Journal of Pediatric Nursing
Volume 22, Issue 4 , Pages 257-260, August 2007

Health Literacy: The Missing Link in the Provision of Health Care for Children and Their Families

Journal of Pediatric Nursing Los Angeles, CA 90027

Article Outline

 

HEALTH LITERACY HAS emerged as an area of public health concern. In the 1992 and again in the 2003 National Assessment of Adult Literacy (NAAL), major national surveys on the literacy of adults aged ≥16 years indicated that approximately 46% of the American public demonstrated inadequate and limited levels of literacy (Kirsch et al., 1993, Kutner et al., 2007). In the 2003 NAAL, a section measuring health literacy was included. Survey results indicated that 22% of adults had a basic level of health literacy and that 14% had a below-basic level of health literacy (Kutner, Greenberg, Jin, & Paulsen, 2006). A person with a basic level of health literacy as measured by the NAAL would require simply worded instructions written at a middle-school or an elementary-school reading level. A person with a below-basic level of health literacy would require very concrete explanations, with graphics for illustration. The reading level of materials would require the use of words with limited syllables in simple sentences.

Health experts have directed efforts to better understand the scope of the problem and to develop and implement strategies for improving the health literacy of the American public. Health literacy is an essential, yet often overlooked, competency in issues pertaining to all aspects of health care, including access to care and treatment adherence (American Medical Association, 1999, Nielsen-Bohlman et al., 2004).

Considerable literature—ranging from anecdotal accounts by clinicians to best-practice guidelines and empirical studies on instructional strategies and methods to instruct children, youth, and their families on learning the knowledge and skills necessary for illness home management, whether it be a common minor illness or care for a child who is technologically dependent—has been published (Feinstein et al., 2005, Krishna et al., 2003, Shaw, 2001, Strawhacker, 2001, Toelle & Ram, 2005). The myriad of instructional approaches described have included the use of self-paced instructional manuals, discharge instructional sheets, classroom teaching, positive provider feedback, and interactive multimedia programs, to name a few (Chang et al., 2003, Onyirimba et al., 2003, Shames et al., 2004, Shegog et al., 2001).

Although there is a body of evidence demonstrating the efficacy and effectiveness of selected instructional approaches, treatment adherence continues to be a major problem. Problems of treatment nonadherence have been discussed, analyzed, and studied to develop and test interventions for the promotion of treatment adherence and for the improvement of health outcomes for children, youth, and their families (Anarella et al., 2004, Onyirimba et al., 2003, Scarfone et al., 2002). A number of variables that influence treatment adherence have been identified. These variables include the following: developmental characteristics associated with each age group of children, such as the ability to read and comprehend treatment explanations; limitations the child experiences due to the illness itself, such as nausea and vomiting, restricted movement, and intellectual disability; and the extent to which the child receives support from health care providers (Kyngas, 2000, Shaw, 2001, Velsor-Friedrich et al., 2004).

More recently, health experts have focused on understanding the impact of another variable, health literacy, and its relationship with the provision of health care in terms of the appropriateness and readability of materials disseminated to consumers and consumers' understanding and use of health information provided to them. Health literacy, as defined in the Institute of Medicine report (Nielsen-Bohlman et al., 2004) entitled Health Literacy: A Prescription to End Confusion, is referred to 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” (Ratzan & Parker, 2000, p. 7). An individual with an adequate level of health literacy will comprehend the health information provided and will have the ability to use that health information appropriately. As an example, a youth with adequate health literacy who receives discharge instructions from a nurse about medication administration following hospitalization will understand the instructions provided and will take the medication correctly. The problem of inadequate health literacy of the American public is a significant public health problem that has considerable clinical and financial ramifications (Nielsen-Bohlman et al., 2004).

There is growing body of research evidence demonstrating that inadequate levels of health literacy are associated with untoward health outcomes, increased hospitalizations and emergency room visits, and extension of usual periods of recovery from illness (American Medical Association, 1999, Baker et al., 1999, Berkman et al., 2004, DeWalt et al., 2004, Greenberg, 2001, Hampers et al., 1999). As mentioned previously, findings from a recent national survey, the 2003 NAAL, revealed that 36% of Americans aged ≥ 16 years have low health literacy, affecting nearly one in four Americans (Kutner et al., 2006). Recognition of this national health problem is addressed as an objective in Healthy People 2010 (Objective 11.2: Improve the health literacy of persons with marginal or inadequate skills; U.S. Department of Health and Human Services, 2000).

National effort has been undertaken to raise the public's awareness of problems associated with health literacy and to provide recommendations to address this problem. The Partnership for Clear Communication (2006) is one of the leading nonprofit organizations dedicated to improving health literacy. It is composed of a coalition of numerous professional associations, including the American Nursing Association, the American Public Health Association, and the American College of Nurse Practitioners. The “Ask Me 3” program is a centerpiece of this coalition's efforts to remedy the problem of low health literacy. This outreach effort is designed to assist consumers in maximizing the benefits of their health care encounter by asking three pertinent questions of their health care provider (whether physician or nurse practitioner) regarding their health status and home care responsibilities to treat their illness/condition. The “Ask Me 3” program suggests that the consumer ask these three basic questions: (1) “What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”

The Plain Language.gov (2004) Web site (www.plainlanguage.gov) is an Internet clearinghouse of the federal government that provides information pertaining to the use of clear and understandable language to foster improved communication. Plain language (also called plain English), according to this federal initiative, is defined as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others” (Plain Language.gov, 2004). This Web site contains pages on health literacy with links to other governmental, private sector, and bibliographic Web sites on health literacy, such as the Health Resources and Services Administration and the National Library of Medicine.

Currently, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the National Institutes of Health have initiated research initiatives to fund studies related to health literacy. The aim of this initiative, which is sponsored by a number of health institutes, including the National Institute of Nursing Research, is to examine the following: “health literacy as a key explanatory variable for some other outcome; methodological or technological improvement to strengthen research on health literacy; and/or prevention and/or intervention strategies that focus on health literacy” (National Institutes of Health, 2006).

What are the implications of inadequate health literacy for nurses who provide services to children, youth, and their families in a multitude of settings, such as typical health care settings of tertiary-level institutions or nonhealth settings wherein health services are provided to children and youth (e.g., school or employment settings wherein work-based experiences are provided)? At this point in time, evidence on the identification of health literacy in adults is limited; most of the research conducted to date has addressed issues pertaining to the word recognition of terminology used in health care settings (Terry C. Davis, personal communication, May 8, 2007). Empirical studies conducted to examine the application of health literacy to consumers' management of their health needs have not been explored. A limited number of studies have been conducted with pediatric populations. The majority of studies have been conducted to assess parental health literacy; a few investigations have studied the health literacy of adolescents (Davis et al., 2006, Davis et al., 1999, Herman & Mayer, 2004, Wilson et al., 2006).

Health literacy experts and the national initiatives referred to previously have advocated an examination of the reading levels of instructional materials provided to families and children. The development and revision of instructional materials for parents, youth, and children should adhere to the health literacy and plain language guidelines of creating materials that are more cognitively accessible and person centered (Monsen, 2007). Studies are needed to increase our understanding of health literacy and its relationship with child and family health outcomes and costs of care; additional research is needed to examine effective approaches to improving health literacy (Wilson et al., 2006).

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PII: S0882-5963(07)00236-9

doi:10.1016/j.pedn.2007.06.001

Journal of Pediatric Nursing
Volume 22, Issue 4 , Pages 257-260, August 2007

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