Understanding Patients' Literacy Level is Crucial Step in Care
Fewer than half of U.S. patients have the necessary skills to read and follow drug label instructions, respond to insurance forms, provide a patient history or communicate effectively with a physician, according to the National Institutes of Health.
If patients don't understand us, how can we possibly expect them to follow our instructions? This massive shortcoming puts patient safety at risk, jeopardizes our patients' quality of life and adds costs to the health care system. According to the NIH, health literacy -- or lack of it -- costs our nation up to $236 billion a year.
The problem isn't new. More than 20 years ago, researchers at the University of Arizona found that the health care costs of Medicare patients with low levels of health literacy were more than four times higher than those who were health literate. In 1993, a national survey found that up to 22 percent of Americans were unable to read a medicine bottle.
The numbers aren't surprising when you consider that more than 40 percent of the U.S. population speaks something other than English as a first language. But this issue is not limited to immigrants or those with low levels of education. It is pervasive, affecting all ethnic, economic and age groups.
The 2003 National Assessment of Adult Literacy ranked subjects into four categories based on their skill levels: proficient, intermediate, basic and below basic. That study found that only 12 percent of Americans (14 percent of whites, 4 percent of Hispanics and 2 percent of blacks) were considered proficient. Meanwhile, 41 percent of Hispanics, 24 percent of blacks and 9 percent of whites were considered below basic.
Although patients with higher levels of education
scored better, only 30 percent of subjects with a bachelor's degree or higher
were considered proficient.
So where does that leave us? Do we understand the extent to which people are health literate? Do we speak and write instructions at a level our patients understand?
One easy, critical step to gauge the level of health literacy in our practices is to include the following question on patient history forms: "How far did you go in school?" Then include check boxes so patients can indicate the appropriate grade level. It should be a standard question, and we need to teach our medical students and residents to ask it.
Sadly, students and residents receive little formal training on this important issue. If you work with residents and students, listen to how they speak to patients, and challenge them to speak at a level patients understand. And ask patients, "Do you understand what is being said?"
Teaching back is vitally important, not only for students and residents, but for all health care professionals. At least 40 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate. The brief time it takes to ask a patient to repeat the instructions you have given them can make a huge difference in compliance and outcomes.
We also should educate our staff members who have contact with patients to be aware of patients' education levels. Not only that, we need to ask in what language patients prefer information -- both written and spoken -- be delivered.
Health education material should be written at a fourth- or fifth-grade level, but it often is prepared at an eighth-grade level. The problem can be even worse when materials are translated into other languages. For example, college-level Spanish isn't helpful to Spanish-speaking patients with a lower education level.
I specifically look for educational materials that address health literacy, and I have even taken the step of making my own handouts when necessary. Keep in mind that pictures and symbols say a lot to patients who aren't literate. Reading isn't the only skill in question. Numbers and measurements are barriers for some patients, who may need extra help from you or your staff.
If you know what issue a patient is being seen for and what their literacy level is, you can give them appropriate materials to read while they wait during their appointment. (FamilyDoctor.org has a number of patient education resources available.) Hopefully, this will help them understand their condition and help them ask questions during their visit.
Patients often don't know what they should ask. The NIH initiative has resources for patients to help them prepare for an office visit and suggests questions they should ask related to a wide variety of conditions, including heart disease, diabetes, weight loss and more.
We might have the best training, the right diagnosis and great bed side manner, but if we don't take the time to understand where our patients are coming from, they might not understand us.
Javette Orgain, M.D., M.P.H., is Vice Speaker of the AAFP.