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Health Literacy: A Prescription To End Confusion
by Lynn Nielsen-bohlman
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From the New England Journal of Medicine, March 3, 2005
The nature and scope of problems regarding health literacy -- the degree to which the lay public has the capacity to obtain, process, and understand the basic information and services needed to make appropriate decisions regarding their health -- are numerous, complex, and important to our nation's well-being. For this reason, the Institute of Medicine (IOM) convened the Committee on Health Literacy, composed of experts from a wide range of academic disciplines and backgrounds, to define the scope of the problem, identify the obstacles to creating a health-literate public, assess the approaches that have been attempted to increase health literacy in the United States and abroad, and identify goals for health literacy and suggest approaches to reach these goals. The committee clearly fulfilled its duty in regard to the first three items listed above, as demonstrated in its comprehensive, well-written report, Health Literacy: A Prescription to End Confusion. The first three items are the equivalent of a public health assessment, one of the three core functions identified in a previous IOM report (The Future of Public Health, Committee for the Study of the Future of Public Health, Institute of Medicine, National Academies Press, 1988). Health Literacy excels not only in the amount of assessment data it contains, but also in the systematic way in which the data are summarized (e.g., in 18 clearly written bullet points, or "findings," appropriately placed throughout the report). This information defines and categorizes most of what we know and do not know about health literacy, about obstacles to creating a health-literate public, and about approaches that have been attempted to increase health literacy. In regard to the fourth component above, the committee created "A Vision for a Health-Literate America," described, in part, as a society "within which people have the skills they need to obtain, interpret, and use health information appropriately and in meaningful ways," and "in which a variety of health systems structures and institutions take responsibility for providing clear communication and adequate support to facilitate health-promoting actions based on understanding." The committee also outlined 15 recommendations, consisting of short statements that can be used to begin a process aimed at fulfilling its vision. The only part of this IOM report I found to be problematic was the fourth component, which I believe to be the equivalent of public health policy development, another core function identified in the 1988 IOM report, as noted above. As expected, the committee approached the issue of health literacy from a national perspective, and its recommendations reflect a very top-down approach. However, like politics, virtually all education in the United States, at least through high school, is local. And that is why I believe the committee should have approached health literacy from the bottom up. For example, families are mentioned throughout this book, but there is not one recommendation that discusses the role of families in solving health-literacy problems, nor is there much (or, in some cases, any) mention of local religious institutions; school and local libraries, health departments, and boards of education; peer, parent, and advocacy or support groups; community colleges; or state boards of education. In addition, for many people, lack of food, clothing, shelter, jobs, and transportation is a higher priority than are problems with access to health care or even health itself, and these problems are mentioned very rarely, if at all, in the book. Like health literacy, such family-centered, community-based issues are best solved by empowered local and state agencies working in concert with the federal agencies identified in the recommendations. Thus, unlike the top-down, policy-development direction suggested in this report, the overall leadership and driving forces for solving health-literacy problems must come primarily from the local and state levels. I think the title of this book should have been Health Literacy: A Prescription to Begin to End the Confusion. Although it is a minor point in a review of this outstanding contribution to the public health literature, I believe that an almost Talmudic-length commentary is needed to describe the assessment, policy development, assurance (implementation and evaluation), infrastructure, and capacity-building activities and resources needed to end the confusion regarding health literacy in the United States today. Robert M. Fineman, M.D., Ph.D.
Copyright © 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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