Health Literacy

Health Literacy 

What is health literacy?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.1

Health literacy is dependent on individual and systemic factors:

  • Communication skills of lay persons and professionals
  • Lay and professional knowledge of health topics
  • Culture
  • Demands of the healthcare and public health systems
  • Demands of the situation/context

Health literacy affects people's ability to:

  • Navigate the healthcare system, including filling out complex forms and locating providers and services
  • Share personal information, such as health history, with providers
  • Engage in self-care and chronic-disease management
  • Understand mathematical concepts such as probability and risk

Health literacy includes numeracy skills. For example, calculating cholesterol and blood sugar levels, measuring medications, and understanding nutrition labels all require math skills. Choosing between health plans or comparing prescription drug coverage requires calculating premiums, copays, and deductibles.

In addition to basic literacy skills, health literacy requires knowledge of health topics. People with limited health literacy often lack knowledge or have misinformation about the body as well as the nature and causes of disease. Without this knowledge, they may not understand the relationship between lifestyle factors such as diet and exercise and various health outcomes.

Health information can overwhelm even persons with advanced literacy skills. Medical science progresses rapidly. What people may have learned about health or biology during their school years often becomes outdated or forgotten, or it is incomplete. Moreover, health information provided in a stressful or unfamiliar situation is unlikely to be retained.


Why is health literacy important?

Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy.  In other words, nearly nine out of ten adults may lack the skills needed to manage their health and prevent disease.  Fourteen percent of adults (30 million people) have Below Basic health literacy.  These adults were more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy.6

Low literacy has been linked to poor health outcomes such as higher rates of hospitalization and less frequent use of preventive services (see Fact Sheet: Health Literacy and Health Outcomes). Both of these outcomes are associated with higher healthcare costs.



Use of preventive services

According to research studies, persons with limited health literacy skills are more likely to skip important preventive measures such as mammograms, Pap smears, and flu shots.1 When compared to those with adequate health literacy skills, studies have shown that patients with limited health literacy skills enter the healthcare system when they are sicker.2

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Knowledge about medical conditions and treatment

Persons with limited health literacy skills are more likely to have chronic conditions and are less able to manage them effectively. Studies have found that patients with high blood pressure,3 diabetes,3-5 asthma,6 or HIV/AIDS7-9 who have limited health literacy skills have less knowledge of their illness and its management.

Rates of hospitalization

Limited health literacy skills are associated with an increase in preventable hospital visits and admissions.10-13 Studies have demonstrated a higher rate of hospitalization and use of emergency services among patients with limited literacy skills.12

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Health status

Studies demonstrate that persons with limited health literacy skills are significantly more likely than persons with adequate health literacy skills to report their health as poor.10, 12 14

Healthcare costs

Persons with limited health literacy skills make greater use of services designed to treat complications of disease and less use of services designed to preventcomplications.1, 11-13 Studies demonstrate a higher rate of hospitalization and use of emergency services among patients with limited health literacy skills.10-13This higher use is associated with higher healthcare costs.15 16,

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Stigma and shame

Low health literacy may also have negative psychological effects. One study found that those with limited health literacy skills reported a sense of shame about their skill level.17 As a result, they may hide reading or vocabulary difficulties to maintain their dignity.18


1Scott TL, Gazmararian JA, Williams MV, Baker DW. 2002. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care. 40(5): 395-404.

2Bennet CL, Ferreira MR, Davis TC, Kaplan J, Weinberger M, Kuzel T, Seday MA, Sartor O. 1998. Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. Journal of Clinical Oncology. 16(9): 3101-3104.

3Williams MV, Baker DW, Parker RM, Nurss JR. 1998. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Archives of Internal Medicine. 158(2): 166-172.

4Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan G, Bindman AB. 2002. Association of health literacy with diabetes outcomes. Journal of the American Medical Association. 288(4): 475-482.

5Schillinger D, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman AB. 2003. Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine. 163(1): 83-90.

6Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. 1998. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 114(4): 1008-1015.

7Kalichman SC, Ramachandran BB, Catz SP. 1999. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. Journal of General Internal Medicine. 14(5): 267-273.

8Kalichman SC, Rompa D. 2000. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 25(4): 337-344.

9Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D. 2000. Health literacy and health-related knowledge among persons living with HIV/AIDS. American Journal of Preventive Medicine. 18(4): 325-331.

10Baker DW, Parker RM, Williams MV, Clark WS. 1997. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health. 87(6): 1027-1030.

11Baker DW, Parker RM, Williams MV, Clark WS. 1998. Health literacy and the risk of hospital admission. Journal of General Internal Medicine. 13(12): 791-798.

12Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, Ren J, Peel J. 2002. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health. 92(8): 1278-1283.

13Gordon MM, Hampson R, Capell HA, Madhok R. 2002. Illiteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy (REALM) score. Rheumatology. 41(7): 750-754.

14National Center for Education Statistics. 2006.  The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy.  Washington, D.C.: U.S. Department of Education.

15Friedland R. 1998. New estimates of the high costs of inadequate health literacy. In:Proceedings of Pfizer Conference “Promoting Health Literacy: A Call to Action.” October 7-8, 1998, Washington, DC: Pfizer, Inc., 6-10.

16Howard DH, Gazmararian J, Parker RM. 2005. The impact of low health literacy on the medical costs of Medicare managed care enrollees. The American Journal of Medicine, 118, 371-377.

17Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. 1996. Shame and health literacy: The unspoken connection. Patient Education and Counseling. 27(1): 33-39.

18Baker DW, Parker MR, Williams MV, Ptikin K, Parikh NS, Coates W, Imara M. 1996. The health care experience of patients with low literacy. Archives of Family Medicine, 5(6): 329-334.

Book Review

Advancing Health Literacy: A Framework for Understanding and Action

By: Christina Zarcadoolas, Andrew F. Pleasant, and David S. Greer


The goal of this book:

How can this model of health literacy and the literacy principles it outlines improve the daily performance of health professionals and health programs in their efforts to advance individual and public health literacy?

Explore a list of questions:

  • What are the goals of communicating with the public about health?
  • How are health issues currently being communicated?
  • Is the language used easy to read, listen to, and understand?
  • What core concepts and vocabulary are essential?
  • If we acknowledge that people will understand messages at different levels, are the messages constructed so that they can actually occur?
  • Is the public able to absorb and use health information in a meaningful way?
  • Does health communication advance the publics understanding of health science and technology?


We define Health Literacy as the ability to understand, evaluate, and act on spoken, written, and visual health information to reduce risk and live a healthier life.


The consequences of low health literacy include poor health outcomes, increased risk in emergency situations, lack of social empowerment and self efficacy, and the financial costs associated with a less healthy population.


It is estimated that low reading level in low health literacy may be responsible for up to $69 billion in additional health expenditures in the USA (Institute of Medicine, 2003).


Chapter 1: Health Literacy Why is It a Public Health Issue?


Low health literacy contributes to a number of difficulties:

  • Improper use of medications
  • Inappropriate use or no use of health services
  • Poor self management of chronic conditions
  • In adequate response in emergency situations
  • Poor health outcomes
  • Lack of self efficacy and self-esteem
  • Financial drain on individuals and society
  • Social any quality


Definitions of key terms

  • Often the terms health communication, health promotion, and health education are used interchangeably.
  • Health promotion is the “process of enabling people to increase control over and to improve their health” (WHO, 1998, p.11)
  • Health promotion relies on health education and health communication, as well as systems and policies that advance the publics health status.
  • Health education is the full range of activities that involve communicating health information to people
  • Health education can take place anywhere: in the home on our community, schools and healthcare settings, worksites, And the consumer market place.
  • Health communication is the use of human and mass or multimedia and other communication skills and technologies to educate or inform an individual or public about a health issue and to keep that issue on the public agenda.
  • Social marketing is the merging of traditional marketing and advertising strategies to persuade people to act and specific ways on social issues such as health and the environment.
  • The goal is behavior change
  • Consumer decision making involves the active cognitive and emotional rolls individuals play and attending to, evaluating, and acting on health information.
  • Health literacy is the wide range of skills and competencies that people develop to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, an increase quality of life.


Chapter 2


Literature References 

Fagherazzi, G., and P. Ravaud. "Digital diabetes: Perspectives for diabetes prevention, management and research." Diabetes & metabolism 45.4 (2019): 322-329.

Shan, Rongzi, Sudipa Sarkar, and Seth S. Martin. "Digital health technology and mobile devices for the management of diabetes mellitus: state of the art." Diabetologia 62.6 (2019): 877-887.

Sørensen, Kristine, et al. "Health literacy and public health: a systematic review and integration of definitions and models." BMC public health 12.1 (2012): 80.