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Health Literacy and Measurement
Paper instructions:
Health Literacy
Review the three types of health information services: clinical, prevention, and navigation of the healthcare system. attached file…
Choose one of the three types and analyze and address potential barriers to health literacy.  How would you go about trying to enhance health literacy or reduce
barriers to literacy in that particular situation?
Assignment must be at least three pages (excluding title and reference pages) and must include at least three scholarly references.
Measurement
The HLC includes three types of health information and services: clinical, prevention, and navigation of the healthcare system. They are key types of health and
healthcare information and services that the general population in the United States might be likely to encounter. The stimulus materials and the associated items in
the HLC were selected to fit these types.
•    The clinical type includes those activities associated with interactions between the healthcare provider and the patient, clinical encounters, diagnosis and
treatment of illness, and medication. Examples include filling out a patient information form for an office visit, understanding dosing instructions for medication,
understanding steps for the self-management of acute and chronic illness, following a healthcare provider’s recommendation for a diagnostic test, and providing
accurate information in a medical history, either verbal or written.
•    The prevention type includes those activities associated with maintaining and improving health, preventing disease, intervening early in emerging health
problems, and engaging in self-care and healthy behaviors. Examples include following guidelines for age-appropriate preventive health services, identifying signs and
symptoms of health problems that should be addressed with a health professional, and changing eating and exercise habits to decrease risks for the development of
serious illness.
•    The navigation of the healthcare system type includes those activities related to understanding how the healthcare system works and individual rights and
responsibilities. Navigation requires being familiar with the vocabulary, concepts, and processes needed to use the healthcare system. Examples include understanding
covered and noncovered benefits for health insurance plans, determining eligibility for public assistance programs, and being able to give informed consent for a
healthcare service.
The question has been raised as to whether the objective should be reworded as a population objective so that data on the health literacy skills of the entire U.S.
population, instead of only those with marginal or inadequate literacy skills, would be measured and reported.
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Issues Pertaining to Measurement
The objective was formulated as an assessment of individuals’ health literacy skills. Individuals’ skills, however, are only one part of the complex health literacy
phenomenon. Healthcare providers, creators of health information and education materials, and the healthcare and public health systems bear a large part of the
responsibility for having created materials, ways of communicating, and systems that are far too technical and complicated to meet the needs of the vast majority of
the populations they serve. Consequently, the burden for change, at least in the short term, lies with healthcare providers, public health professionals, and
healthcare and public health systems, in partnership with adult literacy programs, to reach those with limited literacy. Long-term, educational programming can work to
raise the general literacy levels of the population and to incorporate training in navigating health systems. Any assessment of individuals’ health literacy skills,
therefore, must be interpreted in light of the systemic factors that strongly influence individuals’ capacity to demonstrate health literacy.
Shame associated with poor literacy skills may be an important factor in obtaining an accurate account of the population’s health literacy skills. Individuals with
poor literacy skills are often very uncomfortable that they cannot read well, and they develop strategies to compensate. Depending on the method of assessment,
individuals may use these strategies to appear to have higher literacy skills than they actually do.
The assessment of health literacy in a population is also influenced by the reading levels of health materials, the skills of individuals, the communication abilities
of health professionals, and the organization of delivery systems for health information and services. Although the literacy and verbal skills of individuals are of
critical importance, so too are the demands made by the health materials themselves, the communication skills of those in the health field, and the complicated nature
of the healthcare and public health systems. The dimensions of these additional factors are briefly examined in the following.
•    Functional literacy measures incorporating currently available health materials do not offer a sufficient assessment of health literacy.
The NAAL’s health literacy measures will be based on common, widely used health information materials. However, three decades of studies published in medical and
public health journals indicate that most health materials fall into reading-level ranges requiring high school, college, or graduate degrees (Rudd, Moeykens, and
Colton, 1999) and often contain jargon and scientific terms rather than everyday or plain language. Additional measures will be needed to monitor improvements in the
format, content, and structure of health materials prepared for the public. The current reading level and demands of health-related materials should be compared with
rewritten and newly formatted materials over time.
Most currently used assessment tools are designed for examinations of prose materials presented in sentence and paragraph format. However, a good deal of health-
related print materials are prepared in document format using phrases, lists, and bullets rather than full sentences and paragraphs. Published studies of health
materials suggest that health researchers have not applied the document assessment tool developed by Mosenthal and Kirsch (1998).
Many critical health-related materials are written in open-entry format (e.g., medical history forms, insurance forms, in-take forms, research queries). The field
would benefit from the development of assessment measures and open-entry format for health documents.
•    Health literacy assessments are too narrowly focused on the ability of individuals to use the written word.
Linguists and reading experts have established links among a variety of skills such as reading, verbal presentation, and oral comprehension (Snow, 1991; Cunningham and
Stanovich, 1998). In medical care settings, patients are expected to offer health histories and descriptions of symptoms and to listen to and comprehend verbal
instructions. Adults are expected to understand, navigate, and meet the demands of bureaucracies and institutions to access entitlement programs and services. In the
community, adults are encouraged to be aware of and act on health-related news and announcements. Each of these settings presents its own set of health literacy
demands and requires different mixes of skills, which should be assessed.
Health communications routinely include written as well as audio and video materials, messages on radio and television, and verbal presentation for information,
diagnosis, and consent. An expanded examination of health-related materials must include information presented on tapes, videos, compact discs, and the Web (Stauffer
et al., 1978; D’Alessandro et al., 2001). Research is also needed to assess how easily these different materials are used by low-literate populations and how well they
can understand messages in these formats.
•    Health professionals’ skills and the burdens of medical jargon, technical language, and complicated bureaucratic processes affect health literacy.
Patients’ ability to understand health and medical issues and directions is related to the clarity of the communication. Consideration needs to be given to the verbal
as well as written communication skills of medical and public health practitioners. Factors of class, age, race, ethnicity, country of origin, gender, geography,
health status, and (because family members may be part of the healthcare episode) family dynamics and roles may affect how patients interact with their healthcare
providers and their ability to take actions to improve their health.
Official documents, including informed consent forms, social services forms, and public health and medical instructions, as well as health information materials often
use jargon and technical language that make them unnecessarily difficult to use. Reductions in the assessed reading levels of forms, instructions, and informational
materials are insufficient. The amount of jargon and technical language could be reduced with greater adoption of plain language.
•    Special consideration should be given to the conduct of health literacy assessments of persons with limited proficiency in English.
Assessments of health literacy for those with limited proficiency in English have some special challenges. Limited proficiency in English may make it difficult if not
impossible for individuals to complete a health literacy assessment in English. Translation of the assessment into native languages is often not an adequate solution.
Translators are typically from a different social class and speak different dialects or even languages than poor and working class individuals who are most frequently
those with limited proficiency in English. In addition, limited proficiency in English is itself a barrier to accessing many types of health information and services,
and, consequently, individuals may not have enough experience with a broad spectrum of health information and services to complete a standard health literacy
assessment in English or their native language. Translation also is not an adequate solution because individuals may have limited literacy and oral communication
skills in their native languages. Even translated materials may be too complex in presentation, writing style, and vocabulary for individuals with low levels of
functional literacy in both English and their native languages.
•    Culturally based understandings of health and health care are relevant to the conduct of functional health literacy assessments.
In addition to the assessment challenges presented by limited proficiency in English, cultural and linguistic considerations must be accounted for. Understanding the
relationships among culture, language, and health is critical for the design and conduct of health literacy assessments in a multicultural society. According to the
Office of Minority Health, HHS, culture and language may affect health, healing, and wellness belief systems; how illness, disease, and their causes are perceived; the
behaviors of individuals seeking health care; and the delivery of healthcare services and provider behavior. Even if assessments of health literacy are conducted in
the appropriate language for a specific population, instruments that are not sufficiently sensitive to cultural and linguistic differences may mischaracterize a
population’s ability to comprehend and act on critical health information and service recommendations.
•    Systemic factors affect individuals’ health literacy skills.
Healthcare and public health delivery systems are complicated bureaucracies with many procedures and processes associated with obtaining health care and public health
services. Patients, clients, and their family members are typically unfamiliar with these systems and the associated jargon. Even highly motivated and educated
individuals may find the systems too complicated to understand, especially when persons are made more vulnerable by poor health. Consequently, assessments of
individuals’ health literacy skills may actually reflect systemic complexity rather than individual skill levels. Studies of the complexity of healthcare and public
health systems need to supplement and inform any assessments of individuals’ health literacy skills.