Rima Rudd

The mismatch between adult literacy skills and available health materials is shocking, still news to many people 10 years after the first publications from the National Adult Literacy Survey, which found that 40 to 44 million US adults had skills in the lowest levels of literacy proficiencies. For example, some surveyed were not able to total entries on a deposit slip. Those and other findings have forced a redefinition of "normal" reading skills, said Rima Rudd, lecturer on health education and director of educational programs in the Department of Health and Social Behavior.

"Because we’ve long assumed that adults read at much higher levels than they actually do, public health practitioners, doctors, and other health professionals wrongly assume that people understand their explanations and advice," said Rudd.

At the invitation of the Institute of Medicine (IOM), Rudd is one of a dozen members of a new health literacy committee. In a letter inviting Dr. Rudd to participate on the committee, Harvey Fineberg, president of the IOM and former Dean of HSPH, outlined broad goals: to define the scope of health literacy, identify obstacles to creating a health-literate public, assess approaches that have been used to increase health literacy both in the US and abroad, and identify goals for health literacy efforts. The committee is expected to finish its work in late summer and to issue a report in the fall.

Limited health literacy has profound implications in much more than bioterrorism preparedness debates. To date, more than 200 studies have consistently found the level of most health materials and medical documents–appointment slips, consent forms, prescriptions–to be written well beyond the functional literacy of the average reader. Yet, few findings from those studies have circulated beyond the adult literacy and health education professional communities.

That may be about to change.

"A group of us have been working very hard to bring health literacy to the national agenda," Rudd said. "The National Academy of Sciences [to which the IOM belongs] is charged to serve as an advisor to Congress. We’re looking at policy. We’re looking at action. It’s an important moment, especially for a relatively new area of inquiry."

In the IOM’s committee roster, Rudd is noted for her work in health communication, for her expertise in the design and evaluation of public health community-based programs, and for her research into literacy-related disparities and literacy-related barriers to health programs, services, and care. Rudd launched the first public health graduate course in health literacy in the country at HSPH. She also developed a comprehensive web site for scholars and others as part of the research program she directs under the auspices of the National Center for the Study of Adult Learning and Literacy. The URL is http://www.hsph.harvard.edu/healthliteracy/.

She also authored the action plan for the health literacy objective in Healthy People 2010, a document from the US Department of Health and Human Services that sets health objectives for the nation. The initiative defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

The field of education has been highlighting health literacy for a long time. In the 1980s, health educators started looking at the reading level of materials used for patient education and other health documents. Slowly, in the 1990s, medical researchers began to examine links between literacy and health-related outcomes. Studies have shown that low literacy is associated with health behaviors such as less use of mammography services or delayed care for prostate cancer. The broad field of health communication has begun to recognize that health professionals are not communicating well with the public.

Recently, researchers are noting the importance of paying attention to literacy for risk communication. For example, Rudd determined that a postcard from the US Postal Service sent to millions of Americans in 2001, advising how to protect themselves from anthrax exposure and requesting them to report suspicious mail, was written at reading levels between grades nine and eleven, above the known reading levels of half of American adults.

Everyday health communication challenges can be equally mismatched as the average person tries to find health information on the Internet, establish credible sources of information, comprehend hospital charges and insurance payments, troubleshoot errors in billing and diagnosis, and more.

In the best case scenario, Rudd hopes that the IOM report will inspire research initiatives that examine the effects of literacy on health, policies that promote plain language, and support for efforts to improve the functional literacy of adults.

"It's not true that reading skills of the average person have necessarily decreased or that significant numbers of people are illiterate," she said. "Experts estimate that about 7 percent of US adults are illiterate. Many people have difficulty reading, but that is not the same as illiteracy." She added, "More important is the fact that our assumptions about the average reader have been wrong, and certainly the demand for more sophisticated reading skills has increased over time. The bar has gone up."

--Carol Cruzan Morton