Health literacy

BMJ 2012; 344 doi: (Published 22 March 2012)
Cite this as: BMJ 2012;344:e2188

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31 May 2012

While there is no denying the importance of communication in health care settings or in relation to an individual's role as a patient, what is being discussed here is not so much 'health literacy' as 'medical literacy.'[1]

A concept of 'health literacy' which is limited to decisions about 'health care' ignores the broader and increasingly accepted understanding of health literacy as it applies to the many health-related decisions that people make in the context of every-day life. These include decisions about keeping well enough to avoid engagement with the health care system. In other words, ‘health literacy’, in its broader sense, is relevant to individuals who may never become patients or deal directly with the health system.

'Medical literacy’ can be thought of as involving the ability to read,understand and act on instructions for taking a cholesterol-lowering drug; ‘health literacy’ involves the ability to access information about cholesterol, to understand it and to apply it to one’s own life.

An obvious difference between medical literacy and health literacy is that, as challenging as it may be for the health sector to influence the former, it is even
less able to influence the latter.

[1] Peerson A. and Saunders M. (2009). health literacy revisited: what do we mean and why does it matter? Health Promotion International 24(3), 285-296.

Competing interests: None declared

Margo H Saunders, Public Health Policy Researcher

Affiliate Member, Freemasons Foundation Centre for Men's Health (Adelaide), Canberra, Australia

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The Department of Health and Human Services defines health literacy as the capacity of individuals to access, process and understand health information and services in relation to how they make decisions pertaining to their healthcare (1). In his editorial, Raynor identifies two other aspects in addition to reading and understanding health information. These aspects – engagement with the healthcare process and removal of barriers to patient understanding and involvement (2), represent a fresh perspective to the health literacy debate. Evans makes an important point regarding how patient inclusion and engagement can help improve healthcare delivery. She also notes that these changes will require allocation of resources (3), a significant challenge in the current economic climate.

It is therefore important to illustrate how patient inclusion and engagement can influence treatment outcomes. Following their evaluation of independent prescribing by nurses and pharmacists, Latter and her colleagues recommended more patient involvement in healthcare planning and provision (4). A recent study that explored perceptions of non-medical prescribing found that although chronic pain patients were under-informed about the policy, they were enthusiastic about engaging with prescribers. More importantly, it also emerged that the nature of their relationships with their prescribers influenced their adherence to prescribed medication as well as whether they considered using other measures in their pain management (for instance, Complementary and Alternative Medicines). This meant that the lack of a trustworthy relationship could influence treatment objectives and patient safety (5).

This indicates that there is case to be made for investing in patient involvement as well as enabling their ability to engage with their care. For instance, more research exploring how patients interact with prescribing professionals and understand healthcare policies. In addition to potentially improving how healthcare is delivered, a better understanding of how patients engage with healthcare, may also contribute to making it safer and more efficient.

1. U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC. U.S. Government Printing Office, 2000.
2. Raynor DKT. Health literacy. Is it time to shift our focus from patient to provider? BMJ 2012;344:e2188.
3. Evans R. Reply to Raynor, DK. Health Literacy. BMJ 2012;344:e2188.
4. Latter S. et al. Evaluation of nurse and pharmacist independent prescribing. 2010. [Online] Available at: 14th May 2012).
5. Adigwe OP. Non-medical prescribing in chronic non-malignant pain. Ph.D. Thesis, University of Leeds, 2012.

Competing interests: None declared

Obi P Adigwe, Researcher

University of Leeds, M.01 Baines Wing. LS2 9JT

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7 May 2012

Dear Editor

The use of simulated and recorded information

In the editorial on Health Literacy, Raynor emphasizes the fact that patient health literacy is an important issue and can contribute to better health outcomes. While we do agree to this issue and its significance, there are also alternatives as pointed out by Bonar1 and others in case of improper literacy. However, in addition to lack of literacy some patients have substantial memory loss due to various conditions which prevents them from efficiently following necessary steps and / or procedures given in the information. This problem requires a practical and easy means for finding or regaining the lost information, steps and procedures. Whether lack of adequate literacy or forgetting information, we want to point out the benefits of instructing patients by recorded simulation or information which can replace written information partially or completely.

Simulation has been used with great success in teaching and providing information to medical personnel around the world2 but very little when it comes to patients. Certain studies related to giving instructions and information to patients, especially in elderly3 reveal that simulated recordings of instructions and various other information could be given successfully and easily to patients instead of written and verbal information. The additional benefits of simulated and recorded information is that if patient forgets any of it, he or she can easily replay it on a variety of electronic device; mobile phones, laptops, desktops, TV/DVD players, digital cameras or any other electronic equipment capable of playing recorded videos or information.

1. Bonar MJ, Clarke M. Reply to Raynor, DK. Health Literacy. BMJ 2012;344:e2188

2. McGaghieW C, Issenberg S B, Cohen E R, Barsuk J H, et al. (2011) Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence. Academic Medicine. 86: 706 – 711.

3. Lee S (2010) Understanding wayfinding for the elderly using Virtual Reality. ACM. doi>10.1145/1900179.1900239

Competing interests: None declared

Heng-Hsin, Shannon Tung, Associate Professor

Jeng Wei, MD, Daniel L. Clinciu, PhD, Jen-Chen Tsai, PhD, Kuan-Chia Lin, PhD

National Taipei University of Nursing and Health Sciences, 365 Ming Te Road, PeiTou, Taipei 112, Taiwan

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16 April 2012

D K Theo Raynor says: "a third and half of people in developed countries have difficulty understanding and engaging in their healthcare and that this has important consequences for health. In light of such findings it seems remarkable that the matter is not given higher priority."

Neither the editorial nor the linked research paper comments on the situation in low- and middle-income countries, where most of the world's population lives. In such countries, it can be strongly argued that poor health literacy is likely to have even greater negative impacts on health. In light of this, it seems remarkable indeed that the matter in not given higher priority *worldwide*. I invite BMJ readers with an interest in this issue to join us:

Neil Pakenham-Walsh is the coordinator of the HIFA2015 campaign and co-director of the Global Healthcare Information Network. He started his career as a hospital doctor in the UK, and has clinical experience in rural Ecuador and Peru. For the last 20 years he has been committed to the global challenge of improving the availability and use of relevant, reliable healthcare information for health workers and citizens in low- and middle-income countries. He has worked with the World Health Organization, the Wellcome Trust, Medicine Digest and INASP (International Network for the Availability of Scientific Publications). He is based near Oxford, UK. neil.pakenham-walsh AT

Competing interests: I coordinate - a global professional network and campaign to improve the availability and use of healthcare knowledge in low and middle income countries

Neil M Dr Pakenham-Walsh, Global health professional

Global Healthcare Information Network, Corner House, Market Street, Charlbury, Oxfordshire OX7 3PN, UK

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15 April 2012

This is so much more than easy read leaflets, it is a way of thinking about what we do as professionals. We could do so much better at the interface between service user and service provision.

This is about inclusion and engagement. It takes in patient experience and service development. It is indeed a 'two way street'.

However, it takes effort. Time, money, energy.
If we think it is important that we address health literacy, then we will need to invest. CCGs will need to consider carefully all the competing priorities for investment, but not miss doing the basics well.

Meantime, where health literacy is being addressed then please let's hear about it, so that a strong case can be made to invest. This will help the most vulnerable people to access care, and will help us to deliver something relevant.

Competing interests: None declared

Ruth Evans, GP

Village Green, Wallsend

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13 April 2012

Raynor`s editorial [1] makes several important points, and has prompted some interesting remarks to which I would like to comment.

I agree that there is a need to shift research focus to the provider. This reflects a conclusion we made in the MILK Report for the HTA [2] when we noted how very few studies had considered health professionals’ perspectives in WMI provision. This shift in focus is probably long overdue, five years since our initial recommendation. It is vital that there is greater focus on the provider because health professionals have a crucial role in providing information, as well as recommending sources of information.

I agree with Thornton [3] that professionals’ numeracy should be improved. It is not just an awkward irony when professionals convey numerical risk information that they themselves may not have a complete handle on. The person taking the medicine needs to know the correct risk of a side effect so that s/he can make an informed choice about taking the medicine or not.

I agree with Bonar and Clarke [4] that looking into alternative means of conveying the information may be useful. But I remain to be convinced if a theatre act is feasible at an individual level. I consider this intervention may be more suitable as a group level either locally or nationally. There are examples of theatre companies that provide health education, e.g. [5]. But I wonder how practical this would be for seeking to inform individuals about the risks and benefits of taking a medicine, for which in many countries throughout the world the patient information leaflet must be supplied, as stipulated by legislation. I wonder if a better example here would be having a You Tube clip of a theatre medium. This may appeal to some people, but still the quality of the visual information would need to be ensured, and it remains to be seen how this would be conducted.

Internet based information about medicines could provide a useful, flexible resource for the professional discussing the medicine with the person. Yet this is not yet the panacea that some may have hoped. Because of the poorly written content of some websites with information about medicines, designers will need to ensure that the content reflects the knowledge and expectations of people accessing it to ensure the information is as understandable a possible [6]. Therefore I would say that while there is a need for the shift in the research focus to examining the provider [1], we ignore the content and the medium at our peril.

1. Raynor, DK. Health Literacy. BMJ 2012;344:e2188

2. Raynor DK, Blenkinsopp A, Knapp P et al. A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technol Assess. 2007 Feb; 11(5):1-178.

3. Thornton H. Reply to Raynor, DK. Health Literacy. BMJ 2012;344:e2188

4. Bonar MJ, Clarke M. Reply to Raynor, DK. Health Literacy. BMJ 2012;344:e2188


6. Nicolson DJ, Knapp P, Gardner P, et al. Combining concurrent and sequential methods to examine the usability and readability of websites with information about medicines. Journal of Mixed Methods Research. 2011 5:25-51

Competing interests: None declared

Donald J Nicolson, Research Fellow

None, n/a

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13 April 2012

Clinicians are likely to see better health outcomes among their older patients if they are more 'easy to understand'.[1] In WHO terminology, health literacy becomes a practical 'asset' when assessing a person's individual assets and liabilities.

However, it can also be a shared asset, where a patient has relatives or friends that can enhance communication and clarify understanding. Typically, women are more aware of family histories and many fathers/ husbands/ sons benefit from a significant other who connects them with a wider understanding of health and illness. Sadly, many older persons live in social isolation. For those aged 75 years and over, 36% of men and 60% of women now live alone.... and there are many more older women surviving than men.[2] Social capital then becomes a key element in resilience, when facing illness. Local authority public health policies around housing and transport could have a role in maintaining contact with family members. For the most isolated older patients, voluntary befriending services can address 'health support needs' [3] and primary care commissioners should nurture local assets like the AgeUK befrienders.

[1] Raynor DKT. Health literacy. Is it time to shift our focus from patient to provider? BMJ 2012;344:e2188

[2] Office for National Statistics. Older People's Day 2011. Statistical Bulletin 29 September 2011.

[3] AgeUK. Why befriending is such a vital service. (Accessed online 13 April 2012 from )

Competing interests: Member of the Health Equalities Alliance (and previously taught Communication skills for medical students).

Woody Caan, Professorial Fellow

Royal Society for Public Health, Duxford, Cambridge CB22 4PA

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13 April 2012

The problem of Health Literacy is even more basic than improving reading and numeracy skills. We do not put our basic reasoning processes in writing, relying only on verbal communication that quickly blow away in the wind. This applies when doctors explain their reasoning to patients, nurses and other doctors and also when they teach trainees and students.

It would help if every diagnosis was followed in writing by a few words that outline the findings that support the diagnosis, followed by the treatment given for that diagnosis and the latest findings in response to the treatment. This is not done at present. It would represent transparent, ‘patient’s evidence’ based medicine. This links the individual’s diagnoses to that individual’s findings (i.e. evidence) and that individual’s treatments. Those who cannot read or understand can show the paper to someone else and would be empowered by being able to do so.

Patients, relatives, nurses and other doctors are delighted to see this information in writing. Simple educational methods of this kind that promote high standards should be supported as well as the latest box-ticking exercises that give more surrogate measures of thoroughness. I have written a web-site to try to help people to understand medical decisions by asking the right questions [1] and a text-book to help doctors to answer those questions [2]. Educational approaches of this kind provide a positive way to change health systems and allow them to support the ability of patients to communicate, understand, access, interact and engage with people working in health services.


1. Llewelyn H. Understanding Medical Decisions.
2. Llewelyn H, Ang AH, Lewis K, Abdullah A. The Oxford Handbook of Clinical Diagnosis, 2nd edition. Oxford University Press, Oxford 2009

Competing interests: None declared

Huw Llewelyn, General physician and endocrinologist

Nevill Hall Hospital, Brecon Road, Abergavenny, NP7 7EG

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2 April 2012

Dear Editor,

Raynor’s editorial on Health Literacy highlights the importance of achieving adequate levels of health literacy in our population in order to improve quality of life, mortality rates and system burden. (1)

One in six people in the U.K. struggle with Literacy Skills. This means their literacy skills are below that expected of an eleven year old. (2) The recent Health Literacy European Study found on average 46.3% of people living in 8 developed European countries have what is deemed to be ‘inadequate’ or ‘problematic’ health literacy assessed using the Health Literacy Survey-EU model. Specific to Mental Health this survey also found that 31.2% of people find it difficult to find information on mental health issues such as stress and depression and 20% of people find it difficult to find out about activities that are good for your mental health (3). These figures may be higher in those with psychotic illness such as Schizophrenia, who demonstrate poorer language comprehension when compared with controls (4).

If we know that 5 million adults in the U.K. lack functional literacy, continuing the dissemination of health information primarily through written means may not be the most effective strategy (5). Is it time to consider alternative means of communicating information about health and health systems? One way of reaching a wide audience, educating and empowering people with limited literacy abilities about a conceptually complex illness such as Schizophrenia is communication through the arts, for example community theatre. This approach could be used for a wide variety of conditions. While great efforts such as The Plain English movement have been made to enhance general literacy, can we afford to wait until the full benefit of these campaigns is apparent before broadening our approaches?

1. Health Literacy, D K Theo Raynor, BMJ 2012;344:e2188.
2. Literacy: State of the Nation, A Picture of Literacy in the U.K. today, Deeqa Jama and George Dugdale, National Literacy Trust 2010.
3. Health Literacy Survey – European Union, University College Dublin Health Literacy in Ireland, Dr Gerardine Doyle, Dr Kenneth Cafferkey, Dr James Fulham 2012.
4. Language comprehension in schizophrenics and their brothers. Biological Psychiatry, 32, 790 -802. R. Condray, S.R. Steinhauer & G. Goldstein. (1992)
5. The Leitch Review of Skills: Prosperity for all in the World Economy – World Class Skills, HM Treasury 2006.

Competing interests: None declared

Maurice Joseph Bonar, Psychiatrist

Dr Mary Clarke

DETECT: Early Intervention for Psychosis Service., DETECT, Avila House, Blackrock Business Park, Carysfort Avenue, Blackrock, Co. Dublin, Ireland.

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26 March 2012

Raynor`s editorial [1] seems to be posited on the assumption that it is only patients and citizens who have poor understanding. Unless and until we identify and understand the full scope of fundamental reasons for health illiteracy generally, we cannot begin to find solutions. The goal of `increasing health literacy to improve health outcomes` also requires recognition of the severe shortcomings of health professionals to understand, report, and communicate statistics and risks, both verbally and written, and their poor ability to convey them in consultations with patients, or with citizens in the case of screening and other public health activities. [2] [3] This is aside from the need for attention to semantics.

In addition, it is essential to appreciate that patients make decisions in ways that deviate from official ideals. [4] Manson and O`Neill ask us to consider what exactly is meant by `information` and make a powerful case for engaging in `effective informative communication` rather than `disclosure`. [5] This will not be achieved if physician innumeracy is not remedied. [6] Good communication and shared decision-making are sub-optimal if doctors` numeracy skills are poor.

Surely the first step, after acknowledging the problem, has to be to improve teaching in schools and medical colleges, and in post graduate courses?

Journal editors have a crucially responsible gate-keeping role to play.

[1] Raynor, TDK. Health literacy. Is it time to shift our focus from patient to provider? BMJ 2012;344:e2188 doi: 101136/bmj.e1288

[2] Moyer VA. What We Don`t Know Can Hurt Our Patients: Physician Innumeracy and Overuse of Screening Tests. Annals of Internal Medicine. 2012;156;5;392-393

[3] Evans I, Thornton H. Transparency in numbers. The dangers of statistical illiteracy. Journal of the Royal Society of Medicine. 2009; 102(9):354-356; doi101258/jrsm.2009.090214.

[4] Armstrong N, Dixon-Woods M, Rusk G, et al. Do informed consent documents for cancer trials do what they should? A study of manifest and latent functions. Sociology of Health and Illness. 2012; ISSN 0141-9889, pp1-16

[5] Manson NC, O`Neill O. Rethinking Informed Consent in Bioethics. Cambridge University Press, Cambridge. 2007

[6] Gigerenzer G, Gaissmaier W, Kurz-Milcke E, et al. Helping Doctors and Patients Make Sense of Health Statistics. Psychological Sciences in the Public Interest. 2008; 8:2:53-96

Competing interests: None declared

Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences

University of Leicester, "Saionara", 31 Regent Street, Rowhedge, Colchester

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