About This Literature Summary
This summary of the literature on Health Literacy as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Language and Literacy literature summary.
Related Objectives (4)
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Related Evidence-Based Resources (4)
Healthy People 2030 has elevated the importance of health literacy by declaring it a foundational principle and overarching goal, and by adopting two definitions that together constitute health literacy.
Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
Healthy People and the U.S. Department of Health and Human Services have long recognized that health literacy is not just the result of individual capacities but also the health-literacy related demands and complexities of the health care system.1,2 This official recognition of the two dimensions of health literacy clarifies the different routes to health literacy improvement and encourages stakeholders to engage on both levels. Healthy People’s new definitions of health literacy also underscores the differences between social risks and social determinants of health.
Personal Health Literacy Is a Social Risk
Personal health literacy is a social risk, one associated with worse health care and health outcomes.3 When individuals have limited personal health literacy, they are at higher risk of misunderstanding information that is important to achieving and maintaining health or losing their way in the fragmented health care system.
Most measures of personal health literacy assess people’s ability to understand written health information and numbers. Using such an assessment in English, the only national health literacy measure found that over a third of adults in the U.S. have limited personal health literacy.4 Assessing personal health literacy at a given point in time for the purpose of targeting interventions to individuals has limitations; measurement tools can lack precision, and personal health literacy skills can fluctuate, declining at times of illness or stress.5 Assessment at the aggregate level, however, allows support and resources to be targeted to communities and populations in greatest need. Currently, there is no national measure of personal health literacy.
Organizational Health Literacy Is a Social Determinant of Health
Living in communities served by health care organizations that lack organizational health literacy can affect the quality of health care delivered and, consequently, health outcomes. People residing in the catchment areas of organizations with limited health literacy may be more likely to suffer from miscommunication and have difficulty accessing services. Even people with high personal health literacy can suffer ill effects from low organizational health literacy. Healthy People 2030 organizational health literacy objectives focus on provider-patient communication and shared decision-making.
The concept of organizational health literacy is still evolving. Attributes of a health-literate organization, as well as strategies for becoming a health-literate organization, have been articulated.6–11 Many measures of aspects of organizational health literacy have been developed, but currently there is no measure of the extent of organizational health literacy in the nation.12,13 Studies of organizational health literacy have largely been descriptive, with few impacts reported.9,14-18 Additional research on the effect of organizational health literacy is needed.19
Health Literacy and Health Equity
Personal health literacy is associated with racial/ethnic minority status, age, poverty, health insurance coverage, educational attainment, language spoken before starting school, and self-reported health.20 Strategies to increase personal health literacy disproportionately benefit populations that have been marginalized and therefore have the potential to decrease health disparities.
Similarly, improving organizational health literacy may reduce disparities. For example, one aspect of being a health-literate organization is meeting the needs of populations with a range of health literacy levels. By ensuring that everyone, regardless of their abilities, can make use of health information and services, health-literate organizations advance health equity.
The National Action Plan to Improve Health Literacy called for interventions that increase both organizational and personal health literacy.2 On the organizational health literacy front, its goals include promoting changes in the health care system that improve communication, informed decision-making, and access to culturally and linguistically appropriate health information and services. On the personal health literacy front, it promotes accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level, as well as expanding adult education and English language instruction.
U.S. Department of Health and Human Services. (2003). Communicating health: Priorities and strategies for progress: Action plans to achieve the health communication objectives in Healthy People 2010.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97–107.
U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2008). America’s health literacy: Why we need accessible health information.
Pleasant, A., Rudd, R. E., O’Leary, C., Paasche-Orlow, M. K., Allen, M. P., Alvarado-Little, W., ... & Rosen, S. (2016). Considerations for a new definition of health literacy. National Academy of Medicine.
Brach, C., Keller, D., Hernandez, L. M., Baur, C., Parker, R., Dreyer, B., ... & Schillinger, D. (2012). Ten attributes of health literate health care organizations. NAM Perspectives.
Abrams, M. A., Kurtz-Rossi, S., Riffenburgh, A., & Savage, B. A. (2014). Building health literate organizations: A guidebook to achieving organizational change. Journal of Research and Practice for Adult Literacy, Secondary, and Basic Education, 69.
Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., ... & West, D. (2015). AHRQ health literacy universal precautions toolkit. Agency for Healthcare Research and Quality.
Brach, C. (2017). The journey to become a health literate organization: A snapshot of health system improvement. Studies in Health Technology and Informatics, 240, 203.
Farmanova, E., Bonneville, L., & Bouchard, L. (2018). Organizational health literacy: Review of theories, frameworks, guides, and implementation issues. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55. doi: 0046958018757848
Koh, H. K., Brach, C., Harris, L. M., & Parchman, M. L. (2013). A proposed “health literate care model” would constitute a systems approach to improving patients’ engagement in care. Health Affairs, 32(2), 357–367.
Kripalani, S., Wallston, K., Cavanaugh, K. L., … & Rothman, R. L. (2014). Measures to assess a health-literate organization. National Academies of Medicine.
Brega, A. G., Hamer, M. K., Albright, K., Brach, C., Saliba, D., Abbey, D., & Gritz, R. M. (2019). Organizational health literacy: Quality improvement measures with expert consensus. HLRP: Health Literacy Research and Practice, 3(2), e127–e146.
Weaver, N. L., Wray, R. J., Zellin, S., Gautam, K., & Jupka, K. (2012). Advancing organizational health literacy in health care organizations serving high-needs populations: A case study. Journal of Health Communication, 17(sup3), 55–66.
Adsul, P., Wray, R., Gautam, K., Jupka, K., Weaver, N., & Wilson, K. (2017). Becoming a health literate organization: Formative research results from healthcare organizations providing care for undeserved communities. Health Services Management Research, 30(4), 188–196.
Institute of Medicine. (2013). Organizational change to improve health literacy: Workshop summary. National Academies Press.
Isibel, D. (2020). Improving health literacy at the organizational level. Journal of Doctoral Nursing Practice, 13(1), 79-83.
Kaphingst, K. A., Weaver, N. L., Wray, R. J., Brown, M. L., Buskirk, T., & Kreuter, M. W. (2014). Effects of patient health literacy, patient engagement and a system-level health literacy attribute on patient-reported outcomes: A representative statewide survey. BMC Health Services Research, 14(1), 1–8.
Agency for Healthcare Research and Quality. (2020). Special emphasis notice (SEN): AHRQ announces interest in research on improving organizational health literacy to prevent and manage chronic disease. https://grants.nih.gov/grants/guide/notice-files/NOT-HS-20-009.html
Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Institute of Education Sciences, National Center for Education Statistics.