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Health literacy has been used as a metaphor as is science literacy or computer literacy, referring to knowledge about and facility with a particular area or process. However, most references to health literacy in scholarly articles move beyond the metaphor and highlight the importance of literacy skills applied in health contexts. Literacy skills encompass a set of related activities that include reading, writing, engaging in oral exchange, and using basic math. Adults apply these skills to numerous health-related activities at home, at work, in the community, and in social service and health care settings. The Institute of Medicine (IOM) report, Health Literacy: A Prescription to End Confusion, proposed that an individual's health literacy capacity is mediated by education, and its adequacy is affected by culture, language, and the characteristics of health-related settings.1

Health literacy is firmly established as a field of inquiry in medicine and public health. Improved health literacy was included as a communication objective in Healthy People 2010 and the US Department of Health and Human Services (DHHS) articulated an action plan for reaching this objective in its report Communicating Health: Priorities and Strategies for Progress.2 Studies linking health literacy to health outcomes were examined by the Agency for Healthcare Research and Quality (AHRQ) and its report, Literacy and Health Outcomes,3 concluded that the weight of evidence supported a link between literacy and health outcomes. The IOM was asked to examine the scope and rigor of health literacy research. The IOM issued a report offering recommendations for policy makers, researchers, government agencies, and the private sector for needed action and further research.1

Evidence for increased interest in health and literacy links may be found in the published literature. The approximately one dozen published journal articles of the 1970s grew to three dozen in number in the 1980s and burgeoned in the 1990s after the publication of findings from the first National Adult Literacy Survey (NALS). By the end of the century, the published literature addressing health literacy consisted of approximately 300 studies.4 An additional 300 articles have been published between 2000 and 2004.5 Most of the published studies are focused on the reading level of health materials such as patient package inserts, informed consent materials, and patient education pamphlets and booklets. Over time, assessments of materials have included examinations of the match between the reading level of printed health materials and the reading skills of the intended audiences. More recent studies have expanded beyond print materials and are examining health information delivered through various channels of communication including television, websites, and other computer-based technologies. Overall, findings continue to indicate that the demands of health materials and messages exceed the average skills of the public and of the average high school graduate.4,1

A smaller section of the literature has focused on health outcomes. Supported by the development of rapid assessment ...

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