Volume 56, Number 3 - Summer 2010

 

By Alpana Kharkar, MD

Health literacy has been defined as, “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”[1] Many factors affect a person’s health literacy level, the most obvious being their general literacy level: their ability to read, write and understand written information.

In 2003, the U.S. Department of Education asked a random sample of 19,000 adults to complete a set of tasks measuring their general literacy level, including their ability to read and assimilate information.[2] The respondents were also asked to complete an additional set of tasks pertinent to their health literacy skills.

The results of both studies were alarming. For general literacy levels, about one-third of respondents were found to be either functionally illiterate (level 1 on a 5-point scale) or marginally literate (level 2). Respondents at these levels were usually unable to locate an intersection on a map, use a bus schedule, or perform other common daily tasks requiring literacy.

For health literacy, respondents were rated on a 4-point scale, ranging from “proficient” to “intermediate,” “basic” and “below basic.” Only 13% of the respondents were judged proficient. About one-half (53%) were intermediate, and the remaining third were basic or below basic. This lower third had problems understanding health education publications, filling out insurance applications, following medication instructions, and calculating BMI from information given on a graph. 

Poor health literacy was common in certain population groups, including the elderly, some ethnic groups, and people with limited education. It is important to remember, however, that not all health-illiterate patients fall into these groups. As physicians, we can’t “tell by looking” who has difficulty understanding the information we give them. 

The consequences of poor health literacy are vast. Limited literacy has been strongly linked, for example, to bad health outcomes, less knowledge of preventive health care, increased risk of hospitalization, low adherence to treatment regimes, and medication errors.[3-6] Poor health literacy also brings billions of dollars of additional costs to the U.S. health system.[7]

The American Medical Association recently developed a health literacy kit with several resources for improving communication with patients (see below).[8] As explained in the kit, one way to improve communication is to always be conscious of expressing information in the clearest and most straightforward way. 

I recently had an experience that drove this point home. My husband and I visited a respected lawyer to set up our living trust. After sitting in her office for 45 minutes and not understanding the complex tax laws she was trying to explain, I felt somewhat perplexed and frustrated by her explanations. I told her that I did not understand what she was saying, and I asked her to explain it again. She continued, however, to use exactly the same words and approach as before, leaving me feeling extremely confused. 

Later, when my husband expressed similar sentiments, we concluded that it was her explanations that left us so perplexed, rather than our abilities to understand what she was trying to say.

We did not use her services.

My experience highlights the fact that physicians must recognize that our patients, irrespective of their educational level, are often faced with complicated treatment plans, medication dosing and medical jargon that can be difficult to understand. Since we are at the forefront with our patients, we must make our explanations clear by using straightforward language to convey our thoughts.

The simple steps outlined below summarize how we can communicate with our patients more effectively:

• Slow down.
• Avoid medical jargon. Instead of analgesic, for example, say painkiller . 
• Draw or show pictures.
• Limit the amount of information given. Repeat directions if necessary.
• Use the “teach back” technique. Ask the patient to repeat your instructions. If he repeats the instructions incorrectly, explain the instructions in a different way. Remember that talking louder does not help the patient understand the information any more clearly!
• Encourage questions. Put the patient at ease by saying, “Many people have difficulty reading and understanding the information I give them, so please feel comfortable asking questions.”

Any patient education materials you use should be written at or below the sixth grade level to ensure understanding by most American adults. Many patient education materials, including those on the Internet, are written at the 12th grade level.

Identifying patients with poor health literacy is not an easy task. Often, not even spouses are aware of their partner’s illiteracy. A classic study done in 1996 found that 68% of patients with low health literacy had never told their spouse about their condition.[9]

The shame associated with illiteracy often leads patients to hide their lack of comprehension. During an office visit, the patient needs a great deal of courage to tell the physician that he is not understanding whatever is being said. We have a responsibility to explain treatment regimes and medication dosing in a way that is easily understandable. 

Since we can’t “tell by looking” who is health illiterate, we should watch for red flags. If a patient is unable to name their medications, or explain the purpose or timing of medications, or express their medical concerns, we should be sensitive to the possibility that they may have poor health literacy.

Some physicians who suspect low literacy use specific questions, such as, “How happy are you with the way you read?” Others use screening questions, such as, “How confident are you filling out medical forms by yourself?” or “How often do you need to have someone help you when you read material from your doctor or pharmacy?”

As physicians, we are faced with increasing demands on our time, and we are often reluctant to unearth “yet another problem” by asking more questions. We may not always need to ask specific literacy questions, but we do need to be aware of the potential problems raised when dealing with poor health literacy. As treatment options and self-care regimes become more complicated, it is in our patients’ best interests to raise our own awareness of health literacy. We should always strive to improve communication between doctor and patient.

1. Institute of Medicine Committee on Health Literacy, Health Literacy: A Prescription to End Confusion, National Academies Press (2004).
2. Kutner M, et al, Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy, National Center for Education Statistics (2006).
3. Weiss BD, et al, “Health status of illiterate adults,” J Am Bd Fam Prac, 5:257-264 (1992).
4. Baker D, et al, “Relationship of patient reading ability to self-reported health and use of health services,” Am J Pub Health, 87:1027-30 (1997).
5. Sudore RL, et al, “Limited literacy and mortality in the elderly,” J Gen Int Med, 21:806-812 (2006).
6. Davis TC, et al, “Low literacy and violence among adolescents in a summer sports program,” J Adol Health, 24:403-411 (1999).
7. Friedland RB, Understanding Health Literacy: New Estimates of the Costs of Inadequate Health Literacy, National Academy on an Aging Society (1998).
8. American Medical Association, Health Literacy and Patient Safety: Help Patients Understand, www.ama-assn.org (2007).
9. Parikh NS, et al, “Shame and health literacy,” Pat Educ Couns, 27:33-39 (1996).

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