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Social Determinants of Health
- Constantin Vintilescu
Predicting future trends in any profession cautions careful review of present and past trends. Over the last two decades, health care in the United States has undergone major changes due to simultaneous advances in the fields of health information and information technology. Advances in health care and life expectancy also have created dramatic changes. Subsequent gains in life expectancy have surpassed the gains achieved, between the years 1940 and 1964 with the advent of antibiotics. In fact, recent gains have exceeded that of any other time this century. The life expectancy projections for the rest of this century may turn out to be even more significant. The educations of the public about health literacy issues and the rights of the elderly have become another dimension of advancement, along with the “rights” of patients and minority groups including the physically handicapped.
In the United States, the term literacy is generally defined as the ability to read and speak English (Andrus, 2002). In the 1992 National Adult Literacy Survey (NALS), the U.S. Department of Education (1993) defined literacy as: “the ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential.” Although no precise point defines the difference between literacy and illiteracy, the commonly accepted working definition of what is meant to be literate is the ability to write and to read, understand, and interpret information written at the eight-grade level or above.
Health literacy refers to how well an individual can read, interpret, and comprehend the health information for maintaining an optimal level of wellness. It is an essential aspect for access to health care and health-related services.
Limited health literacy leads to poor health outcomes. In fact, literacy skills are “a stronger predictor of an individual’s health status than age, income, employment status, education level, and racial or ethnic group” (Weiss, 2003).
Health literacy is also important for people’s maintenance of health and wellness. Health literacy is very important because requires peoples to have a more active role in health decision and their management.
Based on available statistics over the past twenty years, it is evident that the United States has significant health literacy problems. Health literacy has been termed the “silent epidemic,” the “silent barrier,” the “silent disability,” and “the dirty little secret” (Conlin & Schumann, 2002). In fact, the United States only ranked among the middle of other industrialized nations in most measures of adult literacy; and yet many of our educators, elected representatives, and social advocates have remained blind on this significant problem (Kogut, 2004).
Over the past two decades, the literacy of the American population has been the subject of increasing interest and concern by educators as well as by government officials, employers, and the media. Health literacy continues to be a major problem in the United States despite public efforts to address the issue and developing health literacy training programs. In our society, many people do not possess the basic literacy to navigate the increasingly complex health care field. Some people have difficulty in reading and comprehending information well enough to be able to fill out job and insurance applications, tax forms, or apply for a driver’s license.
In the early 1980s, President Reagan launched the National Adult Literacy Initiative, which was followed by the United Nation’s declaration of 1990 as the International Literacy year (Belton, 1991).
In light of the relatively recent attention given to health literacy in the last twenty years, we must acknowledge the efforts of two organizations — Literacy Volunteers of America, Inc., and Lauback Literacy International – that served for many years as advocates for the most marginalized adult populations in United States and around the globe. Of particular concern to the health care industry are the numbers of consumers who are illiterate, functionally illiterate, or marginally literate. People with poor reading and comprehension skills have disproportionately higher medical costs, increased number of hospitalizations, readmissions, and more perceived physical and psychosocial problems than do literae persons (Baker, 1998). Today the health care literacy problem has grave consequences, because patients are expected to assume responsibility for their self-care and health promotion. If people with low literacy abilities cannot fully benefit from given information, then they cannot be expected to maintain their health independently.
Computer literacy is also an increasingly popular concern of health literacy. Many health care providers and consumers are relying on computers as educational tools. “Those clients who are well educated and career oriented are already likely to own a computer and be computer literate, but those with limited resources, literacy skills, and technological know-how are being left behind” (Zarcadoolas et al., 2006).
Health care providers relied for many years on printed education brochures as a cost-effective way to communicate health instructions with people. For many years, nurses and doctors thought that written materials given to the patients were sufficient to ensure informed consent for different test or procedures. This way they promoted compliance with treatment regimens and discharge instructions. Kessels (2003) pointed out that 40-80% of medical information provided by health professionals is forgotten immediately, because not only medical terminology is too difficult to understand, but also because too much information contributes to poor recall. He also noted that half of the information remembered is incorrect.
Recently the health care providers have begun to realize that if the scientific and technical terminology in education materials are not written at a level and style appropriate for their intended audiences, people cannot be expected to be able or willing to accept responsibility for self-care.
In improving written health materials and in implementing health education it is important to know the literacy skills of the patients in the community and their families. Nurses play an important role in assessing patient’s literacy skills because nurses interact more with the patients and their families than the physicians do. The nurses can evaluate the ability of the healthcare client to understand printed health information by assessing the patients’ comprehension and reading skill level. There are specific guidelines for writing effective health education materials and teaching strategies for patients and their families. An individual‘s functional health literacy is likely to be significantly worse than his or her general literacy skills, because of the more complicated language used by health care providers.
Now that manage care insurance companies are requiring subscribers to take more responsibility for their self-care, poor health literacy can increasingly lead to negative consequences and escalated morbidity, and mortality. People with low health literacy don’t have knowledge or are misinformed about the body and the causes of illnesses. Because they do not have the proper knowledge, they don’t understand the relationship between lifestyle factors, like diet and exercise, and wellness .Those people with limited knowledge may not know how to seek care.
Health literacy tactics that improve written health materials may include:
- Written health materials should have plain language for better understanding and ease of sharing with people.
- Written health materials should be scientifically accurate and culturally appropriate.
- If the client does not fluently speaks English, provide the written health information in his/hers native language.
- If such information is unavailable, and a translator must be employed, it is critical to assess the client’s understanding of the written material.
- Written health information should include pictures for better understanding.
- Personal electronic devices such as cell phones, tablets, palm pilots, and talking kiosks can be a new method for sending health information to the patients.
- Before health providers make a health education brochure, they should also consider alternate methods such as individual, group, organizational, community and mass media.
- Use a short brochure that presents “bottom line” information, systematic instructions, and uses pictures with visual cues that highlight most important information to be absorbed.
- Health brochures should align health information with recommendations to services, resources, and other available support.
Removing the barrier to communication between individuals and health care providers is a good opportunity for nurses to function as facilitators and work in collaboration with other health care professionals for improvement of quality of care. As Advanced Practice Nurses, it is our mandated responsibility to teach in non-complicated terms so our patients can understand an fully benefit from our nursing interventions.
Andrus, M.R., & Roth, M.T. (2002). Health literacy: A review. Pharmacotherapy, 22(3), 282- 302.
Baker, D. W., Parker,R. M., Williams , M. V, & Clark , W. S. (1998). Health literacy and the risk of hospital admission. Journal of Internal Medicine, 13, 791-798.
Belton, A. B. (1991).Reading levels of patients in a general hospital. Beta Release, 15 (1), 21-24.California HealthCare Foundation. 2005. Consumers in Health Care: The Burden of Choice. Available at http://www.chcf.org
Conlin, K. K., & Schumann, L. (2002). Literacy in the health care system: A study on open heart surgery patients. Journal of the American Academy of Nurse Practitioners, 14 (1), 38-42.
Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion. National Academies Press: Washington, DC.
Kessels, R.P.C. (2003). Patients’ memory for medical information. Journal of the Royal Society of Medicine, 96,219-22.
Kogut, B.(2004).Why adult literacy matters. Pbi Kappa Pbi Forum, 26-28.
U.S. Department of Health and Human Services. Making Health Communication Programs Work. National Cancer Institute: Washington, DC.
U.S. Department of Health and Human Services. 2003. Communicating Health: Priorities and Strategies for Progress. Washington, DC.
Weiss, B. D. (2003). Health literacy: A manual for clinicians. Chicago: American Medical Association and American Medical Association Foundation.
Zarcadoolas. C., Pleasant, A. F., & Greer, D. J. (2006). Advancing health literacy: A framework for understanding and action. San Francisco: Jossey Bass.
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