Health Literacy: Is Educational Attainment Enough?

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the second blog  in a three-part series the IH Blog will feature this summer, Global Health Literacy: Conceptual Basis, Measurement and Implications.

Part II: Health Literacy: Is Educational Attainment Enough?

For over a decade I worked in primary care practices providing health education to patients with a broad range of educational and professional backgrounds, from persons who had dropped out of high school to those with dual doctoral degrees. I recall that when I first started I assumed that persons with higher levels of educational attainment would more readily understand and incorporate health education into their daily lives. I soon realized that I was entirely wrong. While persons who had higher levels of education were somewhat more likely to comprehend health information, a large proportion of these persons were unable to adequately understand and act on the health information presented to them. I remember sitting with a patient who had a doctoral degree who explained to me how his depression medication worked best when taken only on Sundays. Conversely, one patient who had not completed high school explained to me the intricacies of high blood pressure management with such clarity that it would have rivaled any veteran educator’s attempts at explaining it. All of these experiences fostered my interest in this concept of health literacy. What was health literacy? How could we adequately measure and improve it? What caused poor health literacy? Was it poor communication, a lack of numeracy skills, cultural barriers or other factors? The complexity of these questions fascinated me and I have pondered them over the last several years in my research.

In recapping my exploration let’s start by discussing how health literacy was initially distinguished from educational attainment. Much evidence has demonstrated that social factors occurring outside of the clinical encounter, namely education and income, profoundly influence health outcomes. Health disparities based on population (e.g. age, race, class, disability) or geographic residence (e.g. neighborhood, urban, country) are significant and have been the subject of much investigation. While a myriad of indicators have been explored in relation to such disparities, many investigations report that educational attainment is the most influential predictor of health. This relationship has been substantiated in a wide range of settings and time periods as well as by the application of varying methodological approaches and indicators of health. Educational attainment improves health through mechanisms on the individual level (e.g., health literacy and skill development); community level (e.g., location of residence characteristics); and macro level (e.g., policies, legislation, infrastructure).

The term health literacy (HL) was introduced and differentiated from educational attainment or literacy beginning in the 1970’s. During this time it was found that while one’s HL level was related to educational attainment (years of schooling) or reading ability/literacy, there was not a perfect linear correlation between educational attainment/literacy and HL. Research showed that individuals who functioned successfully at home or work often lacked adequate literacy to function within the context of a health care system. While varying opinions on the definition of HL have existed over time and are the subject of ongoing debate, generally speaking, being health literate meant that one could read, understand, and act on health information that was provided to them. HL encompassed proficiency in more than just reading ability but also writing, speaking, and listening as well as computational abilities (numeracy). A health literate individual was able to understand health information and use that health information appropriately. For example, a health literate elderly adult who received instructions from a primary physician on how to take medication for blood pressure would both understand the instructions and then take the medication as instructed by the physician. Thus, those with low HL were unable to adequately function within the healthcare environment increasing their risk for poor outcomes.

Some recent initiatives have sought to document stories related to health literacy. To this end, the U.S. federal government hosted an initiative called ‘Stories from the field’ as a part of a program to reduce the burden of low HL. In one story a doctor in Wisconsin struggled with his patients’ lack of comprehension of his instructions during medical encounters. He pondered whether it was poor communication on his part or whether there were other causes. After research and reflection he identified low HL as a prominent underlying cause and founded a small statewide literacy organization aimed at improving low HL called Wisconsin Literacy.

In order to address what has been called a “Health Literacy Epidemic,” both governmental and non-governmental initiatives have been developed to improve HL and in turn, reduce it’s public health burden. A transdisciplinary approach has been encouraged and specific guidelines have been established to foster improved communication. The U.S. Department of Health and Human Services (HHS) developed a National Action Plan to Improve Health Literacy. Broad goals and strategies of this plan are to improve HL in every sector and organization that provides health information and services. With the aim of fostering effective communication the federal government created The Plain which is an internet clearinghouse of information pertaining to the use of clear and understandable language. This initiative defines plain language as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others.” The Plain Language Action and Information Network (PLAIN), a group of federal employees from many different agencies and specialties who support the use of clear communication in government writing, work to manage the initiative’s website. The Partnership for Clear Communication was established to spread awareness and address the issue of low HL. It established the “Ask me 3” program which informs healthcare consumers of 3 questions that should be asked during a medical encounter: (1)“What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”  The Health Literacy Tool Shed, is a database created and administered by Boston University and the National Library of Medicine to foster collaboration and resource-sharing related to health literacy. The online search engine includes 129 tools related to the assessment of health literacy which range in terms of their purpose and design. They are either general in scope or focus on a certain domain(s) within the construct of health literacy (e.g. numeracy). Many of these tools aim to assess HL related to a specific medical condition (e.g. arthritis or cancer), categorization of health (e.g. oral health) or population (e.g. Dutch, Japanese).  Some tools were developed for rapid assessment.

For the global examination of HL the Institute of Medicine Roundtable on Health Literacy was convened to bring together leaders in the global health field to discuss activities and progress around the world related to HL. The United Nations as well as over a dozen countries were present at this meeting. The roundtable discussed different country’s unique approach to addressing low HL. For example, in Australia HL initiatives are part of the national Commission on Safety and Quality in Health Care. Canada connects HL with health promotion activities and the public health sector governs HL initiatives. A consensus from the meeting was that educational systems do not provide their students with the skills to adequately use health information and access health services. Furthermore, participants agreed that there was a lack of capacity for health care services to meet the needs of persons with low HL. This was accompanied by a lack of data on the nature and scope of the problem of low HL as well as the effectiveness of interventions targeting HL. This issue was particularly pronounced in LICs and LMICs, in which very little research had examined HL in any form.

Given the lack of evaluation of HL in LICs and LMICs there is an urgent need to develop a measure HL that can be feasibly employed. Establishing a measure that can assess the burden of low HL as well assess it’s relation to health outcomes is important so that effective interventions can be developed and deployed. Please stay tuned for Part III: The Evaluation and Measurement of Health Literacy in which I discuss my research group’s work in creating and establishing a measure of HL for use in LICs and LMICs.


Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.


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