December 26, 2006 Features

Health Literacy

Research Directions for Speech-Language Pathology and Audiology

Health literacy—the "degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions" (Ratzan & Parker, 2000)—is a national concern. Reports indicate that more than 90 million adults, nearly one-third of the population, have problems comprehending and acting upon health information (Institute of Medicine [IOM], 2004).

To maintain and improve their health, it is essential that individuals understand discussions with their physicians, comprehend written health information, be adequately informed when they consent to participate in research studies, and use health care equipment and prescription medication appropriately. Poor health literacy has been associated with increased hospitalizations, poor treatment outcomes, depression, and increased mortality levels (Chew, Bradley & Boyko, 2004; Mika, Kelly, Price, Franquiz & Villarreal, 2005).

Populations that appear to be at greatest risk for inadequate health literacy include non-English and limited-English speakers; the poor; minorities; the homeless; the elderly; and people with speech, language, hearing, vision, and mental disorders (IOM, 2004; Mika, et al., 2005).

Health literacy poses a particular challenge for people with communication disorders and differences; therefore, speech-language pathologists and audiologists have an integral role in health literacy research and intervention. However, an online search of the speech-language pathology and audiology literature revealed a scarcity of information related to this topic—only three related studies.

One study involved readability of educational materials for clients with cleft palate and their families (Kahn & Pannbacker, 2000), and another examined the effects of text and reader variables on understanding health information (Harris, Fleming, & Graham, 2003). The findings from both studies indicated that the materials exceeded the reading level of many clients and their families. A third study, which may be considered related to health literacy, involved factors that influence utilization of speech-language pathology services by older individuals (Shadden & Raiford, 1984). Results of this study indicated that limited knowledge of availability of speech and hearing services was a major barrier in older adults receiving services.

In the audiology literature, a "spotlight" on health literacy provided a definition and related health literacy Web sites (Access Audiology, Jan.-Feb. 2005). Although SLPs and audiologists have directed little attention to health literacy, speaking and listening have been specifically identified by the IOM (2004) as an area in need of improvement in health literacy research and intervention.

Improving Health Outcomes

Mika et al. (2005) outlined issues that need to be addressed in a 21st century research agenda to increase health literacy and improve health outcomes. Similar health literacy concerns have been noted by the IOM (2004). Here are sample research questions that might be addressed by researchers in communication disorders:

  • What types of interventions improve health literacy?
  • What type of impact or outcomes can be expected with appropriate intervention?
  • What types of screening instruments can effectively and efficiently screen health literacy, particularly for non-English speakers?
  • What effect does low parental literacy have on the health of children?
  • What is the relationship of overall literacy to health literacy?
  • What is the complexity level of materials used in health literacy?
  • How is health literacy related to domains of speaking and listening comprehension?

Schillinger's (2004) outcomes for improved health literacy are consistent with the IOM's (2004) Vision for a Health-Literate America and target:
(a) improved provider-patient communication; (b) enhanced community factors involving accessibility and availability of providers; and (c) expanded home-based monitoring, clinical support, and patient care, as well as family empowerment and continuity of communication. Although these outcomes were established as part of a chronic care model, each of these components could be applied to speech-language pathology and audiology to improve health literacy for clients with communication disorders and their caregivers.

Current health literacy assessments have been noted to be time-consuming, limited in scope and culturally insensitive (Chew et al., IOM, 2004; McCray, 2004; Mika et al., 2005). SLPs with expertise in language and cultural differences and test development can apply this knowledge to health literacy assessments for non-English speakers and other populations.

Research studies are needed to look at the impact of parental literacy on parents' understanding and management of disorders such as pediatric hearing loss and organic speech and swallowing disorders. How do parents' understanding and management of these disorders impact the overall health of the child? High literacy skills in general have been associated with good health literacy skills (Drew, 2002); however, highly educated people have also demonstrated low health literacy skills in some studies (Benson & Foreman, 2002). One methodological problem is that existing measures of health literacy are limited to print literacy. However, the IOM (2004) refers to literacy involving reading, writing and "oral literacy," which includes speech and speech comprehension.

Studies also are needed to examine the level of complexity of information brochures provided to clients and families regarding communication, similar to the study conducted by Kahn and Pannbacker (2000) on cleft palate brochures. Such studies will provide information regarding modification of communication disorder materials for clients and families with low literacy. The study by Harris et al. (2003) expands the examination of materials to health information materials used in the general population. Such studies can contribute further to health literacy research outside of the profession.

The IOM (2004) has noted that current health literacy research and assessments lack assessment of speaking and listening skills, which are essential within the health care setting. Moreover, communication problems have been noted as possible contributors to health disparities in certain populations, such as minorities and the elderly (Caris-Verhallen, deGruijter, Kerkstra, & Bensing, 1999; Kreps, 2006; Tran, Haidet, Street et al., 2004; Williams, Davis, Parker & Weiss, 2002). Studies on provider-patient communication interaction conducted by other disciplines have indicated communication failures on the part of both provider and patient, with providers making assumptions about patients' understanding and patients demonstrating limited skill in reporting, questioning, and requests for clarification (Kreps, 2006; Tran et al, 2004; Williams et al., 2002; Cooper & Roter, 2003). SLPs and audiologists can add to communication aspects of health literacy by investigating the impact of communication disorders on health literacy and examining the relationship between existing health literacy assessments and speech-language and hearing.

In summary, "improving health literacy requires great effort from the public health and health care system, the education system and society overall" (IOM, 2004). The need for our involvement in health literacy is clear. It is now our responsibility to address this need through research to improve health literacy assessments and intervention.

Eva J. Hester, is associate professor in the Department of Audiology, Speech-Language Pathology and Deaf Studies at Towson University in Towson, MD. Contact her at

Mercedes Benitez-McCrary, USPHS, Commissioned Officer, is a senior public health policy analyst in the Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services (CMS). Contact her at The views expressed are her own and do not necessarily represent the views of the CMS or the U.S. government.

cite as: Hester, E. J.  & Benitez-McCrary, M. (2006, December 26). Health Literacy : Research Directions for Speech-Language Pathology and Audiology. The ASHA Leader.

ASHA Health Literacy Resources

  • Health literacy Web page. General information, including a link to resources in three categories: information, resources for teaching, and cultural competence.
  • Healthy People Consortium ( ASHA has been an active member of this mortality-reduction project of the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services, since 1989. The project aims to increase life expectancy and improve the quality of life for people of all ages, and eliminate health disparities among different segments of the population. 
  • E-newsletters. Two have focused on health literacy. Access Audiology devoted an entire issue to health literacy and plain language; Access SLP Health Care also included health literacy information in a recent issue.


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