training Courses
Health Communication Activities. Office of Disease Prevention and Health Promotion. U.S. Department of Health and Human Services. Available at: www.health.gov/communication/literacy/powerpoint/default.htm
CDC: Health Literacy for Public Health Professionals. Available at: www2a.cdc.gov/TCEOnline/registration/detailpage.asp?res_id=2074
New York New Jersey Public Health Training Center: Health Literacy & Public Health: Strategies for Addressing Low Health Literacy. Available at: www.nynj-phtc.org/pages/catalog/phlit02/
>Health Literacy, New Field New Opportunities. World Education National Network of Libraries Medicine New England Region (NNLM NE). Available at: www.healthliteracy.worlded.org/docs/tutorial/SWF/flashcheck/main.htm
Improving Health Literacy: Training Resources. University of Michigan Library. Available at: guides.lib.umich.edu/healthliteracyU.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, D.C.: Available at: www.health.gov/healthliteracyonline/index.htm
America’s Health Literacy: Why We Need Accessible Health Information. An Issue Brief from the U.S. Department of Health and Human Services. Available at: www.health.gov/communication/literacy/issuebrief/
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