Staying healthy isn't easy. In the U.S., the health care system is complex, and information about health and disease changes constantly. Moreover, for at least 90 million adults -- about one in two -- these messages aren't coming through clearly.

Part of the problem is that, as more than 400 studies show, health materials are written at levels far above the skills of the average reader. This mismatch means that most adults have trouble reading medication labels, following doctor's instructions, interpreting charts, and accessing other information critical to their health.

The consequences are serious, says Rima Rudd, a health educator at the Harvard School of Public Health who helped write Health Literacy: A Prescription to End Confusion, a 2004 report from the Institute of Medicine (IOM). Patients may miss doctor appointments, for example, overuse emergency rooms, and under-use preventive care, or have difficulty managing a chronic disease, such as diabetes.

Health literacy isn't just about reading skills, Rudd notes. Basic mathematics, writing, listening, and speaking count, too. A Prescription to End Confusion calls on schools for grades K through 12 to work health-related skills into lesson plans. Adult education and professional schools should do the same.

Health-related activities take place not just in the doctor's office, but in the home, the workplace, and the community, Rudd adds. "Our health system makes complex demands on patients -- to fill out insurance forms, follow directions for self care, compute dosages, and give truly informed consent.

"These skills can't be assumed," Rudd says. "Some patients struggle with figuring out the appropriate timing for their medicine. If you need to take a pill two hours before eating, and lunch starts at 1:30 p.m., how would you subtract 2?

"Tools used to measure health literacy have mainly assessed reading skills. We need new ones to evaluate a wider range of skills," Rudd asserts. These kinds of studies are just starting to be funded by the National Institutes of Health and the Centers for Disease Control and Prevention.

U.S. Surgeon General Richard Carmona calls health literacy "the currency of success for everything we do in primary and preventive medicine," the foundation for improving quality, cutting costs, and reducing disparities between the health system's "haves" and "have-nots." IOM President Harvey Fineberg, a former HSPH dean, calls health literacy "a neglected, final pathway to high-quality care."

To the average person, fields like medicine and dentistry can seem alien, Rudd says. Practitioners speak in jargon, saying "ambulatory" clinic rather than "walk-in," "nephrology" instead of "kidney." Unwittingly, they erect communication barriers, especially for patients who are very sick, who are hearing impaired, who find doctors intimidating, or whose first language is not English.

The year 2004 was a breakthrough year for researchers like Rudd, who authored two other influential reports in her field. Literacy and Health in America, published by the Educational Testing Service, offers baseline statistics regarding the average literacy skills of elders, minority groups, and other populations. And for the U.S. Agency for Healthcare Research and Quality, Rudd also served as an advisor for a review of studies linking literacy measures to health outcomes, such as hospitalization and diabetes.

Rudd boils all these documents down to clear terms. "When it comes to keeping people healthy," she says, "health literacy is fundamental -- just like A, B, C."

M.J. Friedrich writes about health and medicine for the Journal of the American Medical Association and other publications.

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