Conscious and Unconscious Biases in Health Care

Addressing Literacy and Health Literacy

Health LiteracyLiteracy is defined in a number of ways. The two definitions of literacy in the box are most useful in the context of health care.55-57 Literacy is often measured using a combination of reading grade-level equivalents and “functional literacy,” or the ability to read and write at the level necessary to participate effectively in society.58 The average U.S. reading level is between 8th and 9th grades. A total of 27 million American adults or 1 in 5 read at or below the 5th-grade level.59 Studies show that persons with low literacy skills are less likely to do the following: (1) seek and get preventive care; (2) understand forms for informed consent; (3) understand their children’s diagnosis; (4) understand medication instructions for themselves and their children; and (5) be knowledgeable about the health effects of risks, behaviors, and diseases.60


Literacy is a set of tangible skills—particularly the cognitive skills of reading, writing, numeracy, and oral expression.55,56

Literacy is the ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential.57

Health Literacy

There is also a robust literature on health literacy and the impact low health literacy has on patients and their families. The Institute of Medicine (IOM) found that over 90 million people residing in the United States have difficulty understanding and acting on health information.62 This IOM study also shifted from the commonly accepted view of health literacy as solely the domain of the individual or patient to include the skill of health care professionals and the capacity of health care systems as well as other entities that provide health information. Most recent and widely recognized research pushes us to re-envision and redefine health literacy from completely different lens. There are two primary assertions from this work.  First, the major responsibility for health literacy should rest in the design and implementation of health care that removes systemic barriers to the communication of health information and which facilitates access to, and the meaningful engagement of people in, such processes. Second, it is essential to recognize the broader socio-cultural contexts in which health literacy is experienced.63 Health care practitioner’s capacity to address health literacy cannot be understated. (see references in excerpt below)

A report on the results of the National Assessment of Adult Literacy-Health Literacy Component identified the following health literacy ability of the U.S. population: 14% below basic, 22% basic, 54% intermediate, and 12% proficient.64

Health Literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.61

“Recognizing that culture plays an important role in communication helps us better understand health literacy. For people from different cultural backgrounds, health literacy is affected by belief systems, communication styles, and understanding and response to health information. Even though culture is only one part of health literacy, it is a very important piece of the complicated topic of health literacy. The U.S. Department of Health and Human Services recognizes that culture affects how people communicate, understand, and respond to health information.”65

Skills Needed for Health Literacy

“Patients are often faced with complex information and treatment decisions. Some of the specific tasks patients are required to carry out may include:

  • evaluating information for credibility and quality,
  • analyzing relative risks and benefits,
  • calculating dosages,
  • interpreting test results, or
  • locating health information.

In order to accomplish these tasks, individuals may need to be:

  • visually literate (able to understand graphs or other visual information),
  • computer literate (able to operate a computer),
  • information literate (able to obtain and apply relevant information), and
  • numerically or computationally literate (able to calculate or reason numerically).

Oral language skills are important as well. Patients need to articulate their health concerns and describe their symptoms accurately. They need to ask pertinent questions, and they need to understand spoken medical advice or treatment directions. In an age of shared responsibility between physician and patient for health care, patients need strong decision-making skills. With the development of the Internet as a source of health information, health literacy may also include the ability to search the Internet and evaluate websites.”66