Book Review

Advancing Health Literacy: A Framework for Understanding and Action

N Engl J Med 2007; 356:757-758February 15, 2007

Article

Advancing Health Literacy: A Framework for Understanding and Action
By Christina Zarcadoolas, Andrew F. Pleasant, and David S. Greer. 368 pp., illustrated. San Francisco, Jossey-Bass, 2006. $50. ISBN: 978-0-7879-8433-5

It is impossible to avoid messages about health in 21st-century America, yet many people don't understand what these messages mean. The National Assessment of Adult Literacy (NAAL) estimates that only 12% of the adult U.S. population is “proficient” at understanding health information; the rest of the population has difficulty understanding the terms that doctors, hospitals, and insurers routinely throw their way. Also according to the NAAL, 14% of the adult population — approximately 30 million people — have “below basic” health literacy, meaning that they can't understand simple information about health.

People with low health literacy are more likely to be hospitalized and to have poor control of chronic illnesses. In 2004, the Institute of Medicine (IOM) discussed this problem in a 345-page report, Health Literacy: A Prescription to End Confusion (Washington, DC: National Academies Press). The report made many recommendations to government agencies, educational institutions, and health care systems, but it did not address individual practitioners.

Sociolinguist Christina Zarcadoolas, communications specialist Andrew Pleasant, and family physician and educator David Greer have written Advancing Health Literacy, a guidebook that serves as a practical, public health companion to the IOM report. The book provides specific, evidence-based strategies for health literacy intended for use by community leaders, health care institutions, and organizations that shape health policy. Many of the book's proposals cost little and can be generalized to many settings.

The authors begin with a general discussion of health literacy, which they define as a “range of skills and competencies that people develop over their lifetimes to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life.” They provide an interesting historical discussion of campaigns for public health education, such as those combating tuberculosis and polio.

The authors also discuss instances in which the public health establishment has failed in its goal to provide clear and useful information. Many of us can empathize with the public health and postal service professionals, for example, who tried to provide useful public health information during the anthrax scare of 2001. Yet the anthrax case also serves as an opportunity to discuss how simple changes in language used during a television interview, on an informational postcard, and on a Centers for Disease Control and Prevention Web site could have helped prevent the unintended spread of dangerous misinformation.

The book's comprehensive descriptions of seven case studies in health communication — including the Massachusetts Tobacco Control Program, the Baby Basics Prenatal Health Literacy Program, and the Sioux San Hospital Diabetes Program — will be especially useful to public health workers. The book is also replete with dozens of specific examples of effective health-information documents for people with low literacy.

For those addicted to “bureaucratese,” the authors offer an 11-step program on how to produce information on health that is easier to read. Specific examples are provided for word replacement (for instance, instead of “potable,” use “safe to drink”), simple sentence structure, and just-in-time instructions (such as definitions or instructions embedded in forms).

Many chapters of this book are designed for teaching public health students. Each chapter closes with thoughtful questions that can be used to reflect on the case study. For example, at the end of the section on genomics, the student is asked, “Find as many ways as you can of explaining what a 25% chance of a person's future child being born with a certain genetic trait means to them.”

The main audience for this book, however, should be the public health professionals responsible for developing new tools for communicating with patients and the general public. We recommend that public health directors make this book required reading for everyone in their communications department.

Lee M. Sanders, M.D., M.P.H.
Erin N. Marcus, M.D., M.P.H.
Leonard M. Miller School of Medicine at the University of Miami, Miami, FL 33101
leesanders@miami.edu