Health literacy is a concept that describes a patient's ability to understand materials provided by
physicians or other providers (Noble, Wan & Fottler, 2012). It is important that physicians help
their patients understand that health literacy is an important part of delivering quality patient
care. It is becoming more common for physicians to adopt electronic health records (EHRs) to
obtain subsidies under Medicare and Medicaid, with this the opportunity to provide personal
health records (PHR) to their patients is becoming more common (Noblin, Wan & Fottler, 2012).
Communication between patient and provider is more efficient and effective with a PHR and the
patient is more engaged in the healthcare process. The PHR system within a healthcare
organization is an excellent opportunity for patients to be more involved and informed with the
care they are receiving. There have been gaps between PHRs and what patients say they want
and need from the electronic tool for managing their health information. The article "The Impact
of health Literacy on a Patient's Decision to Adopt a Personal Health Record" explains what
factors determines a patient's health literacy and how patients would receive a system if it was to
be introduced by the physician's office. The research in the article is a cross-sectional study of
patients' intention to use a PHR and its association with perceived health literacy, income,
education, and age (Noblin, Wan, & Fottler, 2012).
The patients used in the research are already patients of the medical practice involved in the
sample. I feel the purpose of the research was to identify barriers for patients to use a PHR.
Technical barriers and policy barriers are challenges that contribute to the slowing down the
process of implementing PHR. Technical barriers could include issues of cost, access and
interoperability; security concerns; and data ownership, but it could also be linked to a failure of
engineering; which has led to products with limited value to the end users (Kahn, Aulakh &
Bosworth, 2009).
The importance of health literacy
Because medical information influences a patient’s ability to understand their treatment and
advocate for themselves, poor health literacy is often associated with poorer health outcomes. At
some point, everyone will need to be able to find, understand, and use medical information and
services.
Lower health literacy is typically found in patients who are older, have a limited education, are
lower income, have chronic conditions, and are non-native English speakers — resulting in
around 80 million United States adults having limited or low health literacy. A lack of health
literacy can result in many poor health outcomes, including:>
Increased hospitalizations: Research has indicated that lower health literacy skills are
associated with an increased use of emergency services and a higher rate of preventable
hospitalizations. Some research also shows that patients with limited health literacy skills often
delay entering the healthcare system when an illness develops, resulting in patients who are
sicker and require more extensive and expensive care from medical teams.
Decreased use of preventative services: Individuals with limited health literacy skills are less
likely to utilize preventative services that can prevent future problems and detect illnesses and
issues earlier. This includes screening services such as mammograms and pap smears, as well as
general wellness services such as primary care visits and vaccinations.
Poorer health management: Patients that have limited health literacy skills have a higher
likelihood of having a chronic condition, and a lower likelihood of being able to manage their
conditions effectively. Patients may not comprehend instructions from their healthcare providers
and not know what questions to ask, which could result in errors in medication dosage or lapses
in a treatment schedule.
Limited health literacy has negative connotations to both physical and mental health outcomes;
with outcomes including a reduction in service utilization, poor management of chronic
conditions, misunderstanding of treatment and medication instructions, poor comprehension of
medical management options, and a reduction in self-reported health concerns.
The effects of poor health literacy has a drastic impact on public health outcomes and the global
burden of disease, incurring astronomical cost, pressure on services, quality-adjusted life years,
morbidity and mortality worldwide. Poor health literacy results in poor decision making
surrounding health and lifestyle, poor health outcomes, poor self-management, increased risk of
hospitalization, avoidable hospital visits and admissions, and an increase in risky decision
making behaviors.
There is a wide array of research and evidence that suggests improved health literacy and self-
management of clinical conditions improves health-related behaviors and results in improved
clinical outcomes. Research studies have found an increase in patient involvement and
understanding results in lower probability of hospitalization, improved health-related quality of
life, improved clinical indicators, more healthy behaviors, and a significant reduction in cost
implications relating to health. Improvements in health literacy have been identified to result in
an increased use of preventative health services, improved ability to utilize health systems,
improved understanding of treatment requirements, positive health outcomes, and lower rates of
anxiety, pain, psychological distress and mortality.
Barriers to health literacy:
With increasingly diverse and aging populations, health literacy challenges are vastly expanding.
Factors influencing an individual’s health literacy include poverty, education, race/ethnicity, age,
and disability. Low health literacy is more prevalent amongst older adults, minority populations,
and individuals with a lower>socioeconomic status. It is important to recognise these barriers in
order to address the gap between where we are now and where we need to be.
The importance of health literacy is not a new concept, patient engagement and understanding of
health related concepts has been considered for many years. In 2018 The Kings Fund Shared
their report ‘Responsibility for health: the cultural change we need.’ Outlining the importance of
shared responsibility in health, and defining steps towards creating a harmonious relationship
between patient and clinician, they state: ‘There is good evidence for people taking greater
responsibility to manage their own health where they have the capabilities and motivation to do
so. However, this must go hand in hand with equipping people with the knowledge and
information that will support them to do this.’
Non communicable disease health literacy and the SDGs
In the 2014 Outcome Document of the high-level meeting of the United Nations General
Assembly on the comprehensive review and assessment of the progress achieved in the
prevention and control of non-communicable diseases6, governments committed to “continue to
develop, strengthen and implement multispectral public policies and action plans to promote
health education and health literacy, with a particular focus on populations with low health
awareness and/or literacy.”
This followed a similar commitment made in the 2011 Political Declaration of the High-level
Meeting of the General Assembly on the Prevention and Control of Non communicable
Diseases.7>Guidance on how to realize these commitments made in 2011 – within a context of
national programming for NCDs – are included in the WHO Global Action Plan for the
Prevention and Control of NCDs 2013-2020.8
High impact of pictorial health warnings
Pictorial health warnings, especially on tobacco product packages, have emerged as a specific
and cost-effective application of the basic function of health literacy. As compared with text-
based warnings, large pictorial health warnings have been shown to have greater impacts in
alerting consumers to the health harms (including severity and magnitude) of tobacco products,
while overcoming literacy challenges, particularly amongst low literacy populations, children
and young people. The tobacco industry often disproportionately targets these same populations
to expand markets and users for its products. Well-designed health warnings and messages on
tobacco product packages are therefore an important and proven policy measure to increase
public awareness of the health harms of tobacco use, reduce tobacco consumption, and address
inequities in health.9
Using pictorial health warnings on tobacco products to build people’s health literacy on the
harms from tobacco use yields benefits far beyond health, given the multidirectional relationship
between tobacco use and SDGs beyond health.10>Through improved health, these benefits
include: reducing the likelihood of falling into poverty (SDG 1), shifting household spending
from tobacco toward nutritious foods (SDG 2), preventing girls and boys from dropping out of
school to care for sick relatives, or to offset lost income by finding work (SDG 4), and, with the
poor benefiting most from pictorial health warnings, reducing inequities (SDG 10).
Traffic light labelling
Pictorial warnings are being used for other health harming products, with similar cross-SDG
benefits expected. For example, Ecuador has introduced traffic light labelling for foods, while
New York City has implemented warning labels for restaurant food with excess sodium. Traffic
light labelling is nearly universally understood by consumers, bypassing language barrier issues
inherent in written nutrition labelling or language warnings.
Graphic warnings on cigarette packages in Canada
In 2001, Canada introduced strong pictorial health warnings on the outside of cigarette boxes.
One evaluation found that Canadian smokers who had read, thought about and discussed the new
labels were more likely to have stopped, made an attempt to stop or reduced their smoking three
months later, after adjusting for intentions to stop and smoking status at baseline.
Similar pictorial warnings have been adopted by about a quarter of countries worldwide. Article
11 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC)
mandates Parties, within three years of acceding, to adopt and implement tobacco product health
warnings that cover at least 30 percent, and preferably 50 percent, of the visible area on a
tobacco product pack.
Language and education barriers can also have an impact on implementing a PHR system. The
eHealth Literacy Scale (eHEALS) is a tool that was developed in 2006 as self-reported tool
based on a patient's perception of skills and knowledge in utilizing electronic healthcare(e-
health) information (Noblin, Wan & Fottler, 2012). The problem with HEALS was that the
document was only in English. This tool would not capture the results of non-English speaking
patients.
The research in this article focuses on demographic characteristics of a population and health
literacy. According to the article by Noblin, Wan & Fottler, the two hypotheses for this research
are: Patients who are younger, are more educated, and have higher income are more willing to
adopt the PHR than those who are older, less educated, and with lower income. Patients who
have high levels of e-health literacy are more willing to adopt the PHR than those with low
levels of e-health literacy. The results of the two hypotheses imply the first was not proven and
the second hypothesis was supported based on the information obtained by eHEALS (Noblin,
Wan, & Fottler, 2012). PHRs can help patients better manage their care by having access to
important health information in electronic form.
The electronic form makes it easy for patients to update and share their records. Although,
accessibility to the internet is more prevalent in today's society, racial and ethnic minorities are
less likely to adopt a PHR than white patients. Also, low income patients are less likely to adopt
a PHR than their higher income counterparts. Ecclesiastes 3:1 states, for everything there is a
season, and a time for every matter under heaven. I feel as healthcare professionals, the more we
focus on providing education and resources for those that are not familiar with the importance of
PHR it will be more utilized among all groups of people.
References:
Noblin, A. M., Wan, T. T. H., & Fottler, M. (2012). The Impact of Health Literacy on a Patient's
Decision to Adopt a Personal Health Record. Perspectives in Health Information Management /
AHIMA, American Health Information Management Association, 9 (Fall), 1e.
Kahn, J.S., Aulakh, V., & Bosworth, A. (2009). What it takes: Characteristics of the ideal
personal health record. Health Affairs (Project Hope), 28(2), 369-376.
doi:10.1377/hlthaff.28.2.369
