Health literacy a hidden barrier for one-third of U.S. population

From the June 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maquire

NEW ORLEANS—The patient enters the office and is handed a clipboard with a questionnaire to complete. For patients with literacy problems, it is just the first of many episodes of shame and confusion they will confront while seeking care.

Illiteracy is a hidden disability that threatens the health care of one-third of all American patients, according to speakers at the Annual Session workshop, "What Your Patients' Health Literacy Means To You." While complete illiteracy does exist in the United States, particularly among senior citizens and inner-city residents, limited literacy is a much more common problem, said panelist Terry Davis, PhD, professor of medicine and pediatrics at the Louisiana State University Medical Center in Shreveport. Although the average American has more than 12 years of education, Dr. Davis said that the reading, writing and computational skills of many Americans fall far short of their grade level completed.

One recent study concluded that literacy problems cost this country $73 billion a year in misdirected or misunderstood health care services. Another survey that focused on Medicare managed care enrollees in four cities found that 33% of all English-speaking patients displayed only marginal literacy skills. That percentage was even higher among Spanish- speaking enrollees.

Speakers pointed out that literacy problems are compounded by new medical technologies and interventions. Panelist Mark V. Williams, FACP, associate professor of medicine at Emory University in Atlanta, said that patients who received only one asthma medication 20 years ago, for instance, must now manage at least six different therapies and procedures.

In addition, literacy problems can pose real dangers, said Ruth M. Parker, FACP, associate professor of medicine at Emory University in Atlanta, particularly in terms of pill box instructions, contraindications, medical terms, informed consent forms, insurance forms and comprehension of treatment risks and probabilities.

The result can be noncompliance, which can increase costs as well as health risks. Research shows that patients with inadequate literacy skills run a 52% greater risk of being hospitalized, Dr. Williams said. In addition, doctors run a higher risk of being sued by patients who do not understand medical terms and instructions.

What can physicians do during a patient encounter to detect and counteract literacy problems? Panelists offered the following suggestions:

• Listen for patients' literacy clues. Many illiterate patients feel intimidated by people at the other end of the literacy spectrum—like doctors— try to hide the problem from physicians. Often, patients who claim they forgot their glasses or say that someone else in their family reminds them when to take medications may actually have a literacy problem.
• Review general medical knowledge. People who struggle with literacy usually do not have the kind of general health care awareness—which panelists referred to as "health literacy"—that is taken for granted. For instance, patients with literacy problems may not readily grasp the general health benefits of losing weight and exercising. They also may not understand what terms like hypertension mean, Dr. Williams said.
• Use "teach back." Have patients repeat your instructions to you to make sure they understand them. Demonstrate any techniques that patients need to use—and make sure they demonstrate them back to you.
• Avoid medical jargon or abstract discussions of illness. Patients with literacy problems need practical information about what actions to take, not in-depth background information on the progression of a disease. Put explanations in the simplest possible terms and stress what patients must do to manage their condition.

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