Although health literacy has been deemed as fundamental to well-being in the 21^st century and is supported by the World Health Organization (WHO) Millennium Development Project 1 plus the United States Healthy People 2020 goals 2, an array of current data show many adults in the United States (US) and elsewhere can be considered to have low to deficient ‘health literacy’ skills. As such, they may have challenges seeking information, understanding instructions, as well as acting upon these. Given the high importance today of self-management practices in securing health, a low health literate individual may arguably be severely comprised in efforts to achieve the health goals advocated by their practitioner, especially in the absence of remediation or acknowledgement of this situation. According to several studies, this situation may be an especially deleterious one to older adults, and to older adults suffering from painful disabling osteoarthritis, where self-management approaches and effective joint protection strategies are crucial to apply accurately and on a consistent basis, but where many overlapping complex health issues and physical limitations can prevail. These include, but are not limited to persistent pain, joint inflammation and swelling, muscle weakness, joint instability, limited mobility, obesity, poor balance, poor posture, sleep problems, depression and anxiety.

Low self-esteem, reduced work capacity, and high levels of comorbid health conditions are other common disease correlates amenable to intervention.

Derived from the field of education, the term ‘health literacy,’ first employed by Simonds 3, has since been used to represent literacy skills related to vocabulary, materials, and directives employed in health care settings 4. It has also been deemed a crucial 21^st century skill, especially in the context of contemporary efforts to manage one’s health. In addition to representing the ability to understand and analyze both written and verbal information, as well as to be able to act on health information, the term health literacy has also come to denote one’s ability to effectively navigate the increasingly complex health care system. Also implied in the context of health literacy is the extent to which an individual is confident to carry out desired health recommendations, choose more helpful rather than harmful beneficial behavioral actions, and to derive sound decisions when faced with oftentimes complex, but essential disaggregated pieces of health related information that must be decoded accurately. There are many definitions of health literacy however, and the diversity of these attributes should be recognized, as well as their possible relevance [See Table 1].

Individuals most affected by health literacy challenges according to the research are those with poor past educational opportunities, those with limited educational access, and those with low incomes. Older adults are found to be more intently affected by health illiteracy than those who are more affluent or younger than 60 years of age 15.

Sondik 16 showed that more than a third of people living in the US, thought to be well-developed country, had problems in using charts to complete health-care tasks, and many had problems following prescriptions or interpreting over the counter medical labels. In addition, even though the majority of people in the US with marginal or low literacy are found to be white native-born Americans, the changing demographics in the US, including an increase in immigration of many diverse racial and ethnic groups who are non-English-speaking, with different languages and culture, plus those with low incomes and those over age 65 with limited schooling is compounding this situation 17. As well, the gap between the required skills and actual skills of many Americans is compounded for persons coming from a non-English speaking household, due to insufficient numbers of appropriately trained interpreters, as well as culturally competent providers who can help assist non-English speaking families of different backgrounds with their health care needs 18.

Since health literacy is context and possibly disease-specific as well as being subject to a variety of external influences including, but not limited to, the nature of the client-provider or other forms of health communication, the nature and availability of desired resources and services, as well as the nature of related policies 19, being health literate may implicate not only knowledge, but also major psychological, social and environmental constructs that influence peoples’ health choices, such as motivation, personal skills, and policy factors 20.

In addition, the predominant focus of undergraduate medical training on the physical determinants of health and disease, rather than on the importance of health literacy attributes, as either a contributory disease factor, or an outcome mediator or moderator or both, may negatively affect healthcare outcomes. As well, medical providers may not only be relatively unfamiliar with the immense clinical ramifications of low health literacy, because this specific issue and its impact on health outcomes are seldom discussed during their training, but these facts are also very poorly documented in the mainstream literature, and especially neglected in the vast osteoarthritis-related literature.

As a result of some of the aforementioned issues, older adults seeking health advice may not be able to follow-up on their health recommendations, and discussions concerning salient health determinants that are imperative to follow such as daily exercise, adequate sleep, and nutrition, may hence go unheeded. Moreover, potentially compounding this problem may be a heightened sense of anxiety as well as fear if the patient with severe disabling osteoarthritis does not clearly understand their condition or why they must or must not undertake certain behaviours, while suffering from periodic bouts of pain, depression, fatigue, and low self-confidence, among other factors.

Health literacy is also influenced by a variety of socioeconomic, environmental, and demographic factors, health status, access to health care, having an empathetic provider, and the nature of any forthcoming educational directives and/or materials. For example, those with limited education, or mainstream language skills, as well as those with limited access to computers or computer skills may not only have difficulties negotiating the broader health care environment, but also accessing the appropriate level of healthcare, as well as problems in information seeking, plus finding materials that are written at an advanced reading level 21, and may hence underutilize available resources-even if available and of potential efficacy 22.

In addition, low health literacy may be especially problematic for adults with osteoarthritis using narcotic medications, and who may be experiencing both depressive symptoms, as well as intractable pain that makes concentrating difficult. These osteoarthritis sufferers may find available educational information especially overwhelming and challenging to decipher, even if they are literate, without some support, especially if the information is too technical, dense or complicated. This patient group may also not have a great deal of mobility or energy to follow through on complex details, nor to navigate the internet, or health care field, unless the nature of the health situation is taken into account and appropriate accommodations are forthcoming, whereby resources they need are made readily accessible and are simplified accordingly.

Farin et al. 23 who conducted a study using a total sample of 577 patients with chronic back pain or osteoarthritis who had undergone inpatient rehabilitation to assess the health education literacy of these patients found 20-30% of the patients admitted to having difficulty understanding important aspects of health education programming such as comprehending what medical information means in relation to their disease. Although the variance explained by sociodemographic and basic medical variables was small (4-8%), the authors concluded greater efforts are required to make health education programs easier to understand.

Since health outcomes today depend to a high degree on inputs and actions of the patient or client, rather than technology, surgery, or medications, alone, the failure of clinicians and service providers to consider and assess the degree to which their clients are likely to exhibit health literacy challenges, and to help them overcome this possible problem accordingly, may prevent them from rendering optimally sound health decisions. Moreover, it may prevent them from effectively negotiating the complex healthcare environment, as well understanding their rights to receiving health care, and high quality care.

Older adults who do not read well, have had a limited education, or have visual challenges or a combination of these issues, are also less likely to be able to critically examine available data, and if uncertain about any important issue may tend to refrain, rather than seek health care and receive treatment, as required. They may thus be sicker or more impaired than those who can critically examine available information, and are confident enough to seek help early on or on an annual basis.

Health literacy challenged patients may experience anxiety once they enter the medical sphere if the signs posted and information on forms is overwhelming. Even after they receive help, they may be more susceptible to medication errors, have less ability to correctly follow treatment instructions, a higher chance of hospitalization than those with adequate literacy skills, with poorer outcomes. They may similarly fail to convey the correct information or to engage in conversations with their health providers, may miss appointments for needed care, or under-utilize or misuse preventive health care resources and services 24, simply because they have limited comprehension of what is required, along with fear of having to fill out forms or answer questions regarding their health status and behaviors. They may not only find challenges in navigating the health care system, but also in understanding their rights, along with their diagnosis, treatment plans and options, and more problems discerning the effects of false medication and food advertising, as well as the marketing of unhealthy foods and sedentary behaviors.

As a result, older adults with osteoarthritis may not adhere to one or more treatment recommendations, even if these are salient. Additionally, their actual diagnoses may be inaccurate, owing to their inability to provide accurate data, and to comprehend the importance of providing clarification about their personal situations, health condition, and foreseeable management challenges. In the context of osteoarthritis, a program to limit mechanical damage that is not adhered to, or is carried out ‘incorrectly’ due to misunderstandings can clearly result in more suboptimal outcomes than not, including a greater need for surgery, and medications than the health literate client with comparable health challenges.

In particular, considerable research implies that adults with osteoarthritis who are health illiterate or marginally literate are less likely to seek preventive care, and more likely to be sedentary 2526. They are also likely to have less knowledge about the benefits of physical activity 27, in particular, even though the maintenance of optimal overall fitness is potentially the single most important outcome determinant in this group 28.

Moreover, since health literacy specifically influences one’s behavioural choices, plus one’s competencies to take action and to carry out decisions that can influence health outcomes, clearly those who are not adequately health literate are likely to suffer more than those who have higher skills, if the individual has to simultaneously change more than one behavior at a time, or their health literacy challenges are overlooked when developing their treatment plans. In addition, having less than optimal disease-specific as well as general health literacy, may especially compromise disease overall self-management processes-an umbrella term used to denote the many types of health-related behaviors and activities that people with one or more chronic diseases such as osteoarthritis are expected to carry out on a regular basis to maximize their health. These activities include exercise, diet, getting enough sleep and controlling stress, among other behaviors, and all require some degree of understanding and an ability to carry out these understandings in a safe and life affirming manner.

In short, an older adult with low health literacy who is not clear about how to use information to manage their osteoarthritis, who cannot make effective decisions as a result, and who does not have the skills required to communicate their challenges, or is ashamed to admit they need assistance to process information, and act on this, may find they progress more rapidly towards disability, require more doctors visits and hospitalizations, or carry out too few visits, than if they are able to understand how they can personally optimize their health condition. Following the definitions provided in Table 1, some of these challenges are likely to include one or more problems with:

Reading or comprehending pill/medication instructions

Obtaining information and critically evaluating this

Derive meaning from available information

Engaging in the provider-patient and other health decision making processes

Acting on health recommendations

Reading and completing health surveys, insurance forms

Overcoming barriers to recommended behaviors

Imparting correct information to the care provider

Interpreting dosage schedules.

Comprehending appointment slips, educational brochures, or informed consent documents.

Confidently filling out medical forms.

To assist health illiterate or low health literate older adults with osteoarthritis to make informed decisions, and to better understand their condition(s), and what they should do and what they should avoid doing, various educational strategies such as attending special group education classes, and having individual counseling, or a trained facilitator may prove helpful. Educators and clinicians can further try to help the individual client by utilizing careful straight forward explanations, understandable instructions, and plain, rather than technical language. A teach back method, and the fostering of any needed skills, while reducing navigational barriers to care, among other strategies, may help to overcome any significant health literacy challenge.

Examining the individual patient insofar as to whether they understand their condition, and health advice, ascertaining whether they can readily follow instructions, and whether they need assistance in this regard is very important in this respect. Moreover, because being health literate may not be predicted accurately solely by one’s literacy ability or educational attainment, no assumptions about an individual patient’s health literacy for managing their disease can be made without some direct assessment approach or standardized tool such as the SAM 29, a short practical comprehension test of health related facts. Even then, since patients may understand what needs to be done, but may have no access to the needed resources, nor the capacity, skills, and/or self-efficacy to undertake this, efforts must be made to ensure the management objectives can be achieved effectively 19. Research clearly supports the view that extending the provider conversation in this direction is certain to have more beneficial long-term influences on the disease outcomes in osteoarthritis cases than not.

Additionally, the necessity of the active participation of the patient in their treatment plan and ensuring they have the requisite skills so they can act accordingly to limit disability should be stressed. This group also commonly presents with multiple other chronic health conditions that may require concurrent attention, thus compounding the management requirements of the patient, unless the provider is prepared to assist health illiterate or marginally literate patients in a comprehensive way.

In this respect, a study by Bill-Harvey et al. 30 showed this may take the form of an extended education course for older adults, such as those with low-incomes who are also patients with osteoarthritis. In this study, indigenous community leaders were trained to teach the course within inner-city neighbourhoods of Hartford, Connecticut with positive results. That is, the researchers found significant differences were obtained using a quasi-experimental group, pre/post-test design in terms of a knowledge increase on both a verbal knowledge test and a picture story test. There was also a significant increase in the subjects’ exercise scale scores, and a slight functional improvement, and use of adaptive equipment after the program, suggesting education is very important to this population’s well-being.

Sperber et al. 31 who explored whether the effects of a telephone-based osteoarthritis self-management support intervention differed by race and health literacy, among 515 veterans with hip and/or knee osteoarthritis found African Americans in the sample with low literacy had the greatest improvement in pain. This group concluded that a similar telephone-based intervention program may be particularly beneficial for patients with osteoarthritis who are racial/ethnic minorities and have low health literacy. However, education alone, may not be sufficient in this case if environmental constraints and ongoing access to an empathetic provider prevail. Tailoring the desired educational information, and delivering it using process a step by step, including opportunities for monitoring and feedback to patients may further help to maximize the self-management ability of older adults with osteoarthritis whose health literacy levels to be suboptimal.

Other solutions that have been put in place given the series of overlapping health challenges that older adults commonly face, include the integration of several aspects of health literacy, including education of providers, and shared decision making into national health policies 28, and medical school curricula. However, the immediate needs of the health illiterate osteoarthritis patient clearly remain, so active focused interventions are needed in real time encounters. Since osteoarthritis is the leading disabler of aging adults, and its outcome is very strongly linked to personal behaviours, every effort to ensure the resources to do this, as well as the directives are clearly articulated, and that all providers can successfully establish the degree to which more effort is needed to ensure their clients’ understanding.

Although an increasing volume of data show patients and caregivers can benefit markedly from forging active partnerships that can empower the patient, ample research indicates that many cases of osteoarthritis may not have an affiliation with an empathetic and knowledgeable provider as far as health literacy goes. They may also have limited knowledge of the fact that their health condition is amenable to the benefits of self-management, among other strategies, because many erroneous myths surround the origins and progression of this disease.

As well, health illiterate individuals may not seek help readily, and even if they do, they may have immense challenges in efforts to follow recommendations that could impact their health. In addition, even if they understand what is desirable, the skills needed to help them offset their risks of excess disability may remain quite limited, unless remediation is forthcoming. Moreover, many who are immigrants and those whose home language is not English or the first language of the country in question, may follow their own health practices, or ignore salient health messages thus placing them at risk for future health problems. As well, even if they understand their risks they may not be able to use, act on or gain access to information that would be helpful to them in offsetting preventable health problems in the future, especially if the provider ignores this potential barrier to obtaining favourable health outcomes. Others may be especially challenged if they have multiple diseases, eyesight and/or hearing problems, and limited functional ability, very common findings in this elderly osteoarthritis patient group. Their ability to positively influence their joint health may be further compromised if they are confused about where to start. Confounding these issues is the fact that most patients hide their confusion from their doctors because they are too ashamed and intimidated to ask for help.

In short, many overlapping issues that can be linked to health literacy challenges can be expected to prevent a low literate patient with disabling osteoarthritis from achieving a high life quality. Among these issues is the fact that not all providers are aware of the ramifications or importance of health literacy and its clinical implications in the context of disabling osteoarthritis, nor of methods that could help them assess this issue in the clinical setting. With so many factors to deal with, and limited time frames for doing this, they may not truly consider the impact of their patient’s ability to understand or act on their instructions on their health outcomes as a major priority. Moreover, more commonly than not, they may assume their patients have the competency to make decisions and carry out their recommendations, even though this expectation is often unrealistic 32. In addition, health literacy in medical settings is often diminished in the face of illness and complex health instructions 33, but the forms and paperwork that must be completed are increasingly overwhelming at the outset. Older individuals may also have cognitive challenges that require carefully construed instructions regarding their health recommendations.

Health literacy, a discrete form of literacy, denoting the ability to understand, act on health information, as well as the ability to successfully negotiate the health environment and seek and utilize required resources, poses a challenge to many older adults, especially if they have to manage one or more complex chronic health conditions on a daily basis 2. Moreover, having low or marginal health literacy not only affects daily management of one s health, but diminishes efforts to prevent health problems from emerging or spreading 27. Low health literacy is hence currently viewed as a highly important public health issue 34 and key factor in health promotion efforts to attain a healthier society, in general, as well as a healthier outcome for all, even in the face of one or more disabilities 28.

However, in an increasingly technologically dependent environment, where many remain poorly educated, or do not communicate in the mainstream language, the literacy needed to decode health messages may be marginal at best. As well, given the nature of the medical model, and the increasing importance placed on self-management for fostering healthy outcomes, limitations in understanding, acting on, or navigating the health system are consistently predicted to yield more unfavourable health outcomes than not.

This problem is also increasing, rather than decreasing if the ability to engage with technology, as well understand the materials that are on the internet, as well as other media outlets, is included in the definition of literacy, and may be a specially challenging for a majority of the older population. In addition, even though citizens both healthy and otherwise, are expected to assume a highly active role in fostering their own well-being and in making health decisions, many confusing messages exist alongside compelling messages to use or engage in unhealthy advertised health practices. It is also apparent that individuals choosing to seek information or to respond to a provider s recommendation to do this must not only have the ability to conduct the search, but also the ability to synthesize and critically analyze the results of the information search, navigate diverse communication channels, and be able to carefully select and process information among many competing approaches. One implication for providers here is that they might try to help clients become more skilled in seeking outside information sources, plus their ability to understand and utilize the information.

On the contrary, without intervention, the dual problem of high levels of exposure to powerful media, and the weak counter-efforts of providers to foster high health literacy among their patients is likely to ensure that negative rather than positive long-term outcomes will prevail 35. In addition to matters related to the volume, quality, accuracy, credibility, and completeness of information available on the more than 70,000 health-related, often unregulated, websites 36, studies have found that the technical terms and medical language displayed required reading skills of high school level or higher 37, even among reputable government online sources 38.

Conceivably, therefore, as with literacy in general, many citizens, including older adults with osteoarthritis may not be able to take full advantage of available health resources, or related preventive or remedial messages that would be to their advantage. At the same time, current clinical efforts to address this issue in real time may be very limited and suboptimal, or non-existent in the context of osteoarthritis disability, as well as other chronic diseases, where the multiple overlapping symptoms can greatly increase the magnitude of the disease, and if the hands are severely affected, navigating the internet might not be a good option for these clients, even if they are literate.

A failure to appreciate all these overlapping factors, and to ensure efforts on behalf of patients with osteoarthritis are taken so they can clearly understand the importance of maintaining a healthy weight, exercising and getting enough sleep and why and how these factors among others affect the disease will in all likelihood prove highly disadvantageous. Moreover, even if the provider is otherwise, caring, empathetic, and knowledgeable, but does not really answer patients questions, or recognize they have limited questioning skills as well as limited skills to follow instructions, the poor self-management adherence rates reported by practitioners among this group should not be surprising. As well, research has revealed that many patient education materials for people with one of the rheumatic diseases are written at readability levels above the recommended sixth-grade reading level and have only adequate suitability according to a validated instrument.

Moreover, even if some aspects of their health issue and its treatment are clear to them, they may still have problems differentiating among competing media messages, acquiring resources and skills, and a limited ability to navigate the complex health system both psychologically and physically if they remain unrecognized and/or unassisted. They may consequently experience poor rather than favourable health outcomes, even if they have access to care and adequate health insurance. Unfortunately, many older clients and others are found to often be ill-equipped to meet these overlapping demands 39 and subsequently may tend to cope less well with their self-management regimens than their healthy or literate counterparts. These regimens are essential for managing any prevailing chronic health condition, including osteoarthritis, thus the low health literate client who receives limited care in this regard is likely to experience a rapid downward spiral of negative disabling and irreversible outcomes, unless carefully construed efforts are taken to avert this situation 40.

To this end, providers are encouraged to engage in straightforward two-way communications, using interpreters as required. They can also assist by carefully explaining medication labels and regimens, treatment contra- indications and their appointment cards 21, in the case of need. Those who are older, with poor educational backgrounds, or are non English speaking may be preferentially targeted.

Unfortunately, health literacy rates are generally poor, and are lower than literacy rates due to the added challenges of decoding and acting on health information in the real world 40, especially if one is in pain or has some form of mental health or physical health challenge, and inadequate health literacy can consequently reduce the ability of an individual to manage their health condition. They may also be unable to effectively participate in medical decision making processes 30 and have to resort to becoming passive recipients of treatment, rather than empowered actors and disease self-managers.

Hence more attention is clearly needed in this realm at the clinical level, given the fact that even in well-developed countries such as Australia, up to a quarter of the population may have suboptimal health literacy 41. Moreover, if we consider the rising rate of older people across the globe and that more than half will have health challenges, including osteoarthritis, and poor health literacy, efforts to address health literacy are clearly imperative in the clinic as well as at national and global levels.