What Led To The National Action Plan to Improve Health Literacy?

For the last three decades, researchers in the United States have been engaged in the challenging endeavor of transforming the approach to combating poor health literacy nationwide. A pivotal moment came in 2010 with the Department of Health and Human Services' release of the National Action Plan to Improve Health Literacy. This plan offered a comprehensive framework, rallying organizations and professionals across various sectors towards a common goal. Now, 14 years post-release, gauging the plan's impact on the evolution of health literacy in the U.S. remains complex. To grasp the journey to this point, it's essential to revisit the studies, reports, and hearings that laid the groundwork for the National Action Plan and to evaluate the developments following its implementation. 

It's important to recognize how intertwined functional literacy and health literacy are in research and policy development. These two forms of literacy, while different in their specific applications, are closely linked in their impact on individuals' ability to manage their health and wellbeing effectively. Understanding this connection helps us trace the roots of health literacy initiatives back to broader educational and policy discussions, including those sparked by the "Nation at Risk" report of 1988.

The release of "A Nation at Risk" in 1983 marked a significant moment in American education, catalyzing a national focus on addressing literacy and educational standards, thereby setting the stage for future initiatives in various literacy domains. The report emphasized the critical need for enhanced adult literacy, pinpointing it as a cornerstone for a more educated and capable society. It called for sweeping reforms in childhood and adult education, stressing the importance of equipping adults with the necessary literacy skills to adapt and thrive in an increasingly complex and information-rich world.

In the wake of the reforms and aspirations set forth by "A Nation at Risk," the focus on adult literacy found new ground in the form of empirical research. This shift led to the 1992 National Adult Literacy Survey, a landmark study that provided an in-depth look at the literacy levels of adults in the U.S.. Conducted by the National Center for Education Statistics, this survey, a first of its kind in the U.S., assessed the literacy levels of nearly 13,600 adults aged 16 and older across the nation. It offered unprecedented insights into the state of adult literacy in the United States. During the hour-long survey, participants were engaged in diverse literacy tasks and demographic inquiries. Their abilities were classified into five distinct levels, with Level 1 indicating the lowest literacy skills. The results were eye-opening: approximately 21-23% of adults demonstrated skills at Level 1, and an additional 25-28% were at Level 2. While the survey provided crucial data, interpreting these levels and understanding the limitations in literacy skills posed a challenge, given it was the first nationally representative study of its kind. Nonetheless, these findings captured the attention of researchers and policymakers, marking a significant step towards addressing health literacy issues.

By 2000, the public health implications of health literacy had gained substantial recognition, particularly with the Healthy People 2010 initiative identifying limited health literacy as a major concern and setting national improvement objectives. The momentum continued: In 2004, the Institute of Medicine released 'Health Literacy: A Prescription to End Confusion.' Also in 2004, the Agency for Healthcare Research and Quality (AHRQ) published a comprehensive scientific review, ‘Literacy and Health Outcomes’. These pivotal publications collectively illuminated how limited health literacy is associated with reduced use of preventive services, poorer management of chronic conditions, lower self-reported health status, an increase in preventable hospital visits and admissions, misunderstandings of prescription medications, medical errors, and difficulties in understanding nutrition labels. Moreover, they underscored the psychological and economic burdens associated with poor health literacy.

In response to these revelations, numerous health professional organizations, including the American College of Physicians, the American Dental Association, the American Medical Association, the American Academy of Pediatrics, and the Association for Clinicians for the Underserved, have since elevated health literacy to a top priority for their members.

In 2006, a pivotal moment in health literacy research occurred when the U.S. Department of Education released the first National Assessment of Health Literacy, focusing on English-speaking adults in the United States. This report, based on a study conducted in 2003, offered a clearer picture of the nation's standing in both functional and health literacy compared to the 1992 survey. Assessing 19,000 individuals, the study employed a methodology similar to the 1992 survey, yet provided results that were more comprehensively interpretable for the American public. Crucially, it revealed that there had been little improvement in literacy skills since 1992. The assessment categorized literacy levels as below basic, basic, intermediate, and proficient. The results were sobering: only 12% of adults demonstrated proficient health literacy, 54% had intermediate levels, 22% were at a basic level, and 14% fell into the below basic category. These findings, particularly the stagnation since the 1992 report, sounded alarm bells at a policy level, underscoring the urgency for a more proactive approach to addressing the United States' ongoing challenges with functional and health literacy."

Following the heightened attention from various government agencies and professional organizations on health literacy, and especially after the revealing insights of the 2006 National Assessment of Adult Literacy, the groundwork for the National Action Plan to Improve Health Literacy was laid. This plan was significantly influenced by the Surgeon General's 2006 workshop on improving health literacy and was further shaped by several town hall meetings held in 2007 and 2008. These meetings provided a platform for major stakeholders in the healthcare sector to voice their insights and concerns. Their valuable feedback was instrumental in shaping the final version of the National Action Plan to Improve Health Literacy, marking a concerted effort to address this critical public health issue comprehensively.

In the next blog, we will delve deeper into the specifics of the National Action Plan to Improve Health Literacy. We'll explore each of its goals and strategies, examine the progress made since its implementation, and discuss the ongoing challenges and opportunities in enhancing health literacy across the nation.