Functional literacy (the ability to read simple text and write simple sentences about everyday life), is a basic skill enabling people to participate more fully in society. There is consistent evidence indicating a link between low literacy and poorer health outcomes. People with lower literacy levels are generally 1.5 to 3 times more likely to have poor health outcomes than people with higher literacy levels.8 The prevalence of low literacy in England is surprisingly high.
The most recent (2003) English national survey of literacy, numeracy, and use of information technology, also known as the The Skills for Life survey, assessed the extent to which these basic skills were present at a level needed to achieve full potential (Level 2 in the National Qualification Framework). This is described as ‘being able to understand a range of texts of varying complexity accurately and independently, and to extract information of varying length and detail form different sources’.11 This survey of 8000 people of working age was based on a direct measurement of skills (for example, on being shown a poster for a concert, questions were asked such as ‘where is the concert, how much will it cost for two people to attend?’). The results were divided into levels which were based on the English national curriculum and showed that 56% (literacy), and 75% (numeracy) of those surveyed have skills below those needed to achieve their full potential, while the opportunities offered by modern information technology, such as the internet, are only fully used by a very small percentage of the population (9%).11
Such results provide practical challenges in health communication. The majority of printed information leaflets used in health care already have a reading age higher than the average population.12,13 Interventions to promote participation, shared decision making, and informed consent may only therefore reach a proportion of the population.
Low literacy and numeracy may contribute to inequity of access to the benefits of prescription medication. It is known that people with low literacy skills are more likely to make mistakes in interpreting medication instructions and warning labels.14 This increases the risk of both unintentional sub-optimal compliance with medication regimes, and increases the risk of adverse events. In addition, the drive to more cost-effective generic prescribing may differentially affect those with low basic skills; community pharmacists report that patients with low literacy experience difficulties when different brands of the same medication are issued.15
Current NHS initiatives to increase patient choice may also be less accessible for people with low literacy. Under the NHS Choose and Book system, patients requiring specialist care are offered a range of potential services; they then choose their preferred service and book their clinic appointment. It can be hypothesised that this process will be more difficult for people with low literacy skills, although to date no research has been undertaken to investigate this; however, research suggests that Choose and Book fails to deliver the expected choice to patients.16