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Health Literacy: Confronting a National Public Health Problem

Policy Date: 11/9/2010
Policy Number: 20109

Related Policies
APHA policy statement 77-42(PP): Toward a policy on health education and public health1
APHA policy statement 84-16(PP): Increasing worked and community awareness to toxic hazards in the workplace2
APHA policy statement 92-02: The prevention of diet-related chronic diseases3
APHA policy statement 92-07: Underscoring the continued need for a sustained national HIV prevention and public education4
APHA policy statement 99-01: Provision of health education within managed care organizations5
APHA policy statement 2001-20: Support for culturally and linguistically appropriate services in health and mental health care6
APHA policy statement 2004-9: Promoting public health and education goals through coordinated school health programs7
APHA policy statement 2005-10: Sexuality education as part of a comprehensive health education program in K-12 schools8
APHA policy statement 2002-1: The role of genomics in public health9
APHA policy statement 59-19(PP): The role of public health in medical care10
APHA policy statement 74-34(PP): The role of official local health agencies11
APHA policy statement 77-08: The role of health professionals in promoting active measures of prevention12
APHA policy statement 99-34(PP): Protecting and strengthening Medicare: financing and prescription drug issues13
APHA policy statement 2000-10: Creating healthier school facilities14
APHA policy statement 2001-7: Support the framework for action on oral health in America: a report of the surgeon general15
APHA policy statement 2004-12: Support for community-based participatory research in public health16
APHA policy statement 2005-2: Developing a comprehensive public health approach to influenza17
APHA policy statement 2006-14: The role of the pharmacist in public health18

According to major reports over the last several decades, the limited level of health literacy of the nation is a serious and escalating public health issue.19–24 Consumers must be proficient in health literacy to lead healthy lifestyles, to effectively navigate the health care system, to advocate for their health care needs, to respond to public health alerts, and to vote on decisions affecting the health of their environments and communities. Promoting an engaged citizenry in decisions about its health is not only a societal issue but also an ethical imperative.24–26
The American Public Health Association (APHA) has long recognized the importance of improving people’s abilities to access, understand, and use health-related information to prevent illness, to treat and manage their health conditions, and to reduce the risk of injury.1–9 Moreover, APHA policies during the last 50 years have outlined the ethics, roles, and responsibilities of health professionals and health systems to provide health information that is appropriate for and useable by the intended audience.10–18
To function in society, people need a general set of literacy skills such as reading, writing, basic math, speech, and comprehension. However, on a continuum, health literacy is more advanced than general literacy and requires a more sophisticated skill set.27 Health literacy is often defined as the ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.”22,24,28 Increasingly, it is being viewed as the product of 2 dimensions: (1) an individual’s abilities, characteristics, and background; and (2) the communications output from various health systems.29 An individual’s health literacy level is influenced by his or her language, ability to communicate clearly and listen carefully, age, socioeconomic status, cultural background, past experiences, cognitive abilities, and mental health. In addition, health literacy is affected by the assumptions and operations of health communicators and their respective health and social systems.19,30 Nearly 9 of 10 adults have difficulty using the everyday health information that is routinely available in health care facilities, media, and communities.19,21,28,31 Most health information is written at high school, college, or graduate school reading levels.32 A person can be literate and still not be considered health literate.21
More than one third of English-speaking adults in the United States have basic (22%) or below basic (14%) health literacy; only 12% have proficient health literacy.21 The percentage of adults with limited literacy skills has not decreased significantly in the past 10 years. Some 30 million Americans are unable to perform even the simplest everyday literacy tasks. Compared with adults with proficient health literacy, 42% of adults with below basic health literacy skills are more likely to report their health as poor, and 28% are more likely to lack health insurance.21 In addition, 54 million adults with any type of disability, difficulty, or illness face significant barriers to health communication.29,34,35People with limited English proficiency are especially challenged to obtain, process, and understand basic health information and services.24
Limited health literacy affects Americans of all ages, races, incomes, languages, cultures, and education levels. Approximately 45% of high school graduates have limited health literacy.21 However, populations most likely to experience limited health literacy include adults over the age of 65 years; most minority populations; some refugees and immigrants; people with less than a high school degree or graduate equivalency degree certificate; and people with incomes at or below the federal poverty level.21 Health literacy has also been identified as a critical factor in contributing to health disparities.35–37
The US Department of Health and Human Services’ Healthy People 2010 Objectives for the Nation includes the objective to “improve the health literacy of persons with inadequate or marginal literacy skills” and recommendations to close the gap.22 The Patient Protection and Affordable Care Act passed by Congress in 2010 includes several provisions designed to help people obtain, process, and understand basic health information and services.39 The United Nations recognizes the significant impact of health literacy on health outcomes and has called for the development of appropriate action plans to address the problem.40 Limited health literacy is negatively associated with physical and mental health outcomes, including the use of preventive services; management of chronic conditions; self-reported health; misunderstanding of prescription medication instructions; medication errors; poor comprehension of nutrition labels; and mortality.41–44 Adults with limited health literacy skills report feeling a sense of shame about their skill deficits and may hide their struggles with reading or vocabulary.45,46 Compared with people with proficient health literacy, those with limited health literacy have higher medical costs, are more likely to use emergency rooms inappropriately, and use an inefficient mix of services.42 Children with parents or caregivers with low literacy are more likely to have poorer health outcomes compared with caregivers with higher literacy levels.47
In addition to adults, the health literacy of children and adolescents is also important. Youth of all ages have the potential to understand the practices associated with health and how to access health information.48 Improving child health literacy can help combat the alarming increase of pediatric chronic diseases and other emerging health threats. It is also vital to adolescents, given that they begin interacting more independently with the health system and are frequent users of technology and mass media.49 Health literacy requires knowledge of the body, healthy behaviors, health system operations, and other areas. School health education programs taught by qualified people are an important strategy to promoting health literacy in youth.24,50,51 The US Department of Health and Human Services National Action Plan to Improve Health Literacy includes strategies to create and require certification standards for teachers in health education and to use the National Health Education Standards in school curriculum reform initiatives.24 The National Health Education Standards specify that students in grades Pre-K to 2 receive a minimum of 40 hours of instruction in health education per academic year and those students in grades 3 to 12 should receive 80 hours of instruction in health education per academic year.52 However, nationwide, fewer than 50% of schools require instruction in health education in each of grades K–3; 60% or fewer require instruction in health education in each of grades 4–8; and fewer than 35% require instruction in health education in each of grades 9–12.53
The full costs of limited health literacy have yet to be calculated, but estimates range from $106 to $236 billion annually; accounting for future costs, the economic toll of limited health literacy rises to $3.6 trillion.54 Limited health literacy also is associated with substantial indirect costs such as more chronic illness and disability, lost wages, and a poorer quality of life.
Successful approaches for improving health literacy are available and include involving the members of the priority audience in the design and testing of communication products, simplifying and improving written materials, using the teach-back method, using video or other targeted approaches to patient education, and improving patient–provider communication.55–57 Picture-based instructions and graphs also have been found to be useful in improving patients’ understanding of medication instructions and in decreasing medication errors.58–60 Another strategy recommended for enhancing health literacy—plain language writing—is defined as a communication in which the audience can quickly and easily find what it needs, understand what it finds, and act appropriately on that understanding.61
Successful organizational and health system strategies that have been used to improve health literacy include modifying informed consent processes,62 redesigning forms to meet low literacy needs,63 and emphasizing the importance of health literacy training for health care professionals.64,65 Some government and accreditation organizations have developed tools and standards for health care organizations to reduce health literacy-related barriers.66,67Although improvements are being made, more cross-collaborative efforts across all sectors are needed to achieve measurable improvements in health literacy across all socioeconomic levels.19,24
Therefore, APHA—
1. Urges Congress and the National Conference of State Legislatures to adopt legislation that requires government documents and those of state-regulated industries to be communicated in plain language that is clear, well organized, and linguistically and culturally appropriate and that incorporates other best practices of plain language principles.
2. Urges Congress and the administration to address health literacy in implementing health reform legislation, including expanding culturally and linguistically appropriate information in the community, as well as require other changes in the public health and health care systems that improve the ability of all people to access, understand, and use health information for informed decision making.
3. Urges Congress and the administration to adopt educational reform legislation that recognizes health education as a core subject by the US Department of Education and requires instruction by people who are certified, licensed, or endorsed by the state in health education.
4. Urges state boards of education to require accurate, standards-based, and developmentally appropriate health education that is taught for the recommended hours by people who are certified, licensed, or endorsed by the state in health education, in accordance with the National Health Education Standards.
5. Urges Congress to require the secretary of the US Department of Education to conduct the Health Literacy Component of the National Assessment of Adult Literacy every 3 years and publish a report. The report will track the economic impact of health literacy on the nation and the nation’s progress over time for addressing health literacy in multiple subgroups, especially those experiencing health disparities.
6. Calls for professional preparation schools and programs for health care providers, public health, allied health, health education, and health communication to strengthen professional preparation and training of health professionals about evidence-based strategies to develop and disseminate health and safety information that is accurate, accessible, and actionable by the intended audiences.
7. Urges the US Department of Health and Human Services and its agencies (including the National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration, Agency for Healthcare Research and Quality, and Health Resources and Services Administration) to provide funding for research, identification, use of new technologies, and dissemination of best practices for improving the health literacy of the US public and to work with the media in communicating accurate, understandable, and actionable health information.
8. Urges public health and health care communities to organize and work with multisectoral coalitions (i.e., consumers, government, businesses, and nonprofit agencies) to reduce individual and structural barriers to health literacy, to promote the dissemination of accurate health information, and to involve and advocate for vulnerable populations and communities in their right to informed health decision making.

References
1. American Public Health Association. APHA policy statement 77-42(PP): Toward a policy on health education and public health. Washington, DC: American Public Health Association; 1977. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=877. Accessed January 16, 2011.
2. American Public Health Association. APHA policy statement 84-16(PP): Increasing worker and community awareness to toxic hazards in the workplace. Washington, DC: American Public Health Association; 1984. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1078. Accessed January 16, 2011.
3. American Public Health Association. APHA policy statement 92-02: The prevention of diet-related chronic diseases. Washington, DC: American Public Health Association; 1992. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=53. Accessed January 16, 2011.
4. American Public Health Association. APHA policy statement 92-07: Underscoring the continued need for a sustained national HIV prevention and public education. Washington, DC: American Public Health Association; 1992. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=59. Accessed January 16, 2011.
5. American Public Health Association. APHA policy statement 99-01: Provision of health education within managed care organizations. Washington, DC: American Public Health Association; 1999. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=172. Accessed January 16, 2011.
6. American Public Health Association. APHA policy statement 2001-20: Support for culturally and linguistically appropriate services in health and mental health care. Washington, DC: American Public Health Association; 2001. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=259. Accessed January 16, 2011.
7. American Public Health Association. APHA policy statement 2004-09: Promoting public health and education goals through coordinated school health programs. Washington, DC: American Public Health Association; 2004. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1292. Accessed January 16, 2011.
8. American Public Health Association. APHA policy statement 2005-10: Sexuality education as part of a comprehensive health education program in K-12 schools. Washington, DC: American Public Health Association; 2005. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1304. Accessed January 16, 2011.
9. American Public Health Association. APHA policy statement 2002-1: The role of genomics in public health. Washington, DC: American Public Health Association; 2002. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=275. Accessed January 16, 2011.
10. American Public Health Association. APHA policy statement 59-19(PP): The role of public health in medical care. Washington, DC: American Public Health Association; 1959. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=439. Accessed January 16, 2011.
11. American Public Health Association. APHA policy statement 74-34(PP): The role of official local health agencies. Washington, DC: American Public Health Association; 1974. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=776. Accessed January 16, 2011.
12. American Public Health Association. APHA policy statement 77-08: The role of health professionals in promoting active measures of prevention. Washington, DC: American Public Health Association; 1977. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=843. Accessed January 16, 2011.
13. American Public Health Association. APHA policy statement 99-34(PP): Protecting and strengthening Medicare: financing and prescription drug issues. Washington, DC: American Public Health Association; 1999. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=205. Accessed January 16, 2011.
14. American Public Health Association. APHA policy statement 2000-10: Creating healthier school facilities. Washington, DC: American Public Health Association; 2000. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=215. Accessed January 16, 2011.
15. American Public Health Association. APHA policy statement 2001-17: Support the framework for action on oral health in America: a report of the Surgeon General. Washington, DC: American Public Health Association; 2001. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=256. Accessed January 16, 2011.
16. American Public Health Association. APHA policy statement 2004-12: Support for community-based participatory research in public health. Washington, DC: American Public Health Association; 2004. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1298. Accessed January 16, 2011.
17. American Public Health Association. APHA policy statement 2005-02: Developing a comprehensive public health approach to influenza. Washington, DC: American Public Health Association; 2005. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1307. Accessed January 16, 2011.
19. American Public Health Association. APHA policy statement 2006-14: The role of the pharmacist in public health. Washington, DC: American Public Health Association; 2006. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1338. Accessed January 16, 2011.
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22. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Department of Health and Human Services; 2000. Also available at: http://web.health.gov/healthypeople/document/. Accessed January 16, 2011.
23. US Department of Health and Human Services. National Call to Action to Promote Oral Health. NIH Publication No. 03-5303. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2003. . Available at: www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.html. Accessed February 15, 2010.
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