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Health Literacy

By Kristine Yahn, RN, MBA
Executive Director
Californians for Patient Care

"Health literacy – The ability to read, understand and act on health information."
-- Council of State Governments

“Low health literacy is so pervasive that it presents a significant threat to patient safety.”
-- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

There is a silent epidemic in California, affecting nearly half of all adults.

Health literacy includes reading, writing and math. It is an issue for both patients, who must read, understand and calculate (dosage, timing, benefit coverage, etc.) and professionals, who must communicate verbally, write clearly and possess cultural competency.

Patients must understand. (And we are all patients – past, present, future.) About 47% of adult patients cannot read basic texts associated with most healthcare decisions.(2)

Professionals must be understood. The average physician allows the patient to talk for 22 seconds before taking control.(8)

Literacy is an essential element of healthcare for patients and providers:

“(A)ll of the studies that have investigated the issue report that literacy skills are a stronger predictor of an individual’s health status than age, income, employment, education and racial or ethnic group,” according to author Barry D. Weiss, MD.(11)

The cost of health illiteracy is high. Exactly how high is unknown. Here is a sampling of two general indicators:

1. Medicaid patients with 3rd grade or lower reading levels had average charges of $10,688, while patients who read above 3rd grade levels had average charges of $2,891, the Institute of Medicine (IOM) discovered in a 2004 study. There are about 1.1 million Medicare patients annually in California, according to the Office of Statewide Healthcare Planning & Development’s (OSHPD) newest statistics. Literacy, then, could save $7,800 for each of about 517,000 patients (assuming a 47% illiteracy rate), or $4 billion. (Adults with chronic illness represent 40% of Medicaid recipients but 80% of expenditures.(6))

2. The cost of health illiteracy is nearly $1,000 per hospital in-patient, according to a 2002 IOM report. There were approximately 3.1 million California hospital in-patients in fiscal year 2004-05, OSHPD recently reported. This might be a savings of 1.5 million patients X $1,000, or $1.5 billion.

“You’re always last when you don’t know.”

Low health literacy has a broad patient impact. Consider a few that surfaced in a Council of State Governments study at two public hospitals:

  • 42% did not know what “taking medication on an empty stomach” meant.
  • 26% couldn’t understand an appointment slip.
  • 60% couldn’t read an informed consent slip.
  • 25% of women weren’t able to explain a mammogram.(1)

As an adult who reads at a third-grade level told researchers, “You’re always last when you don’t know.”

Health literacy will improve patients’ active participation in controlling chronic conditions like heart disease, asthma and diabetes, as well as recuperate from cancer and trauma. Together with mental illnesses, these ailments accounted for 31% of the health care spending increases from 1987 to 2000.(4)

For example, only 31% of low-literacy asthmatics understood they needed to see their doctors regularly, according to Williams, Baker, Honig, in “Inadequate Literacy Is a Barrier to Asthma Knowledge and Self-Care.” (Chest, 1998, v114)

“Take Once Daily”

Statistics aside, there is the individual human trauma inflicted by failure to understand. Here are two cases reported by the IOM:

A two-year-old is diagnosed with an ear infection and prescribed an antibiotic. Her mother understands that her daughter is to take the medicine twice daily. After carefully studying the label at home, and deciding it doesn’t tell how to give the medicine, the mother fills a teaspoon and pours the antibiotic into her daughter’s painful ear.

A 45-year-old man gets a prescription for two high blood pressure medicines from a local hospital, after being told he cannot continue at his job until his blood pressure is controlled. Both medication labels include the instruction, “Take once daily.” One week later, the man enters the emergency room with dizziness and very low blood pressure. He says he has been taking his medicine as directed. Several puzzled practioners struggle with a diagnosis until one who speaks Spanish asks the Hispanic man how many pills he took each day. “22,” he says. The provider explains to his colleagues that “once” means “11” in Spanish.

Immediate Needs, Prescribed Remedies

Improving health literacy is a shared responsibility among patients, practitioners, insurers, educators, employers and community groups. There are specific health illiteracy remedies already prescribed by a wide variety of respected sources:

1. Communicate precisely and clearly. Simplicity is the key. Healthcare professionals must write clearly, using a basic vocabulary. This is seldom the case: About half of HMO patient reading material is written at the graduate school level and 45% for college graduates, the state Office of Patient Advocate found in a 2002 survey. Only 6% of material was written for high school graduates. Most patient education materials included with medications are written at a 10th-grade or higher level.(8) A 4th-6th grade level for written communication is recommended by Californians for Literacy.

Communications should be tailored to specific audiences, when possible. For example, the biggest and most immediate audience is baby boomers entering their 60s. They have strong preferences. Medicare beneficiaries preferred messages that specified an action to be taken and a mode of implementation, according to the US Agency for Healthcare Research and Quality.

A multimedia approach – including print, audio, video and interpersonal communication – is required to appeal to different learning styles, a recent California HealthCare Foundation study discovered.(6)

Communications must be based on audience research – like any consumer marketing campaign. Frequently there are strong biases to overcome, the federal research disclosed. For example, patients told researchers that they are often unwilling to ask questions to verify that a treatment or drug is both necessary and correct.

And patients must take control of their health care. Ask questions, conduct your own research, take a friend to your appointments and listen carefully…and ask more questions.

2. Include healthcare literacy training as part of education curriculum for all learners.

Education at the elementary, junior high and high school levels needs coordinated curriculum and more teachers with health education training. The IOM survey found health education in 44% of 5th grade classes, 10% of 9th grade and 2% of 12th grade. Only 10% of health education classes are taught by a teacher who majored in health or PE. Classes at one level are not usually built on prior instruction. And health education texts could be a part of regular literacy classes for under -18 education and in adult classes.

California Education Code Section 51890 already requires that “Pupils will receive instruction to aid them in making decisions in matters of personal, family and community health….”

3. Employers can integrate health literacy into regular employee training or benefit enrollment sessions, which could result in lower costs in lost time and insurance premiums. Nearly three-quarters of large employers already have regular training programs, according to the National Assn. of Manufacturers, and virtually all provide health coverage. The next step is to simply make health coverage education a part of the training program.

4. Education, healthcare and other policymakers should consider including literacy in their legislation, regulation and programs. As JCAHO proclaimed: “Health literacy has gone unnoticed as a public policy issue.”

1. “State Official’s Guide to Health Literacy,” Trudi Matthews and Jenny Sewell, The Council of State Governments, 2002
2. “Health Literacy: A Prescription to End Confusion,” Lynn Nielsen-Bohlman, Allison Panzer and David Kindig, editors, Institute of Medicine of the National Academies of Science, 2004
3. “Treated for Illness, Then Lost in Labyrinth of Bills,” Katie Hafner, New York Times, October 13, 2005
4. “What Medical Conditions Account for the Rise in Health Care Spending?” Kenneth Thorpe, Curtis Florence and Peter Joski, Health Affairs, August 25, 2004
5. “Speaking Plainly: Communicating the Patient’s Role in Health Care Safety,” US Agency for Healthcare Research and Quality, 2005
6. “When You’re 64: What Consumers Don’t Know About Medicare,” California HealthCare Foundation, February 2006
7. “White Coats and Many Colors,” American Hospital Association, 2005
8. “Eradicating Low Health Literacy,” The Partnership for Clear Health Communication, March 2003
9. “Health Literacy: A Manual for Clinicians,” American Medical Association Foundation, Barry D. Weiss, 2003
10. “The Role of Inadequate Health Literacy Skills in Colorectal Cancer Screening,” Cancer Investigation, Davis et al, 2001
11. “Health Status of Illiterate Adults,” American Board of Family Practitioners, Weiss et al, 1992


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