The public health importance of improving health literacy.

The US National Library of Medicine definition of 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.”1 With the expansion of the number of insured in the United States as a result of health reform, several of the Affordable Care Act (ACA) provisions address health literacy.2 There is an enhanced effort in play with the ACA to increase the education of the health workforce dealing with English as a second language and enhanced provider appreciation of health literacy issues.3 The projected number of newly insured provides both an opportunity and an issue that needs addressing – how to ensure the most positive outcomes for many that have never experienced having health insurance. The difficulties that many encounter in navigating the health care system because of health illiteracy have the potential to reach unacceptable degrees of negative consequences. For a significant period, the focus pertaining to health literacy has been on identifying deficits of the general public and/or patients.4 The importance of this focus will not diminish nor should it not be ameliorated. However, with the emerging need to address providers and improving health professional attention on health literacy, Rudd has noted: “If we forge a better match between the expectations and processes of the system and the skills of US adults, we can solve the problem of health literacy and reduce barriers to good health.”4, pp.2284-2285. Those already within a health-insured framework have been shown to suffer negative health outcomes due to health illiteracy. In a well-designed and accomplished study in an integrated health managed care organization in the state of Colorado, low health literacy was found to be significantly associated with higher mortality due to all causes of death.5 This study tracked patients for over a year post discharge and the impact of the health literacy was independently associated with the mortality outcome. The patients in this 2011 study with both health insurance and access to health information points to the breadth of the negative impact of low health literacy even among patients with advantageous health options available.5 Federal efforts aimed at health literacy awareness and impact of the ACA are noble efforts. US Health and Human Services Undersecretary Koh and colleagues6 have noted: “The promises of medical research, health information technology, and advances in health care coverage and delivery can be realized only if our nation addresses the challenge of limited health literacy.”6(p439) However, some federal efforts have fallen short. A recent study examining the readability, suitability, and comprehensibility of medications guides with patients with limited health literacy is instructive of how “one shot fits all” approaches have not and will not be successful in impacting health illiteracy.7 The results of this study examining 185 of the Food and Drug Administration (FDA) approved medication guides found that the guides had a mean reading level of the 10th to11th grade.7 The average reading level in the US population is at the 7th grade level.7 Within the study, the understanding of the medication guides was poor, the mean level of correct responses was 52.7%, and marginal literacy was associated with poor understanding.7 The authors concluded that the current FDA medication guides were of little value to patients due to complexity and difficulty of patients’ understanding the content.7 Efforts to enhance proper use of medications and subsequent outcomes have been influenced by health illiteracy. For example, problems with health literacy have proven to be difficult to overcome with medication reconciliation efforts.7 Our efforts within the academy, the profession of pharmacy, and our affiliated health professions need to be enhanced with the training of our future health professionals. The problems accumulating due to health illiteracy will not abate with more receiving insurance and succeeding provision of care. Efforts focusing on training, implementing changes within our curricula, continuing education efforts for current practitioners, and outreach activities with community group and patients and representatives are called for to positively impact this public health concern.