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Looking an Elephant in the Eye
HHS Agencies Forge Strategy on Health Literacy

By Jennifer Wenger

On the Front Page...

Ask anyone who's ever considered having surgery, starting a new drug therapy or changing a diet: To make smart health decisions, a person needs to be informed.


So imagine how tough it must be for someone to get a handle on her newly diagnosed diabetes if she has difficulty reading a brochure explaining the hemoglobin A1c test. Or for someone to control his hypertension if his limited understanding of English prevents him from determining whether his prescription drugs will be covered by Medicare.

Such are the concerns that brought nearly every agency within the Department of Health and Human Services to the NIH campus on Apr. 2. The purpose of the all-day dialogue was to address an issue so pervasive it's often referred to as "the elephant" by those most closely involved — health literacy.

Healthy People 2010 defines 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." One key indicator of a person's health literacy is his or her ability to read. According to the 1992 National Adult Literacy Survey, 90 million adults — 47 percent of the adult U.S. population — occupy the lowest two literacy levels. Although they may be able to read and interpret a traffic sign or paycheck, they are generally unable to comprehend a bar chart or lengthy news article. According to Dr. Dean Schillinger, associate professor of medicine at San Francisco General Hospital and a leading expert on health literacy, the average reading level for Americans is between the eighth and ninth grades, while those on Medicaid, on average, read at the fifth-grade level.

But health literacy doesn't stop with materials that are in print. It can include the ability to understand what's spoken, such as when a doctor tells a patient how to follow a prescription, or what's presented on a videotape, audiotape or web page. Aging, vision and hearing problems, poverty, learning disabilities, immigration and minority status and education all contribute to low health literacy.

"We wanted to bring people and agencies that didn't know about health literacy or hadn't been part of the health-literacy discussion into the discussion, and we wanted to share information about the variety of health-literacy activities going on in the department," said Dr. Cynthia Baur, health communication and e-health advisor in HHS's Office of Disease Prevention and Health Promotion, and chief organizer of the workshop. Her office is responsible for ensuring that the health-literacy objectives of Healthy People 2010 — namely, improving the health literacy of individuals with inadequate literacy skills, and improving the communication skills of healthcare providers — are met.

"We don't need to discover new genes, or invent new technology," Dr. James Battey, Jr., director of NIDCD, told the group of 70-plus in his welcoming remarks. "We need to put into practice things that we already understand. To not do so would be a major mistake."

U.S. Surgeon General Richard Carmona voiced his endorsement of departmental activities in health literacy as well. "The evidence indicates that health literacy may be both a cause of and contributor to health disparities," he said in a letter read at the meeting. "The bottom line for our department is we need to present health information in ways that people of all races and ethnicities, all walks of life, and all regions of this country will understand, and more important, use it."

Already, some headway is being made in the area of health literacy, both within and outside the department. Baur reported that HHS has sponsored external experts to draft an action plan, now in the clearance process, for achieving the health-communication objectives in Healthy People 2010, including those pertaining to health literacy. The department has also added 20 questions related to health literacy to the U.S. Department of Education's 2003 National Assessment of Adult Literacy. Responses to those questions will be used to determine if health-literacy objectives in Healthy People 2010 are being met.

Efforts outside HHS include an Institute of Medicine study in progress to assess the problem of health literacy and to recommend steps to remedy the situation through public health and education. And the American Medical Association and Pfizer have both named health literacy as an issue of top priority.

Marin Allen, director of communication for NIDCD, told the group that communication disorders such as aphasia, auditory processing disorder, language impairments, and hearing loss, as well as other challenges such as dyslexia and dementia, can significantly influence a person's ability to obtain, process and understand health information. Health-literacy programs at NIDCD are being conducted in such areas as early identification of hearing loss, informed consent, and antibiotic use; in addition, bibliographical and information resources on health literacy for health communicators and other professionals will soon be posted in a new section on NIDCD's health information web site at

NIDCR was the lead agency for the development of the Surgeon General's report Oral Health in America, as well as the chapter on oral health for Healthy People 2010, both of which identified the need to raise oral health literacy, said Dr. Alice Horowitz, NIDCR senior scientist. Among NIDCR's endeavors are several studies to determine the level of knowledge related to the prevention and early identification of oral cancer, a disease for which there is a 50 percent survival rate.

For more information on departmental health-literacy activities and how to become involved, contact Cynthia Baur at; Marin Allen at; or Alice Horowitz at; or contact your institute's Healthy People 2010 coordinator.

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