An alarming number of American adults have poor health literacy, but improving it may be as simple as encouraging patients to ask questions.
Michael Paasche-Orlow, MD, MPH, an associate professor of medicine at Boston University, offered suggestions for increasing literacy during a teleconference sponsored by the Institute for Healthcare Improvement and the Journal of the American Medical Association.
Health literacy — an individual's capacity to obtain and understand the health information and services needed to make informed decisions and take action — mostly affects minorities and those with low incomes. A national assessment of English literacy among Americans 16 and older sponsored by the National Center for Education Statistics found that 14 percent had below-basic health literacy skills, according to the 2003 National Assessment of Adult Literacy. Twenty-four percent of blacks and 41 percent of Hispanics in that subset have below-basic health literacy skills, the study found.
Those with an income of less than $10,000 scored in the lower half on a health literacy test while those with an income of $100,000 or more scored about 100 points higher. “This is a huge difference,” said Dr. Paasche-Orlow in the teleconference. “This is akin to educational disparity in our society. Something happens that transforms this educational disparity into a health disparity.”
Another disquieting statistic comes from an Archives of Internal Medicine study: low literacy independently predicts all-cause and cardiovascular deaths in the elderly, he said. (2007;167:1503.) Over the course of the 80-month study, the rate of death among those with inadequate literacy compared with those with adequate health literacy was 39.4 percent vs. 18.9 percent. “We have a society that has significant health access barriers,” he said. “There are patient and provider factors. Often the blame falls on the patient, but whenever you think of the patient side of the coin, think of how you can reduce complexity from providers.”
Dr. Paasche-Orlow said patient education must be greatly improved to increase health literacy among patients. “Everything you put in front of a patient should be conceptualized as an educational opportunity,” he said. “All things designed for patients should be developed with the view of them as a learner. In a way, you can think of people in your population with limited literacy as canaries in the coal mine, in that when you do present simple, clear, easy-to-use, short materials to people, you can improve comprehension and retention for everyone, irrespective of literacy status.”
Unneeded complexity also has to be reduced, Dr. Paasche-Orlow said, and physicians should define terms and be specific about the diagnosis, procedures, and the like. “Don't let things be up to people's interpretation when you think it is critical for them to know how to do it. Help with other methods or modes of communication such as analogies and pictures,” he said. “Patients tend to be … really bad at understanding content. Provide actual interpretive framing, and explain what you mean.”
Dr. Paasche-Orlow recounted a story about a patient who he told not to eat red meat. The patient reported back that he was following the order: “He was cooking the meat through now.”
Successful communication, plain language, and mutual understanding are all important elements to reducing complexity, but the best way to make sure the patient understands is by encouraging questions. “Create a shame-free environment for question asking,” he said. “I think we must say it's a clinician's responsibility to confirm comprehension. When you order food at McDonald's, they tell you back your order. But we don't in health care. Define the question and persist. Don't let them go without questions being asked.”
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