Functional literacy (the ability to read simple text and write simple sentences about everyday life), is a basic skill enabling people to participate more fully in society. There is consistent evidence indicating a link between low literacy and poorer health outcomes. People with lower literacy levels are generally 1.5 to 3 times more likely to have poor health outcomes than people with higher literacy levels.8
The prevalence of low literacy in England is surprisingly high.
The most recent (2003) English national survey of literacy, numeracy, and use of information technology, also known as the The Skills for Life survey, assessed the extent to which these basic skills were present at a level needed to achieve full potential (Level 2 in the National Qualification Framework). This is described as ‘being able to understand a range of texts of varying complexity accurately and independently, and to extract information of varying length and detail form different sources’.11
This survey of 8000 people of working age was based on a direct measurement of skills (for example, on being shown a poster for a concert, questions were asked such as ‘where is the concert, how much will it cost for two people to attend?’). The results were divided into levels which were based on the English national curriculum and showed that 56% (literacy), and 75% (numeracy) of those surveyed have skills below those needed to achieve their full potential, while the opportunities offered by modern information technology, such as the internet, are only fully used by a very small percentage of the population (9%).11
Such results provide practical challenges in health communication. The majority of printed information leaflets used in health care already have a reading age higher than the average population.12,13
Interventions to promote participation, shared decision making, and informed consent may only therefore reach a proportion of the population.
Low literacy and numeracy may contribute to inequity of access to the benefits of prescription medication. It is known that people with low literacy skills are more likely to make mistakes in interpreting medication instructions and warning labels.14
This increases the risk of both unintentional sub-optimal compliance with medication regimes, and increases the risk of adverse events. In addition, the drive to more cost-effective generic prescribing may differentially affect those with low basic skills; community pharmacists report that patients with low literacy experience difficulties when different brands of the same medication are issued.15
Current NHS initiatives to increase patient choice may also be less accessible for people with low literacy. Under the NHS Choose and Book system, patients requiring specialist care are offered a range of potential services; they then choose their preferred service and book their clinic appointment. It can be hypothesised that this process will be more difficult for people with low literacy skills, although to date no research has been undertaken to investigate this; however, research suggests that Choose and Book fails to deliver the expected choice to patients.16
The relationship between literacy and the quality and outcome of healthcare interactions has been the subject of increasing attention, especially in the US where the study of ‘health literacy’ has developed over the past decade.17
Health literacy has been defined as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.17
Basic literacy and numeracy skills are fundamental requirements for health literacy, but are not sufficient. A person can be ‘literate’ within a familiar environment and context, but functionally ‘illiterate’ when required to comprehend and respond to unfamiliar vocabulary and concepts in an unfamiliar environment. For many individuals — as patients, carers, and members of the community — healthcare settings are unfamiliar environments in which many are exposed to unfamiliar vocabulary and concepts. To make the healthcare ‘environment’ less alienating, it is important that healthcare providers, and those responsible for patient management and administration are sensitised to the challenges faced by patients in communicating effectively. Simple practical steps that could be taken by health professionals are to assess the readability of the printed materials that they are using and to make conscious efforts to minimise the use of technical language, using lay terminology whenever possible.
Not surprisingly, research on health literacy over the past decade has shown that those who have poor health literacy are less responsive to health education and use of disease prevention services, less able to manage successfully chronic disorders, such as diabetes and asthma, and incur higher healthcare costs.8,18
This research has led to progressive testing of interventions designed to mitigate the effects of poor health literacy through modified communications, and improved service organisation.19
For these reasons, understanding the concept of health literacy, and the research that underpins the concept are especially important in achieving current UK priorities to promote greater patient participation in health care and to achieve greater equity in health outcomes.
Perhaps more challenging still, Kickbusch et al
have argued that health literacy is ‘a critical empowerment strategy to increase people's control over their health, their ability to seek out information and their ability to take responsibility’.20
Healthcare professionals and patients have vastly different status and roles in healthcare interactions. In addition to improving health literacy, there is a need for a more symmetrical balance of ‘power’ to encourage relationships that actively foster joint decision making and, therefore, facilitate genuine participation in decision making.
Disappointingly, there has been little research into health literacy in the UK. The National Consumer Council (now referred to as ‘Consumer Focus’) reported that low health literacy appears to be particularly prevalent among lower socioeconomic groups, ethnic minorities, older people, and those with chronic conditions or disabilities.21
This reduced ability to access information and function effectively in the current health service may be an explanatory factor in health inequalities.22
Reviewing the evidence, the American Medical Association found that health literacy is a stronger predictor of health status than age, income, employment status, education level, race, or ethnic group.23
Without careful implementation, current policies to promote greater patient participation in healthcare decisions may exacerbate existing inequities by engaging only those who are most literate and confident in a healthcare setting, and further alienating those least able to navigate their way into the healthcare system, interact successfully with healthcare professionals, and understand disease prevention and management options.