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.”
Sources:
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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