Health Literacy

What is Health Literacy?

Several definitions of health literacy have been used during the past decades, and its evolving description highlights the complex role it plays in health. The early definitions of health literacy considered it as an individual-level factor and focused on individuals' skills and deficits. In fact, the American Medical Association Ad Hoc Committee on Health Literacy proposed one of the early definitions in 1999, describing functional health literacy as “a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment.” Several investigators proposed revised descriptions of the term, including the Institute of Medicine, which defined it as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” in its 2004 report, Health Literacy: A Prescription to End Confusion.

The national initiative Healthy People 2030 includes attaining health literacy in one of its foundational principles and in one of its overarching goals and offers an expanded definition that considers health literacy as multidimensional, including both personal and organizational health literacy. This more recent definition of health literacy considers an individual's capabilities as well as their access to resources and the influence of the complex healthcare system on their health and others. It describes personal health literacy as “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,” and organizational health literacy as “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.” ^,

Although there are many dimensions to health literacy, numeracy—often referred to as quantitative literacy—is considered one of its major features and has been defined as “the ability to access, use, interpret, and communicate mathematical information and ideas, to engage in and manage the mathematical demands of a range of situations in adult life.” Numeracy has also been described as “how facile people are with mathematical concepts and their applications.” In the context of health literacy, health numeracy has been defined as “the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions.” An individual's math skills are considered objective numeracy, and their self-assessment of their understanding of mathematical data is characterized as subjective numeracy. A proposed framework has operationalized health numeracy into four functional and overlapping categories: basic (e.g., identifying numbers), computational (e.g., performing simple calculations), analytical (e.g., making sense of information and understanding percentages and basic graphs), and statistical (e.g., understanding probabilities and complex health information). Other investigators have proposed a health numeracy model that includes six main functions (facilitating computation, encouraging more information seeking, improving interpretation of the meaning of provided numbers, facilitating assessment of likelihood and value, increasing or decreasing acceptance of numerical data, and promoting individuals to act and make a behavioral change).

The updated concept of health literacy includes several factors––notably health numeracy (e.g., understanding of risk)––considers the influence of health institutions, provides an ecological perspective of health, and recognizes the complex contextual influences on personal health literacy that enable individuals to access, understand, and use information to navigate the healthcare system. This expanded definition of health literacy is critical for patients, surgeons, and the surgical team and healthcare organizations in the perioperative period.

Health Literacy as a Social Determinant of Health

Evaluating the influence of health literacy alone on health outcomes is challenging as it is associated with many other established social determinants of health, including educational, economic, environmental, cultural, and social factors. ^, Many of these factors ( Fig. 11.1 ) have been shown to influence individuals' access to care, and their abilities to communicate and apply critical skills to seek, analyze, and use information to address their health. Moreover, having inadequate health literacy is associated with less access to timely and quality care, increased healthcare costs, an extensive range of health-related behaviors and outcomes, including a lack of adherence to prescribed medications, less frequent use of preventive services, poor management of chronic diseases, more use of emergency care and hospitalizations, and higher morbidity and mortality rates. ^,

There are two opposing perspectives on health literacy as a social determinant of health. The clinical perspective considers it a risk factor and focuses on screening for limited health literacy among patients who interact with healthcare providers and systems. This perspective is goal-oriented and aims to develop health information interventions that improve patient–provider communication to optimize care in complex healthcare environments. The opposing perspective of health literacy considers it an asset and is aligned with health promotion and public health. This perspective focuses on developing and implementing interactive and adaptable interventions to improve health outcomes by improving individuals' knowledge and decision-making skills to empower them to take control of their health. Both perspectives are relevant and reflect the importance of health literacy for clinical care and public health as well as its contribution to achieving health equity.

It is also important to recognize that health literacy has three potential causal mechanisms of impacting health: directly as a social determinant of health, as a mediator between other social determinants of health and health, or as a moderator of the effect of other social determinants on health. ^, The different potential relationships of health literacy, other social determinants of health, and health outcomes draw attention to this multifaceted concept. To explain the complex causal relationship of health literacy and other factors, several frameworks have been proposed to explain the association of health literacy and health outcomes.

Social determinants of health are also gaining recognition for the important role they play for surgical patients ^, ; thus, further research and discussion of health literacy as a social determinant of health is warranted to better understand its impact on how patients navigate the perioperative period.

In addition to personal health literacy, organizational health literacy also impacts the ability of surgical patients to navigate the healthcare system during the perioperative period. In 2012, the Institute of Medicine's Roundtable on Health Literacy published the Ten Attributes of Health Literate Health Care Organizations, providing strategies to improve patients' experiences by including health literacy as an organizational value. Surgeons, as healthcare providers and leaders in organizations, can play a significant role in establishing and maintaining strategies to improve organizational literacy to meet the needs of all patients.

The Agency for Healthcare Research and Quality (AHRQ) developed a Health Literacy Universal Precautions Toolkit that includes tools to improve clear communication (oral and print), patient self-management and empowerment, and supportive systems. Although the AHRQ toolkit is designed to provide evidence-based guidance for primary care settings, many of the tools are applicable to and may benefit other types of medical practices, including surgery.

Many factors at the individual, interpersonal, organizational, community, and societal levels may influence an individual's health literacy, which complicates the process of documenting health literacy as an independent social determinant of health. Therefore, a necessary step in understanding the concept of health literacy and the role it may play in the perioperative period is to consider its prevalence in the general adult population and among surgical patients as well as how it measured.