September 5, 2011

This entry will address both education and literacy since they are closely linked concepts, albeit with very different meanings. The MerriamWebster Dictionary defines education as “the action or process of providing schooling for” or “to train by formal instruction and supervised practice especially in a skill, trade, or profession.” Literacy is defined as the quality or state of being able to read and write. Often these terms are used interchangeably; however, although one might be educated, it does not ensure that one is literate. In a review of the literature, some studies used the terms interchangeably, others discussed education but measured literacy, while still others distinguished between general literacy and health literacy.

The National Institutes of Health report associations between education and health across a broad range of illnesses, including coronary heart disease, many types of cancer, Alzheimer’s disease, some mental illnesses, diabetes, and alcoholism. In addition, many important health risk factors for disease, such as use of cigarettes, have been linked to educational attainment. For most diseases, segments of the population with lower levels of education have higher risks of these diseases.

Education appears to be a protective factor in health. In some studies of clinical treatments, those with lower levels of educational attainment demonstrated poorer outcomes. In studies of chronic diseases such as HIV or diabetes, the effectiveness of self-management and adherence to medical treatment appear related to educational attainment. However, there is little research on what specific aspect of the educational process or experience is linked to health.

Several different types of biological, psychological, and social pathways have been proposed as possibly explaining the association between education and health. Examples of possible psychological or social pathways include the following:

  1. Education leads to higher income, which allows the purchase of more health insurance, better housing, and other goods and services.
  2. Education might lead to greater optimism about the future, self-efficacy, or sense of control, which might alter health behaviors or adherence to medical treatments or ability to self-manage chronic illnesses.
  3. Education might improve important cognitive skills including literacy, enhanced decisionmaking, and analytical skills, which allow individuals to be more successful in managing their health problems, in interacting with the health care system, or in preventing future health problems.


Domestic Violence

According to results from the National Violence against Women survey, couples with status disparities (e.g., educational level, income) experience more intimate partner violence than do couples with no status disparities; however, women were significantly more likely to report violence by a current partner if their education level was greater than their partners. In a study of pregnant Mexican women, women with less than a primary education were 1.78 times more likely to be victims of domestic violence.

Preventive Care

Regardless of race and ethnicity, women of color who had a regular doctor were at least twice as likely as those who did not to receive preventive care. However, women with less than a high school education were less likely to seek preventive care.


In its 1991 National Literacy Act, Congress defined literacy as “an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.” Literacy was redefined in the Workforce Investment Act of 1998, as “an individual’s ability to read, write, and speak in English, compute and solve problems at levels of proficiency necessary to function on the job, in the family of the individual and in society.” This new definition is a broader view that recognizes literacy as more than just an individual’s ability to read. As information and technology have increasingly shaped our society, the skills we need to function successfully in it have gone beyond reading, and literacy has come to include the skills listed in the updated definition.

Measuring Literacy

When literacy was simply a synonym for reading skill, it was typically measured in grade-level equivalents. In other words, an adult’s literacy skill was described as equivalent to reading at a specific grade in the U.S. educational system of kindergarten through twelfth grade. A more complex and realistic conception of literacy that emphasizes its uses in adult activities helped create momentum for new forms of literacy measurement. To determine the literacy skills of American adults, the 1992 National Adult Literacy Survey (NALS) used test items that resembled everyday life tasks involving reading prose, understanding common legal and governmental documents, and using quantitative skills. The NALS classified the results into five levels that are now commonly used to describe adults’ literacy skills.

Almost all adults in Level 1 can read a little but not well enough to fill out an application, read a food label, or read a simple story to a child. Adults in Level 2 usually can perform more complex tasks such as comparing, contrasting, or integrating pieces of information, but usually not higher level reading and problemsolving skills. Adults in Levels 3 through 5 usually can perform the same types of more complex tasks on increasingly lengthy and dense texts and documents.

The NALS found a total of 21-23%—or 40-44 million—of the 191 million American adults age 16 or older at Level 1, the lowest literacy level. Although many Level 1 adults could perform a number of tasks involving simple texts and documents, all adults scoring at Level 1 displayed difficulty using certain reading, writing, and computational skills considered necessary for functioning in everyday life. Rather than classifying individuals as either “literate” or “illiterate,” NALS created three literacy scales: prose literacy, document literacy, and quantitative literacy. Each scale reflects a different type of real-life literacy task.

Many factors help to explain why so many adults demonstrated English literacy skills in the lowest proficiency level defined (Level 1). Twenty-five percent of the respondents who performed in this level were immigrants who may have been just learning to speak English. Nearly two thirds of those in Level 1 (62%) had terminated their education before completing high school. A third were age 65 or older, and 26% had physical, mental, or health conditions that kept them from participating fully in work, school, housework, or other activities. Nineteen percent of the respondents in Level 1 reported having visual difficulties that affected their ability to read print.

In the executive summary of the 1993 report, “Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey,” the National Center for Educational Statistics reported that individuals surveyed who demonstrated higher levels of literacy were more likely to be employed, work more weeks in a year, and earn higher wages than individuals demonstrating lower proficiencies. Adults in the lowest level on each of the literacy scales (17-19%) were far more likely than those in the two highest levels (4%) to report receiving food stamps. Nearly half (41-44%) of all adults in the lowest level on each literacy scale were living in poverty, compared with only 4-8% of those in the two highest proficiency levels.


The term health literacy was first used in a 1974 paper titled “Health Education as Social Policy.” In discussing health education as a policy issue affecting the health care system, the educational system, and mass communication, Simonds called for minimum standards for health literacy for all school grade levels. This early use of the term shows there is a link between health literacy and health education. The President’s Committee on Health Education defined, in 1973, health education as “… a process which bridges the gap between health information and health practices.” Failures in health education have certainly contributed to poor health literacy, but the roots of health literacy problems in the United States are not just in the history of our system of education. Health literacy problems have grown as patients are asked to assume more responsibility for self-care in a complex health care system. Patients’ health literacy, then, can be thought of as the currency needed to negotiate this complex system.

A 1999 report of the Council of Scientific Affairs of the American Medical Association refers to functional health literacy as “the ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials required to successfully function as a patient.” The National Institute on Deafness and Other Communication Disorders defines health literacy as incorporating ” . a range of abilities to read, comprehend, and analyze information; decode instructions, symbols, charts, and diagrams; weigh risks and benefits; and, ultimately, make decisions and take action… specifically associated with disease prevention and health promotion.” Therefore, health literacy is essential to health promotion, defined as “the science and art of helping people change their lifestyles to move toward a state of optimal health,” particularly as we address issues of primary prevention. A health literate individual is more apt to know how to answer the question “How do I keep myself well?” Adequate health literacy may be of even greater importance in secondary prevention (prevention of complications or after effects of existing disease), as ineffective communication between health providers and patients can result in medical errors due to misinformation about medications and self-care instructions.

According to Healthy People 2010, an individual is considered to be “health literate” when he or she possesses the skills to understand information and services and use them to make appropriate decisions about health. Alarmingly, these skills and strategies are absent in more than half of the U.S. population. This fact is more disturbing when one considers that these are the very skills and strategies that often lead to longer life, improved quality of life, reduction of both chronic disease and health disparities, as well as cost savings.


A woman’s health reflects both her individual biology and her sociocultural, economic, and physical environments. These factors affect both the duration and the quality of her life. For example, the average life expectancy for a woman varies considerably according to her race. In 1997, the average life expectancy for white women was 5 years longer than that of African American women (80 vs. 75 years). Women who live in poverty or have less than a high school education have shorter life spans; higher rates of illness, injury, disability, and death; and more limited access to high-quality health care services.

Historically, women have also been the primary health care providers and health decision-makers for their families. Nearly two thirds of women polled in a recent national survey indicated that they alone were responsible for health care decisions within their family, and 83% had sole or shared responsibility for financial decisions regarding their family’s health. Women are also the primary caregivers for ill or disabled family members. Of the estimated 15% of Americans who are informal caregivers, an estimated 72% are women—many of them sandwiched between caring for an ailing relative and caring for their own children.

In a recent review article on literacy and women’s health, Tomlinson found that literacy, rather than ethnicity, was more strongly associated with risks for poor health, except in the case of childbirth outcomes and smoking habits. In some studies where formal education was high and health literacy was low, she found that this was due to a lack of specific information, misconceptions, or misinterpretations. These findings led to the conclusion that formal education neither assures health literacy nor eliminates genetic or environmental predisposition for disease since traditional beliefs, values, and religion influenced health knowledge and perceptions.

In a study by Shimouchi and colleagues, literacy was identified as a predictor of infant mortality in 97 developing countries. In Nicaragua, a survey of women and infants found fertility and infant mortality declining over 30 years; the former explained by an increase in the level of education, the latter by targeting socioeconomically disadvantaged women with interventions to reduce infant mortality.


Health care practitioners’ efficacy in delivering services and disseminating information regarding women’s health is influenced largely by formal education, cultural beliefs and perceptions about health, and access to health care information and resources. Reports of traditional practices (ways of protecting and restoring health that existed before the arrival of modern or Western medicine) often reflect patient and provider relationships based on common links, informal literacy, and perceptions. Tomlinson reports that traditional providers are the preferred health care provider for many women, regardless of provider level of literacy or training.

The impact of literacy on women’s health illuminates the measure of responsibility providers must assume in educating their patients, and the magnitude of the need to provide systematic support. Health communication professionals must consider education and literacy and all their facets when developing health materials and communication strategies for a range of diverse audiences—each with differing abilities, experiences, levels of knowledge, and cultural beliefs and practices.

The National Literacy and Health Project of the Canadian Public Health Association has conducted numerous surveys that confirm that low literacy has a major negative impact on health and that literacy is a major factor underlying other determinants of health. They report that poverty, low literacy, and health problems are interrelated in a number of ways, for example, literacy affects people’s access to decent jobs and decent incomes. Low-literacy workers are more likely to have unskilled jobs that tend to be more dangerous, leading to a higher than average rate of workplace injury. Low literacy limits the opportunities, resources, and control that people have over their lives, which may lead those individuals to have limited opportunities to make informed choices about their lifestyle resulting in unhealthy lifestyle practices. Literacy and health goals have a better chance for success when pursued together, and people working in health and adult education fields should form partnerships, using literacy as a channel for health promotion among low-literacy populations.

SEE ALSO: Cancer screening, Gender, Life expectancy, Preventive care

Suggested Reading

  • Canadian Public Health Association. (2003, July). National literacy and health program. Ottawa, Canada.
  • Castro, R., Peek-Asa, C., & Ruiz, A. (2003). Violence against women in Mexico: A study of abuse before and during pregnancy. American Journal of Public Health, 93, 1110—1116.
  • Cornelius, L., Smith, P., & Simpson, G. (2002). What factors hinder women of color from obtaining preventative health care? Journal of Public Health, 92(4), 535-538.
  • Simonds, S. K. (1974). Health education as social policy. Health Education Monograph, 2, 1-25.
  • Tomlinson, L. (2003). Patient and practitioner literacy and women’s health: A global view from the closing decade 1990-2000. Ethnicity and Disease, 248-258.

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