In OHPE Bulletin 270.1, I discussed the possible relevance of the concept of health literacy for health promotion (Rootman, 2002). In this issue, I continue the discussion by drawing on Health Literacy: A Prescription to End Confusion, a report on health literacy recently released by the U.S. Institute of Medicine (IOM, 2004) to which I made a contribution as a member of the committee that produced it. This report is important because Institute of Medicine reports tend to have a significant impact on policy, practice, and research in the United States, and often beyond. At a minimum, they give prominence to health issues that are considered to be important by policymakers, practitioners, and researchers. Moreover, this particular report has implications for health promotion in Canada and elsewhere. After presenting the background and summarizing findings and recommendations, I will discuss its implications for health promotion in Canada and elsewhere.
The IOM set up the committee that produced the report for a number of reasons. One was a view that modern health systems make complex demands on consumers and that there is a mismatch between people's skills and these demands. A second was that many people find health information difficult to obtain, understand, and use. A third reason was the fact that health literacy has been linked to issues such as safety and quality of care. It was also made an important health objective for the United States and was identified as one of two cross-cutting issues in health care by a previous IOM committee.
The committee was asked to assess the problem of health literacy and consider the next steps. Specifically, it was charged with (1) defining the scope of the problem of health literacy, (2) identifying the obstacles to creating a health-literate public, (3) assessing approaches that have been attempted to increase health literacy, and (4) identifying goals for health literacy efforts and suggesting approaches to overcoming obstacles.
It carried out this charge by reviewing relevant research, commissioning three papers and a study to determine promising initiatives, and by holding hearings. It was also able to draw on a comprehensive critical review of research on the effectiveness of health literacy initiatives commissioned by the Agency for Health Care Research and Quality. Before the report was released, it was reviewed by an expert panel assembled by the IOM.
~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ *
III Summary of Report
The committee accepted the definition of health literacy used in the Healthy People 2010 report: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Ratzan and Parker, 2000). It also developed a framework for health literacy that identifies three major areas of potential action: the health system, the education system, and culture and society. The framework also suggested that health contexts interact with individual factors to produce health outcomes. In other words, the committee suggested that health contexts, including public health, bear as much or more responsibility for addressing health literacy as individuals who are affected.
Before presenting the committee's findings and recommendations in relation to the three intervention points, the report reviewed existing evidence regarding the extent and possible effects of limited health literacy. In doing so, it suggested that although there are limitations in the current measures of health literacy, as many as 90 million Americans may lack the literacy skills to use the U.S. health system well. The report also noted that certain groups such as older adults, those with less education, poorer people, and those from minority groups and from groups with limited English skills are more likely than others to have limited literacy and health literacy skills. However, according to the report, limited health literacy affects more than just the uneducated and poor. At some point, most individuals will encounter health information they cannot understand. Even well-educated people with strong reading and writing skills may have trouble comprehending medical forms or doctor's instructions regarding a drug or procedure.
Evidence is also presented that adults with limited health literacy, as measured by current tests, have less knowledge of disease management and of health promoting behaviours. They also have poorer health and are less likely to use preventive services. Some evidence is also reported that people with limited health literacy were more likely to be hospitalized and use emergency services. This overuse has been connected to higher health care costs. Thus, although the evidence is by no means complete, in the view of the committee there is enough to suggest that health literacy is an issue of some concern.
As reported in the chapter on culture and society the committee suggested that health literacy must be understood and addressed in the context of culture and language, among other things. Culture and ethnicity may influence patients' perceptions of health, illness, and the risks and benefits of treatments. Differing cultural and educational backgrounds between a patient and provider also contribute to problems in the patient's comprehension. Thus, they recommended the development of conceptual frameworks that take culture into account and the development and testing of approaches to improve health communication with different cultural groups.
The chapter on educational systems reports that the committee found many obstacles and barriers to successful health literacy education programs in schools. These include crowded curricula, overworked teachers, and shortage of teachers with training in health education. The committee also found that health professionals and staff have limited opportunities to develop skills for improving health literacy. On the other hand, it also noted opportunities to address issues of literacy in adult education programs where studies have found a desire by adult learners and adult education programs to form partnerships with health communities. Based on these findings, the committee recommended, among other things, that educational institutions should require that National Education Standards, which include standards for health literacy, be implemented. The committee also recommended that health knowledge and skills be incorporated into the existing curricula of kindergarten through 12th grade classes, as well as into adult education, professional education, and community programs.
The health systems chapter reports the committee's conclusion that health literacy is fundamental to quality care. One of the barriers to quality care is the fact that the demands of health systems for reading, writing, and numeracy skills exceed the health literacy skills of most adults in the United States. These demands are intensified by the complexity of health care systems, advancements in scientific discoveries and new technologies. Four recommendations were suggested by the committee to address these issues. The first is that demonstration programs to find the best ways to reduce the negative effects of limited health literacy be supported. The second is to fund research to help improve health care quality (some of the research should involve consumers). The third is that the assessment of health literacy should be part of health care information quality data collection. And the final recommendation is that standards be developed to address health literacy in research, training, and service-funding applications.
The report concludes with a "vision for a health literate America." To quote the committee, "We envisage a society in which people have the skills that they need to obtain, interpret, and use health information effectively and within which a wide variety of health systems and institutions take responsibility for providing clear communication and adequate support to facilitate health-promoting actions." This is followed by a list of specific criteria for such a society, such as "everyone should have the opportunity to improve their health literacy."
~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ *
IV Implications for Health Promotion
Although the motivation for establishing the committee came more from a concern about the impact of health literacy on health care than from a concern about health promotion, health promotion thinking played an important role in the work of the committee and in the report itself. This was due to the fact that several members of the committee, including myself, had a health promotion perspective and were willing to share it with the other members of the committee. In addition, many of the community groups that spoke to the committee had a health promotion perspective. As a result, the report itself contains many elements relevant to health promotion.
One critical element is the concept of health contexts, which was a prominent part of the conceptual framework developed by the committee. The committee and the report recognized that health contexts include more than just the health care context. The concept also includes public health, community, and health promotion contexts. Thus, many of the recommendations have implications for health promotion practice and policy.
For example, the recommendations regarding the development of conceptual frameworks that take culture into account and the development and testing of approaches to improve health communication with different cultural groups clearly apply to health promotion work. Similarly, the recommendations regarding education have application to health promotion educational efforts, whether at the school level or other levels of education, including health professional education. Even the recommendations regarding the health care system apply, at least in part, to health promotion (e.g., the need to develop standards to address health literacy in research, training, and service funding applications). Thus, it is clear that the report does have implications for health promotion and deserves the critical attention of health promotion practitioners, policymakers, and researchers.
Although this report was obviously written for an American audience, it does have implications for Canada and other countries. For one thing, based on the findings of the International Adult Literacy Survey, it is likely that Canada and many other countries have significant health literacy problems. Second, the definition of health literacy adopted by the committee as well as the conceptual framework are relevant to other countries. And third, and perhaps most importantly, some of the recommendations made by the committee, although directed at U.S. agencies and groups, are likely relevant to other countries.
On the other hand, we need to recognize that each country is different and that any solutions "made in the U.S.A." need to be carefully examined before being implemented anywhere else. This is particularly true in relation to different health care and public health systems. Thus, it is important that other countries embark on a dialogue about health literacy in relation to their own circumstances. The IOM report can be a valuable starting point, but it is necessary to examine the extent and nature of low health literacy and the approaches that are being used within the country in order to assess and develop solutions that are most likely to succeed. We also need to put health literacy in a larger context of literacy and general and the role of literacy as a mechanism through which determinants of health such as education impact on health.
~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ *
To stimulate discussion of these issues, the Canadian members of the IOM committee and others are planning to actively raise the level of awareness of the report in Canada. Among other things, we conducted a workshop on the implications of the report at the Canadian Public Health Association Conference in June. We are also planning to feature the report at the Second National Conference on Literacy and Health in October 2004 (see http://www.ohpe.ca/ebulletin/ViewAnnouncements.cfm?ISSUE_ID=343, item B5, for details). In addition, we are exploring the possibility of commissioning the Royal Society of Canada to establish an Expert Panel to examine the field of Literacy and Health in Canada.
Thus, the issue of health literacy within the context of literacy and health will be one that the health promotion community in Canada will want to watch and promote in the coming years. I encourage you to get involved though attending the National Literacy and Health Conference, debating the IOM report and its implications, and examining your own work and context in relation to health literacy.
Rootman, I., Health Literacy and Health Promotion, OHPE Bulletin #270.1, August 2, 2002, http://www.ohpe.ca/ebulletin/ViewFeatures.cfm?ISSUE_ID=271.
Institute of Medicine, Health Literacy: A Prescription to end Confusion, Washington: The National Academies Press, 2004.
Ratzan, S.C. and Parker, R,M., Introduction. Selden, C.R., Zorn, M,, Ratzan, S,C,, Parker, R.M., Editors. In: National Libraries of Medicine Current Bibliographies in Medicine: Health Literacy. Vol. NLM Pub.No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.