Health Literacy

Research Facts and Findings, May 2013

A publication of the Act for Youth Center of Excellence


by Jennifer Manganello, PhD, MPH and Laura P. Shone, DrPH, MSW

About the Authors

Jennifer Manganello, PhD, MPH is associate professor of Health Policy, Management, and Behavior at the University at Albany School of Public Health, State University of New York. Laura P. Shone, DrPH, MSW is associate professor of Pediatrics, Clinical Nursing, and the Center for Community Health at the University of Rochester Medical Center.


Adolescence is a pivotal time to "learn by doing." As adolescents move toward young adulthood, they begin to make independent health decisions and manage their own health. The health habits, knowledge, and skills needed to make those decisions are established during adolescence, and will shape medical care and overall health throughout life (Giedd et al., 1999; Sawyer et al., 2012; Wolf et al., 2009). Maintaining health does not necessarily come naturally to adolescents, but having good health literacy skills can help adolescents get information and health services when they need it.

What is health literacy, and why does it matter?

Health literacy is the ability to understand, communicate, and use health information to function effectively in the health care system (Nutbeam, 2000; Parker, Ratzan, & Lurie, 2003). More broadly, it is "…a set of skills used to organize and apply health knowledge, attitudes, and practices relevant when managing one's health environment" (Massey et al., 2012). Health literacy includes skills such as basic reading and vocabulary, numeracy including computation, and interactive communication.

One-third to one-half of U.S. adults have low health literacy and consequently have difficulty accessing and using health information. In addition, they may have issues with (1) accessing and using health care; (2) interacting with providers; and (3) managing chronic conditions and personal health (Kutner, Greenberg, Jin, & Paulsen, 2006; Von Wagner, Steptoe, Wolf, & Wardle, 2009). Many studies have linked health literacy problems to overuse, underuse, and misuse of care, worse health outcomes and greater mortality risk, inappropriate health care service use (using care you don't need or not getting care you do need), and higher health costs (U.S. Department of Health and Human Services, n.d.; Weiss & Palmer, 2004).

The skills associated with health literacy allow people to:

While there is little research on health literacy specifically among adolescents, health literacy is complementary to many concepts and skills that have long been important for youth and are well studied (Davis et al., 1999; Bennett et al., 2012). Health literacy is important as a way to describe, model, and foster essential skills as teens develop and prepare to independently manage their own health as young adults, yet it is one of many important concepts. It neither stands alone nor eclipses these other concepts; instead, it can enrich our insight in our work to build adolescents' strengths and foster healthy youth development.

Who has low health literacy?

Few studies have measured adolescent health literacy, but existing data suggest that disparities exist. In 2003, Hispanic adults (16 or older) had the greatest difficulties with health literacy, with 41% having "below basic" health literacy skills. This is compared to 25% of American Indian, 24% of African American, 13% of Asian/Pacific Islander, and 9% of white adults (Kutner et al., 2006). One study of 261 teens found that 52% of adolescents had adequate literacy, with those who were Hispanic or qualified for free lunch being more likely to have limited literacy (Ghaddar, Valerio, Garcia, & Hansen, 2012).

It is important to remember that you can't tell who has low health literacy just by looking at someone.

Health literacy environment

A newer definition of health literacy says people are health literate when "the skills and ability of those requiring health information and services are aligned with the demand and complexity of information and services" (Parker & Ratzan, 2010, p. 28). This reference to the complexity of the system and the need to create user-friendly materials and services refers to the health literacy environment. Finding and entering a health care facility, using information to navigate around the facility once inside, filling out forms, providing consent, reading health information, and knowing how to ask questions and understand answers are all skills one needs to succeed in the health care environment (Rudd, Renzulli, Pereira, & Daltroy, 2005). Useful resources for organizations include health literacy environment assessment tools developed by Rima Rudd (2010) and Brach and colleagues' 2012 Institute of Medicine paper Ten Attributes of Health Literate Health Care Organizations.

Health Policy

Health literacy has become a priority at the federal level of government. * In 2004, the Institute of Medicine released the report Health Literacy: A Prescription to End Confusion, with recommendations for health care systems (Nielsen-Bohlman, Panzer, & Kindig, 2004)

Measurement and Assessment

Because health literacy is a complex concept with varying definitions, measuring and assessing health literacy can be challenging. There are a number of tools that have been used, but many have not been used with adolescents, and many are designed to be administered one-on-one (as opposed to a self-administered survey). The most common assessment tools are shown in the resources section. These measures are used in research among adults and sometimes used in clinical settings. They can help identify teens with lower health literacy levels, but the need for using such tools and which tool is most appropriate varies.

Rather than routine use of these assessment tools, The National Action Plan for Health Literacy encourages the use of "universal precautions" in all communications (comparable to the use of gloves at all times rather than only with specific patients) (U.S. Department of Health and Human Services, 2010). Examples of health literacy universal precautions include basic communication strategies such as using non-technical language, speaking at a moderate pace, encouraging questions, limiting written material to essentials, writing for no higher than a 6th grade reading level, and much more. See the Health Literacy Universal Precautions Toolkit for more information (DeWalt et al., 2010).


A handful of studies have evaluated interventions to change health literacy skills, whereas more have intervened to change health literacy environments, mainly materials. Of 42 studies identified in a 2010 review by the Agency for Healthcare Research and Quality, interventions included redesigning documents, improving readability, presenting numerical information in a different way, using pictures, and using non-text media to present information. Few specifically included adolescents (Brey, Clark, & Wantz, 2007). The community, education system (Benham Deal & Hodges, 2009), and health system are all potential points of intervention for fostering teens' ability to navigate the health system, and improving the systems themselves. Much more work is needed in the area of intervention. We need to understand how health literacy develops, design strategies to foster that development, and evaluate to see what works to improve health-related skills, experiences, and outcomes. We also need to evaluate interventions to be able to demonstrate their effectiveness, and ultimately disseminate evidence-based best practices.

Anticipating the future

The agenda for research in adolescent health literacy calls for studying predictors of health literacy, looking at the influence of health literacy on outcomes for adolescents, and developing and evaluating interventions targeting health literacy and adolescents (Manganello, 2008). The Institute of Medicine has identified three overarching domains where this health literacy research could potentially take place, including the health system, the education system, and communities (Nielsen-Bohlman et al., 2004). The challenges that lie ahead for our youth demand that we continue to identify and build on adolescents' strengths and skills to ultimately foster their ability to have healthy and productive lives. Inclusion of health literacy concepts in future work can help achieve this goal.


Online courses in health literacy

Health Literacy and Public health: Introduction (NYNJ Public Health Training Center)

Effective Communication Tools for Healthcare Professionals (Health Resources and Services Administration)

Health Literacy for Public Health Professionals (CDC)

Assessment Tools

Newest Vital Sign



Literacy Assessment Instruments, NC Program on Health Literacy

Resources for designing user-friendly material

A Guide to Writing and Designing Easy-to-Use Health Web Sites (HHS)

Simply Put (CDC)

Easy to Read NYC (Mayor's Office of Adult Education)

Health Literacy & Public Health: Strategies for Addressing Low Health Literacy (NYNJ Public Health Training Center)