Health literacy influences how patients are able to advocate for themselves when interacting with care providers. Unfortunately, a staggering percentage of adults in the United States fall below proficient in health literacy, making it difficult to navigate conversations within the healthcare system.
Julie Gaspar, BSN, RN, PCCN, and Jessica Phillips, MSN, RN, NPD-BC, (PhD-c), who are presenting on health literacy and health equity at the 2023 ANPD Aspire Convention, discussed the consequences of inadequate health literacy levels as they pertain to patients receiving care.
Only 12% of Adults Are Proficient in Health Literacy
The U.S. Department of Health and Human Services performed a nationally representative assessment called the National Assessment of Adult Literacy, and this was the first large-scale assessment in the U.S. that had a component measuring health literacy,” said Gaspar. “That assessment found that an estimated 12% of U.S. adults had health literacy ranked as proficient, which means they had health literacy levels sufficient enough to navigate all aspects of the U.S. healthcare system. The other 88% of the U.S. population were ranked anywhere from intermediate health literacy, basic health literacy, or below basic health literacy.”
According to Gaspar, lower literacy rates correlate to what she refers to as an information revolution. As technological and information-sharing capabilities have expanded, interpretation of health information by the broader population has stagnated. While more than half of American adults read at a fifth-grade level or below, most health education materials are written at a 10th-grade level or above.
“It really is an urgent necessity for U.S. educational systems, both for children and adults, to expand their respective health literacy curriculum,” said Phillips. “This includes training on health literacy amongst healthcare professionals. Additionally, we haven't completely understood and therefore framed health literacy as a social determinant of health that really drives many of our health disparities that we're seeing in our patients.”
Low Health Literacy Connected to Poor Health Outcomes
Health literacy encompasses several components and has become the epicenter of improving patient outcomes. Patients need to feel they have access to meaningful information that provides them with the power to make informed choices to improve their quality of life. Statistics show that lower levels of health literacy correspond with higher mortality rates, more emergency room visits, and other challenges.
“Health literacy is really about being able to first obtain health information, understand that information, and then act on it in order to improve your health,” said Gaspar. “Patients with low health literacy have higher susceptibility to following treatments based on misinformation, and they incur four times the cost as those with high health literacy. This results in an extra $236 billion in cost to the U.S. healthcare sector per year. According to Phillips, this is the reason why the U.S. Department of Health and Human Services created a national action plan to improve health literacy. Additionally, the CDC also convened an expert panel to improve health literacy, while the World Health Organization has identified and signified health literacy as key to achieving their 2030 goals.”
Information gaps have exacerbated the health literacy epidemic in the U.S., and organizational health literacy information exists as the root cause. Organizational health literacy is about an entire health system rallying around the cause of improving health literacy outcomes. Unfortunately, information measurement relative to measuring an organization’s success in improving health literacy remains sparse.
“Organizational health literacy is a term that was coined by the U.S. Department of Health and Human Services. It's since also been taken up by the CDC, and it refers to an institution's ability to equitably meet the information and service needs of patients who have a range of health literacy levels,” said Gaspar. “Another large information gap that exists has to do with comparing health literacy levels across populations.”
Phillips and her organization have prioritized a focus on data collection and educational infrastructure development in an effort to improve health literacy among their patients. She acknowledges that data capture and dissemination need improvement in order to fully understand how literacy rates in the U.S. compare to other populations.
“Unfortunately, there's very limited data and research, specifically on racial and ethnic disparities, quality of life indices, and health literacy of adults in the United States,” said Phillips.
Health literacy rates show variations between different ethnic groups with the highest literacy rates in the U.S. being among those who identify as White or Asian Pacific Islander and the lowest being among those who identify as Black or Hispanic. Additionally, those of an older age or lower socioeconomic status often experience lower health literacy rates.
“I think it's important to avoid generalizing or stigmatizing certain populations. The CDC and the AHRQ have recommended taking a standard precautions approach, which means that every patient should be provided health education at the same level,” said Gaspar. “We should assume there are health literacy level issues present in all of our patients, and this is because anyone from any group can be impacted by low health literacy, even patients who generally have high overall literacy levels.”
Building a Bridge to Health Literacy
According to Phillips, the causes of lower health literacy rates are all an interplay of the five domains within the social determinants of health.
“Organizational health literacy is truly the most critical social determinant of health, and I say this because the research and available evidence suggests that if we improve health literacy, it can impact socioeconomic factors that contribute to overall health disparities,” said Phillips. “If we improve health literacy, patients may become more empowered to not only improve their health, but also potentially their education in the process, which may lead to improvements in socioeconomic status, neighborhood and physical environments, and their interactions within those environments and social support networks.”
It’s widely accepted that much can be done to improve health literacy rates and equity in health care. Gaspar asserts that routine assessments of patient-facing communications are an integral first step in improving literacy and readability.
“In conjunction with these assessments, organizations can develop and implement education to make sure it meets a mandated literacy grade level of fifth grade,” said Gaspar. “Another thing we can do is routinely assess and track literacy in all inpatients. At UCLA, we use what we call the SILS-2 Assessment, which is a very well-validated, informal, single question that you can ask patients. We take that literacy assessment, and we use it to track data such as admission rates tied to health literacy, readmissions, social determinants of health, as Jessica mentioned, and mortality rates tied to health literacy. Those tracking mechanisms really allow us to identify appropriate intervention measures. It’s also increasingly important to invest in the ongoing education of your health care clinicians.”
To Phillips, the ANPD Scope and Standards of Practice aids nursing professional development (NPD) practitioners in identifying opportunities to address social determinants of health in their practice and close glaring gaps in health care.
“By interweaving these standards with the social determinants of health, we're essentially building an educational infrastructure for our workforce, and a bridge for our patients in which healthcare information can now move from being very confusing and maybe misunderstood, to clear and comprehendible,” said Phillips. “This results in better safety and health outcomes, potentially lower costs, and a reduction of this burden and pressure on health care systems at a time when we really need to reduce some of that pressure post-pandemic. In building this bridge for our patients, we are essentially building a bridge for ourselves and NPD practice.”