Background Document on Literacy and Health

Section 2. Key issues to consider

Section 2 attempts to critique and move beyond the mainstream literature on health education and health literacy, looking at key issues that are relevant to our project.


2.1 The limits of assessing patient literacy

There are significant limits to assessing patient literacy. Most health provider are not trained to make this type of assessment, and even if they were, there is rarely sufficient time to go through actual tests. Direct assessment can be embarrassing and increase anxiety for the patient. Research has demonstrated that there can be a gap between level of instruction and functional literacy level. A patient's level of education is not always an accurate indicator of literacy level. As time passes, reading skills and the capacity to comprehend more complex written words diminish when there are few opportunities to use these skills. In fact, research on literacy in the United States tell us that many adults read 3 to 5 grade levels below the last level of education completed (quoted in CPHA, 1999). Also, some low-literate patients may claim to have a higher level of education than what was actually completed. In Canada, we could not find health forms that even asked patients information about their education.

In cases where tests are used, they also have limitations. A patient's ability to understand a word does not necessarily mean that she understands the significance of the instruction being provided. A patient may be able to read all the words in a sentence but not comprehend its full meaning. This is an important consideration when one employs tests, such as REALM, that only assess the capacity to decode but not comprehension skills. Patients are expected not merely to decode health information, but to comprehend and apply it by modifying their behaviour in day-to-day living.



2.2 Over-reliance on plain language

Many researchers question an over-reliance on plain language in health education to address the issue of low-literate patients. According to a Health Canada profile paper entitled How does Literacy Affect the Health of Canadians?

Plain language is a useful step but not the answer. Presenting written health information in easy-to-read, rather than complex, technical language, is undoubtedly a useful step… Plain language is not the primary solution to addressing the health difficulties associated with literacy. As the CPHA has indicated, written information should be secondary to verbal communication and should only supplement the exchange between physician and patient. Personal contact between patient and physician is the best way to ensure the transmission of a message.
(Perrin, 1998, p.16)

American researcher Marcia Hohn also criticizes the over-reliance on plain language but looks beyond the individual patient-physician relationship. She presents the issue in the context of community dynamics and group participation:

The view of addressing the health education needs of low literacy groups through simply rewriting existing materials at a simpler language level is exceedingly limited. Information is only one piece of a process that needs to include community context, participation, and support.
(Hohn, 1998)

Hohn's views on low literacy, health and empowerment are expanded in sub-section 2.4.

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