health literacy health literacy health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. there are multiple definitions of health literacy, in part, because health literacy involves both the context (or setting) in which health literacy demands are made (e.g., health care, media, internet or fitness facility) and the skills that people bring to that situation. the ability to read and understand medication instructions is a form of health literacy. since health literacy is a primary contributing factor to health disparities, it is a continued and increasing concern for health professionals. the 2003 national assessment of adult literacy (naal) conducted by the us department of education found that 36% of participants scored as either "basic" or "below basic" in terms of their health literacy and concluded that approximately 80 million americans have limited health literacy. these individuals have difficulty with common health tasks including reading the label of a prescribed drug. several factors may influence health literacy. however, the following factors have been shown to strongly increase this risk: age (especially patients 65 years and older), limited english language proficiency or english as a second language, chronic conditions, less education, and lower socioeconomic status. patients with low health literacy understand less about their medical conditions and treatments and overall report worse health status. various interventions, such as simplifying information and illustrations, avoiding jargon, using "teach-back" methods, and encouraging patients' questions, have improved health behaviors in persons with low health literacy. the proportion of adults aged 18 and over in the u.s., in the year 2010, who reported that their health care providers always explained things so they could understand them was about 60.6%. this number increased 1% from 2007 to 2010. the healthy people 2020 initiative of the united states department of health and human services (hhs) has included health literacy as a pressing new topic, with objectives for improving it in the decade to come. in planning for healthy people 2030 (the fifth edition of healthy people), hhs issued a "solicitation for written comments on an updated health literacy definition for healthy people." several proposals address the fact that "health literacy is multidimensional", being the result of a concerted effort that involves the individual seeking care or information, providers and caregivers, the complexity and demands of the system, and the use of plain language for communication. characteristics a poster about airborne disease transmission encouraging the use of a handkerchief to prevent the spread. plain language plain language refers to the use of writing strategies that help readers find, understand, and apply information to fulfill their needs. it has a vital role to play in improving health literacy. in conjunction with readers education, provider cultural training, and system design, plain language helps people make more informed health choices. plain language is not, however, a one-size-fits-all approach. some strategies can be used to improve communication among medical professionals, while others will improve communication with patients and caregivers. it is in this area of provider-patient communication that health literacy efforts have been strongest. patients and consumers in general need to understand concepts that professionals often refer to in technical terms. health professionals must know their audience in order to better serve their patients and general readers or listeners. plain language is defined by the international plain language federation as writing whose "wording, structure, and design are so clear that the intended readers can easily find what they need, understand what they find, and use that information." some key elements of plain language include: organizing information so most important points come first breaking complex information into understandable chunks using simple language or language familiar to the reader defining technical terms and acronyms using active voice in subject-verb-object (svo ) sentences when subject/agent/topic coincide varying sentence length and structure to avoid monotony using lists and tables to make complex material easier to understand the national institute of health (nih) recommends that patient education materials be written at a 6th–7th grade reading level; further recommendations provided by the nih office of communications and public liaison are published in their "clear communication" initiative. the uk's national institute for health and care research (nihr) recommends involving patients and non-academic members of the public in writing plain language summaries of research articles. factors that contribute to health literacy many factors determine the health literacy level of health education materials or interventions: readability of the text, the patient's current state of health, language barriers between the clinician and patient, cultural appropriateness of the materials, format and style, sentence structure, use of illustrations, and numerous other factors. a study of 69,000 patients conducted in 1995 by two us hospitals found that between 26% and 60% of patients could not understand medication directions, a standard informed consent form, or materials about scheduling an appointment. the 2003 national assessment of adult literacy (naal) conducted by the us department of education found that 36% of participants scored as either "basic" or "below basic" in terms of their health literacy and concluded that approximately 80 million americans have limited health literacy. results of a systematic review of the literature found that when limited english proficient (lep) patients receive care from physicians who are fluent in the patients' preferred language, referred to as having language concordance, generally improves outcomes. these outcomes are consistent across patient-reported measures, such as patient satisfaction, and also more such as blood pressure for patients with diabetes. standardized measures of health literacy are the newest vital sign (nvs), which asks people about a nutrition label, and the test of functional health literacy (tofhla), which asks test-takers to fill in 36 blanks in patient instructions for x-rays and a medicaid application, from multiple choices, and 4 numbers in medicine dosage forms. history the young and multidisciplinary field of health literacy emerged from two groups of experts: physicians, health providers such as nurses and health educators; and adult basic education (abe) and english as a second language (esl) practitioners in the field of education. physicians and nurses are a source of patient comprehension and compliance studies. adult basic education / english for speakers of languages other than english (abe/esol) specialists study and design interventions to help people develop reading, writing, and conversation skills and increasingly infuse curricula with health information to promote better health literacy. a range of approaches to adult education brings health literacy skills to people in traditional classroom settings, as well as where they work and live. biomedical approach the biomedical approach to health literacy that became dominant (in the u.s.) during the 1980s and 1990s often depicted individuals as lacking health literacy or "suffering" from low health literacy. this approach assumed that recipients are passive in their possession and reception of health literacy and believed that models of literacy and health literacy are politically neutral and universally applicable. this approach is found lacking when placed in the context of broader ecological, critical, and cultural approaches to health. this approach has produced, and continues to reproduce, numerous correlational studies. level of health literacy is considered adequate when the population has sufficient knowledge, skills, and confidence to guide their own health, and people are able to stay healthy, recover from illness, and/or live with disability or disease. mcmurray states that health literacy ist important in a community because it addresses health inequities. it is no coincidence that individuals with lower levels of health literacy live, disproportionately, in communities with lower socio-economic standing. a barrier to achieving adequate health literacy for these individuals is a lack of awareness, or understanding of, information and resources relevant to improving their health. this knowledge gap arises from both patients being unable to understand information presented to them and hospitals' inadequate efforts and materials to address these literacy gaps. a more robust view of health literacy includes the ability to understand scientific concepts, content, and health research; skills in spoken, written, and online communication; critical interpretation of mass media messages; navigating complex systems of health care and governance; knowledge and use of community capital and resources; and using cultural and indigenous knowledge in health decision making. this integrative view sees health literacy as a social determinant of health that offers a powerful opportunity to reduce inequities in health. this perspective defines health literacy as the wide range of skills, and competencies that people develop over their lifetimes to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life. while various definitions vary in wording, they all fall within this conceptual framework. defining health literacy in that manner builds the foundation for a multi-dimensional model of health literacy built around four central domains: fundamental literacy, scientific literacy, civic literacy, and cultural literacy. the cited paper by zarcadoolas et al. focussed on "the public discourse about terrorism and bioterrorism that dominated the mass media during the anthrax threat in the united states during 2001." there are several tests, which have verified reliability in the academic literature that can be administered in order to test one's health literacy. some of these tests include the medical term recognition test (meter), which was developed in the united states (2 minute administration time) for the clinical setting. the meter includes many words from the rapid estimate of adult literacy in medicine (realm) test. the short assessment of health literacy in spanish and english populations (sahl-s&e) uses word recognition and multiple choice questions to test a person's comprehension. the chc-test measures critical health competencies and consists of 72 items designed to test a person's understanding of medical concepts, literature searching, basic statistics, and design of experiments and samples. patient safety and outcomes according to an institute of medicine (2004) report, low health literacy negatively affects the treatment outcome and safety of care delivery. the lack of health literacy affects all segments of the population. however, it is disproportionate in certain demographic groups, such as the elderly, ethnic minorities, recent immigrants, individuals facing homelessness, and persons with low general literacy. these populations have a higher risk of hospitalization, longer hospital stays, are less likely to comply with treatment, are more likely to make errors with medication, and are more ill when they initially seek medical care. the mismatch between a clinician's communication of content and a patient's ability to understand that content can lead to medication errors and adverse medical outcomes. health literacy skills are not only a problem in the general population. health care professionals (doctors, nurses, public health workers) can also have poor health literacy skills, such as a reduced ability to clearly explain health issues to patients and the public. in addition to tailoring the content of what health professionals communicate to their patients, a well arranged layout, pertinent illustrations, and intuitive format of written materials can improve the usability of health care literature. this in turn can help in effective communication between healthcare providers and their patients. outcomes of low levels of health literacy also include relative expenditures on health services. because individuals with low health literacy are more likely to have adverse health statuses, their use of health services is also increased. this trend is compounded by other risk factors of low health literacy, including poverty. homelessness and housing insecurity can hinder good health and recovery in attempts to better health circumstances, causing the exacerbation of poor health conditions. in these cases, a variety of health services may be used repeatedly as health issues are prolonged. thus overall expenditures on health services is greater among populations with low health literacy and poor health. these costs may be left to individuals and families to pay which may further burden health conditions, or the costs may be left to a variety of institutions which in turn has broader implications for government funding and health care systems. a review of studies that focused on health literacy and its associated costs concluded that low levels of health literacy is responsible for 3–5% of healthcare cost—approximately $143 to 7,798 per individual within the healthcare system. for example, studies have shown that the increased prevalence of poor health and low health literacy has resulted in a greater use of emergency services by homeless individuals. a study conducted in san francisco showed that "72% of the total