On health literacy and health outcomes: Background, impact, and future directions

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Decades of studies indicate that income and education are, together and independently, predictors of health outcomes.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Until recently, however, little inquiry has focused on the pathways between education and health outcomes. Literacy is emerging as an important pathway, offering insight into how education influences health and provides opportunities for efficacious change.Health literacy, a relatively new area of research was spurred by the reports of the first international surveys of adult literacy in the 1990s<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and the subsequent Adult Literacy and Lifeskills Surveys (ALLS) in the early part of this century.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> These surveys, conducted in industrialized nations and focused on the use of commonly available print materials, indicated that a majority of adults in most nations have difficulty using these materials to accomplish everyday tasks with accuracy and consistency. Tasks included following directions on an over the counter medicine, figuring out a discount for a marketplace sale, or determining which bus to take to arrive at a specific location at a specific time. Shocked by these findings, health researchers began to explore possible health implications. In just over a decade researchers have established a strong link between literacy skills and health outcomes. A substantial body of research indicates that limited literacy (measured, at first, by reading skills) is associated with limited participation in health promotion and disease detection activities, with diminished management of long term chronic diseases, with increased hospitalization and re-hospitalization, and with increased morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0020">4–8</a>Definition of health literacyNutbeam notes that there are two coexisting and valid conceptualizations of the term health literacy: the clinical perspective that views health literacy as a risk factor and the public health view of health literacy as a personal asset.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> In both instances, however, health literacy is viewed as an attribute or characteristic of individuals. In our research we embraced the Institute of Medicine's concept of health literacy, as discussed in 2004, as an interaction between skills of individuals and demands of our complex health systems.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>However, health literacy goes beyond the individual. It also depends upon the skills, preferences, and expectations of health information providers: our doctors, nurses, administrators, home health workers, the media and many others. Health literacy arises from a convergence of education, health services, and social and cultural factors, and brings together research and practice from diverse fields.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> This focus on the interaction is relevant for researchers, clinicians, administrators, and policy makers as they seek to understand how to develop and test efficacious programs to eliminate barriers to health information, services, and care.Health literacy and health outcomesLimited health literacy is being recognized as a serious issue for industrialized nations with both health and financial consequences. Study findings have garnered a good deal of attention among health professional organizations, health agencies and institutions, and policy makers. As a result, faulty assumptions about the adequacy of adults literacy skills are being corrected and efforts are underway to determine efficacious action through education, program implementation, practice modification, and policy change. This increased interest in health literacy can be seen in the development and dissemination of focused reports and white papers,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> in efforts to determine nation-wide measures of adults’ health literacy skills for policy considerations<a class="elsevierStyleCrossRefs" href="#bib0060">12–16</a> and in policy and legislative change.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>The most obvious correction – improved literacy skills of adults is possible, but surely requires a substantial investment in education as well as in time. However, in the light of documented negative health outcomes, health practitioners are not content to wait for another generation of a more literate citizenry to emerge from school systems before health is improved. Action must be taken now, for this generation, and by the health sector.In addition, patients also acknowledge the need to improve their literacy skills, working along with health professionals. In this context, different experiences from patients organizations across countries have shown an important change from the traditional model of patients to a more active one including participation in the health decision making process.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> In patients’ view, improved health knowledge and skills lead to empowerment and, therefore, a better quality of life. In order to share decision-making, there is a need for dialogue between and among patients, family members, and health providers.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Improving health literacyUnfortunately, early studies of the links between literacy and health outcomes were almost exclusively focused on the literacy skills of patients and related health outcomes and so did not did offer insight into action steps beyond improving literacy skills. The initial efforts to explore links between literacy and health outcomes neglected to explore factors controlled by the health sector – the quality and accessibility of information, professionals’ communication skills, and structural barriers to healthful action. These factors constitute what educators call the ‘demand side’. Educators, for example, measure text difficulty before determining reading skills and assess the clarity of a speaker and the complexity of the speech before determining a listener's skills. More recent health literacy studies factor in the difficulty of health materials in use, the clarity of the spoken communication skills of health professionals, and/or the complexity of the physical and social environment of health institutions and health care settings.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> This more balanced approach in health literacy includes measure of skills, measures of demands, as well as measures of health outcomes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A rigorous examination of skills as well as demands resonates with a public health perspective and is modeled on epidemiology, the foundation science of public health. Epidemiology calls attention to the reciprocal relationship between persons and environments. Environmental factors for health literacy include the plethora of information available in print, on line, over the airwaves, and in discussion as well as the physical and social environments of health and health care institutions.Given its importance for service utilization and health outcomes, it is crucial that health professionals are aware of the impact of health literacy as well as health literacy demands on health outcomes. Several recent studies on providers’ awareness and perception of health literacy show that there is a general trend of physicians overestimating patient literacy and underutilizing enhanced communication techniques which are known to improve health outcomes.<a class="elsevierStyleCrossRefs" href="#bib0110">22–24</a>Research indicates that the market place of ideas and information does not allow easy access. Despite the wealth of materials available in print and on-line, health information is often not accessible to the majority of people. For example, over 2000 peer-reviewed studies in the U.S. indicate that health materials across a wide swath of content areas and formats (such as patient brochures, discharge instructions, directions for medicine, instructions for procedures, and even general forms, lists, and charts) have been poorly designed or awkwardly formatted, poorly written, and geared to a very sophisticated audience – limiting their usefulness. This strong body of evidence establishes a clear mismatch between the literacy demands of health materials and the literacy skills of adults with secondary school education.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Recommendations related to print and on-line materials include calls for more rigor in the development and design of health information with attention to vocabulary, organization, and clarity.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> The same scientific rigor applied to the testing of medicines and procedures are called for and suggestions include institutional review boards with well articulated minimum requirements for rigorous pilot testing with members of intended audiences, evidence of revisions related to ease of use and clarity, and reports of assessment processes and findings. A starting point for many institutions is the design and development of critical texts that can have serious life and death consequences as well as legal and financial outcomes. Such texts include directions on medicine labels, discharge instructions, as well as documents related to informed consent.Furthermore, emerging studies indicate that this mismatch exists for the oral exchange as well – health efforts to alert and educate the public over the airwaves as well as discussions between patients and a wide variety of clinicians. Thus, research findings indicate that the problem identified in health literacy studies is not entirely located in the literacy deficits of patients or members of the public. Recommendations for ‘talk’, so essential for information exchange, problem identification, and action are drawn from studies of professional/patient communication. Plain language associations are encouraging health professionals to re-learn their first language, sometimes referred to as ‘kitchen-talk’ or ‘living room language’ for use with the public and patients.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>Professional organizations are considering plain language as a critical skill, along with other articulated communication competencies, for schooling and possibly for licensing examinations. In addition, current best practice guidelines in health literacy call for the use of critical communication checks such as teach-back where the professional avoids the question: “do you understand” and instead checks by asking for help: “I want to be sure that I included all the important information about your medicine; tell me what you will do”.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a>Math is also on the agenda and represents another literacy related area often taken for granted. Computational tasks are imbedded in many health activities and numerical concepts are important components of exchanges between health professionals and patients. These exchanges often include basic arithmetic (adding, subtracting, multiplication, and division) as well as use of percentage and higher level tasks such as estimation, problem-solving, and risk assessment.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The adult literacy surveys of the 1990s and the 2000s indicate that a large proportion of adults in most industrialized nations have difficulty with higher level mathematical tasks.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Overall, health literacy recommendations to improve access to information call for all health professionals to improve the clarity and quality of their written and spoken health information. Although emerging studies of changes in text and in talk offer evidence of improved outcomes, additional efforts focused on the communication of complex information including risk, are called for. Rigorous evaluative studies are needed to establish gold standards. At the same time, consideration must be given to professional education and licensing and to opportunities for on-the-job workforce education and training.The health literacy environmentBut the burden of change cannot rest on the shoulders of health workers and professionals alone. Their practices and their time allocations are shaped by institutional norms, by established protocols, and by the physical environment within which they work. Institutional norms put a heavy burden on the shoulders of those working within as well as on those patients and family members entering for visits and stays. Health and health care institutions are complex structures and intense work places with multiple entrances, busy hallways, layered signs and postings, and with the sounds of the foreign languages of medicine, nursing, public health, and the varied allied health professionals.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Initial studies conducted in health facilities to understand the barriers faced by patients have identified multiple issues that are similar across countries and locations. They include problematic web sites and phone interactions, incomplete navigation aides and poorly placed signs; unmarked entrances, passageways, and destination points; complex maps that do not match signs or place colors; as well as jargon-filled forms for health and family background information, for legal documents such as informed consent, and for critical directions such as those for test preparations or for discharge and home care. Recommendations point to the need for orientation booklets, staff training, way finding measures, and improved documents that have been rigorously developed and tested.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Best practices call for shame free environments where patients and visitors feel comfortable asking for help, where people feel welcomed, where help is offered to all, where clear signs and postings ease the burden on patients and visitors, where materials are provided and are well-designed for use, and where talk is friendly and jargon free. Here attention must be paid to aspects of institutional culture including restrictions on professional time, procedural guidelines, and opportunities for skill building. Initial studies point to the need for awareness building, orientation for all staff, and plain language training. Change in institutional environments often requires policy regulations.The Joint Commission of Accreditation of Healthcare Organizations (2007) calls upon institutions to take action and responsibility for patient safety through attention to health literacy. The Health Literacy Roundtable of the Institute of Medicine has begun a process to promote more accessible institutions with enhanced workforce communication skills and environmental improvements.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Tools are readily available to help both clinical staff and administrators experience health care settings from the perspective of patients and visitors, to examine and assess the social and physical environments of health and health care settings, and to identify and remove barriers.<a class="elsevierStyleCrossRefs" href="#bib0150">30,33,34</a>This strategy to identify and remove literacy related barriers to services and care draws from Kurt Lewin's Force Field Theory.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Lewin calls for an identification of facilitating factors and barriers but urges attention to the removal of barriers as a first step. One cannot, for example, urge people to access information that is inaccessible or to ask questions in an environment that discourages interruptions. Attention to the physical and social environment of institutions and buildings, reducing the demands and expectations of health and health care systems, and improving communication skills of health professionals can reduce unnecessary literacy related barriers and burdens.Implications for actionSince the late 1990s, researchers in health literacy have successfully documented the links between literacy skills of individuals and health outcomes. Furthermore, they have provided evidence that a good deal of critical health information is inaccessible and that health and health care environments are complex and difficult to navigate. More studies are needed to document the positive as well as negative contribution of new communication approaches and enhanced environments. Such actions would set the foundation for comparative analyses of change strategies and the development of gold standards.While we must call on the education sector to improve the literacy skills of our populations, we in the health fields must take action to remove literacy-related barriers to information, to services, and to care. As we seek to improve health literacy, research attention and institutional resources must be provided for the removal of the barriers that constrain efficacious action and that enhance rather than inhibit patient partnerships and citizen activation for healthful change. Documented negative health outcomes as a result of the mismatch between skills and demands make a call to action imperative.Conflicts of interestThe authors have no conflicts of interest to declare." 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It draws attention to the undisputed relationship between literacy levels of the population, the complexity of health systems and health outcomes. Authors believe that instead of focusing on improving individual skills, health institutions and health care settings should concentrate their efforts on making their physical and social environment more accessible and easy to navigate for their users. A more balanced approach to health literacy action includes improving the quality and accessibility of information, professionals’ communication skills, and eliminating structural barriers to healthful action." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El artículo muestra una visión general de un área emergente en investigación sanitaria denominada alfabetismo o competencias en salud. Dicha área se centra en la relación indiscutible que existe entre los niveles de alfabetización de la población, la complejidad de los sistemas sanitarios y los resultados en salud. Según los autores es necesario que instituciones y centros sanitarios centren sus esfuerzos en crear un entorno físico y social de sus instalaciones que resulte más accesible y fácil de utilizar para sus usuarios, en lugar de centrarse únicamente en la mejora de las capacidades del paciente individual, como se viene haciendo tradicionalmente. Un enfoque más equilibrado y global sobre el alfabetismo en salud de la población incluye la mejora de la calidad y accesibilidad de la información, las habilidades de comunicación de los profesionales y la eliminación de las barreras estructurales que, en conjunto, se traduzcan en una acción saludable." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1962 "Ancho" => 2250 "Tamanyo" => 765139 ] ] "descripcion" => array:1 [ "en" => "Assessment of the health literacy environment in Catalonia." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Socioeconomic status & health chartbook. 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On health literacy and health outcomes: Background, impact, and future directions

Sobre alfabetismo y resultados en salud: antecedentes, impacto y tendencias

R.E. Rudda,

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rrudd@hsph.harvard.edu

Corresponding author.

, O.R. Groeneb, M.D. Navarro-Rubioc

a Senior Lecturer on Health Literacy, Education, and Policy, Harvard School of Public Health, United States

b London South Bank University, Faculty of Health and Social Care, United Kingdom

c Responsable del Área de Epidemiología y Salud Pública, Facultad de Medicina y Ciencias de la Salud, Universidad Internacional de Catalunya, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Health literacy&#58; an emerging area of research</span><p id="par0005" class="elsevierStylePara elsevierViewall">The social gradation in health and the links between social economic status and health status have been known to us for a long time&#46; Decades of studies indicate that income and education are&#44; together and independently&#44; predictors of health outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Until recently&#44; however&#44; little inquiry has focused on the pathways between education and health outcomes&#46; Literacy is emerging as an important pathway&#44; offering insight into how education influences health and provides opportunities for efficacious change&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Health literacy&#44; a relatively new area of research was spurred by the reports of the first international surveys of adult literacy in the 1990s<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the subsequent Adult Literacy and Lifeskills Surveys &#40;ALLS&#41; in the early part of this century&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These surveys&#44; conducted in industrialized nations and focused on the use of commonly available print materials&#44; indicated that a majority of adults in most nations have difficulty using these materials to accomplish everyday tasks with accuracy and consistency&#46; Tasks included following directions on an over the counter medicine&#44; figuring out a discount for a marketplace sale&#44; or determining which bus to take to arrive at a specific location at a specific time&#46; Shocked by these findings&#44; health researchers began to explore possible health implications&#46; In just over a decade researchers have established a strong link between literacy skills and health outcomes&#46; A substantial body of research indicates that limited literacy &#40;measured&#44; at first&#44; by reading skills&#41; is associated with limited participation in health promotion and disease detection activities&#44; with diminished management of long term chronic diseases&#44; with increased hospitalization and re-hospitalization&#44; and with increased morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition of health literacy</span><p id="par0015" class="elsevierStylePara elsevierViewall">Nutbeam notes that there are two coexisting and valid conceptualizations of the term health literacy&#58; the clinical perspective that views health literacy as a risk factor and the public health view of health literacy as a personal asset&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In both instances&#44; however&#44; health literacy is viewed as an attribute or characteristic of individuals&#46; In our research we embraced the Institute of Medicine&#39;s concept of health literacy&#44; as discussed in 2004&#44; as an interaction between skills of individuals and demands of our complex health systems&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; health literacy goes beyond the individual&#46; It also depends upon the skills&#44; preferences&#44; and expectations of health information providers&#58; our doctors&#44; nurses&#44; administrators&#44; home health workers&#44; the media and many others&#46; Health literacy arises from a convergence of education&#44; health services&#44; and social and cultural factors&#44; and brings together research and practice from diverse fields&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This focus on the interaction is relevant for researchers&#44; clinicians&#44; administrators&#44; and policy makers as they seek to understand how to develop and test efficacious programs to eliminate barriers to health information&#44; services&#44; and care&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Health literacy and health outcomes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Limited health literacy is being recognized as a serious issue for industrialized nations with both health and financial consequences&#46; Study findings have garnered a good deal of attention among health professional organizations&#44; health agencies and institutions&#44; and policy makers&#46; As a result&#44; faulty assumptions about the adequacy of adults literacy skills are being corrected and efforts are underway to determine efficacious action through education&#44; program implementation&#44; practice modification&#44; and policy change&#46; This increased interest in health literacy can be seen in the development and dissemination of focused reports and white papers&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in efforts to determine nation-wide measures of adults&#8217; health literacy skills for policy considerations<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;16</span></a> and in policy and legislative change&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The most obvious correction &#8211; improved literacy skills of adults is possible&#44; but surely requires a substantial investment in education as well as in time&#46; However&#44; in the light of documented negative health outcomes&#44; health practitioners are not content to wait for another generation of a more literate citizenry to emerge from school systems before health is improved&#46; Action must be taken now&#44; for this generation&#44; and by the health sector&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In addition&#44; patients also acknowledge the need to improve their literacy skills&#44; working along with health professionals&#46; In this context&#44; different experiences from patients organizations across countries have shown an important change from the traditional model of patients to a more active one including participation in the health decision making process&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In patients&#8217; view&#44; improved health knowledge and skills lead to empowerment and&#44; therefore&#44; a better quality of life&#46; In order to share decision-making&#44; there is a need for dialogue between and among patients&#44; family members&#44; and health providers&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Improving health literacy</span><p id="par0040" class="elsevierStylePara elsevierViewall">Unfortunately&#44; early studies of the links between literacy and health outcomes were almost exclusively focused on the literacy skills of patients and related health outcomes and so did not did offer insight into action steps beyond improving literacy skills&#46; The initial efforts to explore links between literacy and health outcomes neglected to explore factors controlled by the health sector &#8211; the quality and accessibility of information&#44; professionals&#8217; communication skills&#44; and structural barriers to healthful action&#46; These factors constitute what educators call the &#8216;demand side&#8217;&#46; Educators&#44; for example&#44; measure text difficulty before determining reading skills and assess the clarity of a speaker and the complexity of the speech before determining a listener&#39;s skills&#46; More recent health literacy studies factor in the difficulty of health materials in use&#44; the clarity of the spoken communication skills of health professionals&#44; and&#47;or the complexity of the physical and social environment of health institutions and health care settings&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This more balanced approach in health literacy includes measure of skills&#44; measures of demands&#44; as well as measures of health outcomes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">A rigorous examination of skills as well as demands resonates with a public health perspective and is modeled on epidemiology&#44; the foundation science of public health&#46; Epidemiology calls attention to the reciprocal relationship between persons and environments&#46; Environmental factors for health literacy include the plethora of information available in print&#44; on line&#44; over the airwaves&#44; and in discussion as well as the physical and social environments of health and health care institutions&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Given its importance for service utilization and health outcomes&#44; it is crucial that health professionals are aware of the impact of health literacy as well as health literacy demands on health outcomes&#46; Several recent studies on providers&#8217; awareness and perception of health literacy show that there is a general trend of physicians overestimating patient literacy and underutilizing enhanced communication techniques which are known to improve health outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Research indicates that the market place of ideas and information does not allow easy access&#46; Despite the wealth of materials available in print and on-line&#44; health information is often not accessible to the majority of people&#46; For example&#44; over 2000 peer-reviewed studies in the U&#46;S&#46; indicate that health materials across a wide swath of content areas and formats &#40;such as patient brochures&#44; discharge instructions&#44; directions for medicine&#44; instructions for procedures&#44; and even general forms&#44; lists&#44; and charts&#41; have been poorly designed or awkwardly formatted&#44; poorly written&#44; and geared to a very sophisticated audience &#8211; limiting their usefulness&#46; This strong body of evidence establishes a clear mismatch between the literacy demands of health materials and the literacy skills of adults with secondary school education&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Recommendations related to print and on-line materials include calls for more rigor in the development and design of health information with attention to vocabulary&#44; organization&#44; and clarity&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> The same scientific rigor applied to the testing of medicines and procedures are called for and suggestions include institutional review boards with well articulated minimum requirements for rigorous pilot testing with members of intended audiences&#44; evidence of revisions related to ease of use and clarity&#44; and reports of assessment processes and findings&#46; A starting point for many institutions is the design and development of critical texts that can have serious life and death consequences as well as legal and financial outcomes&#46; Such texts include directions on medicine labels&#44; discharge instructions&#44; as well as documents related to informed consent&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Furthermore&#44; emerging studies indicate that this mismatch exists for the oral exchange as well &#8211; health efforts to alert and educate the public over the airwaves as well as discussions between patients and a wide variety of clinicians&#46; Thus&#44; research findings indicate that the problem identified in health literacy studies is not entirely located in the literacy deficits of patients or members of the public&#46; Recommendations for &#8216;talk&#8217;&#44; so essential for information exchange&#44; problem identification&#44; and action are drawn from studies of professional&#47;patient communication&#46; Plain language associations are encouraging health professionals to re-learn their first language&#44; sometimes referred to as &#8216;kitchen-talk&#8217; or &#8216;living room language&#8217; for use with the public and patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Professional organizations are considering plain language as a critical skill&#44; along with other articulated communication competencies&#44; for schooling and possibly for licensing examinations&#46; In addition&#44; current best practice guidelines in health literacy call for the use of critical communication checks such as teach-back where the professional avoids the question&#58; &#8220;do you understand&#8221; and instead checks by asking for help&#58; &#8220;I want to be sure that I included all the important information about your medicine&#59; tell me what you will do&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Math is also on the agenda and represents another literacy related area often taken for granted&#46; Computational tasks are imbedded in many health activities and numerical concepts are important components of exchanges between health professionals and patients&#46; These exchanges often include basic arithmetic &#40;adding&#44; subtracting&#44; multiplication&#44; and division&#41; as well as use of percentage and higher level tasks such as estimation&#44; problem-solving&#44; and risk assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The adult literacy surveys of the 1990s and the 2000s indicate that a large proportion of adults in most industrialized nations have difficulty with higher level mathematical tasks&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Overall&#44; health literacy recommendations to improve access to information call for all health professionals to improve the clarity and quality of their written and spoken health information&#46; Although emerging studies of changes in text and in talk offer evidence of improved outcomes&#44; additional efforts focused on the communication of complex information including risk&#44; are called for&#46; Rigorous evaluative studies are needed to establish gold standards&#46; At the same time&#44; consideration must be given to professional education and licensing and to opportunities for on-the-job workforce education and training&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The health literacy environment</span><p id="par0085" class="elsevierStylePara elsevierViewall">But the burden of change cannot rest on the shoulders of health workers and professionals alone&#46; Their practices and their time allocations are shaped by institutional norms&#44; by established protocols&#44; and by the physical environment within which they work&#46; Institutional norms put a heavy burden on the shoulders of those working within as well as on those patients and family members entering for visits and stays&#46; Health and health care institutions are complex structures and intense work places with multiple entrances&#44; busy hallways&#44; layered signs and postings&#44; and with the sounds of the foreign languages of medicine&#44; nursing&#44; public health&#44; and the varied allied health professionals&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Initial studies conducted in health facilities to understand the barriers faced by patients have identified multiple issues that are similar across countries and locations&#46; They include problematic web sites and phone interactions&#44; incomplete navigation aides and poorly placed signs&#59; unmarked entrances&#44; passageways&#44; and destination points&#59; complex maps that do not match signs or place colors&#59; as well as jargon-filled forms for health and family background information&#44; for legal documents such as informed consent&#44; and for critical directions such as those for test preparations or for discharge and home care&#46; Recommendations point to the need for orientation booklets&#44; staff training&#44; way finding measures&#44; and improved documents that have been rigorously developed and tested&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Best practices call for shame free environments where patients and visitors feel comfortable asking for help&#44; where people feel welcomed&#44; where help is offered to all&#44; where clear signs and postings ease the burden on patients and visitors&#44; where materials are provided and are well-designed for use&#44; and where talk is friendly and jargon free&#46; Here attention must be paid to aspects of institutional culture including restrictions on professional time&#44; procedural guidelines&#44; and opportunities for skill building&#46; Initial studies point to the need for awareness building&#44; orientation for all staff&#44; and plain language training&#46; Change in institutional environments often requires policy regulations&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The Joint Commission of Accreditation of Healthcare Organizations &#40;2007&#41; calls upon institutions to take action and responsibility for patient safety through attention to health literacy&#46; The Health Literacy Roundtable of the Institute of Medicine has begun a process to promote more accessible institutions with enhanced workforce communication skills and environmental improvements&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Tools are readily available to help both clinical staff and administrators experience health care settings from the perspective of patients and visitors&#44; to examine and assess the social and physical environments of health and health care settings&#44; and to identify and remove barriers&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;33&#44;34</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">This strategy to identify and remove literacy related barriers to services and care draws from Kurt Lewin&#39;s Force Field Theory&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Lewin calls for an identification of facilitating factors and barriers but urges attention to the removal of barriers as a first step&#46; One cannot&#44; for example&#44; urge people to access information that is inaccessible or to ask questions in an environment that discourages interruptions&#46; Attention to the physical and social environment of institutions and buildings&#44; reducing the demands and expectations of health and health care systems&#44; and improving communication skills of health professionals can reduce unnecessary literacy related barriers and burdens&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Implications for action</span><p id="par0110" class="elsevierStylePara elsevierViewall">Since the late 1990s&#44; researchers in health literacy have successfully documented the links between literacy skills of individuals and health outcomes&#46; Furthermore&#44; they have provided evidence that a good deal of critical health information is inaccessible and that health and health care environments are complex and difficult to navigate&#46; More studies are needed to document the positive as well as negative contribution of new communication approaches and enhanced environments&#46; Such actions would set the foundation for comparative analyses of change strategies and the development of gold standards&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">While we must call on the education sector to improve the literacy skills of our populations&#44; we in the health fields must take action to remove literacy-related barriers to information&#44; to services&#44; and to care&#46; As we seek to improve health literacy&#44; research attention and institutional resources must be provided for the removal of the barriers that constrain efficacious action and that enhance rather than inhibit patient partnerships and citizen activation for healthful change&#46; Documented negative health outcomes as a result of the mismatch between skills and demands make a call to action imperative&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Article information

ISSN: 1134282X
Original language: English

DOI:10.1016/j.cali.2013.03.003

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Year/Month	Html	Pdf	Total

2024 November	4	5	9
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2024 September	72	19	91
2024 August	66	18	84
2024 July	36	10	46
2024 June	36	6	42
2024 May	33	7	40
2024 April	47	14	61
2024 March	65	15	80
2024 February	82	10	92
2024 January	149	8	157
2023 December	59	14	73
2023 November	85	25	110
2023 October	93	20	113
2023 September	59	12	71
2023 August	57	15	72
2023 July	56	11	67
2023 June	48	4	52
2023 May	84	10	94
2023 April	77	9	86
2023 March	116	13	129
2023 February	78	17	95
2023 January	172	17	189
2022 December	202	17	219
2022 November	114	13	127
2022 October	76	16	92
2022 September	80	34	114
2022 August	192	40	232
2022 July	57	13	70
2022 June	53	37	90
2022 May	54	18	72
2022 April	67	17	84
2022 March	66	13	79
2022 February	32	9	41
2022 January	67	12	79
2021 December	41	14	55
2021 November	45	15	60
2021 October	44	14	58
2021 September	58	13	71
2021 August	68	19	87
2021 July	37	14	51
2021 June	50	21	71
2021 May	40	11	51
2021 April	125	35	160
2021 March	84	15	99
2021 February	44	11	55
2021 January	52	17	69
2020 December	79	10	89
2020 November	83	12	95
2020 October	34	17	51
2020 September	26	13	39
2020 August	34	16	50
2020 July	44	18	62
2020 June	36	10	46
2020 May	52	19	71
2020 April	62	10	72
2020 March	50	19	69
2020 February	58	18	76
2020 January	56	32	88
2019 December	63	20	83
2019 November	66	18	84
2019 October	57	17	74
2019 September	47	16	63
2019 August	43	21	64
2019 July	36	17	53
2019 June	75	41	116
2019 May	172	86	258
2019 April	70	27	97
2019 March	23	8	31
2019 February	16	13	29
2019 January	13	5	18
2018 December	6	9	15
2018 November	14	33	47
2018 October	26	14	40
2018 September	14	1	15
2018 August	10	3	13
2018 July	5	3	8
2018 June	10	2	12
2018 May	11	1	12
2018 April	9	1	10
2018 March	11	5	16
2018 February	8	0	8
2018 January	17	1	18
2017 December	10	0	10
2017 November	20	1	21
2017 October	19	3	22
2017 September	20	6	26
2017 August	20	5	25
2017 July	36	4	40
2017 June	28	6	34
2017 May	23	3	26
2017 April	30	2	32
2017 March	29	28	57
2017 February	27	2	29
2017 January	14	2	16
2016 December	35	3	38
2016 November	29	3	32
2016 October	56	5	61
2016 September	31	7	38
2016 August	24	6	30
2016 July	22	1	23
2016 June	47	17	64
2016 May	33	11	44
2016 April	31	26	57
2016 March	28	14	42
2016 February	23	11	34
2016 January	26	12	38
2015 December	29	13	42
2015 November	32	10	42
2015 October	24	10	34
2015 September	23	10	33
2015 August	15	8	23
2015 July	16	6	22
2015 June	9	3	12
2015 May	8	25	33
2015 April	0	9	9
2015 March	0	2	2
2015 January	1	0	1
2014 October	1	1	2
2014 September	1	0	1
2014 August	1	1	2
2014 June	2	1	3
2014 May	2	1	3
2014 April	0	1	1
2014 March	23	11	34
2014 February	26	3	29
2014 January	22	11	33
2013 December	26	9	35
2013 November	16	4	20
2013 October	15	8	23
2013 September	7	3	10
2013 August	12	1	13
2013 July	10	7	17
2013 June	3	3	6
2013 April	159	0	159

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