Health Literacy and Health PolicyLaura P. Shone, DrPH, MSW

From the Departments of Pediatrics, Clinical Nursing, and the Center for Community Health, University of Rochester Medical Center(Dr Shone), Rochester, NYAddress correspondence to Laura P. Shone, DrPH, MSW, Departments of Pediatrics, Clinical Nursing, and the Center for CommunityHealth, University of Rochester Medical Center, 601 Elmwood Avenue, Box 777, Rochester, NY 14642 (e-mail: Laura_Shone@URMC.

Rochester.edu).

ACADEMIC PEDIATRICS 2012;12:253–254

HEALTH LITERACY SKILLS allow individuals to obtain,process, understand, and communicate information abouthealth, as well as function in the health care system andmake informed health decisions.1 Health literacy can alsoplay an important role in successful implementation ofhealth policies.2 Health literacy is therefore recognizedas “.one of the top four national priorities for publichealth”,3 with health literacy research “becoming founda-tional in reforming health and health care in the UnitedStates”.4

Two articles in this issue illustrate specific healthliteracy-related challenges that can confront parents: 1)the renewal application process for publicly subsidizedhealth coverage; and 2) the use of common pediatricover-the-counter (OTC) medicines. Health professionalsoften play a crucial role in helping parents understandand use health-related information; however, these twoactivities typically require parents to act without the benefitof advice from a health care professional. Therefore,parents’ success in navigating these tasks can be heavilyinfluenced by the underlying policy-level decisions thatgovern how materials are designed, implemented, andevaluated. By examining these two challenges, results ofthe studies by Pati et al5 and Yin et al,6 respectively, haveimplications for two areas of active health policy change:health insurance reform and labeling of pharmaceuticalproducts.

With regard to health coverage, Pati et al5 examined thereading level of Medicaid renewal forms in 50 states andthe District of Columbia, using three well-validatedreading-level analysis tools. The authors found thatalthough 46 states/DC had reading-level guidelines(ranging from 3rd to 8th grade), comparison of stateMedicaid forms to these guidelines revealed that overhalf exceeded the state’s guidelines by one to six gradelevels.5 This discrepancy is important because more than50% of uninsured and 60% of Medicaid enrollees havebasic or below basic health literacy, a challenge faced bymore than a third of US adults.7 Hence, these or similarforms will likely be difficult to read and potentially unus-able by many of the individuals who are most likely toencounter them.

The findings of Pati et al5 support the need for a uniformFederal usability standard for public program materials,and the need for accountability strategies to monitor adher-

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ence to uniform guidelines, once set. It remains difficult,however, to identify a single optimal grade-level standard,because most adults read roughly five grade levels belowthe highest grade completed in school.8 However, althoughthe reading level is commonly used alone, additional factorsinfluence the usability of documents and materials,including “sentence length, word choice, organization,tone, layout, use of illustrations, and relevance to readers”.9

This more comprehensive set of factors, including but notlimited to reading level, should be considered together ina potential Federal standard for usability – in research andin practice – rather than considering reading level alone.With regard to use of OTC medicines, Yin et al6 con-

ducted a descriptive study of packaging (bottles and boxes)for the 200most common nonprescription liquid medicinesfor children younger than 12 years of age. The authorsfocused specifically on presentations of: 1) the activeingredient and 2) the dosing instructions found on the Prin-cipal Display Panel and the Food and Drug AdministrationDrug Facts panel for each medication. They report thatalthough most products met Food and Drug Administrationrequirements for content, packages were inconsistent in theplacement and layout of information (eg, small or variablefont size; brand name or product flavor more prominentthan active ingredients), any of which could interferewith parents’ understanding of the active ingredient ordosing instructions. Such understanding is essential toprevent unintentional harm from mismeasurement orfrom inadvertently taking too much of the same activeingredient in more than one product. The authors highlightopportunities to incorporate evidence-based health literacystrategies in product labeling6 to improve the clarity andplacement of this information (ie, on the outer box ANDon the inner bottle). Examples of evidence-based strategiesinclude: 1) using plain language in a large clean font withample white space; 2) prioritizing messages and limitingextraneous material; 3) using font size and placement toemphasize priority information; and 4) breaking text intosmaller, more manageable “chunks”.7

Collectively, the findings reported by Pati et al5 and Yinet al6 illustrate challenges that may confront parents in per-forming two common tasks in caring for child health: usingthe application forms needed to maintain health coverage,and using common pediatric OTC medicines. They illus-trate how activities that are already challenging can be

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further complicated by lack of attention to health literacyand principles of clear communication. Yet, even whenevidence-based strategies exist and requirements are inplace to use them, three challenges remain: 1) lack ofaccountability and monitoring to ensure that guidelinesare being met; 2) lack of built-in mechanisms to measureoutcomes and impact; and 3) lack of uniformity in healthliteracy guidelines for usability, resulting in too much vari-ation to evaluate health impact even if measures did exist.

Further efforts are clearly needed to close these gaps inthe existing process, from creating and implementingguidelines to measuring and monitoring aspects of the im-plementation process as well as outcomes. Importantly, inidentifying gaps, the results presented by Pati et al5 and Yinet al6 also point to opportunities within current areas ofactive health policy change, to integrate health literacyprinciples in order to close these gaps. Health policy andsubsequent guidelines can call for and operationalize theuse of evidence-based best practices for health literacy.They can call for uniform standards to minimize inter-state variation and they can consider more comprehensivefactors in usability – beyond reading level alone. They canalso call for accountability – for guidelines to be monitoredas well as implemented. Health policy that incorporateshealth literacy principles in these and other ways canlead to actionable changes that can improve communica-

tion and health-related experiences, protect those withlow health literacy, and ultimately affect health.

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