Low Literacy: A Health Care Quality Issue 

By Brigette Settles Scott, MA


Closing the Gap, First Summit Packs the House • January/February 2003


Take two tablets by mouth every six hours. When lying down, Racial and ethnic minorities with basic English skills are more 

elevate limbs above heart level to reduce swelling. Simple likely to have low health literacy.The National Adult Literacy Survey 

instructions? For some. Yet many Americans cannot under­ (NALS) data concluded that African American, American Indian/ 

stand common medical terms or follow their doctors’ instructions. Alaska Native, Hispanic, and Asian American/Pacific Islander adults 

Very few adults in the U.S. are truly illiterate, but there are many were more likely than White adults to perform in the lowest two 

adults with low literacy skills who lack the foundation they need to literacy levels. “Fewer years of schooling and English as a second lanfind and keep decent jobs, support their children’s education, and guage are important contributing factors. Twenty-five percent of those 

properly manage their health, accord­ with the lowest level of literacy skills 

ing to the National Institute for Lit- were immigrants. Lack of facility in 

eracy (NIFL). “Health literacy impacts the English and lack of knowledge about 

“Year 2000 statistics indicate that quality of health and healthcare.” the U.S. healthcare system and its norms 

45 percent of the adult population, or and expectations compound the prob90 million people, perform at Levels 1 lem for these individuals,” added Baur. 

or 2 (8th grade or below reading level),” said Carolyn Staley, deputy According to the non-profit Center for Health Care Strategies of 

director, NIFL, as she opened the Summit session-Health Literacy and Lawrenceville, NJ, patients with poor reading skills have a hard time 

Quality Health Care. understanding basic medical instructions, have difficulty complying 

Almost all adults in Level 1 can read a little but not well enough with their recommended treatments, and struggle to understand even 

to fill out an application, read a food label, or read a simple story to a basic medical forms. People who have difficulty reading are often 

child. Adults in Level 2 usually can perform more complex tasks such ashamed and hide their illiteracy from health care providers. 

as comparing, contrasting, or integrating pieces of information, but Currently, the full scope of the health literacy problem is unusually not higher-level reading and problem-solving skills. Literacy known. There have been some extrapolations from data collected in 

experts believe that adults with skills at Levels 1 and 2 lack a sufficient the NALS, although it assessed literacy skills rather than health litfoundation of basic skills to function successfully in our society. eracy. “In general, we estimate that about 50 percent of Englishspeaking adults in the U.S. have limited enough literacy skills that 

Health Literacy they would have trouble handling some of the more basic, routine 

aspects of health and healthcare activities, such as taking medication 

Loosely defined, health literacy is the degree to which people can in a correct dose and on schedule,” explained Baur. “For the first time, 

obtain, process, and understand the basic health information and beginning in 2002, there will be a national assessment of health litservices they need to make appropriate health decisions. eracy. The data that we will get from the 2002 National Assessment of 

“Health literacy impacts the quality of health and healthcare,” Adult Literacy (NAAL), which is being sponsored by the National 

said Dr. Cynthia Baur, health communication and e-health advisor Center for Education Statistics, U.S. Department of Education, will 

from the Office of Disease Prevention and Health Promotion. “Read­ give us the first national estimates of the scope of the problem, at least 

ing health information materials, following prevention recommenda­ for the adult English-speaking population.” 

tions, filling out insurance forms, explaining the nature of a health 

problem, adhering to medication regimens, reading and signing informed consent documents-—each of these routine tasks requires functional health literacy skills that we estimate a large segment of the adult 

U.S. population does not have. Moreover, many adults who do have 

low health literacy do not acknowledge it as a problem. They may be 

too ashamed, or they have developed coping mechanisms to deal with 

their limited skills. Yet, there is danger in leaving health literacy a 

hidden problem. The implications of limited health literacy for patient safety, medical errors, health status, and overall quality are enormous. Consider the implications if 25 percent of the adult population 

cannot read and understand directions, such as ‘take four tablets daily 

by mouth.’” 

Making the Connection 

Professionals in the health community have long recognized that 

low literacy can be a barrier to quality health care. Likewise, literacy 

professionals have found that health is a topic often asked about most 

in the educational setting. So, would it make sense to simply marry 

the two? 

Charged with making this connection, Health Literacy El Paso 

(HLEP) was created to develop and implement a health literacy program to serve academically and economically disadvantaged Texas 

residents, so that they might have a better understanding of healthrelated issues, take an active role in preventing health problems, access 

Low Literacy: A Health Care Quality Issue is based on the 

Summit workshop Health Literacy and Quality Health 

Care, Thursday, July 11, 2002. 

available health services, and improve their understanding of the 

healthcare system. 

continued on page 2>>>> 

Office of Minority Health Resource Center 1 U.S. Department of Health and Human Services 
Low Literacy: A Health Care Quality Issue 

By Brigette Settles Scott, MA


Closing the Gap, First Summit Packs the House • January/February 2003


Since its formation in 1998, HLEP has been incorporating health 

messages into its adult education and GED programs offered at El 

Paso Community College. “Philosophically, we believe that the best 

way to learn or improve communication and math skills in adults is to 

engage topics that have meaning to the participants,” said Andres 

Muro, manager, of the El Paso Community College, Community 

Education Program. “Instead of using a textbook that was published 

some time ago, we introduce topics that affect their lives directly and 

have an impact. For example, if while learning to read or write, I’m 

learning to fill out a questionnaire that may be used in a doctor’s office, 

or if reading about diabetes, cancer, or heart disease among Hispanics 

piques my curiosity, I’m going to have a greater desire to learn that 

information because it’s something that affects me, my children, my 

spouse, and so on.” 

HLEP students range in age from 18 and up, but the majority 

are women, 30-35 years old, of Mexican ancestry, with one to two 

children. Because of this demographic, the emphasis on health issues 

is well received by program participants. To work the health information into the curriculum, classroom teachers partner with health educators already working in the community. The program uses local 

health service providers, such as the county hospital, local health clinics, and the city health offices, as well as national consumer organizations like Planned Parenthood, the American Diabetes Association, 

and the American Cancer Society. Representatives from these agencies come into the classroom and speak on a given health topic. The 

classroom teacher then incorporates their information into instruction. Breaking news items are mixed into lessons to add clarity and 

increase understanding. 

One hot issue in El Paso is the high level of lead and arsenic in the 

environment as the result of a recycling plant that has allegedly polluted a large area of the community. 

“Our instructor is incorporating this news and its impact on the 

health status of El Paso residents by integrating it into a discussion on 

the periodic table of elements, and how these chemicals in certain 

forms can be harmful to your health,” explained Muro. 

Are We There Yet? 

The idea of incorporating health information into every aspect of 

general education is new. Too many may recall their high school 

experiences, of having health education taught for a semester by someone like a football coach, whether or not the instruction was effective. 

“In practice, there are still some barriers that have to do with 

professional development and training, that our teachers and health 

educators have to receive to turn health information into something 

that can be well received by the students,” Muro said. “There’s still a 

lot of work to be done. The whole idea that we are trying to implement is new. Some teachers are having difficulty changing their way 

of thinking about teaching. They want to teach from a book. They 

want to start on page 1 and end on page 10, with multiple-choice 

questions on tests. To tell teachers not to use a textbook and instead 

use a handout from the local health department for a lesson is difficult. Likewise, the students themselves expect a traditional class with 

textbooks. So, when you want to do something that is non-traditional, they resist. With resistance from the students, and resistance 

from the teachers, it requires a lot of work on our part. But, we believe 

it’s worth it.” 

Results from HLEP’s initial evaluation demonstrate that the approach is making an impact on the community. Of the 500 participants in the program, 400 were screened for diabetes and all female 

participants (90 percent of the total) received information on breast 

cancer and learned to perform a breast self-examination. Male participants were instructed in testicular self-examination, and 160 participants now have primary health insurance where they were once uninsured. 

“HLEP has had a significant and beneficial impact on the El Paso 

community,” concluded Muro. 

For more information on Health Literacy El Paso and the curriculum, go to http://www.worlded.org/us/health/docs/elpaso/ 

index.htm. 

To reach Andres Muro, e-mail him at andresm@epcc.edu. For more 

information on literacy, visit the National Institute for Literacy at http:/ 

/www.nifl.gov

Office of Minority Health Resource Center 2 U.S. Department of Health and Human Services