The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Health Literacy is a key issue in the Health and Health Care domain.
The U.S. Department of Health and Human Services (HHS) defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.”1, 2Adequate health literacy may include being able to read and comprehend essential health-related materials (e.g., prescription bottles, appointment slips, etc.).3, 4 Adequate health literacy may increase a person’s capacity to take responsibility for their health and their family’s health.5, 6 However, health literacy is not just the result of individual capacities but also the health-literacy related demands and complexities of the health care system.3, 7, 8 For example, individuals with low literacy may not be able to understand prescription labels—but an organization that values health literacy makes it a priority to implement systems and interventions such as visual aids and counseling that increase understanding and thereby advance patient safety.7
Low overall literacy may impact health literacy; however, the relationship between them is complex.9 For example, an individual may have high overall literacy and still have low health literacy.9 Low or limited health literacy skills are more prevalent among certain population groups and may be linked to many poor health outcomes. Health literacy has the potential to impact a broad array of functional skills that are required to make health decisions in various settings.10 Although there are many ways in which health literacy may impact health and health outcomes, this summary focuses on health literacy related to reading and comprehension of essential health-related materials.
A number of factors impact health literacy including a patient’s receipt of appropriate written health communication materials, ability to accurately interpret written health-related information, and communication with providers. When patients receive written health communication materials that don’t match their reading level, patient education is not effective.11, 12 Additionally, when patients have low overall literacy skills but high verbal fluency, their verbal fluency can mask their inability to interpret written information.9 Potential communication barriers between patients and health care providers created by low health literacy may lead to a variety of negative health outcomes for the patient.11, 13 For example, such communication barriers have been associated with patients being more likely to be hospitalized.11, 14, 15
The impact of health literacy on skills needed to make health-related decisions may affect a patient’s adherence to a treatment regimen (e.g., medication),11, 16, 17, 18, 19 which may decrease its benefits.11, 20 Patients with low health literacy also tend to use the emergency department more often and are more likely to return to the emergency department after 2 weeks.21 One systematic review found low literacy (used as a proxy for health literacy) may impact parent/caregiver behavior (e.g., medication dosing, duration of breastfeeding).22, 23, 24, 25 The study also found some evidence of an impact of parents’ low literacy on children’s health outcomes (e.g., depressive symptoms, persistent asthma).25, 26
A number of factors may influence an individual’s health literacy, including living in poverty, education, race/ethnicity, age, and disability. Adults living below the poverty level have lower health literacy than adults living above the poverty level.27 Certain characteristics influenced by poverty, including insurance status, may impact health literacy more than other factors. For example, uninsured and publicly insured (e.g., Medicaid) individuals are at higher risk of having low health literacy.27 Studies have found that older adult Medicare beneficiaries with low health literacy have higher medical costs,28 increased ER visits and hospital admissions,29 and decreased access to health care.30 Education may also impact health literacy. For example, in a nationally representative sample, almost half of adults who did not graduate from high school had low health literacy.27
Some of the greatest disparities in health literacy occur among racial and ethnic minority groups from different cultural backgrounds and those who do not speak English as a first language. Results from the National Assessment of Adult Literacy demonstrated that Hispanic adults have the lowest average health literacy scores of all racial/ethnic groups, followed by black and then American Indian/Alaska Native adults.27 People with low health literacy and limited English proficiency are twice as likely as individuals without these barriers to report poor health status.31 One study found that 74% of Spanish-speaking patients have less-than-adequate health literacy as compared to 7% of English-speaking patients.32 Cultural beliefs may also impact communication between patients and providers and affect a patient’s ability to follow a physician’s instructions.33
Health literacy challenges may impact older adults more than other age groups.12 On average, adults age 65 and older have lower health literacy than adults under the age of 65.27 Low health literacy among older adults is associated with increased reports of poor physical functioning, pain, limitations of daily activities, poor mental health status34, 35
Improvements in health practice that address low health literacy are needed to reduce disparities in health status. As limited health literacy is common and may be difficult to recognize, “experts recommend that practices assume all patients and caregivers may have difficulty comprehending health information and should communicate in ways that anyone can understand.”37 Examples include: simplifying communication; confirming comprehension for all patients to minimize risk of miscommunication; making the health care system easier to navigate; and supporting patient’s efforts to improve their health.37
Additional research is needed to increase the evidence base for what works to improve the effects of health literacy on health outcomes and disparities. This additional evidence will facilitate public health efforts to address health literacy as a social determinant of health.
Disclaimer: This summary of the literature on access to primary care as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i, ii Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National action plan to improve health literacy. Washington (DC): Author; 2010.
2 Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National Library of Medicine current bibliographies in medicine: health literacy. Bethesda (MD): National Institutes of Health, U.S. Department of Health and Human Services; 2000. NLM Pub. No: CBM 2000-1.
3 Baker DW. The meaning and the measure of health literacy. J Gen Intern Med. 2006 21(8), 878–83.
4 Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 1999;281(6):552–57.
5 Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health, 2012;12(1):1.
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7 Brach C. Keller D, Hernandez LM, Baur C, Parker R, Dreyer B et al. Ten attributes of health literate health care organizations. Washington (DC): National Academy of Sciences; June 2012. http://nam.edu/wp-content/uploads/2015/06/BPH_Ten_HLit_Attributes.pdf
8 Rudd R. Objective 11–2: Improvement of health literacy. In: Communicating health: priorities and strategies for progress. Washington (DC): U.S. Department of Health and Human Services; 2003.
9 Easton P, Entwistle VA, Williams B. Health in the 'hidden population' of people with low literacy. A systematic review of the literature. BMC Public Health. 2010;10:459. doi: 10.1186/1471-2458-10-459.
10 Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav. 2007;31(Suppl 1):S8–18.
11 Ngoh LN. Health literacy: A barrier to pharmacist-patient communication and medication adherence. J Am Pharm Assoc. 2009;49(5):E132-49. doi: 10.1331/JAPhA.2009.07075.
12 Buck ML. Providing patients with written medication information. Ann Pharmacother. 1998;32(9): 962–69.
13 Nelson AR, Stith AY, Smedley, BD, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press; 2002.
14 Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Peel J. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American J Public Health. 2002;92(8):1278–83.
15 Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. Journal General Intern Med. 1998:13(12):791–98.
16 Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355 :229–31
17 Pignone MP, DeWalt DA. Literacy and health outcomes: is adherence the missing link? J Gen Intern Med. 2006;21:896–7
18 Poss J. Developing a new model for cross-cultural research: synthesizing the Health Belief Model and the Theory of Reasoned Action. ANS Adv Nurs Sci. 2001;23:1–15
19 Becker M, Maiman L. Sociobehavioral determinants of compliance with health and medical care recommendations. Med Care. 1975;13(1):10–24.
20 Wroth TH, Pathman DE. Primary medication adherence in a rural population: the role of the patient-physician relationship and satisfaction with care. J Am Board Fam Med. 2006;19:478–86.
21 Griffey RT, Kennedy SK, D'Agostino McGowan L, Goodman M, Kaphingst KA. Is low health literacy associated with increased emergency department utilization and recidivism? Acad Emerg Med. 2014;21(10):1109–15. doi: 10.1111/acem.12476.
22 Yin HS, Dreyer BP, Foltin G, van Schaick L, Mendelsohn AL. Association of low care-giver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambul Pediatr. 2007;7(4):292–298.
23 Kaufman H. Skipper B, Small L, Terry T, McGrew M. Effect of literacy on breast-feeding outcomes. South Med J. 2001;94(3):293–296.
24 Sleath BL, Jackson E, Thomas KC, et al. Literacy and perceived barriers to medication taking among homeless mothers and their children. Am J Health Syst Pharm. 2006; 63(4): 346-351
25 DeWalt DA, Hink A. Health literacy and child health outcomes: a systematic review of the literature. Pediatrics. 2009;124 Suppl 3:S265–74. doi: 10.1542/peds.2009-1162B
26 DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr. 2007;7(1):25–31.
27 Kutner M, Greenburg E, Jin Y, Paulsen C. The health literacy of America's adults: results from the 2003 national assessment of adult literacy. National Center for Education Statistics; 2006. Report No.: NCES 2006-483.
28 Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005;118(4):371–77.
29 Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med. 2008;66(8):1809–16.
30 Sudore RL, Mehta KM, Simonsick EM, Harris TB, Newman AB, Satterfield S, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54(5):770–76.
31 Sentell T, Braun KL. Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. J Health Commun. 2012;17 Suppl 3:82–99. doi: 10.1080/10810730.2012.712621.
32 Brice JH, Travers D, Cowden CS, Young MD, Sanhueza A, Dunston Y. Health literacy among Spanish-speaking patients in the emergency department. J Natl Med Assoc. 2008;100(11):1326–32.
33 Shaw SJ, Huebner C, Armin J, Orzech K, Vivian J. The role of culture in health literacy and chronic disease screening and management. J Immigr Minor Health. 2009;11(6):460–67. doi: 10.1007/s10903-008-9135-5.
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37 Brega AG, Barnard J, Mabachi NM, Weiss BD, DeWalt DA, Brach C, Cifuentes M, Albright K, West, DR. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition. (Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10.) AHRQ Publication No. 15-0023-EF. Rockville, MD. Agency for Healthcare Research and Quality. January 2015. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf