Limited literacy has been shown to be associated with poor health in a wide variety of settings, and is particularly prevalent among the elderly, minorities, those with lower levels of educational attainment, and those with chronic disease.1 The literacy and health literature calls attention to the ways in which the current health care system is inadequate, not only for the estimated 90 million U.S. adults with limited literacy, but for most users of the system. The implications of limited literacy should be understood as a challenge to the basic justice of a health care system organized for the most highly educated and powerful members of our society.
The National Institutes of Health have defined health literacy as the “degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”2,3 According to this definition, health literacy relates to both the cognitive and functional skills a person has to make health-related decisions. This definition is problematic from a number of perspectives. While an individual's health literacy is likely to be associated with their literacy level, as suggested by the article by Fang et al.4 in this issue, we believe that an individual's level of health literacy is not a fixed characteristic, and that it should not be defined only via an evaluation of an individual's skills. Rather, health literacy reflects the contextual demands placed on the individual by (a) their specific clinical condition and associated health care decisions, (b) the communication characteristics of the dominant medical culture, (c) the structure and function of clinical services that assume limitless health literacy and require self-advocacy and vigilance, and (d) the emphasis that society (fueled by a health consumer-oriented marketplace) places on individual, rather than ecological, determinants of health. As such, at a minimum, when we conceptualize health literacy, we consider not only a patient's literacy and numeracy skills but also the complexity of the tasks required, the accessibility of the health care workforce for the target populations, the preparedness of this health care workforce to engage productively with the patient, and the features of the health care system and communities in which care-giving and self-management support take place.
The Institute of Medicine has identified health literacy as a national priority area for transforming health care quality.5 How will this occur? A fundamental reevaluation of health care in America is warranted. The goal of this paper is to shift the focus of inquiry and analysis from the patient to the system. We offer 3 overarching principles to guide needed adaptations to health care. Our suggestions reflect changes to the organization and delivery of health care based on an integration of emerging research findings related to literacy and the Care Model.6 Such changes could ameliorate not only the health effects of limited literacy, but improve the overall quality of U.S. health care and engender a more “health literate” society.7,8