Low Health Literacy

In the past few years, a national movement to address health literacy has developed. The issue is a significant problem for both patients and healthcare providers; it may also be a factor contributing to health disparities. The medical community must play a key role in mounting strategies to ensure that patients receive assistance in overcoming barriers that limit their ability to function adequately in managing their medical care.

Literacy affects every area in an individual’s personal and private life, including education, employment, social relationships, and health. In fact, literacy skills are a stronger predictor of health status than a range of other categories, including race/ethnicity, income, age, employment status, and educational level (1). Most individuals with limited general literacy also have limited health literacy. By definition, health literacy is the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment (2). The American Medical Association Council on Scientific Affairs specifically defines functional health literacy as “the ability to read and comprehend prescription bottles, appointment slips, and other essential health-related materials required to successfully function as a patient” (3). Inadequate health literacy affects all segments of the population. However, it is more common in certain demographic groups, such as the elderly, the poor, members of minority groups, and recent immigrants to the United States (4).

Exchange of health information in an understandable manner is essential for the delivery of effective healthcare. This level of communication is specifically important in interactions between providers and low health literacy patients.

Because medical care has grown increasingly complex, the need for patients to be health literate is greater than ever. Patients are treated with an ever-increasing array of medications and asked to adhere to more and more complicated self-care regimens. Therefore, communication between a patient and their provider is essential to their health and well-being. Unfortunately, there is often incompatibility between a clinician’s level of communication and a patient’s level of comprehension. In fact, the Institute of Medicine reports that almost half of American adults (90 million people) have difficulty understanding and using health information (5). A patient’s inability to understand health information can lead to medication errors, missed appointments, adverse medical outcomes, and even malpractice (2).

Inadequate or low health literacy has both human and financial costs. A recent study by Research Triangle Institute (RTI) International, the University of North Carolina’s Evidence-based Practice Center, revealed that patients with low literacy had lower health knowledge, less utilization of health resources, and poorer health outcomes, including intermediate disease markers, measures of morbidity, and general health status (6). Patients with low health literacy were 1.5 to 3 times more likely to experience a poor health outcome than patients with higher health literacy. Also, low health literacy is significantly associated with an increased risk of hospitalization. Moreover, patients who struggle with low health literacy are: 1) often less likely to comply with prescribed treatment and self-care regimens, 2) fail to seek preventative care and are at higher (more than double) risk for hospitalization, and 3) remain in the hospital nearly two days longer than adults with higher health literacy. In regards to medical costs, people with low health literacy incur medical expenses that are up to four times greater than patients with adequate literacy skills. These costs are often associated with increased emergency department visits, doctor visits, prescribed medications, and longer hospital stays. As much as $58 billion each year is spent on unnecessary doctor visits and hospital stays due to low health literacy (1).

There is a strong possibility that some of your patients are among the 90 million people in the United States whose health may be at risk due to difficulty in understanding and acting on the health information received. You may not have identified these patients because some patients: 1) hide their confusion from their doctors because they are often embarrassed or ashamed to admit that they are having difficulty understanding health information or instructions, 2) use well-practiced coping mechanisms that effectively mask their problem, and/or 3) may be too intimated to ask for help. Examples of patient coping mechanisms include taking medical forms home to complete them, saying that they can’t read it now because they’ve forgotten their glasses, handing written materials to a relative or someone else accompanying them, and/or aloofness or withdrawal during physician/provider explanations.

Physicians and medical organizations can improve the treatment of their low health literacy patients by using tools specifically designed for such patients to overcome barriers that may limit their ability to function in the healthcare environment. The AMA Foundation has developed a health literacy education kit specifically for clinicians. The learning objectives of the kit are to understand the full scope of health literacy, recognize health system barriers faced by patients with low health literacy, improve verbal and written communication to patients, and create a “shame-free” environment for patients. The kit can also be used to obtain continuing education credit and can be purchased through AMA Press by calling (800) 621-8335. For more information visit the AMA Foundation website at www.ama-assn.org.

There are six easy steps that providers may employ to enhance understanding among patients with low health literacy (7). First, slow down and take the time to assess your patients’ health literacy skills with available tool kits. Second, use “living-room” language instead of medical terminology. Instead of saying, “the cancer has metastasized,” say that “the cancer has spread.” Third, show or draw pictures to enhance patients’ comprehension and recall of the information at a later time. Fourth, repeat information and don’t overwhelm patients with too much information. Fifth, ask patients to repeat information back to you; this tactic is known as “teach back” and helps providers determine if patients understood what they were told. Lastly, throughout this process, demonstrate respect and sensitivity towards patients, which empowers them to participate in their own healthcare.

The County of San Diego, Health and Human Services Agency is working through community coalitions and partnerships, such as the Reduce and Eliminate Health Disparities Initiative (REHDI), to increase awareness about the importance of health literacy. In addition, the Agency is devising efforts to address the issue within County public health facilities. Specifically, emphasis is being placed on generating reading materials at a fifth-grade reading level or lower, as well as improving communication between providers and patients. The Agency’s health disparity task force is reviewing current practices for developing written materials and meeting language interpretation needs. The task force will eventually make recommendations for the development of written materials and the provision of translation services in the public health facilities.

References:

1. A Selection of Health Literacy Articles and Research, Partnership for Clear Health Communication. www.phfch.org.
2. Health Literacy: A Manual for Clinicians, American Medical Association Foundation and American Medical Association, 2003.
3. Ad Hoc Committee on Health Literacy for the Council Scientific Affairs, American Medical Association. JAMA 1999;281:552;25.
4. A Selection of Health Literacy Articles and Research, Center for Health Care Strategies, Fact Sheet #2. www.chcs.org.
5. Health Literacy: A Prescription to End Confusion, Institute of Medicine of the National Academies, 2004.
6. Darren A. DeWalt, MD, MPH, Nancy D. Berkman, PhD, Stacey Sheridan, MD, and others. “Literacy and Health Outcomes, A Systematic Review of the Literature. J Gen Intern Med 2004; 19:1228-1239.
7. Richard S. Safeer, M.D. and Jann Keenan, Ed.S. Health Literacy: The Gap Between Physicians and Patients. Amer Fam Physician 2005;72:463–8.

San Diego County Health Stats: Health Literacy

• Most healthcare materials are written at a tenth-grade level or higher. However, most adults read between the eighth and ninth grade levels, with 21 to 23 percent of adults reading at the lowest reading level, approximately fifth-grade or lower (1).
• Patients with inadequate health literacy skills have difficulty controlling chronic illnesses (2), are unable to follow prescription directions (3), and are more likely to be hospitalized (4), which results in an additional $69 billion in healthcare costs annually (5).

To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 515-4318. To access the latest data and data links, including the 2004 Core Public Health Indicator document, go to www.sdhealthstatistics.com.

References:

1. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the findings of the national adult literacy survey. Washington, DC: National Center for Education Statistics, U.S. Department of Education, 1993. Accessed online September 21, 2005, at: http://nces.ed.gov/pubs93/93275.pdf.
2. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166–72.
3. Holt GA, Dorcheus L, Hall EL, Beck D, Ellis E, Hough J. Patient interpretation of label instructions. Am Pharm 1992;NS32:58–62.
4. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Pub Health 2002;92:1278–83.
5. Health literacy: a prescription to end confusion. Institute of Medicine, 2004.