Health Literacy-Learning to Read, Reading to Learn

By Dr. Tish Doyle-Baker, clinical exercise physiologist and doctor of public health, Faculty of Kinesiology, University of Calgary, as published in winter 2012, Fitness Informer

Conventional Literacy is often associated with the ability to read and write coherently. Thinking back to grade school you might remember the first book you read in kindergarten. For example the book series titled Dick and Jane. The words were small, the paragraphs were short, and the concepts were straight forward. Your favourite book might have been “See Spot Run” because you wanted a dog.

Primer books such as the Dick and Jane series introduced a few words at a time to the readers. Each page in the book was accompanied by pictures and dominated by word repetition to ensure the meaning of each word was learned. This approach to reading and comprehending is the beginning of a solid foundation for future education.


Not only does reading provide the foundation for further education, it is also associated with future health. Many research sources confirm that low literacy has a negative impact on all aspects of health, including overall morbidity and all-cause mortality (Perrin, 1998). This strong health correlation with low literacy is recognized as a determinant of health because it influences an individual’s personal well-being. For example low literacy is a barrier to accessing health care services and information related to both prevention and treatment of diseases. As well low literacy often leads to poverty and poverty impacts the health of individuals at all stages of the life cycle (see Therefore, education, poverty and health problems are interrelated in a number of ways and these can undermine an individual’s ability to be health literate.
Determinants of Health

  • The Public Health Agency of Canada (PHAC) suggests that following determinants of health are also inextricably linked to education and health literacy. These determinants include: genetics, environment (physical and social ), health care services (access and availability); income (social economic status); social support networks; employment/working conditions; behaviours (personal health practices and coping skills); healthy child development, sex; and culture ( click here to find out more about the social determinants of health ).

For example, several research studies demonstrate a strong direct relationship between income level of the mother and the baby’s birth weight. Mothers at each step up the income scale have babies with higher birth weights, on average, than those on the step below. The issue of low birth weight is not just a result of poor maternal nutrition and poor health practices associated with poverty, although the most serious problems occur in the lowest income group. It seems that factors such as coping skills and a sense of control and mastery over life circumstances also come into play and these attributes are closely associated with education and health literacy.

What is Health Literacy?

Health Literacy is formally defined as “the degree to which individuals have the capacity to obtain, process and understand the health information and services needed to make the appropriate health decisions” (IOM 2004). Based on this definition health literacy is not only dependent on the individual’s ability to comprehend and act on the information but also on the communication skills of the health care professionals.

Communication skills are context specific

Health care professionals need to be able to communicate and converse easily with their colleagues in a context specific manner. This can affect how they communicate with the public making it more difficult to relay their information in a jargon-less way. For example a physician could easily tell another colleague that the patent had an event and experienced an MI (myocardial infarct). This acronym would not be familiar to a patient and therefore referring to the event as heart attack would bring immediate clarity to situation. Similarly, those of us who work in the fitness industry often use abbreviations and specific terminology. For example the terms peak and maximum oxygen uptake (VO2 peak and VO2 max, respectively) are often used as though they are synonymous, yet they have distinct differences in exercise physiology. VO2 peak is the easier to define and determine, yet its relevance to physiological and patho-physiological functioning is less secure (see “The Peak vs Maximum Oxygen Uptake Issue” in file attachments below this article.)

VO2 peak is the highest value of VO2 attained on a particular test regardless of the subject’s effort. Thus the individual’s VO2 max which is defined as the volume of oxygen consumed while exercising at maximum capacity, has not necessarily been attained after one test. In this example confusion can easily occur and therefore avoiding the use of acronyms, context specific terms and sticking to plain language is very important. Health Canada recently has taken steps to introduce plain language into prescriptions, vaccine brochures and nutritional labeling. Plain language therefore is a technique for communicating clearly and is a one tool for improving health literacy.

Health Communication
Distributing health information to the public to change health behaviour practices is a form of health communication that has recently attracted the attention of researchers (Rootman and Ronson, 2005). Few studies exist in this area and most that do, are not study designs that contribute to the highest levels of evidence based medicine which would involve a randomized controlled trial (RCT) since it is considered the gold standard. There are some examples, however to draw on such as the RCT completed by Davis et al., in 1979. In this reading comprehension study the researchers compared the use of a simplified polio vaccine brochure with the regular version with parents bringing children to a pediatric care facility. The authors of this study found that parents who read the simplified one had significantly higher comprehension than those who read the regular one with the exception of the parents with the lowest reading levels. These individuals with lowest reading levels did not show increased comprehension. Perhaps this outcome is not unexpected as about fifty percent of adult Canadians have some degree of difficulty with everyday reading materials (Statistics Canada, 1989).

Reading Levels
Literacy level 3 is the most popular every day writing and reading level and includes the functional abilities necessary for Internet use. To obtain this level in Canada, requires all twelve years of formal education (level 1 is normally achieved by grade 4; level 2 is normally attained by the end of grade 8). Individuals below this level may have reading difficulties from many different causes. These causes can include lack of education, visual, hearing or cognitive impairment, or language or cultural differences. Individuals with one or possible combination of these barriers could easily become marginalized in the health care system. The reason this may occur is because of the heavy reliance the health care system puts on individuals to make decisions in managing their health. Recognising these barriers exist and developing appropriate tools around readability would increase the health communication and minimize the difficulties.

There have only been a handful of published studies in Canada that have evaluated the readability of health materials (Farkas et al., 1987; Smith and Haggerty, 2003).One of the most recent studies showed that the reading level of 120 educational pamphlets used in a Montreal primary care practise was at a grade level of 11.5. This reading level would be too high for most patients with low literacy skills (Smith and Haggerty, 2003).

Literacy Skills
Recent studies have suggested that literacy skills predict health status even more accurately than education level, income, ethnic background, or any other socio-demographic variable (Grossman et al., 1997). The Federal Provincial Territorial Advisory Committee on Population Health, (1999) suggests that we need to “take positive action to provide all Canadians with the opportunities they need to obtain a solid education and achieve adequate literacy skills.” Perhaps another way of envisioning this is based on the eloquent statement by Dr. David Lau, a physician working at the University of Calgary. “If we improve the health of Canadians, we improve the wealth of Canada” (Picard, 2001b).

Connection between Health and Literacy
This connection between health and wealth and literacy provides the working foundation for strengthening our health care system. Our healthcare system needs to serves all Canadians well and therefore we must consider the many links between literacy and health outlined so very briefly in this article. Stated again, the higher an individual’s education status, the greater their ability to learn about health and the better their health is. In conclusion, the basic foundation for health literacy begins with learning to read and reading to learn. Who would have thought that the education of a child in kindergarten mastering the sentences of “See Spot run! Run, Spot, run!” would contribute to the greater health and the wealth of a nation.

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