Compared to is older counterparts, health literacy is barely a fetus in the realm of public health problems. The concept was first introduced in 1974 and focused predominantly on its relevance within professional healthcare. Only recently, in its already short five decades of research, has there been some momentum of its prominence in public health.

To holistically understand health literacy, a combination of definitions, components and classifications must be established. The nature of health literacy as a fundamentally non-biological crisis requires meticulous organization and explanation for its complex factors.

Health literacy is often perceived as an interaction between three skills: functional-interactive-critical. This three-level model was first introduced by Don Nutbeam and has since been further expanded and by corroborated by peer researchers (Nutbeam, 2000). As for the written definitions of health literacy, it exists in three forms: As defined by the Healthy People 2030 initiative, Personal health literacy, is “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others” (ODPHP). Organizational health literacy is “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others” (ODPHP). Finally, Digital health literacy is “the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” (ODPHP).

The components of health literacy are well represented by another model, one developed by the Institute of Medicine. While the different definitions of health literacy are good indicators of who the issue impacts, four key components: cultural and conceptual knowledge, print health literacy, oral health literacy and numeracy, answer the question of what health literacy is, and its relevance (IOM, 2004). These components generalize the many other complex factors of health literacy. A few examples include the ability to read and understand health information, the access to health care and services, the ability to communicate in health scenarios and make decisions according, the acceptance of different health knowledge and beliefs and countless others. Ultimately, health literacy is presented as the general skills and conditions needed to obtain, process and apply information for the purpose of wellbeing and healthcare (BMJ, 2020).

The classifications of health literacy rank the depth of which people or groups of people are health literate. Following Nutbeam’s functional-interactive-critical model, an individual’s level of health literacy improves as they gain more of these three skills, therefore each level also details one’s capabilities to make health-related decision and actions that in turn impact their overall wellbeing (Nutbeam, 2000). Having functional health literacy is the most basic of all the levels. One is able to obtain and apply health knowledge to perform and maintain medication, as well as recognize need for prevention and behavior changes. Interactive health literacy indicates that an individual can them further extract health information from a wider range of mediums, as well as gain insightful knowledge through communicating. Finally, critical health literacy describes skills that can be used to interpret and derive complex, analytical meaning from multiple perspectives, ones that are health-related, but also especially ones that are indirectly associated with health. This cohort of people is often capable of positively impacting all levels of the socio-economical model for intervention, as those with critical health literacy often better understand and engage with others with the information they acquire.

Health literacy can be better interpreted epidemiologically through prevalence rather than incidence. Incidence is hard to determine because there are many reasons measuring new cases of poor health literacy in a specific time period is difficult. Its non-life-threatening nature makes it easy to go undetected. Its long duration of development makes it near impossible to pinpoint its time of onset. Furthermore, its severity is extremely indeterminate. There exists no definite recovery nor death, meaning there is almost never clear causal mortality nor cured cases to significantly add to data of disease incidence. By studying its prevalence, however, a lot of data regarding its impact and trajectory is exposed. The standard measurement in the United States is the National Assessment of Adult Literacy Survey, ranking its sample group on a scale that progresses from below basic, to basic, intermediate, then proficient health literacy. To account for the imprecise nature of this crisis, the sample group of this survey aims to cover diverse characteristics such as age, demographic, residential location and others (NCBI, 2006). The study results showed 36% of adult Americans with below basic or basic health literary skills, 53% with intermediate and only 12% with proficient. It should be noted, however, that this data encompasses the collective adult Americans, as there exists differently skewed data for different demographics. On average, 9 out of 10 adults in the United States struggle with health literacy.

Risk factors and social determinants of Health literacy:

The risk factors and social determinants of health literacy are often discussed collectively, yet again due to the little influence biology has on health literacy levels. This results in little causality between poor health literacy and individual characteristics, hence, why there currently exists no national measure for personal health literacy.

However, that does not mean that there are no risk factors associated with health literacy, of which the most notable is stress and sickness (Pleasant, 2016). Atypical physical and psychological conditions often impair short-term health literacy, as it may cloud judgement when making medical decisions, interfere with memory and affect the ability to understand and interpret information or instruction. There are also several studies that provide statistically significant associations between chronic illnesses such as diabetes, hypertension, hyperlipidemia or lifestyle habits such as smoking and drinking with low health literacy.

As for social determinants of health, every one of its domains impact some level of health literacy.

The first is socio-economic status. Education plays a crucial role in adequate health literacy. Basic mathematics, reading, writing, and speaking skills are imperative to interpretation in any context, but particularly when making decisions potentially detrimental or beneficial to health. Furthermore, the ability to infer and make calculated decision is also related to general education. Therefore, it comes as no surprise that as education level increases, so does health literacy. The same is the case with unemployment or low income, with a particular study noting that with an approximate every $5000 decrease in income, there exists an association of lower health literacy levels (Baker, 2002).

The social environments of health literacy are extremely pertinent to the diversity in the United States. Language proficiency plays a huge role in interpretation of health information. Medicine dosing, medical directions and nutrition labels are almost exclusively in English, therefore understanding the language is crucial to interpreting any and all health information, as well as making informed health decisions. The culture of different communities also affects health literacy, particularly traditional beliefs on medicine shared in these communities. People with different perceptions, regardless of their proficiency in health literacy, will inevitably reject certain information that is not in line with their own practices. This barrier is further perpetuated by the inflexible healthcare views in the United States. Not only is there a cultural disagreement towards health knowledge, there is also little amenability to other input. An already present hesitancy towards an already intimidating and stubborn healthcare system deters certain communities from the healthcare and therefore health literacy.

Physical environment is also a strong contributor to poor health literacy, particularly one’s location of residency. Only 7.7% of groups living in rural settings were proficient in health literacy, while urban residents had 12.7%. Much of this is due to increased exposure to daily health information in urban areas, such as medical television, conversations about health, or access to local clinics and hospitals. There is also a correlation between rural environments and less digital connectivity. With a majority of healthcare shifting online, this adversely affects communities’ abilities to access web-health information, conduct telehealth visits, make medical appointments or request medication refills, or access e-portals for medical records. This is applicable to both people who look for information from their homes, as well as patients and physicians in clinics and centers in the neighborhoods.

With the combination of socio-economic status, physical and social environments, and social risks, different demographics will experience more or less of these social determinants, and therefore suffer more or less health literacy. The prevalence of health literacy indicates that on average, 12% of American adults had proficient health literacy. When analyzed separately by racial groups, however, proficiency for white adult Americans rose to 14%, Hispanic decreased to 4%, and black Americans dropping to a whopping 2%. Other ethnic groups combined have 12% of proficient health literacy (HHS, 2008). Stress as a risk factor is also more prevalent amongst marginalized groups as a result of the systemic discrimination they face daily in their social environment. It is then further exasperated in medical settings as minority groups are more likely to have negative experiences in doctor’s offices and hospital settings. This not only deters them from seeking care in the future, but also lessens the trust they have in the system, setting them up for even further poor health literacy.

Community of interest

It is important to analyze the United States as a whole rather than by specific demographics because this country is simultaneously the leading nation in terms of healthcare resources, but also has the greatest range between incredibly well and incredibly poor health conditions within its population.

Analyzing the United States as an entire community was also crucial to understanding the relativity of each of each specific community. Health literacy and its proficiency is subjective to the healthcare in the status quo, therefore the health literacy in certain communities conforms to the conditions of the environment or nation it is in. This was visible in the case of the proficiency amongst different racial groups, where it was important to understand the general prevalence of proficient health literacy before being able to compare it to characteristic-influenced variables such as marginalized ethnic and racial groups

Intervention:

In looking at the socio-economic model, risks for low health literacy exist at every level, and impact of high health literacy can reach every level. This means that, depending on both individual and collective health literacy, populations can be in either negative or positive feedback cycles. Hence, unlike other typical diseases and conditions, prevention and intervention collectively have the potential to not only stop health literacy decline, but also improve it.

On an individual level, personal comprehension and interpretation skills are strongly associated with health literacy. On an interpersonal level, health literacy is often prone to influences cast by social communities. Peer and parental interactions and different levels of social skills have been shown to impact the health literacy of adolescents (Manganello, 2008). Standardizing and promoting correct medical jargon and conversation, greater exposure to online content, and also simplifying the communication of information to be comprehensible by the general public are all methods to promote better health literacy.

Organizationally, traditional existing interventions take form as one-directional information dissemination, such as through advertisements or pamphlets in public areas (Baratta, 2018). Common is also patient education sessions and lectures at healthcare facilities, or mass health promotion in work and school environments. Extending to community levels, referrals to social support resources or community events collaborated between prominent medical and non-medical organizations encourage community engagement and education of health information.  

There currently exists policies to improve general health Literacy. The National Action Plan presented by the US department of Human and Health services contains seven objectives with the intent of ensuring all people the right to health information to make informed decisions. Said information must also be presented in ways interpretable to meaningfully promote wellbeing and quality of life (HHS, 2010). Key goals include improving linguistics and language, implementing health curricula in public education and building partnerships to name a few. The Health Literacy Action Plan presented by the Center for Disease Control is another public policy intervention that is adapted from the previous HHS National Action Plan. This plan, however, provides more specific framework centered around three goals with a greater focus on public health planning, funding, as well as its relation to other diseases and treatment. Furthermore, the Plain writing Act signed into law on October 13, 2010 ensures that communication and language of information is easily understandable by the public. These are all legislative standardization of health literacy expectations that aim to increase chances of proficient health literacy amongst the population.

The majority of health literacy interventions are upstream, supported by downstream efforts. The slow and accumulative nature of this problem means that primary prevention efforts as early as possible is what will build a secure foundation for health literacy in future generations. The most repeated examples of such are integrating education and awareness into the public. It is more complicated to focus on downstream interventions as there is no medical treatment that can lead to a definite cure. Tertiary prevention methods such as inpatient schooling of condition management, however, as still practiced in tandem with all other interventions.

Conclusion:

Ironically, much like health literacy as a public health problem itself, there is still an inherit lack knowledge of it as a problem. Furthermore, the deterioration of health literacy proficiency is a public health crisis that will only perpetuate not only itself as a problem, but countless other health issues as well. Health literacy is an important public health crisis to study because it is often lost amongst the countless other physical diseases that have noticeable causality with poor health. This public health crisis has begun to earn the name of the “hidden” social determinant, as it becomes increasingly evident that not only can certain conditions lead to poor health literacy, poor health literacy also contributes in a widespread way to public health, much like the already existing social determinants of health.

Its lack of consideration, however, is not in line with its significance in public health and wellbeing. It paradoxically undermines the entire precipice of medicine and healthcare, as the fundamental reason for medical study is so that people can become healthier from it. Yet, fundamentally without the knowledge of both these resources as well as how to utilize them, they are useless, contribute nothing to healthcare and make as much impact as if they didn’t exist.

The duality of health literacy makes it a unique public health problem in that it can do both harm and good. Looking forward, its success goes hand in hand with health equity, as standardized knowledge offers equality, but doesn’t account for the disparities that hinder many from obtaining the resources despite their existence. Health literacy informs what resources exist, however equitable health access or lack thereof still stands as a barrier for who can or cannot reap the benefits of privatized and profitable health.

Ultimately, the study of health literacy as a public health problem has led to a plethora of studies and data. Its novelty in universal wellbeing, however, makes it urgent for more awareness and further research. As more is understood of its definition, the communities it impacts, and its potential interventions, the more possibility of it becoming a proprietor in health living, rather than as a crisis.

References

America’s Health Literacy: Why We Need Accessible Health Information. An Issue Brief From the U.S. Department of Health and Human Services. 2008.

Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J. Functional Health Literacy and the Risk of Hospital Admission Among Medicare Managed Care Enrollees. Am J Public Health. 2002

Baratta, J. (2018, December). Health literacy interventions - stanford medicine. Health Literacy Interventions: Improving Diabetic Care and Reducing Healthcare Costs. https://med.stanford.edu/content/dam/sm/schoolhealtheval/documents/JBaratta_Policy_Brief.pdf

Centers for Disease Control and Prevention. (2023, July 11). What is health literacy?. Centers for Disease Control and Prevention. https://www.cdc.gov/healthliteracy/learn/index.html#:~:text=Personal%20health%20literacy%20is%20the,actions%20for%20themselves%20and%20others.

Coughlin, S. S., Vernon, M., Hatzigeorgiou, C., & George, V. (2020). Health Literacy, social determinants of health, and disease prevention and control. Journal of environment and health sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889072/

Health literacy. Health Literacy - Healthy People 2030. (n.d.). https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/health-literacy

An introduction to health literacy. NNLM. (n.d.). https://www.nnlm.gov/guides/intro-health-literacy

L, N.-B., AM, P., & DA, K. (Eds.). (2004). Executive summary - health literacy - NCBI bookshelf. Health Literacy: A Prescription to End Confusion. https://www.ncbi.nlm.nih.gov/books/NBK216029/

Liu, C., Wang, D., Liu, C., Jiang, J., Wang, X., Chen, H., Ju, X., & Zhang, X. (2020, May 1). What is the meaning of health literacy? A systematic review and qualitative synthesis. Family Medicine and Community Health. https://fmch.bmj.com/content/8/2/e000351

Lopez, C., Kim, B., & Sacks, K. (2022). Health Literacy in the United States - Milken Institute. HEALTH LITERACY IN THE UNITED STATES. https://milkeninstitute.org/sites/default/files/2022-05/Health_Literacy_United_States_Final_Report.pdf

Mahadevan, A. R., & Mahadevan, R. (2023, May 22). Health Literacy Fact Sheets. Center for Health Care Strategies. https://www.chcs.org/resource/health-literacy-fact-sheets/

Manganello JA. Health literacy and adolescents: a framework and agenda for future research. Health Educ Res. 2008

Muscat, D. M., Shepherd, H. L., Nutbeam, D., Trevena, L., & McCaffery, K. J. (2021, February). Health Literacy and shared decision-making: Exploring the relationship to enable meaningful patient engagement in healthcare. Journal of general internal medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878628/

Nutbeam, D. (2000). Health Promotion International (Vol. 15). Oxford University Press.

Nutbeam, D., & Lloyd, J. E. (2021, April). Understanding and responding to health literacy as a social determinant ... Understanding and Responding to Health Literacy as a Social Determinant of Health. https://www.annualreviews.org/doi/10.1146/annurev-publhealth-090419-102529

Pinheiro, P. (2021, April). Conceptualizations of Health Literacy: Past Developments, current trends, and possible ways forward toward social practice. Health literacy research and practice. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082953/#x24748307-20210316-01-bibr6

Pleasant, A., Rudd, R. E., O’Leary, C., Paasche-Orlow, M. K., Allen, M. P., Alvarado-Little, W., ... & Rosen, S. (2016). Considerations for a new definition of health literacy. National Academy of Medicine.

Rowlands, G., Shaw, A., Jaswal, S., Smith, S., & Harpham, T. (2015, September 28). Health Literacy and the social determinants of health: A qualitative model from adult learners. OUP Academic. https://academic.oup.com/heapro/article/32/1/130/2950953

Sørensen, K., Broucke, S. V. den, Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H. (2012, January 25). Health Literacy and Public Health: A systematic review and integration of definitions and models - BMC public health. BioMed Central. https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-80

Schillinger, D. (2020a, June 25). The intersections between social determinants of Health, health literacy, and Health Disparities. Studies in health technology and informatics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710382/

Schillinger, D. (2020b, June 25). The intersections between social determinants of Health, health literacy, and Health Disparities. Studies in health technology and informatics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710382/

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author.

U.S. Department of Health and Human Services. (2021, July 7). Health literacy. National Institutes of Health. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/health-literacy#:~:text=Health%20literacy%20incorporates%20a%20range,decisions%20and%20taking%20an%20action.

Urstad, K. H., Andersen, M. H., Larsen, M. H., Borge, C. R., Helseth, S., & Wahl, A. K. (2022, February 14). Definitions and measurement of Health Literacy in Health and Medicine Research: A systematic review. BMJ open. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8845180/#:~:text=According%20to%20Nutbeam%2C%20health%20literacy,health%20literacy)%20and%20to%20more

Van den Broucke, S. (2014, April 1). Health literacy: A critical concept for Public Health. Archives of public health = Archives belges de sante publique. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3994208/

Whitehurst, R. (2006, September). Home - books - NCBI. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books