1. Zuzelo, Patti Rager EdD, RN, ACNS-BC, ANP-BC, FAAN

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Managing care of the whole self can be a daunting responsibility, with overwhelming challenges even in the best of circumstances. Self-care and promoting the health of loved ones require abilities to navigate through complex ideas, access information via unfamiliar technologies, and discern whether or not information is relevant to a particular health question. Holistic practitioners must be aware of these potential challenges and capable of effectively responding to these health care barriers. Health literacy is defined by the Patient Protection and Affordable Care Act of 2010, Title V, as "the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions."1 Health literacy relates to language literacy, but it differs in its components and its usage. Nurses and other providers are often familiar with literacy specific to readability and grade level of written materials and consents but may not appreciate the enormity of the health literacy problem.2


The National Assessment of Adult Literacy (NAAL) was last conducted in 2003 to assess English literacy in the United States.3 A nationally representative, probability sample of American adults 16 years or older (N = 19 000), recruited from homes and prisons, provided results in prose, document, and quantitative literacy that were ranked into 5 levels, ranging from least to most proficient. NAAL components included health literacy evaluation based on an ability to use literacy skills to make sense of health-related materials and forms.3 Findings revealed that at the time, approximately 43% of Americans were functioning at below basic or basic levels of literacy, with an inability to perform basic literacy tasks including reading and comprehending long texts or calculating 2-step arithmetic functions. Considering the types of health-related forms, insurance documents, consent forms, pharmaceutical pamphlets, and labels for medications, foods, and supplements that play important roles in health management, this illiteracy has potentially grave consequences.


The Institute of Medicine of the National Academies assembled an expert committee to consider the health literacy problem.4 The Committee on Health Literacy constructed a framework characterizing health literacy as a synergistic relationship between culture and society, the health system, the educational system, and health outcomes and cost.4 This framework provides an opportunity to consider literacy interventions within or across one or more of these systems. As an example, holistic health practices and associated materials, documents, and calculations may need to be taught in schools and promoted within the society and systems of public health while also supported and encouraged during health care system encounters. One specific exemplar may be teaching people how to read nutrition labels and to make action plans and judgments based on the provided information.


The NAAL findings do not include Web-based or technology-based literacy. The Organization for Economic Cooperation and Development released its 2013 report describing adult skills in literacy, numeracy, and technology across 24 countries and found that Americans scored below average across all 3 categories.5 The Survey of Adult Skills is an international survey conducted in more than 40 countries to measure the key cognitive and workplace skills needed for individuals to participate in the society and for economies to prosper.5 Similar to concerns related to health quality identified by the Committee on Health Literacy, survey findings make clear that individuals with low literacy are at increased risk for lower income, poorer health outcomes, and lower levels of civic engagement.5 While the survey does not focus on health literacy, the connections between literacy, numeracy, and problem solving in technology-abundant environments and quality of health and health care confidence appear obvious.


Health literacy is an important concern that should be continuously considered by holistic health care providers. At some point in time, all citizens need to be able to access, interpret, use, and evaluate health information, services, and benefits. Although people with low literacy in its broadest sense are at greater risk for poorer health outcomes, even people who are well-read and highly educated can find themselves confronting difficulties related to health literacy. Navigating insurance plans, dealing with complex health expenditures, interpreting risks and benefits associated with medical or surgical therapies, managing sophisticated self-care requirements, and manipulating and maintaining health care equipment are a few examples of the sorts of health-related challenges that may be daunting, regardless of education and financial means.


The NAAL survey and the Committee on Health Literacy efforts were conducted well over a decade ago, and Web-based health technologies have burgeoned during this time period. Access to health data via Web-based portals is increasingly commonplace. Users are often required to provide an e-mail address and create a complex password often recommending or demanding lowercase and upper case letters, symbols, and numbers. Insurance information that is necessary to understand billing and benefits is readily available online, providing one has both access and technological understanding. Health reports and warning notices abound in the world of the Web; however, discerning truth from fiction and avoiding scams necessitate technological health literacy. Apps or applications offer many opportunities to monitor and improve health via mobile devices, including smartphones, tablets, electronic readers, and other devices. These apps are often user-friendly, providing that one is comfortable navigating the device platforms and setting up the systems in such ways that unique, individual health concerns are detected and monitored. Many devices connect to other devices, and these seemingly easy but technologically complex interplays can be overwhelming to those who are technologically illiterate.


Nurses and other health care providers need to consistently address health literacy, including technologically based literacy, during any and all encounters with patients and families. There are many health literacy resources that could be useful to improve clinical practice education processes and also to open coaching and conversation opportunities during practice encounters. The National Patient Safety Foundation offers an educational program, Ask me 3, that teaches people to ask their providers 3 important questions: What is my main problem? What do I need to do? Why do I need to do this?6 This program is designed to facilitate clear communication between providers and those they serve. The Center for Plain Language is a not-for-profit organization that helps government agencies and businesses write clearly.7 Its Web site offers excellent examples of before and after writing samples, including an exemplar on revising a health care benefit flyer. A tip sheet for clear writing is available, and there are educational resources that focus on health literacy.


Nurses should consider whether or not basic instruction sheets pertaining to operative procedures, medication usage, discharge instructions, or other important self-care information require plain language revisions. Popular readability tools such as the SMOG (simple measure of gobbledygook) index, Gunning-Fog index, and the Flesch Reading Ease score are available on the Web and can be useful when health care providers are evaluating whether or not written materials may be too difficult for the typical patient/client to read and comprehend. Microsoft Word offers readability scores, but this feature is not provided as a default function.2 To take advantage of this feature, select it within the Proofing options. The selection process depends on the software edition, so use the Help feature to search "readability" within Microsoft Word.


Pfizer also offers health literacy resources, including the Newest Vital Sign toolkit for health literacy assessment.8 There are many other freely available resources to support providers that recognize the importance of and obligation to address and promote health literacy. EthnoMed ( provides education materials tailored to many cultures including Amharic, Cambodian, Chinese, Eritrean, Hispanic, Somali, Vietnamese, and others.9 Instruction sheets about numerous clinical topics are freely available in many languages. This compendium is an excellent source of information for providers and offers unique materials that can be very useful when working with culturally diverse patients and families, including refugees.


Healthy People 2020 has a goal to "use health communication strategies and health information technology (IT) to improve population health outcomes and health care quality, and to achieve health equity."10 The objectives for this goal are ambitious and include improving the population's health literacy; increasing people's access to the Internet, including mobile devices; increasing the number of health practices that use electronic health records; and increasing health care providers' communication skills as evaluated by the care recipients. Nurses and other health care professionals are charged with responsibility for addressing key components of health literacy, and, to do so, they need to consider health literacy assessment as an essential component of holistic care and necessary to promote optimal health.




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