Three years ago my husband was diagnosed with esophageal cancer; at that time he was not health literate. The signs of both esophageal cancer and health literacy can be subtle. Both have serious consequences if they remain undetected. However, esophageal cancer is immediately recognized as dangerous because cancer is frequently considered a life and death matter that needs immediate intervention. In contrast, low health literacy is generally not recognized as dangerous. Although the incidence of esophageal cancer is increasing, it remains a relatively rare cancer. In contrast, as Egbert and Nanna note in their article, 88 percent of Americans have some deficiency in health literacy (White, 2008). Thus low health literacy is a common issue that impacts us both professionally and personally as we care for and advise our patients as well as our family and friends regarding their health issues. Today my husband is cancer free and he has increased his health literacy level immensely. He is able to explain his symptoms, monitor and re-order medications, manage lists of questions for his appointments, ask for clarification from his providers, reconcile the list of medications he takes regularly on his follow-up visits, and make informed decisions about his health and treatment plans.
Recognizing his previous health-knowledge limitations, my husband said to me while hospitalized after his esophagectomy, “It's important you are studying health literacy. I didn't know what I didn't know.” In a like manner I am glad that this issue of OJIN is devoted to health literacy, a concern that nurses, as individuals and as professionals, can do so much about.
Although it will take the wisdom and skill of professionals in many disciplines to address the problem of low health literacy, nurses are in key positions to address this problem. Nurses working in clinical, educational, administrative, research, and political positions will all be needed to increase health literacy in the United States (US) and around the world. Join me in reading these articles that emphasize individual, person-centered health literacy efforts and recognize the broader issues of health literacy within our society, noting the unique contributions nurses can make at every level of healthcare.
These introductory articles addressing healthcare literacy articulate the extent of the problem of low health literacy, clarify the concept of health literacy, and offer concrete suggestions for increasing health literacy. These rich articles will be of value across roles and settings whether you are a nurse, or other professional, seeking to address this common, yet elusive, and often hidden, problem of low health literacy.
The article, “Health Literacy: Challenges and Strategies,” by Egbert and Nanna provides a strong introduction to the topic of health literacy, presenting the historical development of the current emphasis on health literacy and providing common definitions of health literacy. Using the framework of the Institute of Medicine's (IOM's) definition of health literacy, the authors discuss the challenges of obtaining, processing and understanding, and using health information, and offer strategies to overcome these challenges. Implications for both practice and research are emphasized. Recognizing that health illiteracy is a broad problem, one not solved at the individual or the disease level, the authors suggest examining health literacy from a social capital perspective and examine the networks and relationships that can build and sustain the health literacy of a population.
Cornett offers a practical discussion on providing clear and effective health communication and outlines health literacy content to include in a nursing curriculum. The article, "Assessing and Addressing Health Literacy" begins with a telling story describing how lack of literacy led a patient to take twice the amount of a prescribed medication and how ashamed this patient was of her illiteracy. Cornett gives detailed guidelines for creating an open, shame-free environment for helping all patients navigate the often confusing healthcare system. She discusses ways to assess literacy in a respectful manner and emphasizes how critical it is to match learning and health literacy skills. Specific examples showing how to talk to patients in plain language about their health problems are provided.
Clearly making the point that reading ability and health literacy are not synonymous, Mayer and Villaire, in “Enhancing Written Communications to Address Health Literacy,” provide plain and understandable guidelines for developing patient education materials. Recognizing that most health education materials are written at a reading grade level that is too high for many adults, the authors examine various readability tests. Substitute wording for common medical phrases, as well as examples of using active voice will help practitioners appreciate how words and sentences can be rephrased for clarity and used with a wide variety of patients without being patronizing or degrading.
Imagine being in a foreign country and becoming ill. Now add to this scenario that the people in the country to which you have traveled do not speak English, yet that is the only language you know. Some of our patients face this reality of being in a ‘foreign environment' each time they seek healthcare in the US. Singleton and Krause in their article, “Understanding Cultural and Linguistic Barriers to Health Literacy,” examine the interplay among language, culture, and health literacy for patients who are from diverse backgrounds, describing how these individuals and groups often carry extra health burdens. The authors review cultural concepts relevant to their examination of the effects of culture and language on health literacy skills. They discuss health literacy issues for disparate groups across the four domains of health literacy, namely the navigational, clinical, public health, and preventive domains. They end their article with recommendations for nurses caring for these patients and a list of linked health literacy web references.
Beginning with a telling quote from a college-educated, 91-year-old woman, Speros lays the groundwork for her thesis that multiple strategies are critical to working with older adults so as to achieve desired levels of health literacy. In “More than Words: Promoting Health Literacy in Older Adults” the author provides an overview of the significant impact low health literacy can have on older adults and advocates for a patient-centered approach based on the individual's unique cognitive, physical, and psychological capabilities. She offers various examples of customized teaching that are based on participants' capabilities and adjusted for possible deficits. Her teaching tips are concrete; they provide help both when developing teaching pamphlets and when teaching face-to-face. The examples Speros offers encompass gerogogy (learning principles for older adults) and are tailored for older adults. Speros, too, provides a concise table summarizing key points and suggests useful, linked web references.
As implied by the title, “Promoting Health Literacy through Storytelling,” Day, in the last article of this series, describes how to incorporate storytelling into teaching activities so that the learner is personally engaged, and not merely presented with facts. The article begins by contrasting linear and experiential learning, noting that storytelling is an especially useful teaching technique for experiential learners. Then Day provides examples illustrating various ways in which storytelling can both help experiential learners better understand how to care for their health conditions and also motivate them to do so.
The journal editors invite you to share your responses to this OJIN topic by sending a Letter to the Editor or by submitting a manuscript that will further the discussion of this health literacy topic which has been initiated by these introductory articles.
Ruth Ludwick, PhD, RN, C
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2009
White, S. (2008). Assessing the nation's health literacy: Key concepts and findings from the National Assessment of Adult Literacy (NAAL). Retrieved March 31, 2009, from http://www.ama-assn.org/ama1/pub/upload/mm/367/hl_report_2008.pdf