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Health Literacy and Health Policy

  • Laura P. Shone
    Correspondence
    Address correspondence to Laura P. Shone, DrPH, MSW, Departments of Pediatrics, Clinical Nursing, and the Center for Community Health, University of Rochester Medical Center, 601 Elmwood Avenue, Box 777, Rochester, NY 14642.
    Affiliations
    Departments of Pediatrics, Clinical Nursing, and the Center for Community Health, University of Rochester Medical Center, Rochester, NY
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      Health literacy skills allow individuals to obtain, process, understand, and communicate information about health, as well as function in the health care system and make informed health decisions.
      • Berkman N.D.
      • Davis T.C.
      • McCormack L.
      Health literacy: what is it?.
      Health literacy can also play an important role in successful implementation of health policies.
      • Martin L.T.
      • Parker R.M.
      Insurance expansion and health literacy.
      Health literacy is therefore recognized as “…one of the top four national priorities for public health”,

      US Department of Health and Human Services (USDHHS). Public Health Priorities. Office of the Surgeon General. Available at: http://www.surgeongeneral.gov.publichealthpriorities.html. Accessed September 30, 2010.

      with health literacy research “becoming foundational in reforming health and health care in the United States”.
      • Parker R.
      • Ratzan S.C.
      Health literacy: a second decade of distinction for Americans.
      Two articles in this issue illustrate specific health literacy-related challenges that can confront parents: 1) the renewal application process for publicly subsidized health coverage; and 2) the use of common pediatric over-the-counter (OTC) medicines. Health professionals often play a crucial role in helping parents understand and use health-related information; however, these two activities typically require parents to act without the benefit of advice from a health care professional. Therefore, parents' success in navigating these tasks can be heavily influenced by the underlying policy-level decisions that govern how materials are designed, implemented, and evaluated. By examining these two challenges, results of the studies by Pati et al
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      and Yin et al,
      • Yin S.
      • Parker R.M.
      • Wolf M.S.
      • et al.
      Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
      respectively, have implications for two areas of active health policy change: health insurance reform and labeling of pharmaceutical products.
      With regard to health coverage, Pati et al
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      examined the reading level of Medicaid renewal forms in 50 states and the District of Columbia, using three well-validated reading-level analysis tools. The authors found that although 46 states/DC had reading-level guidelines (ranging from 3rd to 8th grade), comparison of state Medicaid forms to these guidelines revealed that over half exceeded the state's guidelines by one to six grade levels.
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      This discrepancy is important because more than 50% of uninsured and 60% of Medicaid enrollees have basic or below basic health literacy, a challenge faced by more than a third of US adults.
      • Doak C.
      • Doak L.
      • Root J.
      Teaching patients with low literacy skills.
      Hence, these or similar forms will likely be difficult to read and potentially unusable by many of the individuals who are most likely to encounter them.
      The findings of Pati et al
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      support the need for a uniform Federal usability standard for public program materials, and the need for accountability strategies to monitor adherence to uniform guidelines, once set. It remains difficult, however, to identify a single optimal grade-level standard, because most adults read roughly five grade levels below the highest grade completed in school.

      National Center for Education Statistics. US Department of Education. The 2003 National Assessment of Adult Literacy (NAAL). Available at: http://nces.ed.gov/naal/health.asp. Accessed September 30, 2010.

      However, although the reading level is commonly used alone, additional factors influence the usability of documents and materials, including “sentence length, word choice, organization, tone, layout, use of illustrations, and relevance to readers”.
      • Osborne H.
      Health literacy from A to Z: practical ways to communicate your health message.
      This more comprehensive set of factors, including but not limited to reading level, should be considered together in a potential Federal standard for usability – in research and in practice – rather than considering reading level alone.
      With regard to use of OTC medicines, Yin et al
      • Yin S.
      • Parker R.M.
      • Wolf M.S.
      • et al.
      Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
      conducted a descriptive study of packaging (bottles and boxes) for the 200 most common nonprescription liquid medicines for children younger than 12 years of age. The authors focused specifically on presentations of: 1) the active ingredient and 2) the dosing instructions found on the Principal Display Panel and the Food and Drug Administration Drug Facts panel for each medication. They report that although most products met Food and Drug Administration requirements for content, packages were inconsistent in the placement and layout of information (eg, small or variable font size; brand name or product flavor more prominent than active ingredients), any of which could interfere with parents' understanding of the active ingredient or dosing instructions. Such understanding is essential to prevent unintentional harm from mismeasurement or from inadvertently taking too much of the same active ingredient in more than one product. The authors highlight opportunities to incorporate evidence-based health literacy strategies in product labeling
      • Yin S.
      • Parker R.M.
      • Wolf M.S.
      • et al.
      Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
      to improve the clarity and placement of this information (ie, on the outer box AND on the inner bottle). Examples of evidence-based strategies include: 1) using plain language in a large clean font with ample white space; 2) prioritizing messages and limiting extraneous material; 3) using font size and placement to emphasize priority information; and 4) breaking text into smaller, more manageable “chunks”.
      • Doak C.
      • Doak L.
      • Root J.
      Teaching patients with low literacy skills.
      Collectively, the findings reported by Pati et al
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      and Yin et al
      • Yin S.
      • Parker R.M.
      • Wolf M.S.
      • et al.
      Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
      illustrate challenges that may confront parents in performing two common tasks in caring for child health: using the application forms needed to maintain health coverage, and using common pediatric OTC medicines. They illustrate how activities that are already challenging can be further complicated by lack of attention to health literacy and principles of clear communication. Yet, even when evidence-based strategies exist and requirements are in place to use them, three challenges remain: 1) lack of accountability and monitoring to ensure that guidelines are being met; 2) lack of built-in mechanisms to measure outcomes and impact; and 3) lack of uniformity in health literacy guidelines for usability, resulting in too much variation to evaluate health impact even if measures did exist.
      Further efforts are clearly needed to close these gaps in the existing process, from creating and implementing guidelines to measuring and monitoring aspects of the implementation process as well as outcomes. Importantly, in identifying gaps, the results presented by Pati et al
      • Pati S.
      • Kavanagh J.
      • Bhatt S.J.
      • et al.
      Reading level of Medicaid renewal applications.
      and Yin et al
      • Yin S.
      • Parker R.M.
      • Wolf M.S.
      • et al.
      Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
      also point to opportunities within current areas of active health policy change, to integrate health literacy principles in order to close these gaps. Health policy and subsequent guidelines can call for and operationalize the use of evidence-based best practices for health literacy. They can call for uniform standards to minimize inter-state variation and they can consider more comprehensive factors in usability – beyond reading level alone. They can also call for accountability – for guidelines to be monitored as well as implemented. Health policy that incorporates health literacy principles in these and other ways can lead to actionable changes that can improve communication and health-related experiences, protect those with low health literacy, and ultimately affect health.

      References

        • Berkman N.D.
        • Davis T.C.
        • McCormack L.
        Health literacy: what is it?.
        J Health Commun. 2010; 15: 9-19
        • Martin L.T.
        • Parker R.M.
        Insurance expansion and health literacy.
        JAMA. 2011; 306: 874-875
      1. US Department of Health and Human Services (USDHHS). Public Health Priorities. Office of the Surgeon General. Available at: http://www.surgeongeneral.gov.publichealthpriorities.html. Accessed September 30, 2010.

        • Parker R.
        • Ratzan S.C.
        Health literacy: a second decade of distinction for Americans.
        J Health Commun. 2010; 15: 20-33
        • Pati S.
        • Kavanagh J.
        • Bhatt S.J.
        • et al.
        Reading level of Medicaid renewal applications.
        Acad Pediatr. 2012; 12: 297-301
        • Yin S.
        • Parker R.M.
        • Wolf M.S.
        • et al.
        Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.
        Acad Pediatr. 2012; 12: 288-296
        • Doak C.
        • Doak L.
        • Root J.
        Teaching patients with low literacy skills.
        2nd ed. JB Lippincott Co, Philadelphia, PA1996
      2. National Center for Education Statistics. US Department of Education. The 2003 National Assessment of Adult Literacy (NAAL). Available at: http://nces.ed.gov/naal/health.asp. Accessed September 30, 2010.

        • Osborne H.
        Health literacy from A to Z: practical ways to communicate your health message.
        Jones and Bartlett Learning, Burlington, MA2013