Health Illiteracy

You and I can read. Individually, we started reading long ago. We read every day. Ours is a profession centered on learning and teaching. Indeed, we take for granted our reading abilities and tend to assume others can read too.

However, according to the San Diego Council on Literacy, one in five American adults reads at or below the fifth-grade level. That number is higher in our border county. Compounding the problem of general functional illiteracy is the fact that most healthcare materials are written above the tenth-grade reading level. Thus, two-thirds of doctors and pharmacists encounter patients who are unable to comprehend prescriptions and unable to administer their medications properly.

What happens to that one San Diegan in five who receives medical attention at an emergency room or urgent care facility and written after-care instructions? Unable or ashamed to admit that he does not understand the written advice, he relies upon his memory of the spoken instructions. We know that even under ideal conditions, people recall only a fraction of what they are told. Listening under conditions of illness or injury is even more unreliable.

What happens to that one patient in five with a chronic illness whose stable medication regimen is changed? Does she remember which medication she must stop? Can she remember or read that the new substitute medication is to be taken just once a day instead of twice a day? Can she read or remember the pharmacist’s warnings about taking the new medication with food … or was it to be taken on an empty stomach?

The threats to patient safety of health illiteracy are obvious in the above scenarios. In addition, patients with low literacy skills have a 50% higher risk of hospitalization than patients who have adequate literacy skills. Illiteracy creates difficulties ranging from the simple logistical issues of finding and getting to the local clinic or hospital, to difficulties filling out medical information forms, locating and getting to an off-site laboratory, medical imaging facility or pharmacy, and understanding and complying with the prescription and follow-up instructions.

San Diego Community Health Improvement Partner’s Charting the Course IV 2004 is a published assessment of the county’s healthcare needs and disparities by region. Functional illiteracy was not a featured need in Charting the Course IV 2004, and yet illiteracy increases the risk of unemployment, underemployment, and poverty, all of which are risk factors limiting access to care in San Diego County. And, as we have illustrated here, the ability to read is essential to quality of care and patient safety.

Health illiteracy not only threatens patient safety, but the cost is enormous as well. The annual cost of low health literacy nationwide is estimated at $73 billion. With approximately 1 percent of the nation’s population living in San Diego County, we estimate the direct and indirect cost of low health literacy at more than $700 million in our county alone.

The San Diego Medical Information Network Exchange (SD MINE) is one of several bold initiatives of the San Diego County Medical Society Foundation. A consumer health education initiative, under the leadership of Steve Carson, MD, chief medical officer of the SDCMS Foundation, has received grant funding to develop and publish patient information written in multiple languages and at a third-grade level on common medical conditions. Fully realized, this health literacy project will permit a physician to access online basic patient education information in the patient’s preferred language and at a basic reading level and print it out for distribution to the patient in the office.

What more can we do as physicians? Support your SDCMS Foundation with your tax-deductible charitable contribution — on your SDCMS membership dues statement or with a call to (858) 565-8888. Contact the San Diego Council on Literacy at (888) 850-7323 or www.literacysandiego.org, and support its local efforts to reach the nearly 450,000 San Diego adults working to improve their literacy. Increase your sensitivity to the issue of illiteracy among the patients you encounter, and improve patient education systems in your practice accordingly — see the article on health literacy by Kimberly C. Pettiford, MPH, in this issue [page 19]. We cannot afford the high cost of illiteracy.