Objective 11-2. Improvement of Health
Rima Rudd, Sc.D., Harvard University
Small Group Participants
Marin Allen, National Institute on Deafness and Other Communication
Disorders, National Institutes of Health, U.S. Department of Health
and Human Services
Elaine Arkin, Consultant
Terry Davis, Louisiana State University School of Medicine
Sue Martone, Office of Disease Prevention and Health Promotion,
U.S. Department of Health and Human Services
Ron Pugsley, U.S. Department of Education
Joanne Schwartzberg, American Medical Association
Yvonne Thayer, Virginia Department of Education
Note taker: Stephanie Smith, Johns Hopkins Bloomberg School of
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Text of Objective
Improve the health literacy of persons with inadequate or marginal
The objective is intended to represent an important aspect of health
literacy but cannot encompass all issues raised by and related to
the subject. The objective means to serve the specific purpose of
providing data on progress for health literacy improvement and the
general purpose of stimulating discussion about a wide range of
health literacy issues.
The objective is developmental and will become measurable with data
from the Health Literacy Component (HLC) of the 2003 National Assessment
of Adult Literacy (NAAL). The NAAL is administered by the National
Center for Education Statistics (NCES), U.S. Department of Education.
The NAAL is the third literacy assessment of American adults. The
first assessment of adult literacy, the Young Adult Literacy Survey,
was administered in 1985, followed by the National Adult Literacy
Survey in 1992. Data from the NAAL, which will be available in late
2004, will be used to establish a baseline and target for the objective
and to complete the Healthy People 2010 data template.
The HLC, which is the first-ever national assessment of health
literacy, was jointly developed by the U.S. Department of Health
and Human Services (HHS) and the U.S. Department of Education. As
the lead agency for the health literacy objective, the Office of
Disease Prevention and Health Promotion (ODPHP), HHS, organized
a multiagency collaboration to identify stimulus materials and items
for the HLC. In addition, ODPHP consulted with established health
literacy experts outside the Federal Government about the appropriateness
of the selected stimulus materials and items. NCES has overall responsibility
to harmonize the HLC with the NAAL.
Currently, the NAAL is scheduled to be fielded only once between
2000 and 2010. If additional measures for the decade are required,
either the NAAL will need to be re-administered or a different instrument
will need to be identified.
The NAAL and its predecessors assess functional literacythat
is, people's ability to apply reading skills to everyday tasks involving
prose, documents, and numbers. The mundane tasks include reading
a newspaper, filling out an employment form, reading a bus schedule,
adding a bank account entry, or computing a tip in a restaurant.
Skills are measured against commonly used materials in society.
The HLC of the 2003 NAAL will similarly focus on functional literacy;
health-related activities, part of adults' typical experiences,
will be incorporated into the functional literacy assessments. The
NAAL will provide data on the percentage of persons with inadequate
or marginal literacy skills who can perform specific health literacy
The HLC includes three types of health information and services:
clinical, prevention, and navigation of the healthcare system. They
are key types of health and healthcare information and services
that the general population in the United States might be likely
to encounter. The stimulus materials and the associated items in
the HLC were selected to fit these types.
- The clinical type includes those activities associated
with interactions between the healthcare provider and the patient,
clinical encounters, diagnosis and treatment of illness, and medication.
Examples include filling out a patient information form for an
office visit, understanding dosing instructions for medication,
understanding steps for the self-management of acute and chronic
illness, following a healthcare provider's recommendation for
a diagnostic test, and providing accurate information in a medical
history, either verbal or written.
- The prevention type includes those activities associated
with maintaining and improving health, preventing disease, intervening
early in emerging health problems, and engaging in self-care and
healthy behaviors. Examples include following guidelines for age-appropriate
preventive health services, identifying signs and symptoms of
health problems that should be addressed with a health professional,
and changing eating and exercise habits to decrease risks for
the development of serious illness.
- The navigation of the healthcare system type includes
those activities related to understanding how the healthcare system
works and individual rights and responsibilities. Navigation requires
being familiar with the vocabulary, concepts, and processes needed
to use the healthcare system. Examples include understanding covered
and noncovered benefits for health insurance plans, determining
eligibility for public assistance programs, and being able to
give informed consent for a healthcare service.
The question has been raised as to whether the objective should
be reworded as a population objective so that data on the health
literacy skills of the entire U.S. population, instead of only those
with marginal or inadequate literacy skills, would be measured and
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Issues Pertaining to Measurement
The objective was formulated as an assessment of individuals' health
literacy skills. Individuals' skills, however, are only one part
of the complex health literacy phenomenon. Healthcare providers,
creators of health information and education materials, and the
healthcare and public health systems bear a large part of the responsibility
for having created materials, ways of communicating, and systems
that are far too technical and complicated to meet the needs of
the vast majority of the populations they serve. Consequently, the
burden for change, at least in the short term, lies with healthcare
providers, public health professionals, and healthcare and public
health systems, in partnership with adult literacy programs, to
reach those with limited literacy. Long-term, educational programming
can work to raise the general literacy levels of the population
and to incorporate training in navigating health systems. Any assessment
of individuals' health literacy skills, therefore, must be interpreted
in light of the systemic factors that strongly influence individuals'
capacity to demonstrate health literacy.
Shame associated with poor literacy skills may be an important
factor in obtaining an accurate account of the population's health
literacy skills. Individuals with poor literacy skills are often
very uncomfortable that they cannot read well, and they develop
strategies to compensate. Depending on the method of assessment,
individuals may use these strategies to appear to have higher literacy
skills than they actually do.
The assessment of health literacy in a population is also influenced
by the reading levels of health materials, the skills of individuals,
the communication abilities of health professionals, and the organization
of delivery systems for health information and services. Although
the literacy and verbal skills of individuals are of critical importance,
so too are the demands made by the health materials themselves,
the communication skills of those in the health field, and the complicated
nature of the healthcare and public health systems. The dimensions
of these additional factors are briefly examined in the following.
- Functional literacy measures incorporating currently
available health materials do not offer a sufficient assessment
of health literacy.
The NAAL's health literacy measures will be based on common, widely
used health information materials. However, three decades of studies
published in medical and public health journals indicate that
most health materials fall into reading-level ranges requiring
high school, college, or graduate degrees (Rudd, Moeykens, and
Colton, 1999) and often contain jargon and scientific terms rather
than everyday or plain language. Additional measures will be needed
to monitor improvements in the format, content, and structure
of health materials prepared for the public. The current reading
level and demands of health-related materials should be compared
with rewritten and newly formatted materials over time.
Most currently used assessment tools are designed for examinations
of prose materials presented in sentence and paragraph format.
However, a good deal of health-related print materials are prepared
in document format using phrases, lists, and bullets rather than
full sentences and paragraphs. Published studies of health materials
suggest that health researchers have not applied the document
assessment tool developed by Mosenthal and Kirsch (1998).
Many critical health-related materials are written in open-entry
format (e.g., medical history forms, insurance forms, in-take
forms, research queries). The field would benefit from the development
of assessment measures and open-entry format for health documents.
- Health literacy assessments are too narrowly focused
on the ability of individuals to use the written word.
Linguists and reading experts have established links among a variety
of skills such as reading, verbal presentation, and oral comprehension
(Snow, 1991; Cunningham and Stanovich, 1998). In medical care
settings, patients are expected to offer health histories and
descriptions of symptoms and to listen to and comprehend verbal
instructions. Adults are expected to understand, navigate, and
meet the demands of bureaucracies and institutions to access entitlement
programs and services. In the community, adults are encouraged
to be aware of and act on health-related news and announcements.
Each of these settings presents its own set of health literacy
demands and requires different mixes of skills, which should be
Health communications routinely include written as well as audio
and video materials, messages on radio and television, and verbal
presentation for information, diagnosis, and consent. An expanded
examination of health-related materials must include information
presented on tapes, videos, compact discs, and the Web (Stauffer
et al., 1978; D'Alessandro et al., 2001). Research is also needed
to assess how easily these different materials are used by low-literate
populations and how well they can understand messages in these
- Health professionals' skills and the burdens of medical
jargon, technical language, and complicated bureaucratic processes
affect health literacy.
Patients' ability to understand health and medical issues and
directions is related to the clarity of the communication. Consideration
needs to be given to the verbal as well as written communication
skills of medical and public health practitioners. Factors of
class, age, race, ethnicity, country of origin, gender, geography,
health status, and (because family members may be part of the
healthcare episode) family dynamics and roles may affect how patients
interact with their healthcare providers and their ability to
take actions to improve their health.
Official documents, including informed consent forms, social services
forms, and public health and medical instructions, as well as
health information materials often use jargon and technical language
that make them unnecessarily difficult to use. Reductions in the
assessed reading levels of forms, instructions, and informational
materials are insufficient. The amount of jargon and technical
language could be reduced with greater adoption of plain language.
- Special consideration should be given to the conduct
of health literacy assessments of persons with limited proficiency
Assessments of health literacy for those with limited proficiency
in English have some special challenges. Limited proficiency in
English may make it difficult if not impossible for individuals
to complete a health literacy assessment in English. Translation
of the assessment into native languages is often not an adequate
solution. Translators are typically from a different social class
and speak different dialects or even languages than poor and working
class individuals who are most frequently those with limited proficiency
in English. In addition, limited proficiency in English is itself
a barrier to accessing many types of health information and services,
and, consequently, individuals may not have enough experience
with a broad spectrum of health information and services to complete
a standard health literacy assessment in English or their native
language. Translation also is not an adequate solution because
individuals may have limited literacy and oral communication skills
in their native languages. Even translated materials may be too
complex in presentation, writing style, and vocabulary for individuals
with low levels of functional literacy in both English and their
- Culturally based understandings of health and health
care are relevant to the conduct of functional health literacy
In addition to the assessment challenges presented by limited
proficiency in English, cultural and linguistic considerations
must be accounted for. Understanding the relationships among culture,
language, and health is critical for the design and conduct of
health literacy assessments in a multicultural society. According
to the Office of Minority Health, HHS, culture and language may
affect health, healing, and wellness belief systems; how illness,
disease, and their causes are perceived; the behaviors of individuals
seeking health care; and the delivery of healthcare services and
provider behavior. Even if assessments of health literacy are
conducted in the appropriate language for a specific population,
instruments that are not sufficiently sensitive to cultural and
linguistic differences may mischaracterize a population's ability
to comprehend and act on critical health information and service
- Systemic factors affect individuals' health literacy
Healthcare and public health delivery systems are complicated
bureaucracies with many procedures and processes associated with
obtaining health care and public health services. Patients, clients,
and their family members are typically unfamiliar with these systems
and the associated jargon. Even highly motivated and educated
individuals may find the systems too complicated to understand,
especially when persons are made more vulnerable by poor health.
Consequently, assessments of individuals' health literacy skills
may actually reflect systemic complexity rather than individual
skill levels. Studies of the complexity of healthcare and public
health systems need to supplement and inform any assessments of
individuals' health literacy skills.
Definition of Terms
Measures of health literacy must be based on clear articulation
of terms, a selection of representative health-related activities,
and a delineation of needed skills.
- Functional literacy. The National Literacy
Act of 1991 (National Institute for Literacy, 1991) offered the
following definition of literacy:
For purposes of this Act, the term "literacy" means
an individual's ability to read, write, and speak in English,
and compute and solve problems at levels of proficiency necessary
to function on the job and in society, to achieve one's goals,
and develop one's knowledge and potential.
- Health literacy. Healthy People 2010
(HHS, 2000) cites and applies the following definition of health
The degree to which individuals have the capacity to obtain,
process, and understand basic health information and services
needed to make appropriate health decisions.
Various other definitions of health literacy have been proposed.
Researchers note that health literacy must be understood as a dynamic
characteristic that ebbs and flows in response to other factors,
including health materials, communication skills of those delivering
the message, changes in life experience, education, and the presence
of comorbid conditions such as depression, mental illness, and functional
status. Functional health literacy must also be understood in terms
of having multiple antecedents or confounders. They include not
only obvious factors such as educational attainment but also factors
such as dyslexia, social deprivation, and mental illness.
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State of Knowledge About
Issues Represented by the Objective
Education, traditionally used as a marker of socioeconomic status
in the United States, has long been linked to health outcomes (Pamuk
et al., 1998). Until recently, few inquiries had looked more closely
at factors associated with education such as literacy. Health literacy,
now squarely on the health agenda, emerged during the 1990s. Now,
evidence is accumulating that persons with limited literacy are
at risk for poor health outcomes.
Most medical and public health publications focused on literacy
in the United States comprised findings from studies examining the
reading level of print materials developed for patient education
and for procedures and processes in healthcare settings (Rudd and
Colton, 1998). Overall, researchers firmly established that the
literacy demands of health materials exceeded the reading abilities
of the average U.S. adult. Unique among the early health literature
was a review article on health literacy in the 1989 Annual Review
of Public Health, highlighting links between literacy and health
outcomes. Based on research conducted in developing countries, Gross
and Auffrey (1989) presented a body of evidence that the health
of children was related to the literacy of their mothers. The findings
noted in the annual review and the subsequent analysis of the National
Adult Literacy Survey in 1993 spurred interest in the links between
literacy and health outcomes in the United States.
The use of reading assessment tools in clinical settings and the
development and use of the health-specific Rapid Estimate of Adult
Literacy Measure (REALM) (Davis et al., 1991) and the Test of Functional
Health Literacy in Adults (TOFHLA) (Parker et al., 1995) provided
tools for health researchers interested in exploring these links.
First, researchers were able to specifically compare the reading
level of the health materials with the reading ability of members
of the intended audience. Initial studies highlighted patients'
difficulty in reading and understanding screening materials, appointment
slips, directions for medicines, and informed consent documents.
These studies more firmly established the disparities between the
demand of health materials and the abilities of the people for whom
the materials were developed, which had been noted in the publications
of the 1970s and 1980s. In addition, researchers were now able to
use these tools to examine health outcomes among patients with differing
A sparse but growing body of literature published during the mid-
to late 1990s includes studies focused on the differences between
various health-related measures in adults with limited literacy
skills and those with literacy skills at or above the ninth grade
level. For example, patients with low literacy report poorer health
than do patients with high literacy (Weiss et al., 1992). They are
less likely to make use of screening (Davis, Berkel, Arnold, et
al., 1998), are more likely to present in later stages of disease
(Bennet et al., 1998), and are more likely to be hospitalized (Baker
et al., 1998). Numerous studies (Rudd et al., 2000) show that low
literacy has been associated with poor health, poor understanding
of treatment, greater use of health services, and low adherence
to treatment regimens (a selection of studies are noted in the references).
Finally, at the end of the decade, the American Medical Association's
Ad Hoc Committee on Health Literacy for the Council on Scientific
Affairs (1999) published a white paper reflecting medicine's growing
recognition of literacy and its role in health. An increasing number
of national and international meetings on health literacy highlighted
a growing recognition of the importance of literacy to those in
the health fields.
Overall, the interest in health literacy has focused more on healthcare
settings than on health actions and decisions at home, in the community,
in the workplace, or in the policy arena. The published literature
offers little evidence that public health practitioners have adequately
met the challenges of limited literacy skills among populations
of interest. The relationship between literacy and health promotion,
health protection, and disease prevention activities has not been
fully explored. For example, only one or two studies and reports
have examined literacy and its relation to the purchase and use
of food and home products, decisions involved in insurance and service
delivery care options, or action related to occupational health
and safety. Literacy links to health outcomes related to the care
of children or elders, participation in community-based health action
groups, or policy decisions have not been established. Little is
known about how many individuals are lost to or excluded from health-related
public assistance programs because of their limited literacy skills
or because of inappropriately constructed documents, forms, and
demands. Furthermore, few studies have examined health literacy
links from the perspective of social justice and links to human
rights; however, several studies have examined the informed consent
process over time (Raich et al., 2001).
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Organizations currently working on health literacy or related issues
include, but are not limited to, the following:
- Academy of General Dentistry
- Adult Literacy Media Alliance
- AMC Cancer Research Project
- American Association of Medical Colleges
- American Hospital Association
- American Medical Association
- American Medical Association Foundation
- American Nurses Association
- American Occupational Association
- American Pharmaceutical Association
- American Physical Therapy Association
- American Public Health Association
- Center for Medicare Education
- Hudson River Center for Program Development
- International Literacy Network
- Joint Commission on Accreditation of Healthcare Organizations
- Maine AHEC Health Literacy Center, University of New England
- Managed Care Consumer Assistance Program, Community Service
Society of New York
- Massachusetts Department of Education: Operation Bootstrap,
The Literacy Project, Read, Write, Now
- Moffitt Cancer Center and Research Institute
- National Academy on an Aging Society
- National Association of Broadcasters
- National Association of Science Writers
- National Cancer Institute
- National Center for the Study of Adult Learning and Literacy
- National Committee for Quality Assurance
- National Institute for Literacy
- NVision (new adult literacy campaign)
- Society of Professional Journalists
- State Adult Education Programs Integrating Health Literacy (California,
Georgia, Massachusetts, New Hampshire, Pennsylvania, Vermont,
- State Health Literacy Coalitions (California, Maine, Massachusetts,
New Hampshire, Ohio, Pennsylvania, and South Carolina)
- The Robert Wood Johnson Foundation
- U.S. Department of Defense, Tricare
- U.S. Department of Education
- U.S. Department of Health and Human Services (including Agency
for Healthcare Research and Quality, Centers for Disease Control
and Prevention, Centers for Medicare & Medicaid Services,
Health Resources and Services Administration, Indian Health Service,
National Institutes of Health, and Office of Disease Prevention
and Health Promotion)
- U.S. Department of Veterans Affairs, Veterans Health Administration
Potential: Additional stakeholders should be identified;
they would include agencies and organizations addressing health
disparities as well as labor, industry, and environmental organizations.
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Status of Selected Stakeholder
A number of States have recently launched health literacy initiatives
(Matthews and Sewell, 2002). Presentations at national organizations
have increased. To date, however, few stakeholders have actively
funded health literacy research or implementation initiatives. Several
Web sites, conference reports, and other publications have reported
on the status of health literacy-related activities. For example:
- Health and Literacy Compendium, World Education, and National
Institute for Literacy
- Health Literacy Proceedings, published and distributed by
- An initiative on health literacy, launched by the American Medical
Association Foundation, to raise physicians' awareness of the
- Forthcoming evidence-based practice review, sponsored by the
Agency for Healthcare Research and Quality, HHS
- Forthcoming report from the Committee on Health Literacy, Institute
- Ongoing research, National Institutes of Health, HHS
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Factors That Can Influence
Barriers to Change
Some of the multiple barriers to change are noted below:
- Poverty as well as minority and immigrant status are associated
with limited literacy skills. The effects of literacy, income,
poverty, and health are related and interdependent.
- As noted in the section on issues related to measurement, limited
proficiency in English and cultural and linguistic differences
present important challenges and likely barriers for individuals
and populations to receive appropriate health information and
- Practitioners, researchers, or funding agencies in the public
health and healthcare fields may be unaware of findings of functional
literacy assessments of adults.
- Reading, writing, and presentation skills are finely tuned in
institutions of higher learning but are geared for dialog and
discussion among members of highly educated and often specialized
audiences. Plain language communication may be considered a new
- Although public health and medical practitioners work to increase
awareness and provide information, neither field has assumed the
task of fully educating the public about how the body functions,
health research findings, health information, and the environment.
- Many interventions aimed at low-literacy populations have been
developed and implemented; however, little has been done to evaluate
the effectiveness of these interventions in terms of meaningful
long-term health outcomes.
- The process of delivering healthcare information, whether oral
or written, does not typically include a method to determine whether
the information is understood by the recipient.
Leverage points for actions that have worked or have potential to
effect change are described below:
- Federal and State legislation that promotes health literacy
can effect change.
- Research findings linking functional literacy to health status
provide critical leverage points for action.
- Costs associated with incorrect use of medications, failure
to comply with medical directions, and safety risks in workplaces
can be used to support changes in policies.
- Government regulations, such as plain language requirements,
can substantially effect changes in materials.
- Legal action provides leverage points for change. To date, a
few court decisions have been related to the literacy of clients
or patients or the reading level of the materials—for example,
see Wong (1998).
- National initiatives to effect change include Leave No Child
Behind, Plain Language, White House Initiative on Hispanics (and
Immigrant Populations), Centers for Medicare & Medicaid Services
campaign to improve communication with Medicare beneficiaries,
Agency for Healthcare Research and Quality efforts to improve
patient safety, and the Government Performance and Results Act.
- Research and interventions in the field of health communication
have improved communication between patients and providers.
- Earlier diagnosis of reading and language disabilities would
permit earlier interventions.
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Strategies and Solutions
All of the proposed strategies and solutions depend on building
increased awareness of the magnitude of health literacy problems
in the United States and on identifying systemic changes that will
make U.S. health systems easier for individuals to understand and
use. A critical link among literacy, health, and health status must
be recognized at a broad societal level. Ensuring health literacy
in the United States is a fundamental issue of fairness and basic
human rights. No single public or private entity can improve the
health literacy of individuals. Partnerships, both traditional and
new, will be required to marshal the necessary resources to make
progress on health literacy. Each population or stakeholder group
needs to engage in skill-building to address both the supply side
(e.g., those who create health messages, information, forms, and
documents; those who staff the healthcare, public health, and health
education systems) and the demand side (e.g., patients, clients,
their families and caregivers, consumers). Stakeholders are likely
to realize the benefits from health literacy improvements by way
of improved communication, greater adherence to treatment regimens,
greater ability to engage in appropriate self-care, improved health
status, and greater efficiency and cost savings to the health system
as a whole. Health literacy, therefore, is relevant not only as
a single objective but as an element of all the Healthy People
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Develop a national focus and agenda for health literacy.
- Convene an exploratory planning committee to assess the opportunities
for a national conference, such as a White House Conference on
Literacy with health literacy as a major component or a separate
White House Conference on Health Literacy.
- Convene a working group to collaborate on a national report
on health literacy based on data from the 2003 National Assessment
of Adult Literacy.
Change professional practice for healthcare providers and public
health professionals, including health educators.
- Encourage professional organizations to make health literacy
issues a high priority on their policy, research, and practice
agendas and to develop positions and issue policy statements and
- Secure commitments from professional organizations to become
involved in health literacy issues and advocate for change.
- Encourage and support effective communication skills of health
professionals, including the development of curricula for health
professional training and continuing education.
- Engage the media to increase professional and public awareness
of the issues.
- Connect health literacy issues to ongoing efforts to improve
the cultural competence of healthcare providers.
- Emphasize and support health communication efforts that address
the needs of low-literate populations.
- Promote the use of plain language and encourage widespread development
and use of health glossaries.
- Encourage health practitioners to work with adult educators
on the delineation of needed skills to support health literacy
rather than on the transfer of health information. Adult education
professionals have long focused on skill-building activities related
to language and vocabulary acquisition, reading, writing, numeracy,
oral comprehension, and discussion. Their expertise can support
and enhance health literacy goals.
- Develop and implement educational curricula in professional
and continuing education programs.
Partner with adult education to improve literacy skills.
- The adult education sectors within several States have launched
health literacy initiatives (Matthews and Sewell, 2002). Adult
education curricula have frequently included health lessons often
related to hygiene, nutrition, healthful or harmful habits, and
substance use. Two national surveys indicated that State directors
and adult education teachers believed that health-related content
would likely engage adult students and thereby increase learner
interest, motivation, and persistence (Rudd and Moeykens, 1999;
Rudd, Zahner, and Banh, 1999). Health practitioners working with
adult education systems gained access to and communicated with
adults not reached through traditional health outreach. Thus,
adult education learning centers provided the health field with
an ideal site for reaching poor, minority, and medically underserved
populations. At the same time, teachers and directors were cautious
about the appropriateness of asking adult education teachers to
present lessons on health content, which is not, after all, their
area of expertise. However, adult education systems, with the
goals of building skills for full participation in society, could
augment students' abilities to access and navigate the difficult
pathways of health information for themselves, their families,
and their communities.
Enhance access to health information.
- Collect comprehensive baseline data on the clarity of existing
health information materials.
- Assess the readability of both prose and document health materials.
- Simplify and clarify health information in both prose and document
- Evaluate the effectiveness of simplified health information.
- Promote the use of plain language and encourage widespread development
and use of health glossaries.
- Promote the development of materials that are culturally and
- Evaluate the effectiveness of improving health literacy on healthcare
outcomes and health status.
- Develop best practices for health literacy.
- Develop resources of patient education materials written in
plain language that can be easily available to health professionals.
- Increase the media's awareness of health literacy issues and
- Work with the media to make scientific information easier to
understand for all types of audiences.
Oral and other nonwritten forms of communication
- Establish a baseline of oral communication.
- Improve understanding of what is effective oral communication.
- Promote the use of culturally and linguistically appropriate
communication in oral and other nonwritten forms of communication.
- Adapt best practices from written communication to all other
forms of communication, including oral, signed, audio, visual,
and alternative or assistive devices.
Collaboration among all professional groups
- Minority news organizations
- Plain language specialists
- Healthcare organizations and health plans
- Public health professionals
- Legal and regulatory experts
Enhance access to health services delivery system (e.g., surveys,
forms, questionnaires, signs, and other explanatory materials in
- Assess the legal requirements of existing forms to determine
how they can be simplified and rewritten within those requirements.
- Develop appropriate tools to assess the comprehension of forms
and other materials used in healthcare delivery.
- Collect comprehensive baseline data on the comprehensibility
of existing forms and other materials.
- Use findings to simplify and clarify forms and other materials.
- Increase the number of ombudsmen in healthcare facilities and
enhance their roles to include assisting patients, clients, and
their families and caregivers with literacy demands.
Support the adult education system, including literacy programs
at work, in correctional facilities and job training, family literacy,
and ESL and distance learning programs.
- Promote the expanded availability of adult education programs,
particularly in worksite and healthcare settings.
Support all forms of literacy skill development for all population
groups (e.g., age 0 to 3 years, preschool, K12, adult, family).
- Expand and strengthen interventions after initial diagnoses
for reading and language disabilities.
- Increase funding and program availability for document and numeracy
Include health literacy as a fundamental consideration in health
policy and program planning.
- Identify financial constraints, such as lack of reimbursement
for patient education, in the healthcare system.
- Initiate cost-benefit studies examining the relationships among
health literacy, health status, and healthcare system costs.
- Provide incentives for recipients of publicly funded grants,
contracts, cooperative agreements, and program funds to demonstrate
how they address the health literacy needs of the populations
studied or served.
- Identify any needed regulations and appropriate agencies to
- Promote additional research, including formative research, and
program funding to address health literacy needs.
- Promote the use of plain language. The Canadian Public Health
System has adopted plain language rules that may provide a model.
- Expand definitions of at-risk population groups to include people
without a high school diploma or with limited literacy skills.
Engage community organizations and the lay public in health
- Inform the lay communication network through community development
- Encourage participatory health and education efforts.
- Work with adult educators to develop communication skills broadly.
Skill-building related to forms, directions, and information packets
is important but will not suffice. Activities such as becoming aware
of new findings, gathering information, and participating in community-
or work-related action groups require efficacy-building and skills
related to research, discussion, analysis, decisionmaking, and action.
Many of these broader communication skills are already being taught
in some adult education programs. Health-related curricula incorporating
attention to these skills can enrich adult learners' experiences
and will support health literacy goals.
Enhance health literacy research and its translation into practice.
- Support studies of effective communication tools and techniques.
The American Medical Association's (AMA's) Ad Hoc Committee on
Health Literacy identified only 38 published articles that discussed
how to communicate with low-literacy populations. Of these, only
17 discussed the development or implementation of interventions
to improve patients' knowledge or outcomes, of which only one
was a randomized, controlled trial.
- Emphasize, support, and study nonprint communication efforts.
- Create standards for the use of nontraditional media.
- Develop and apply new markers for quality effective communication.
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Lead Organizations and Responsibilities
Examples: AMA and the AMA Foundation are working to increase awareness
of health literacy among physicians and other health professionals
through the distribution of health literacy kits and materials and
a campaign on health literacy to reach medical societies, medical
schools, conferences, group practices, and hospitals. Led by Pfizer,
Inc., a number of national organizations have recently joined together
to launch a program to educate consumers and patients about how
to communicate better with their healthcare providers.
Timeframe for Action
National conference on health literacy: 3 to 5 years
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For More Information
Canadian National Adult Literacy Database
Health Literacy Literature
International Adult Literacy Survey
Literacy and the Web
National Adult Literacy Survey
National Center for the Study of Adult Learning and Literacy
National Institute for Literacy
National Partnership for Reinventing Government
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