The final report of the National Health and Hospitals Reform Commission, A healthier future for all Australians, has rightly stimulated debate in Australia about what it takes to create an equitable and sustainable health care system.1 The report draws attention to the importance of strengthened consumer engagement, boldly described as “giving people real control and choice about whether, how, where and when they use health services, supported by access to evidence-based information that facilitates informed choices”, as a platform for creating an “agile and self-improving health system”.1 Building health literacy is identified as a key strategy that will underpin strengthened consumer engagement.

This ambitious commitment is long overdue. Research indicates that those who actively participate in health care decisions generally achieve better health outcomes compared with those who do not, and that most patients are not currently involved in health care decisions to the degree they would like to be.2 Those most likely to participate in health care decision making tend to be younger, female and educated.

Regardless of personal preferences, not everyone is equally equipped to participate in health care decisions. The Commission’s report recognises this in its advocacy of action to build health literacy. Health literacy can be simply defined as the capacity to acquire, understand and use information for health. A 2006 Australian Bureau of Statistics survey examined health literacy in Australia using data derived from the Adult Literacy and Life Skills Survey, which assessed respondents’ prose and document literacy, numeracy, and problem-solving skills.3 From these data, information relating to respondents’ health literacy was derived, using specific questions related to health issues. The study found that 60% of Australians lack basic health literacy, described as the “minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy”.3 In a country that prides itself on achieving high rates of functional literacy, this is surprising, and indicates that individuals with higher levels of general literacy may not be able to consistently apply it in situations requiring specific content knowledge, or in an unfamiliar environment. For many individuals, as patients, carers and members of the public, health care settings are unfamiliar environments in which alien vocabulary and concepts are used.

The relationship between literacy and the quality and outcome of health care has gained increasing attention, especially in the United States.4 Research shows that people with poor health literacy are less responsive to health education and use of disease prevention services, are less able to successfully manage chronic disorders such as diabetes and asthma, and incur higher health care costs.5 This has led to progressive testing of interventions designed to mitigate the effects of poor health literacy through modified communication and improved health service organisation.6

The limited research on health literacy conducted in Australia, such as the article by Adams and colleagues in the current issue of the Journal, confirms both the findings of the Australian Bureau of Statistics survey on the extent of the problem, and the established link between poor health literacy and poor health outcomes.7 Research from New South Wales provided insight to the needs and preferences of people with low literacy in the development of clinical decision aids.8 Given the policy recommendations and potential importance of their impact, this remains an underdeveloped area of research.8

Although the Commission’s attention to health literacy is encouraging, the practical actions proposed in its report are underdeveloped and will require early attention to seize this opportunity for action. Health literacy is best developed through education that is customised to individuals and their specific priorities. The recommendation that health literacy be incorporated into the National Curriculum for school children is commendable; however, the educational needs of a person with diabetes who is receiving patient education, or a pregnant woman attending antenatal classes, or a carer of a person with long-term mental illness will be greatly different. School health education will not prepare us for the different individual health challenges we may face.

If we are to see “real control and choice about whether, how, where and when [people] use health services”,1 three strategies are required. First, health care providers and those responsible for patient management and administration need to demonstrate greater sensitivity to the needs of patients with poor health literacy by creating a less alienating health care environment that is more responsive to patient needs. Second, greater care needs to be taken to improve the quality of patient communication and the materials that support it. Both of these strategies require further research, and both can be achieved in part through modification of basic and continuing education. Third, outside the health care system, as well as investing in school education, Australia would do well to follow the lead of the United Kingdom in adopting innovative adult education programs such as the Skilled for Health program, which brings health content into an adult basic skills program.9

It is over 15 years since national goals and targets for health literacy were first proposed in Australia.10 Since then, our understanding of health literacy has grown considerably. If this knowledge is not applied, the policy goal of achieving meaningful control and choice by patients is unlikely to be met. Worse, increasing patient participation without specific interventions to address low health literacy could exacerbate existing health inequalities by further alienating those with poorer literacy skills and less confidence in using the health care system.