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Center for Health Literacy Promotion Blog

9 out of 10 adults lack the skills to manage their health. Really?

I just saw it again:  In fact, 9 out of 10 US adults do not have the skills to manage their health (from a newsletter whose author shall remain unnamed)
 
Last week, I saw that figure, stated as a related but different known fact, on the NYU student health website:  Nearly 9 of 10 adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media, and communities (not sure who our refers to). That same quote is found in the CDC report titled The State of Aging and Health in America 2013  

Here’s another version made somewhat more accurate by qualifiers: Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy. In other words, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease.
 
The source of this oft quoted and variously interpreted statement is data from the 2003 National Assessment of Adult Literacy. That was a lengthy pencil and paper literacy test taken by 19,000 US adults 12 years ago. It included “health tasks”, hypothetical situations thought to represent common literacy activities related to health.
 
 Use your critical literacy skills
•   The statement is not a fact.
It is a national-level estimate extrapolated from a population sample. Research, and especially literacy testing, does not produce fact, only likelihood; in this case, at the national level. The statement is meaningless in discussion of individuals.

•   The test has been used once. Its validity is unknown.

•   “Health literacy tasks” in the test are common only to insured, experienced patients.

For example: A Proficient rating means the person can use a table to calculate an employee’s share of health insurance costs for a year. This is nonsense to a person who has never qualified for employer-based coverage.
 
Below Basic means a person cannot read a short set of instructions and identify what is permissible to drink before a medical test.  More nonsense for a person who has never had a medical test.
 
•   The information was produced to publicize a problem, spur action and advocate for research funding. That may explain why reports refer to “only 12 % are Proficient” and then round down to 10% and delete nearly to state that 9 out of 10 are not proficient; and suggest that individuals need to score at the Proficient level to manage their health, or use everyday health information, or prevent disease.  A more accurate, but less motivating report might have said,  “Only 14% of US adults scored Below Basic in heath literacy. They are primarily impoverished, socially disadvantaged adults who attended low quality schools and are excluded from the healthcare system.”   
 
•   It is rarely reported that “the majority of US adults” (53%) scored at the Intermediate level, and another 22% (“[nearly] 1 in 4”) demonstrated Basic health literacy.   If it is true, as suggested, that a Proficient heath literacy score translates to proficient management of health, disease prevention, and “understanding basic heath information to make appropriate decisions”; and if it’s also true an Intermediate or Basic score translates to incompetence, that’s an incrimination of a healthcare system that benefits only 1 out 10 it intends to serve.
 
•   It’s rarely reported that 30% of college graduates scored at the Proficient level, compared to 3% of high school graduates and 1% of non-graduates. That figure suggests making higher education accessible to all adults as a matter of health policy and healthcare cost containment. It also suggests you need a college degree to benefit from “the best healthcare system in the world”
 
It is imperative to move away from this questionable, disempowering, self-defeating, system-centric oft-repeated extrapolation that 9 out of 10 US adults do not have the skills to manage their health. Healthcare would benefit by using theories of health literacy as an asset and a pragmatic intervention to design health services that benefit people with the skills they have instead of lamenting that people just are not smart enough to use health information and services. As long as we contend that what we need in order to have quality, equitable, affordable healthcare is a smarter patient; we’re spinning our wheels.

 
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