Kirsten E. Schmutz MSN/Ed, RN, CCRN-CSC
PhD Student, College of Nursing
June 3rd, 2021
Over the past two decades, researchers and clinicians have been paying a lot more attention to health literacy[1]. But what is health literacy? To sum it up in a short, sweet sentence: 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.”[2] Seems simple enough, but there is so much that goes into health literacy: the patient’s ability to understand, interpret and apply information, the healthcare provider presenting information in a manner that is easy to understand, and cultural and societal influences, to name a few. The concept of health literacy is extremely complex and there are multiple models to describe it. Baker’s (2006) model is presented in Figure 1 as an example.
Why Health Literacy Matters
If health literacy is so complex, why are so many big organizations like the Institute of Medicine and HealthyPeople2020 paying so much attention to it? Well, research studies show that the lower a patient’s health literacy, the worse their health outcomes. Some of these poor outcomes take the form of increased rates of hospital (re)admissions, alcohol and drug use, and depression; and lower rates of breastfeeding and engaging in preventative healthcare measures – like getting vaccinated or cancer screenings completed.[3] All of these poor outcomes result in more money spent on healthcare. So, if healthcare providers can better identify patients with low health literacy, they can better intervene to prevent some of these negative health outcomes.
How to Identify a Person’s Health Literacy Level
However, screening tools are rarely used in the clinical
setting – they are mostly used for research purposes. And, while screening
tools are quite skilled at identifying patients with low health literacy
abilities, they don’t actually measure health literacy. Health literacy
screening tools measure a patient’s ability to read, interpret, and apply words
and numbers, but, as described earlier, that is only a small part of health
literacy.1 A person can score 100% on a health
literacy screening tool and still have poor health literacy. For example, I
administered the Newest Vital Sign (a health literacy screening tool) to my
husband, a quality chemical engineer with an MBA who likes statistics. He
scored 100%. However, when I asked him what he took for his headache he said
aspirin. We didn’t have any aspirin. What we did have was acetaminophen and he
thought the two were the same.
Now that we know why health literacy is so
important, how do we go about identifying patients with low health literacy?
One option is to perform a health literacy screening. A health literacy
screening usually takes the form of a question/answer survey with the patient’s
score indicating their level of health literacy. But, what screening tool
should you use? Boston University and the National Library of Medicine put
together a website called the Health Literacy Tool
Shed to
help healthcare providers and researchers narrow down the over 200 different
health literacy screening tools to find the one that best meets their purposes.
Test Yourself!
Want to see what the Newest Vital Sign rates your health literacy as? Click here to take the test! Correct answers are provided at the bottom of this post.
What Does that Mean for Clinical Practice?
If health literacy screening tools don’t actually measure a patient’s health literacy abilities, is there any point to using them in clinical practice? Yes and no. Health literacy screening tools give providers an opportunity to empirically assess a patient’s ability to read and interpret words and numbers. If a person cannot read and interpret words and numbers, it will be extremely difficult for them to engage in activities like reading a prescription label or following pre-procedural directions without additional assistance. In this aspect the screening tool has helped significantly.
The hazard comes when a patient is able to read and interpret words and numbers well, and so scores well on the tool, but does not have a high level of health literacy – as illustrated by my husband. How do we screen those patients? The solution: health literacy universal precautions (HLUP). HLUP is not a screening tool, but is an assumption that all patients, regardless of sociodemographic information, will require some level of assistance navigating their health and the healthcare system.1 HLUP aides in catching those with low or moderate health literacy from falling through the cracks as the providers use the same techniques to assist those with low health literacy as those with moderate or high health literacy.
What Does that Mean for Research?
There is still a great deal that needs to be investigated regarding health literacy. Firstly, a screening tool that truly assesses health literacy, and not just elements of it, needs to be developed. Only then can researchers reliably and accurately assess health literacy in their participants to determine health literacy’s effect on health outcomes. The screening tools currently available do a fairly good job of this already, but they are incomplete, and so their use in research will also add an element of limitation.
Another aspect of health literacy that needs attention in research is the testing of HLUP. HLUP is highly advocated for by many health literacy scholars,1 but there is little evidence in the literature testing its efficacy. Until such evidence exists, the paradigm shift to HLUPs acceptance and implementation by researchers and providers will be delayed.
Parting Thoughts
Health literacy is a complex concept. While research still has far to go in evaluating health literacy, it has come a long way. The development of health literacy screening tools is helping to identify previously unrecognized low levels of health literacy. This recognition helps providers adjust their teaching and interventions to help improve patient outcomes. However, researchers and healthcare providers should use caution when using health literacy screening tools as they actually measure a patient’s ability to read and interpret words and numbers, not their ability to navigate their health and the healthcare system. If researchers develop a way to empirically measure health literacy, providers will more effectively and accurately identify a patient’s health literacy needs so as to provide better health education and interventions. Alternatively to a screening tool, if empirical research emerges to support HLUP, this will shift the health literacy paradigm in a new direction. There is much yet to be seen in the future of health literacy.
Correct Answers to the Newest Vital Sign: 1) 1,000. 2) Up to 1 cup or half the container. 3) 33. 4) 10% 5) No. 6) It has peanut oil.
1. Baker, D. W. (2006). The meaning and the measure of health literacy. Journal of General Internal Medicine, 21(8), 878-883. https://doi.org/10.1111/j.1525-1497.2006.00540.x
2. Institute of Medicine Committee on Health, L. (2004). In L. Nielsen-Bohlman, A. M. Panzer, & D. A. Kindig (Eds.), Health Literacy: A Prescription to End Confusion. National Academies Press https://doi.org/10.17226/10883
3. Dewalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P. (2004). Literacy and health outcomes: A systematic review of the literature. J Gen Intern Med, 19(12), 1228-1239. https://doi.org/10.1111/j.1525- 1497.2004.40153.x
4. National Library of Medicine. (2021, April 19). Health Literacy Tool Shed. Retrieved April 19, 2021 from https://healthliteracy.bu.edu/all
5. SeekPNG. (n.d.). Magnifying glass scientist cartoon clip art – cartoon scientist magnifying glass [Clip Art].
Retrieved April 20, 2021 from https://www.seekpng.com/ipng/u2y3a9r5w7o0y3i1_magnifying-glass-scientist-cartoon-clip-art-cartoon-scientist/
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