The Bombing of Tokyo (東京大空襲Tōkyōdaikūshū) was a series of firebombingair raids by the United States Army Air Forces during the Pacific campaigns of World War II. Operation Meetinghouse, which was conducted on the night of 9–10 March 1945, is regarded as the single most destructive bombing raid in human history. 16 square miles (41 km2) of central Tokyo were destroyed, leaving an estimated 100,000 civilians dead and over 1 million homeless.
Over 50% of Tokyo's industry was spread out among residential and
commercial neighborhoods; firebombing cut the whole city's output in
half.
Doolittle Raid
The first raid on Tokyo was the Doolittle Raid of 18 April 1942, when sixteen B-25 Mitchells were launched from USS Hornet to attack targets including Yokohama and Tokyo and then fly on to airfields in China. The raid was retaliation against the Japanese attack on Pearl Harbor. The raid did little damage to Japan's war capability but was a significant propaganda victory for the United States. Launched at longer range than planned when the task force encountered a Japanese picket boat, all of the attacking aircraft either crashed or ditched short of the airfields designated for landing. One aircraft landed in the neutral Soviet Union
where the crew was interned, but then smuggled over the border into
Iran on 11 May 1943. Two crews were captured by the Japanese in occupied
China. Three crewmen from these groups were later executed.
B-29 raids
Aerial view of Tokyo following the war
The key development for the bombing of Japan was the B-29 Superfortressstrategic bomber,
which had an operational range of 3,250 nautical miles (3,740 mi;
6,020 km) and was capable of attacking at high altitude above 30,000
feet (9,100 m), where enemy defenses were very weak. Almost 90% of the
bombs dropped on the home islands of Japan were delivered by this type
of bomber. Once Allied ground forces had captured islands sufficiently
close to Japan, airfields were built on those islands (particularly Saipan and Tinian) and B-29s could reach Japan for bombing missions.
The high-altitude bombing attacks using general-purpose bombs
were observed to be ineffective by USAAF leaders due to high winds—later
discovered to be the jet stream—which carried the bombs off target.
Between May and September 1943, bombing trials were conducted on the Japanese Village set-piece target, located at the Dugway Proving Grounds. These trials demonstrated the effectiveness of incendiary bombs against wood-and-paper buildings, and resulted in Curtis LeMay ordering the bombers to change tactics to utilize these munitions against Japan.
The first such raid was against Kobe
on 4 February 1945. Tokyo was hit by incendiaries on 25 February 1945
when 174 B-29s flew a high altitude raid during daylight hours and
destroyed around 643 acres (260 ha) (2.6 km2) of the snow-covered city, using 453.7 tons of mostly incendiaries with some fragmentation bombs.
After this raid, LeMay ordered the B-29 bombers to attack again but at a
relatively low altitude of 5,000 to 9,000 ft (1,500 to 2,700 m) and at
night, because Japan's anti-aircraft artillery defenses were weakest in
this altitude range, and the fighter defenses were ineffective at night.
LeMay ordered all defensive guns but the tail gun removed from the
B-29s so that the aircraft would be lighter and use less fuel.
Operation Meetinghouse
A residential section Tokyo that was destroyed following Operation Meetinghouse, the firebombing of Tokyo on the night of 9/10 March 1945
On the night of 9–10 March 1945,
334 B-29s took off to raid with 279 of them dropping 1,665 tons of
bombs on Tokyo. The bombs were mostly the 500-pound (230 kg) E-46 cluster bomb which released 38 napalm-carrying M-69 incendiary bomblets
at an altitude of 2,000–2,500 ft (610–760 m). The M-69s punched through
thin roofing material or landed on the ground; in either case they
ignited 3–5 seconds later, throwing out a jet of flaming napalm globs. A
lesser number of M-47 incendiaries
were also dropped: the M-47 was a 100-pound (45 kg) jelled-gasoline and
white phosphorus bomb which ignited upon impact. In the first two hours
of the raid, 226 of the attacking aircraft unloaded their bombs to
overwhelm the city's fire defenses.
The first B-29s to arrive dropped bombs in a large X pattern centered
in Tokyo's densely populated working class district near the docks in
both Koto and Chūōcity wards
on the water; later aircraft simply aimed near this flaming X. The
individual fires caused by the bombs joined to create a general conflagration, which would have been classified as a firestorm but for prevailing winds gusting at 17 to 28 mph (27 to 45 km/h). Approximately 15.8 square miles (4,090 ha) of the city were destroyed and some 100,000 people are estimated to have died.
A grand total of 282 of the 339 B-29s launched for "Meetinghouse" made
it to the target, 27 of which were lost due to being shot down by
Japanese air defenses, mechanical failure, or being caught in updrafts
caused by the fires.
Results
A bird's-eye view of Tokyo before and after the air raids
Damage to Tokyo's heavy industry was slight until firebombing
destroyed much of the light industry that was used as an integral source
for small machine parts and time-intensive processes. Firebombing also
killed or made homeless many workers who had taken part in the war
industry. Over 50% of Tokyo's industry was spread out among residential
and commercial neighborhoods; firebombing cut the whole city's output in
half. The destruction and damage was especially severe in the eastern areas of the city.
Emperor Hirohito's
tour of the destroyed areas of Tokyo in March 1945 was the beginning of
his personal involvement in the peace process, culminating in Japan's surrender six months later.
Casualty estimates
Charred remains of Japanese civilians after Operation Meetinghouse
The US Strategic Bombing Survey
later estimated that nearly 88,000 people died in this one raid, 41,000
were injured, and over a million residents lost their homes. The Tokyo
Fire Department estimated a higher toll: 97,000 killed and 125,000
wounded. The Tokyo Metropolitan Police Department established a figure of 83,793 dead and 40,918 wounded and 286,358 buildings and homes destroyed. Historian Richard Rhodes put deaths at over 100,000, injuries at a million and homeless residents at a million. These casualty and damage figures could be low; Mark Selden wrote in Japan Focus:
The charred body of a woman who was carrying a child on her back
The figure of roughly 100,000
deaths, provided by Japanese and American authorities, both of whom may
have had reasons of their own for minimizing the death toll, seems to be
arguably low in light of population density, wind conditions, and
survivors' accounts. With an average of 103,000 inhabitants per square
mile (396 people per hectare) and peak levels as high as 135,000 per
square mile (521 people per hectare), the highest density of any
industrial city in the world, and with firefighting measures ludicrously
inadequate to the task, 15.8 square miles (41 km2) of Tokyo
were destroyed on a night when fierce winds whipped the flames and walls
of fire blocked tens of thousands fleeing for their lives. An estimated
1.5 million people lived in the burned out areas.
In his 1968 book, reprinted in 1990, historian Gabriel Kolko cited a figure of 125,000 deaths. Elise K. Tipton, professor of Japan studies, arrived at a rough range of 75,000 to 200,000 deaths. Donald L. Miller, citing Knox Burger, stated that there were "at least 100,000" Japanese deaths and "about one million" injured.
The Operation Meetinghouse firebombing of Tokyo on the night of 9 March 1945 was the single deadliest air raid of World War II, greater than Dresden, Hamburg, Hiroshima, or Nagasaki as single events.
Postwar recovery
1947 U.S. military survey showing bomb-damaged areas of Tokyo
After the war, Tokyo struggled to rebuild. In 1945 and 1946, the city
received a share of the national reconstruction budget roughly
proportional to its amount of bombing damage (26.6%), but in successive
years Tokyo saw its share dwindle. By 1949, Tokyo was given only 10.9%
of the budget; at the same time there was runaway inflation devaluing
the money. Occupation authorities such as Joseph Dodge
stepped in and drastically cut back on Japanese government rebuilding
programs, focusing instead on simply improving roads and transportation.
Tokyo did not experience fast economic growth until the 1950s.
Between 1948 and 1951 the ashes of 105,400 people killed in the attacks on Tokyo were interred in Yokoamicho Park in Sumida Ward. A memorial to the raids was opened in the park in March 2001.
After the war, Japanese author Katsumoto Saotome, a survivor of 10 March 1945 firebombing, helped start a library about the raid in Koto Ward called the Center of the Tokyo Raids and War Damage.
The library contains documents and literature about the raid plus
survivor accounts collected by Saotome and the Association to Record the
Tokyo Air Raid.
Postwar Japanese politics
In 2007, Japanese Prime Minister Shinzō Abe apologized in print, acknowledging Japan's guilt in the bombing of Chinese cities
and civilians beginning in 1938. He wrote that the Japanese government
should have surrendered as soon as losing the war was inevitable, an
action that would have prevented Tokyo from being firebombed in March
1945, as well as subsequent bombings of other cities. In 2013, during his second term as prime minister, Abe's cabinet stated that the raids were "incompatible with humanitarianism,
which is one of the foundations of international law", but also noted
that it is difficult to argue that the raids were illegal under the
international laws of the time.
In 2007, 112 members of the Association for the Bereaved Families
of the Victims of the Tokyo Air Raids brought a class action against
the Japanese government, demanding an apology and 1.232 billion yen in
compensation. Their suit charged that the Japanese government invited
the raid by failing to end the war earlier, and then failed to help the
civilian victims of the raids while providing considerable support to
former military personnel and their families. The plaintiffs' case was dismissed at the first judgement in December 2009, and their appeal was rejected. The plaintiffs then appealed to the Supreme Court, which rejected their case in May 2013.
Partial list of missions
B-29
24 November 1944: 111 B-29s hit an aircraft factory on the rim of the city.
29–30 November 1944: two incendiary raids on industrial areas, burning 2,773 structures.
19 February 1945: 119 B-29s hit port and urban area.
24 February 1945: 229 B-29s plus over 1600 carrier-based planes.
25 February 1945: 174 B-29s dropping incendiaries destroy 28,000 buildings.
4 March 1945: 159 B-29s hit urban area.
10 March 1945: 334 B-29s dropping incendiaries destroy 267,000 buildings; 25% of city (Operation Meetinghouse) killing some 100,000.
2 April 1945: 100 B-29s bomb the Nakajima aircraft factory.
3 April 1945: 68 B-29s bomb the Koizumi aircraft factory and urban areas in Tokyo.
7 April 1945: 101 B-29s bomb the Nakajima aircraft factory again
13 April 1945: 327 B-29s bomb the arsenal area.
20 July 1945: 1 B-29 drops a Pumpkin bomb (bomb with same ballistics as the Fat Man nuclear bomb) through overcast. It aimed at, but missed, the Imperial Palace.
8 August 1945: 60 B-29s bomb the aircraft factory and arsenal.
10 August 1945: 70 B-29s bomb the arsenal complex.
Other
16–17 February 1945: carrier-based aircraft, including dive bombers, escorted by Hellcat
fighters attacked Tokyo. Over two days, over 1,500 American planes and
hundreds of Japanese planes were in the air. "By the end of 17 February,
more than five hundred Japanese planes, both on the ground and in the
air, had been lost, and Japan's aircraft works had been badly hit. The
Americans lost eighty planes."
18 August 1945: The last U.S. air combat casualty of World War II occurred during mission 230 A-8, when two Consolidated B-32 Dominators of the 386th Bomb Squadron, 312th Bomb Group, launched from Yontan Airfield, Okinawa, for a photo reconnaissance run over Tokyo, Japan. Both bombers were attacked by several Japanese fighters of both the 302nd Naval Air Group at Atsugi and the Yokosuka Air Group that made 10 gunnery passes. Japanese IJNASacesSadamu Komachi and Saburō Sakai
were part of this attack. The B-32 piloted by 1st Lt. John R. Anderson,
was hit at 20,000 feet; cannon fire knocked out the number two (port
inner) engine, and three crew were injured, including Sgt. Anthony J.
Marchione, 19, of the 20th Reconnaissance Squadron,
who took a 20 mm hit to the chest and died 30 minutes later. Tail
gunner Sgt. John Houston destroyed one attacker. The lead bomber, Consolidated B-32-20-CF Dominator, 42-108532, "Hobo Queen II", piloted by 1st Lt. James Klein, was not seriously damaged but the second Consolidated B-32-35-CF Dominator, 42-108578,
lost an engine, had the upper turret knocked out of action, and
partially lost rudder control. Both bombers landed at Yontan Airfield
just past ~1800 hrs. having survived the last air combat of the Pacific
war. The following day, propellers were removed from Japanese aircraft
as part of the surrender agreement. Marchione was buried on Okinawa on
19 August, his body being returned to his Pottstown, Pennsylvania home on 18 March 1949. He was interred in St. Aloysius Old Cemetery with full military honors. "Hobo Queen II" was dismantled at Yonton Airfield following a 9 September nosegear collapse and damage during lifting. B-32, 42-108578, was scrapped at Kingman, Arizona after the war.
Mental health literacy has been defined as "knowledge and beliefs about mental disorders
which aid their recognition, management or prevention. Mental health
literacy includes the ability to recognize specific disorders; knowing
how to seek mental health information; knowledge of risk factors and
causes, of self-treatments, and of professional help available; and
attitudes that promote recognition and appropriate help-seeking". The concept of mental health literacy was derived from health literacy, which aims to increase patient knowledge about physical health, illnesses, and treatments.
Framework
Mental
health literacy has three major components: recognition, knowledge, and
attitudes. A conceptual framework of mental health literacy illustrates
the connections between components, and each is conceptualized as an
area to target for measurement or intervention.
While some researchers have focused on a single component, others have
focused on multiple and/or the connection between components. For
example, a researcher may focus solely on improving recognition of
disorders through an education program, whereas another researcher may
focus on integrating all three components into one program.
Recognition
Recognition
can be broken down into symptom or illness recognition. Symptom
recognition is the ability to detect beliefs, behaviors, and other
physical manifestations of mental illness, without knowing explicitly
which disorder they link to. Specific illness recognition is the ability
to identify the presentation of a disorder, such as major depressive disorder.
The recognition of difference between knowledge and attitudes is a
crucial part of the mental health literacy framework. While some
efforts have focused on promoting knowledge, other researchers have
argued that changing attitudes by reducing stigma is a more prolific way
of creating meaningful change in mental healthcare utilization.
Overall, both approaches have benefits for improving outcomes.
Knowledge
Knowledge is the largest component of mental health literacy, and is divided into four sub-components:
Where/how to get information: the networks and systems
individuals use to get information about mental disorders. This may
include friends, family, educators, or broader sources, such as
entertainment or social media.
Risk factors: what factors put individuals at greatest risk for
specific mental health disorders. Risk factors can be biological,
environmental,
Self-treatment or self-help:
what individuals can do to help themselves recover without consulting
with professionals, including the use of self-help books and media.
Although many self- treatments are quite ineffective and even harmful
due to lack of knowledge.
Professional help: where to get professional help and/or what professional help is available.
Attitudes
Attitudes
are studied in two sub-components: attitudes about mental disorders, or
persons with mental disorders, and attitudes about seeking professional
help or treatment. Attitudes can vary greatly by individual, and can
often be difficult to measure or target with intervention. Nonetheless, a
large body of research literature exists on both sub-components, though
not always explicitly tied to the mental health literacy.
Recent research recognizes the varying attitudes across mental
health professionals towards prognosis, long-term outcomes and
likelihood of discrimination as more negative than those of the public.
The attitudes of mental health professionals also differ towards
interventions, but this variability is usually related to professional
orientation.
Public outlook
Surveys of the public have been carried out in a number of countries to investigate mental health literacy.
These surveys demonstrate that the recognition of mental disorders is
lacking and reveal negative beliefs about some standard psychiatric
treatments, particularly medications. On the other hand, psychological,
complementary and self-help methods are viewed much more positively. The
public tends to prefer self-help and lifestyle interventions, opposed
to medical, and psychopharmacological interventions.
Implications surrounding public attitudes towards mental
disorders include negative stereotypes, prejudice, or stigma. As a
result, this can influence help-seeking behaviour or failure to seek
treatment.
Media influence plays a huge role in perpetuating negative mindsets
towards mental illness, such as prescribing menacing qualities. A recent
study highlights how the majority of participants note the media as the
primary source of their beliefs about mental illness being associated
with violence, and how this attitude is more prevalent towards serious
mental illnesses.
Fear and perceptions of danger related to mental illness have increased
over the past few decades, largely due to serious mental illness such
as schizophrenia being associated as potentially violent and harmful to
others. These beliefs and attitudes are potential barriers to seeking individual professional help and being supportive of others.
Measures
Researchers have measured aspects of mental health literacy in several ways.
Popular methodologies include vignette studies and achievement tests.
Vignette studies measure mental health literacy by providing a brief,
detailed story of an individual (or individuals) with a mental health
problem, and asks participants questions to identify what problem the
individual is experiencing, and at times, additional questions about how
the individual can help themselves.
Achievement tests measure mental health literacy on a continuum,
such that higher scores on a test indicate greater overall knowledge or
understanding of a concept. Achievement tests can be formatted using
multiple-choice, true/false, or other quantitative scales.
Various scales have been created to measure the various components of mental health literacy, though not all are validated.
Mental health literacy has been measured across several populations,
varying in age range, culture, and profession. Most studies have focused
on adult and young adult populations, though improving literacy in
children has been a focus of prevention efforts.
Limitations
Low
literacy within a population is a relevant concern, since at the most
basic level, mental health literacy is linked to general literacy.
Without this foundation, the beneficial effects of mental health
literacy are challenging for those who
face difficulties with reading and writing.
Increased measures to increase literacy rates must be employed to
empower and encourage the self-help components of mental health
literacy.
Populations can be diverse which means barriers, such as cultural
and social contexts, must be addressed. Within and across cultures,
social, economic and political factors profoundly influence mental
health. There are numerous socioeconomic and environmental determinants
of mental health and mental illness, just as there are for physical
health and physical illness. Social determinants of physical health including poverty, education and social support also serve as influencers. In order to encompass mental health literacy and diverse perspectives, further research in these areas are needed.
Recognizing less common mental disorders is another hurdle that
can disrupt mental health literacy within the public. Recent research
shows that most studies are limited to identifying depression,
generalised anxiety, and schizophrenia. In a recent Canadian study, most
participants demonstrated good mental health literacy in regard to most
mental health disorders, but a poor understanding of panic disorder. An increased awareness surrounding underrepresented or more uncommon mental disorders is needed to widen public knowledge.
A concluding limitation is the lack of research on child mental
health literacy, as the majority of studies focus on adults and
adolescents. If caregivers are not educated on recognizing and
supporting mental disorders, this could create confusion and result in
delayed treatment or wrongful prognosis for dependents. A child mental
health literacy (CMHL) initiative could be implemented to target all
adults in the general population, as well as parents, teachers, health
professionals and/or children themselves.
Improvement approaches
A
number of approaches have been tried and suggested to improve mental
health literacy, many of which have evidence of effectiveness. These
include:
Whole of community campaigns. Examples are beyondblue and the Compass Strategy in Australia, the Defeat Depression Campaign in the United Kingdom, and the Nuremberg Alliance Against Depression in Germany.
School-based interventions. These include MindMatters and Mental Illness Education in Australia, and the Mental Health & High School Curriculum Guide in Canada
Individual training programs. These include mental health first aid training and training in suicide prevention skills. Initiatives that encourage empowerment and choice would also be beneficial, such as web-based self-directed therapy.
Websites and books aimed at the public. There is evidence that both websites and books can improve mental health literacy. However, the quality of information on websites can sometimes be low.
Rapport between mental health professionals and clients. By
creating a partnership, professionals can promote competence, informed
choice, and comprehensible knowledge for all levels of understanding,
such as translating research findings into simpler language.
The ability to read and understand medication instructions is a form of health literacy.
Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. There are multiple definitions of health literacy,
in part, because health literacy involves both the context (or setting)
in which health literacy demands are made (e.g., health care, media,
internet or fitness facility) and the skills that people bring to that
situation.
Since health literacy is a primary contributing factor to health disparities,
it is a continued and increasing concern for health professionals. The
2003 National Assessment of Adult Literacy (NAAL) conducted by the US
Department of Education found that 36% of participants scored as either
"basic" or "below basic" in terms of their health literacy and concluded
that approximately 80 million Americans have limited health literacy. These individuals have difficulty with common health tasks including reading the label of a prescribed drug.
Several factors may influence health literacy. However, the following
factors have been shown to strongly increase this risk: age (especially
patients 65 years and older), limited English language
proficiency or English as a second language, less education, and lower
socioeconomic status. Patients with low health literacy understand less
about their medical conditions and treatments and overall report worse
health status.
Various interventions, such as simplifying information and illustrations, avoiding jargon, using "teach-back"
methods, and encouraging patients' questions, have improved health
behaviors in persons with low health literacy. The proportion of adults
aged 18 and over in the U.S., in the year 2010, who reported that their
health care providers always explained things so they could understand
them was about 60.6%. This number increased 1% from 2007 to 2010. The Healthy People 2020 initiative of the United States Department of Health and Human Services has included health literacy as a pressing new topic, with objectives for improving it in the decade to come.
Society as a whole is responsible for improving health literacy.
Most importantly, improving health literacy is the responsibility of
healthcare and public health professionals and systems.
Characteristics
Plain language
In
order to have a patient that understands health terms and can make
proper health decisions, the language used by health professionals has
to be at a level that others who are not in the medical field can
understand. Health professionals must know their audience in order to
better serve their patients. The language used by these professionals
should be plain language.
Plain language is a strategy for making written and oral information
easier to understand; it is communication that users can understand the
first time they read or hear it.
Some key elements of plain language include:
Organizing information so most important points come first
Breaking complex information into understandable chunks
Using simple language and defining technical terms
Using active voice
Using lists and tables to make complex material easier to understand
The National Institute of Health (NIH) recommends that patient
education materials should be not written higher than a 6th-7th grade
reading level; further recommendations provided by the NIH Office of
Communications and Public Liaison are published in their "Clear Communication" Initiative.
Factors
Many factors determine the health literacy level of health education materials or interventions: readability of the text, the patient's current state of health, language barriers
of the patient, cultural appropriateness of the materials, format and
style, sentence structure, use of illustrations, and numerous other
factors.
A study of 2,600 patients conducted in 1995 by two US hospitals
found that between 26% and 60% of patients could not understand
medication directions, a standard informed consent form, or materials about scheduling an appointment.
The 2003 National Assessment of Adult Literacy (NAAL) conducted by the
US Department of Education found that 36% of participants scored as
either "basic" or "below basic" in terms of their health literacy and
concluded that approximately 80 million Americans have limited health
literacy.
History
The young and multidisciplinary field of health literacy emerged from two groups of experts: physicians, health providers such as nurses, and health educators; and Adult Basic Education (ABE) and English as a second language (ESL) practitioners in the field of education. Physicians and nurses
are a source of patient comprehension and compliance studies. Adult
Basic Education / English for Speakers of Languages Other Than English
(ABE/ESOL) specialists study and design interventions to help people
develop reading, writing, and conversation skills and increasingly
infuse curricula with health information to promote better health
literacy. A range of approaches to adult education brings health
literacy skills to people in traditional classroom settings, as well as
where they work and live.
Biomedical approach
The biomedical approach
to health literacy that became dominant (in the U.S.) during the 1980s
and 1990s often depicted individuals as lacking health literacy or
"suffering" from low health literacy. This approach assumed that
recipients are passive in their possession and reception of health
literacy and believed that models of literacy and health literacy are
politically neutral and universally applicable. This approach is found
lacking when placed in the context of broader ecological, critical, and
cultural approaches to health. This approach has produced, and continues
to reproduce, numerous correlational studies.
Level of health literacy is considered adequate when the
population has sufficient knowledge, skills, and confidence to guide
their own health, and people are able to stay healthy, recover from
illness, and/or live with disability or disease.
McMurray states that health literacy is important in a community
because it addresses health inequities. It is no coincidence that
individuals with lower levels of health literacy live,
disproportionally, in communities with lower socio-economic standing. A
barrier to achieving adequate health literacy for these individuals is a
lack of awareness, or understanding of, information and resources
relevant to improving their health. This knowledge gap arises from both
patients being unable to understand information presented to them and
hospitals' inadequate efforts and materials to address these literacy
gaps.
A more robust view of health literacy includes the ability to understand scientific concepts,
content, and health research; skills in spoken, written, and online
communication; critical interpretation of mass media messages;
navigating complex systems of health care and governance; knowledge and
use of community capital and resources; and using cultural and
indigenous knowledge in health decision making.
This integrative view sees health literacy as a social determinant of
health that offers a powerful opportunity to reduce inequities in
health.
This perspective defines health literacy as the wide range of
skills, and competencies that people develop over their lifetimes to
seek out, comprehend, evaluate, and use health information and concepts
to make informed choices, reduce health risks, and increase quality of
life. While various definitions vary in wording, they all fall within this conceptual framework.
Defining health literacy in that manner builds the foundation for
a multi-dimensional model of health literacy built around four central
domains:
fundamental literacy,
scientific literacy,
civic literacy, and
cultural literacy.
There are several tests, which have verified reliability in the
academic literature that can be administered in order to test one's
health literacy. Some of these tests include the Medical Term
Recognition Test (METER), which was developed in the United States (2
minute administration time) for the clinical setting. The METER includes many words from the Rapid Estimate of Adult Literacy in Medicine (REALM) test.
The Short Assessment of Health Literacy in Spanish and English
populations (SAHL-S&E) uses word recognition and multiple choice
questions to test a person's comprehension.
The CHC-Test measures Critical Health Competencies and consists of 72
items designed to test a person's understanding of medical concepts,
literature searching, basic statistics, and design of experiments and
samples.
Patient safety and outcomes
According to an Institute of Medicine (2004) report, low health literacy negatively affects the treatment outcome and safety of care delivery.
The lack of health literacy affects all segments of the population.
However, it is disproportionate in certain demographic groups, such as
the elderly, ethnic minorities, recent immigrants, individuals facing homelessness, and persons with low general literacy.
These populations have a higher risk of hospitalization, longer
hospital stays, are less likely to comply with treatment, are more
likely to make errors with medication, and are more ill when they initially seek medical care.
The mismatch between a clinician's communication
of content and a patient's ability to understand that content can lead
to medication errors and adverse medical outcomes. Health literacy
skills are not only a problem in the general population. Health care
professionals (doctors, nurses, public health workers) can also have
poor health literacy skills, such as a reduced ability to clearly
explain health issues to patients and the public.
In addition to tailoring the content of what health professionals
communicate to their patients, a well arranged layout, pertinent
illustrations, and intuitive format of written materials can improve the
usability of health care literature. This in turn can help in effective
communication between healthcare providers and their patients.
Outcomes of low levels of health literacy also include relative
expenditures on health services. Because individuals with low health
literacy are more likely to have adverse health statuses, their use of
health services is also increased. This trend is compounded by other risk factors of low health literacy, including poverty.
Homelessness and housing insecurity can hinder good health and recovery
in attempts to better health circumstances, causing the exacerbation of
poor health conditions. In these cases, a variety of health services may be used repeatedly as health issues are prolonged. Thus overall expenditures on health services is greater among populations with low health literacy and poor health.
These costs may be left to individuals and families to pay which may
further burden health conditions, or the costs may be left to a variety
of institutions which in turn has broader implications for government
funding and health care systems.
A review of studies that focused on health literacy and its
associated costs concluded that low levels of health literacy is
responsible for 3-5% of healthcare cost—approximately $143 to 7,798 per
individual within the healthcare system.
For example, studies have shown that the increased prevalence of poor
health and low health literacy has resulted in a greater use of
emergency services by homeless individuals.
A study conducted in San Francisco showed that “72% of the total cost
of emergency services may be attributed to the top 13% of homeless
users”. In this way, low health literacy produces financial outcomes as well as those of health.
Risk identification
Identifying
a patient as having low health literacy is essential for a healthcare
professional to conform their health intervention in a way that the
patient will understand. When patients with low health literacy receive
care that is tailored to their more limited medical knowledge base,
results have shown that health behaviors drastically improve. This has
been seen with: correct medication use and dosage, utilizing health
screenings, as well as increased exercise and smoking cessation.
Effective visual aids have shown to help supplement the information
communicated by the doctor in the office. In particular, easily readable
brochures and videos have shown to be very effective.
Healthcare professionals can use many methods to attain patients'
health literacy. A multitude of tests used during research studies and
three minute assessments commonly used in doctors offices are examples
of the variety of tests healthcare professionals can use to better
understand their patients' health literacy.
The American Medical Association showed that asking simple single
item questions, such as "How confident are you in filling out medical
forms by yourself?", is a very effective and direct way to understand
from a patient's point of view how they feel about interacting with
their healthcare provider and understanding their health condition.
Homelessness
Individuals facing homelessness constitute a population that holds intersectional identities, is highly mobile, and is often out of the public eye.
Thus the difficulty of conducting research on this group has resulted
in little information regarding homelessness as a condition that has
increased risk of low health literacy levels among individuals.
Nonetheless, studies that do exist indicate that homeless individuals
experience increased prevalence of low health literacy and poor
health—both physical and mental—due to vulnerabilities brought on by the
insecurity of basic needs among homeless individuals.
The combination of poor health and homelessness has been found to
increase the risk for further decline in health status and increased
housing insecurity, all of which is highly affected—and in many cases
perpetuated—by low levels of health literacy.
Intervention
In
order to be understood by patients with insufficient health literacy,
health professionals must intervene to provide clear and concise
information that can be more easily understood. Avoidance of medical
jargon, illustrations of important concepts, and confirming information
by a "teach back" method have shown to be effective tools to
communicating essential health topics with health illiterate patients. A program called "Ask Me 3"
is designed to bring public and physician attention to this issue, by
letting patients know that they should ask three questions each time
they talk to a doctor, nurse, or pharmacist:
What is my main problem?
What do I need to do?
Why is it important for me to do this?
There have also been large-scale efforts to improve health literacy.
For example, a public information program by the US Department of Health
and Human Services encourages patients to improve healthcare quality
and avoid errors by asking questions about health conditions and
treatment.
Additionally, the IROHLA (Intervention Research on Health Literacy of
the Ageing population) project, funded by the European Union (EU),
seeks to develop evidence-based guidelines for policy and practice to
improve health literacy of the ageing population in EU member states.
The project has developed a framework and identified and validated
interventions which together constitute a comprehensive approach of
addressing health literacy needs of the elderly.
Health illiterate-related diabetes prevalence in Vietnamese-American populations
Diabetes
is a rapidly growing health problem among immigrants—affecting
approximately 10 percent of Asian-Americans. It is the fifth-leading
cause of death in Asian-Americans between the ages of 45 and 64. In
addition, type 2 diabetes is the most common form of the disease. Those
who are diagnosed with type 2 diabetes have high levels of blood
glucose because the body does not effectively respond to insulin. It is
a lifelong disease with no known cure. Diabetes is a chronic,
debilitating, and costly social burden—costing healthcare systems about
$100 billion annually.
Diabetes disproportionately affects underserved and ethnically
diverse populations, such as Vietnamese-American communities. The
relationship between the disease and health literacy level is in part
because of an individual's ability to read English, evaluate blood
glucose levels, and communicate with medical professionals. Other
studies also suggest lack in knowledge of diabetes symptoms and
complications.
According to an observational cross-sectional study conducted, many
Vietnamese-American diabetic patients show signs of poor blood glucose
control and adherence due to inadequate self-management knowledge and
experience.
Diabetes health literacy research is needed to fully understand the
burden of the chronic disease in Vietnamese-American communities, with
respect to language and culture, health literacy, and immigrant status.
Ethnic minority groups and immigrant communities have less knowledge of
health promoting behavior, face considerable obstacles to health
services, and experience poor communication with medical professionals.
According to a recent review, studies have supported an independent
relationship between literacy and knowledge of diabetes management and
glucose control, but its impact on patients has not been sufficiently
described.
With the demand of chronic disease self-management (e.g., diabetic
diet, glucose monitoring, etc.), a call for cultural-specific patient
education is needed to achieve the control of diabetes and its adverse
health outcomes in low- to middle-income Vietnamese-American immigrant
communities.
Oral health literacy in school teachers of Mangalore, India
The
problem of low oral health literacy (OHL) is often neglected which may
lead to poor oral health outcomes and under utilization of oral care
services. A cross-sectional survey of school teachers working in
schools at Mangalore, India was undertaken. Details regarding
demographics, medical, and dental history, oral hygiene practices and
habits, diet history, and decay promoting the potential of school
teachers were obtained using face-to-face interview method. The Rapid
Estimate of Adult Literacy in Dentistry-99 (REALD-99) was used to assess
their OHL.The OHL was high in the school teachers with the REALD-99
scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94. Th This
study found that there was a statistically significant difference
between OHL and education, frequency of brushing and the filled teeth.
Although this study indicated high OHL levels among school teachers in
Mangalore, India the magnitude of dental caries in this population was
also relatively high and very few had a healthy periodontium.
eHealth literacy
eHealth
literacy describes the relatively modern concept of an individual's
ability to search for, successfully access, comprehend, and appraise
desired health information from electronic sources and to then use such
information to attempt to address a particular health problem.
Due to the increasing influence of the internet for
information-seeking and health information distribution purposes,
eHealth literacy has become an important topic of research in recent
years.
Stellefson (2011) states, "8 out of 10 Internet users report that they
have at least once looked online for health information, making it the
third most popular Web activity next to checking email and using search
engines in terms of activities that almost everybody has done."
Though in recent years, individuals may have gained access to a
multitude of health information via the Internet, access alone does not
ensure that proper search skills and techniques are being used to find
the most relevant online and electronic resources. As the line between a
reputable medical source and an amateur opinion can often be blurred,
the ability to differentiate between the two is important.
Health literacy requires a combination of several different
literacy skills in order to facilitate eHealth promotion and care. Six
core skills are delineated by an eHealth literacy model referred to as
the Lily model. The Lily Model's six literacies are organized into two
central types: analytic and context-specific. Analytic type literacies
are those skills that can be applied to a broad range of sources,
regardless of topic or content (i.e., skills that can also be applied to
shopping or researching a term paper in addition to health) whereas
context-specific skills are those that are contextualized within a
specific problem domain (can solely be applied to health). The six
literacies are listed below, the first three of the analytic type and
the latter three of the context-specific:
Traditional literacy
Media literacy
Information literacy
Computer literacy
Scientific literacy
Health literacy
According to Norman (2006), both analytical and context-specific
literacy skills are "required to fully engage with electronic health
resources." As the World Wide Web and technological innovations are
more and more becoming a part of the healthcare environment, it is
important for information technology to be properly utilized to promote
health and deliver health care effectively. Furthermore, it was argued
by Hayat Brainin & Neter (2017), that digital media fosters the
creation of interpersonal ties, that can supplement eHealth literacy.
According to Hayat Brainin & Neter (2017), individuals with low
eHealth literacy who were able to recruit help when performing online
activities demonstrated higher health outcomes compared to similar
individuals who did not find help. Also relating to the proliferation of
digital media is the fact that many individuals now can create their
own ‘media content’ (user-generated content).
This means that the boundary between “information” and “media” content,
as proposed by Norman in 2006, now is increasingly blurred, creating
additional challenges for health practitioners (Holmberg, 2016).
It has also been suggested that the move towards patient-centered care and the greater use of technology for self-care and self-management requires higher health literacy on the part of the patient. This has been noted in several research studies, for example among adolescent patients with obesity.
Improvement
Incorporate information through the university level
The United States Department of Health and Human Services created a National Action Plan to Improve Health Literacy.
One of the goals of the National Action Plan is to incorporate health
and science information in childcare and education through the
university level. The target is to educate people at an early stage;
that way individuals are raised with health literacy and will have a
better quality of life. The earlier an individual is exposed to health
literacy skills the better for the person and the community.
Programs such as Head Start and Women, Infants, and Children (WIC)
have impacted our society, especially the low income population. Head
Start provides low-income children and their families early childhood
education, nutrition, and health screenings. Health literacy is
integrated in the program for both children and parents through the
education given to the individuals. WIC serves low-income pregnant women
and new mothers by supplying them with food, health care referrals, and
nutrition education. Programs like these help improve the health
literacy of both the parent and the child, creating a more knowledgeable
community with health education.
Although programs like Head Start and WIC have been working with
the health literacy of a specific population, much more can be done with
the education of children and young adults. Now, more and more
adolescents are getting involved with their health care. It is crucial
to educate these individuals in order for them to make informed
decisions.
Many schools in the country incorporate a health class in their
curriculum. These classes provided an excellent opportunity to
facilitate and develop health literacy in today's children and
adolescents. The skills of how to read food labels, the meaning of
common medical terms, the structure of the human body, and education on
the most prevalent diseases in the United States should be taught in
both private and public schools. This way new generations will grow with
health literacy and would hopefully make knowledgeable health
decisions.
Framework and potential intervention points
The National Library of Medicine defines health literacy as:
The degree to which individuals have the capacity to obtain, process, and understand basic health literacy
information and services needed to make appropriate health decisions.
Based on this clinical definition, health literacy gives
individuals the skills that they need to both understand and effectively
communicate information and concerns. Bridging that gap between literacy skills
and the ability of the individual in health contexts, the Health Literacy Framework highlights the health outcomes and costs
associated with health contexts including cognitive abilities, social skills,
emotional state, and physical conditions such as visual and auditory contributions.
Potential Intervention Points are illustrated in reflection of the Health Literacy Framework.
While these potential intervention points include interactions such as those of individuals and the education systems
that they are engaged with, their health systems, and societal factors as they
relate to health literacy, these points are not
components of a causal model. The three
potential intervention points are culture and society, the health system, and
the education system. Health outcomes and costs are the products of the health
literacy developed during diversity of exposure to these three potential intervention
points.
Referring to shared ideas, meanings, and values that
influence an individual's beliefs and attitudes, cultural and societal
influences are a significant intervention point for health literacy
development. As interactions with healthcare systems often first occur at the
family level, deeply rooted beliefs and values can shape the significance of
the experience. Included components that reflect the development of health
literacy both culturally and societally are native language, socioeconomic status,
gender, race, and ethnicity, as well as mass media exposure. These
are pathways to understanding American life paralleling conquests for a health
literate America.
The health system is an intervention point in the Health Literacy Framework. For the
purposes of this framework, health literacy refers to an individual's
interaction with people performing health-related activities in settings such
as hospitals, clinics, physician's offices, home health care, public health agencies,
and insurers.
In the United States, the education system consists of K-12 curricula. In addition to this standard educational
setting, adult education programs are also environments in which individuals
can develop traditional literacy skills founded in comprehension and real-world
application of knowledge via reading and writing. Tools for educational development provided by
these systems impact an individual's capacity to obtain specific knowledge
regarding health. Reflecting components of traditional literacy such as
cultural and conceptual knowledge, oral literacy (listening and speaking,)
print literacy (reading and writing,) and numeracy, education systems are also
potential intervention points for health literacy development.
Development of a health literacy program
A
successful health literacy program will have many goals that all work
together to improve health literacy. Many people assume these goals
should communicate health information to the general public, however in
order to be successful the goals should not only communicate with people
but also take into account social and environmental factors that
influence lifestyle choices.
A good example of this is the movement to end smoking. When a health
literacy program is put into place where only the negative side effects
of smoking are told to the general public it is doomed to fail. However,
when there is a larger program put in – one that includes strategies
outlining how to quit smoking, raises tobacco prices, reduces access to
tobacco by minors, and reflect social a social unacceptability of
smoking – it will be much more effective.
The U.S. Department of Health and Human Services suggests a
National Action Plan to implement a comprehensive Health Literacy
Program. They include 7 goals:
Develop and disseminate health and safety information that is accurate, accessible, and actionable
Promote changes in the health care system that improve health
information, communication, informed decision making, and access to
health services
Incorporate accurate, standards-based, and developmentally
appropriate health and science information and curricula in child care
and education through the university level
Support and expand local efforts to provide adult education, English
language instruction, and culturally and linguistically appropriate
health information services in the community
Build partnerships, develop guidance, and change policies
Increase basic research and the development, implementation, and
evaluation of practices and interventions to improve health literacy
Increase the dissemination and use of evidence-based health literacy practices and interventions
These goals should be taken into account when implementing a health literacy program.
There are also goals for the outcomes of a Health Literacy Program.
Health Related Goals
Promoting and protect health and prevent disease
Understand, interpret, and analyze health information
Apply health information over a variety of life events and situations
Navigate the healthcare system
Actively participate in encounters with healthcare professionals and workers
Understand and give consent
Understand and advocate for rights
In the creation of a program aimed to improve health literacy, it is
also important to ensure that all parties involved in health contexts
are on the same page. To do this, programs may choose to include the
training of case managers, health advocates, and even doctors and
nurses.
Due to the common overestimations of health literacy levels of
patients, the education of health literacy topics and training in the
identification of low health literacy in patients may be able to create
significant positive change in the understanding of health messages. The Health Belief Model
has been used in the training of health professionals in order to share
insight on the knowledge that it has been shown to most likely change
health perceptions and behaviors of their patients.
The use of the health belief model can provide basis for which patient
health literacy may grow. The training of health workers may be seen as a
“work around intervention” but is still a viable option and opportunity
for mediating the negative outcomes of low health literacy.
Effective health literacy programs are created with cultural
competency, and individuals working within health institutions can
support individuals with low health literacy by being culturally
competent themselves.
In working to improve the health literacy of individuals, a
multitude of approaches may be taken. Systematic reviews of studied
interventions reveal that one works to improve health literacy in one
patient may not work for another patient. In fact, some interventions were found to worse health literacy in individuals.
Nonetheless, studies have illuminated general approaches that help
individuals understand health messages. A review of 26 studies concluded
that “intensive mixed-strategy interventions focusing on
self-management” and “theory basis, pilot testing, emphasis on skill
building, and delivery by a health professional” do aid in increasing
levels of health literacy among patients.
Another study revealed that programs aimed at targeting more than one
behavior through increased health literacy are no less successful than
programs with a single focus.
The importance of dignity and respect is emphasized when creating
programs for increasing health literacy of vulnerable individuals.
In intervention programs created for homeless individuals in specific,
it has been found that “successful intervention programs use aggressive
outreach to bring comprehensive social and health services to sites
where homeless people congregate and allow clients to set the limits and
pace of engagement”.
A social justice model is recommended for homeless individuals which is
based on shared support of the community and their health literacy
needs by those who provide services for this underserved group as well
as the professionals who create and implement health literacy
interventions.
Libraries
Libraries have increasingly recognised that they can play a role in health literacy since the 2000s, influenced by the Medical Library Association.
Library initiatives have included running education programs,
fostering partnerships with health organisations, and using outreach
efforts.
United States
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