Improving Health Literacy and Decreasing Health Disparities Essay

Improving Health Literacy and Decreasing Health Disparities Essay

From hospital bedsides to executive office suites to research laboratories to the halls of the United States Congress, nurses practice in many areas. American Nurses Association (ANA), encourages all nurses to be politically active to ensure safe and effective care for all patients, to elevate the profession, and to work to eliminate health disparities across our country (Pollitt, 2020). Improving Health Literacy and Decreasing Health Disparities Essay


Eddie Bernice Johnson, RN, BSN, MPA, a Texas nurse was elected to serve the 30th Congressional District of Texas in the United States House of Representatives. Twenty-six years later, Johnson continues to serve her district. In the ensuing years, she has been joined by seven other nurses from across the country. The group of Congressional nurses is African American and white, Democrat and Republican. They range in age from 32 to 84. As a group, they represent all areas of the country and a cross-section of race, age, and political affiliation. They have all brought their professional experiences, ethics, and commitment to caring with them into the political arena (Pollitt, 2020).

Congresswoman Eddie Bernice Johnson introduced the National Nurse Act of 2019. This bill, H.R. 1597, will designate the Chief Nurse Officer of the U.S. Public Health Service as the “National Nurse for Public Health.” The responsibilities of the position would task the National Nurse for Public Health with identifying and addressing national health priorities. The National Nurse Act of 2019 improves the health care of Americans across the country by appointing a National Nurse to join the Surgeon General in advocating for nurses who provide care for millions of Americans. “This act would empower a medical professional to focus on critical issues, such as promoting healthier practices, improving health literacy and decreasing health disparities” (Congresswoman Johnson Introduces National Nurse Act of 2019, 2019). Improving Health Literacy and Decreasing Health Disparities Essay

In the United States, racial/ethnic and socioeconomic disparities within the educational system have long been reported. As a result, two thirds of African American adults and 74% of Hispanic adults have limited functional literacy skills, compared to 32% of whites (Kutner, Greenberg, Jin, Boyle, Hsu, & Dunleavy, 2007). The consequences of early failures in education have more recently been linked to problems in healthcare. Research has begun to emerge showing how a health literacy skill set is linked to a range of health outcomes, and evidence has also emerged demonstrating how deficits in these skills possibly explain certain disparities (Bennett, 2009; Osborn, Cavanaugh, Wallston, White, & Rothman, 2009; Osborn, Paasche-Orlow, Davis, & Wolf, 2007; Sentell, 2006; Waldrop-Valverde, 2010; Wolf, 2006). Improving Health Literacy and Decreasing Health Disparities Essay

According to the most widely cited definition, health literacy is the “degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (Nielsen-Bohlman, 2004). As such, health literacy must be framed in the context of the specific tasks that need to be accomplished. In its seminal 2004 health literacy report A Prescription to End Confusion, the IOM recognized that patients’ health-related knowledge, skills, and behaviors are heavily influenced by: (1) cultural background, (2) health system demands, and (3) prior learning opportunities (Nielsen-Bohlman, 2004). The report frames limited health literacy not as a patient problem, but as a challenge to healthcare providers and health systems to reach out and more effectively communicate with patients. Specifically, the construct incorporates not only the individual cognitive and functional skills one uses when making health-related decisions, but it takes into account the contextual demands placed on the individual by (a) their specific clinical condition and associated health care decisions, (b) the communication characteristics of the dominant medical culture, (c) the structure and function of clinical services that assume adequate health literacy proficiency and require self-advocacy and vigilance, and (d) the emphasis that society places on individual, rather than ecological, determinants of health. Improving Health Literacy and Decreasing Health Disparities Essay

As one of the primary public health goals in the United States and other industrialized countries is to better understand and respond to health disparities, a health literacy perspective provides an important new direction for seeking perhaps more potentially modifiable strategies for reducing inequities in the short-term, with a multitude of targets. Health literacy researchers are now recognizing the need for comprehensive strategies that go beyond considering only a patient’s functional literacy abilities. Rather, health literacy interventions should examine the complexity of the tasks required of patients and families within healthcare settings, the accessibility of providers for the target populations, the preparedness of health and public health professionals to engage productively with patients, and the features of the health care system, working environments, and communities in which care-giving and self-management support take place.

Perhaps the most significant attribute of health literacy research is that it calls attention to the many ways in which unnecessarily complex healthcare exacerbates the impact of underlying educational and income disparities. The implications of this extensive body of literature should be understood as a direct challenge to health systems that have been organized for the most highly educated and affluent members of a society. While seminal reports about the problem of limited health literacy have been issued by the Institute of Medicine (Nielsen-Bohlman, 2004), Agency for Healthcare Research and Quality (Berkman, 2004), American Medical Association (1999) and Joint Commission among others (Murphy-Knoll, 2007), none have addressed how health literacy research may help eliminate disparities. Improving Health Literacy and Decreasing Health Disparities Essay

Herein, we have sought to present recommendations for a research agenda that is focused on advancing the science for how health literacy research can promote the effort to eliminate health disparities and thereby promote health care equity. As this field is currently insufficiently developed, and there are many things that are not yet known about eliminating health disparities, the agenda presented here should be viewed as a work in progress.

1. Integrate Health Literacy Assessment in Disparities Research
The first step in most circumstances is to measure health literacy. Without measurement, it is not possible to know when and how health literacy may be relevant, and it would be very easy to design interventions that fail to attend to relevant factors. For example, in an adjusted analysis that excluded health literacy, African Americans were 2.4 times more likely to be non-adherent to their HIV medication regimen than whites (95% confidence interval [CI] = 1.14–5.08). When health literacy was included in the final model adjusting for relevant covariates, the effect estimates of race diminished to non-significance and health literacy remained a significant independent predictor of non-adherence (adjusted odds ratio [AOR] = 2.12, 95% CI = 1.93–2.32) (Osborn, Paasche-Orlow, Davis, & Wolf, 2007). In another study, patients were asked their preferences regarding end-of-life care if they would develop advanced dementia. The African American subjects were found to prefer more aggressive care than the white subjects. When health literacy was included in the final model, health literacy—but not race—significantly predicted of preferences for care (low literacy OR 7.1, 95% CI 2.1–24.2) (Volandes et al., 2008). Health literacy clearly mediated the influence of race on end-of-life preferences. In both of these investigations, completely different conclusions would have been made without concurrent evaluation of race and health literacy. Improving Health Literacy and Decreasing Health Disparities Essay

2. Improve Patient Education
Limited health knowledge has been the most widely identified outcome in health literacy research, followed by certain health behaviors (Berkman, 2004). Given the strong associations between race, educational attainment, and health literacy, improving the timely access to information for specific health conditions or recommended actions among vulnerable populations is a logical step for promoting health equity (Ayotte, Allaire, & Bosworth, 2009; Bailey et al., 2009). Decades of research have produced an innumerable supply of publicly and commercially available patient education tools, available in an array of print, video, and web-based formats. Very few of these materials have incorporated a range of patient perspectives in their development, and even fewer have been formally tested to confirm their utility among culturally diverse and lower literate populations. While learning styles vary, efforts should be made to direct health providers and systems to the best available educational tools. This will likely require established criteria for evaluating their adequacy. To do this will be particularly challenging, as many tools that have already been developed specifically for lower literate audiences have not been entirely successful. Gerber et al. demonstrated a lack of significant knowledge gains for educating patients on diabetes self-care concepts using state-of-the-art multimedia (Gerber, 2005), and early efforts by Davis and colleagues found plain language print health information to produce only minimal improvement compared to existing brochures for polio vaccination (Davis, 1998). While guidance is available throughout various sources as to how best to create and field test plain language health information materials for diverse patient groups, there remains a need to consolidate recommendations, systematically assess the efficacy of newly available materials, and offer streamlined means to disseminate them at low or no cost to health care providers and systems. Equally important, finding ways to fund and produce language concordant versions of patient education tools for use among practices serving patients with limited English proficiency should be viewed as a public health priority. Improving Health Literacy and Decreasing Health Disparities Essay

3. Simplification of the Health Care System: Access and Utilization
Unneeded and complex barriers to access and utilize health services exacerbate the impact of underlying educational disparities. There is great potential for health insurance reform to improve the lives of millions of Americans. However, health insurance and other health benefit systems need to be designed to succeed. Complex application forms, terms and conditions, and documentation requirements are significant barriers that disproportionately burden vulnerable populations (Davidoff, 2010; Ettner, 2010). A health literacy lens should be taken to all public programs: How will a person with limited literacy get and use this program? Answering such questions will help economically progressive programs fulfill their mission of reducing socioeconomic class disparities. Improving Health Literacy and Decreasing Health Disparities Essay

4. Simplification of the Health Care System: Education and Training of Health Professionals
Health professionals contribute to the unneeded complexity of the healthcare system with poor communication and limited dedication to patient education. Clinicians frequently use jargon (Castro, 2007) and rarely confirm if their patients understand what is being discussed (Schillinger, 2003). Consequently, patients frequently misunderstand a broad array of critical information (Fang, 2009). The Centers for Disease Control hosts a Web-based training program on health literacy that is geared toward public health ( and the Health Resources Services Administration hosts a unified health communication course ( to address Health Literacy, Cultural Competency, and Limited English Proficiency. These are free, on-line training programs to improve patient-provider communication. Integration of health literacy curricula into professional education, however, is in a nascent state. To date, there is a dearth of research on the impact of educational initiatives to promote the knowledge and skills of health professionals regarding health literacy. Curricular initiatives to address health disparities are further advanced. There is a National Consortium for Multicultural Education for Health Professionals including educators from 18 U.S. medical schools, which collect lessons learned from curriculum implementation to guide similar educational endeavors across the consortium (Carter-Pokras, 2010). Indeed, several states have laws and or regulations that mandate training health professions in cultural competence ( Inclusion of health literacy in such policy initiatives can help promulgate health literacy curricula, but research will be needed to identify programs that work, can be replicated, and help eliminate health disparities. Improving Health Literacy and Decreasing Health Disparities Essay

5. Simplification of the Health Care System: Self-Care
Renewed interest in case management services, including care coordination, patient navigation, and certain proposed definitions of a medical home offer possible means for having lay workers or allied health professionals support patients in self care endeavors. Many longstanding, controversial health care practices that have previously been implicated as examples of poor health system design are now being confronted. For instance, solutions are being tested to manage the longstanding problem of variable and poor quality clinician prescribing practices that have been at the root of patient misunderstanding and prescription misuse. In fact, laws have now been set that lay out standards for both prescribing and labeling medicines to ensure patient-centered and evidence-based practices are in place to promote comprehension and adherence. In California and New York City, these regulations include providing language concordant spoken and text medication information (Bailey, Pandit, Curtis, & Wolf, 2009; “California State Board of Pharmacy, Title 16-1707.5 Patient-Centered Labels on Medication Containers”). Indeed, there is a broad range of self-care tasks that could benefit from simplification. For example, ways to improve the FDA’s Nutritional Facts label have been proposed, as Rothman and colleagues had previously reported more than half of adults can successfully navigate the current label and compute necessary information to support appropriate and safe decision making on food products (Lokker, 2009). There are many excellent targets for simplification and standardization as methods to improve self care and there remain great research opportunities in designing self-care systems that are effective for people with low health literacy. Moreover, very little is understood about the role of health literacy and its influence on health disparities for all the self-care tasks that occur outside of any relationship with a health provider. The public health arena has really been under explored. Improving Health Literacy and Decreasing Health Disparities Essay

6. Health Information Technology
There are increasing opportunities to leverage various health technologies to deliver health literacy-related interventions for a variety of purposes. Information technologies may range from automated telephone calls, to integrated electronic health record systems with patient portals and computerized agents. The value is clear; as health systems become automated, these tools allow for greater outreach, accountability, and standardization in the way health and healthcare is communicated to patients and families. Sarkar and colleagues compared the effectiveness of a diabetes self-management intervention using automated telephone calls with a nurse follow-up versus group medical visits and usual care (Sarkar, 2008). Those receiving the automated calls reported better perceived diabetes care, communication, and both intervention arms documented improved self-care behaviors, fewer bed days, and less interference with daily activities. In a small pilot of an animated, computerized agent to standardize communication for an informed consent process, Bickmore et al. (2009) found patients to be more accepting of the technology even compared to human interactions, although no differences in knowledge acquisition were noted. In the current issue Bickmore and colleagues extend this work to show that people with no prior computer experience and limited health literacy can readily use such a system. These studies highlight the potential value of health technologies for engaging patients, particularly those with limited health literacy; yet more research is needed to better document the link between these interventions and health outcomes. Greater attention to human-computer interaction considerations must also be made as Czaja (2008) aptly described the health literacy challenge to older adults in attempting to navigate and access information on the Medicare website. Improving Health Literacy and Decreasing Health Disparities Essay

The term health literacy was introduced in 1974 in a paper calling for minimum health education standards for all grade-school levels in the United States (US) [5]. The World Health Organization (WHO) later defined health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” [6]. Improving Health Literacy and Decreasing Health Disparities Essay


Kirsch et al. [7] explained that the inability to read, write, and use numbers effectively, is common and is associated with a wide range of adverse health outcomes in the Caribbean and the Americas. There are five health outcomes of low health literacy, which are health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. However, this chapter will only focus on health knowledge and health behaviors because research indicates that knowledge affects behavioral outcomes [7]. Additionally, in order to reduce hospital mortality rates, individuals must have the knowledge base to obtain, process, and understand basic health information and services needed to make appropriate health decisions [8]. Improving Health Literacy and Decreasing Health Disparities Essay

Health knowledge, or health education, refers to the knowledge and understanding people have about health-related issues [9]. It is important that people understand the causes of ill-health and recognize the extent to which they are vulnerable to, or at risk from, a health threat. The World Health Organization’s (WHO) definition of health was expanded in 1996 as a state of complete physical, mental and social well-being and now includes a social dimension. Additionally, some social scientist of that era, believed that WHO expansion of the health, must include a spiritual dimension [10].

According to the aforementioned [11] definition of health, it summarized complete health as the development of the social, physical, mental and spiritual dimension of a person. These four aspects of health were highlighted in the Bible, by Jesus Christ, when he said in Luke 2 verse 52 “he (Jesus) increased in wisdom (mental health) and stature (physical health) in favor with God (spiritual health) and man (social health),” [12]. Therefore, in order for a person to experience complete health, there must be growth in these four dimensions. Individuals in this twenty-first century must know that impairment in any one of these dimensions will affect the proper function of the other dimensions. These four components of health knowledge, spiritual, mental, social and physical will be defined and discussed below. Improving Health Literacy and Decreasing Health Disparities Essay

2.1 Spiritual health
The term “spiritual intelligence” was coined by Danah Zohar in 1997. Additionally, Ken O’Donnell in 1997 who is an Australian author and consultant living in Brazil, also introduced the term “spiritual intelligence” and Michal Levin in 2000 use this “spiritual intelligence” in his book to draw attention to the concept of linking the spiritual and the material reality of life that is eventually concerned with the well-being of the universe and those who coexist in it [13, 14, 15].

It appears challenging to outwardly define spiritual health or spiritual intelligence without comprehending that the perception of spirituality is divergent from religiosity [16]. Fogel [17] opines that, for a very long time “spiritual” was, considered to be separate from “religious” and our secular societies prefers to steer as far as possible away from discussions on religion, for fear of kindling dormant conflicts or intruding on a taboo subject. Improving Health Literacy and Decreasing Health Disparities Essay

However, some researchers have tried to coin some functional definitions. For instance, [18] “spiritual intelligence is concerned with the inner life of mind and spirit and its relationship to being in the world.” On the other hand, [19] defines spiritual intelligence as “the ability to act with wisdom and compassion, while maintaining inner and outer peace, regardless of the circumstances.”

Research conducted by medical ethicists has reminded us that religion and spirituality form the basis of meaning and purpose for many people [20]. It is important to note that patients in health care institution, not only have the pain of physical ailment to confront with but the mental and spiritual pain that is associated with their sickness. Improving Health Literacy and Decreasing Health Disparities Essay

2.2 Mental health
According to [21], mental health literacy (knowledge) is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention.” According to [22], there are key areas that help to equip persons with mental health knowledge. This will assist them with overcoming cultural and societal obstacles by challenging the fear of stigmatization. These areas include, but are not limited to; (a) the ability to recognize specific mental health problems, (b) knowledge and beliefs about risk factors, self-management approaches and the professional help available, (c) knowledge and beliefs about self-help interventions, (d) attitudes which facilitate recognition and appropriate help-seeking behaviors and (e) knowledge of how to seek and access mental health information. Improving Health Literacy and Decreasing Health Disparities Essay

The economic impacts of mental illness include its effects on personal income. These effects can only be quantified based on the ability of the persons with mental disorders or their caregivers to gauge the measurable economic burden of mental illness [23]. Bloom et al. [24] on the World Economic Forum (WEF) described three different approaches used to quantify economic disease burden, which do not only acknowledge the “hidden costs” of diseases, but also their impact on economic growth at a macroeconomic level (Figure 1).

Figure 1.
Different approaches used to estimate economic costs of mental disorders [25].
Mental health is now getting a great deal of scrutiny around the world, it is an area of health that developing countries are seeking to end stigmatization and discrimination through literacy [26]. In a study conducted by [27] opines that the most commonly expressed emotional response to the mentally ill and mental illness was fear, often specifically a fear of “dangerousness.” While the study reported some positive and empathetic responses, the most prominent emotional response was fear. Mental health literacy is the one of the most effective ways that fear towards the mentally challenged can be mitigated [28]. Improving Health Literacy and Decreasing Health Disparities Essay

The possible recommendation could be that, to be effective and relevant, mental health educators must seek to improve individual literacy and numeracy skills. Furthermore, mental health information needs to be written clearly and the information must be accessible to those who need it. This type of information must be useful in improving practical social skills and the communicative elements should aid these persons to access and maintain health [29].

2.3 Social health
The idea of social health is less recognizable to that of physical or mental health, but nonetheless, it’s one of the four pillars (spiritual, mental and physical) that forms the WHO definitions of health. According to [30] accentuates that “a society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen.” Therefore, the success of a healthy society is influenced by the rule of law, equality in wealth distribution, public involvement in the decision-making process and a level of social capital.

In developing countries like Jamaica, there are many determinants of social health that affects the livelihood of many such as inequality, poverty, exploitation, violence and injustice, these are at the root of ill-health and the deaths of poor and marginalized people [31]. According to [32] mentioned that a determinant is any factor that contributes to person current state of health. Based on researchers, it is believed that social determinants of health are the situations in which people are born, grow, live, work and age. These conditions are molded base on the supply of money, power and resources at the global, national and local levels [33].

Julianne et al. [34] postulated that the quality of life and social relationship are closely related to mental health and the mortality rate. Furthermore, their opinion is that this modern way of life limits individual’s social interactions, which results in people living insolation from extended families in developing countries. It is clear, that people of all different ages around the world are living alone, and loneliness on this crowded planet is becoming common [35]. Improving Health Literacy and Decreasing Health Disparities Essay

2.4 Physical health
According to [36], physical health literacy is the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person. Moreover, it is supported by researchers that physical literacy is an essential and valuable human competency that can be described as a disposition learnt by human individuals surrounding that enthusiasm, confidence, physical competence, knowledge and understanding that establishes physical quests as an important part of their lifestyle [37]. Improving Health Literacy and Decreasing Health Disparities Essay

In her research, [38] gave a summary of the key features of physical literacy:

Everyone can be physically literate as it is appropriate to each individual’s endowment,

Everyone’s physical literacy journey is unique, physical literacy is relevant and valuable at all stages and ages of life,

The concept embraces much more than physical competence,

At the heart of the concept is the motivation and commitment to be active, the disposition is evidenced by a love of being active, born out of the pleasure and satisfaction individuals experience in participation,

A physically literate individual values and takes responsibility for maintaining purposeful physical pursuits throughout the life course and charting of progress of an individual’s personal journey must be judged against previous achievements and not against any form of national benchmarks.Improving Health Literacy and Decreasing Health Disparities Essay

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