Low health literacy is common, but can be addressed


Physician assistant Lisa Kerr, PA-C, shares techniques for improved patient understanding and care.

Lisa Kerr, PA-C
Urology Times


Working at a county hospital with a large population of patients who are impoverished, incarcerated, homeless, or living below the federal poverty line provides a unique patient care experience. Every day, I encounter challenges with language barriers, explaining test results and diagnoses, and providing patient education. Patient non-compliance, failure to follow instructions, and limited understanding of illness are common themes during office visits.

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Could the basis of these issues be low health literacy? I know my patient population may be very different from yours, but how common is low health literacy?

More than 90 million Americans have low health literacy, which is defined in the 2004 Institute of Medicine report, “Health Literacy: A Prescription to End Confusion” as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Next: Who has low health literacy?



Who has low health literacy?

The largest proportion of American adults with limited literacy are native-born English speaking Caucasians. The below groups are also at risk (adapted from the National Network of Libraries of Medicine [NNLM]):

Older adults: Health literacy issues associated with older adults include:

  • 71% of adults older than age 60 have difficulty using print materials.

  • 80% have difficulty using documents such as forms or charts.

  • 68% have difficulty interpreting numbers and performing calculations.

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Immigrant populations: The National Assessment of Adult Literacy (NAAL) reports that low health literacy is higher among adults who spoke a language other than English before starting school.

Education: Low health literacy is higher among individuals who did not complete high school. More than 76% of respondents in the survey who did not complete high school scored at the "below basic" or "basic" level of health literacy.

Minority populations: NAAL also reported a relationship between health literacy and race or ethnicity. Caucasian respondents scored better on the survey than other ethnic or racial groups. Only 9% of Caucasian respondents scored at the lowest (below basic) level. However, 24% of African-American, 41% of Hispanics, 13% of Asians, and 25% of American Indian and Native Alaskan respondents scored at the "below basic" level.

Low income: Based on the NAAL research, adults living below the poverty level have lower average health literacy than adults living above the poverty threshold. In adults who receive Medicaid, 30% have "below basic" health literacy.

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Chronic Medical Problems: People with chronic mental and/or physical health conditions have lower heath literacy. 42 % and 33 % of people who rate their health status as poor or fair scored at the “below basic level."

Next: Why is health literacy important?


Why is health literacy important?

Differences in health literacy level were consistently associated with the use of more health care services, increased hospitalizations, a higher utilization of expensive services such as emergency care and inpatient admissions, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. (Health Literacy: A Prescription to End Confusion. Institute of Medicine (US) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Washington (DC): National Academies Press (US); 2004.)

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Low health literacy also significantly impacts our society economically. Low Health Literacy: Implications for National Health Policy estimates that the cost of low health literacy to the U.S. economy is between $106 billion and $238 billion annually. According to the NNLM, “The cost represents an amount equal to the cost of insuring every one of the more than 47 million people who lacked coverage in the United States in 2006.”

How can we improve health literacy?

Identify your patient population. Develop screening tools to alert you to who is at risk. For example, the medical assistants screening patients in our clinic enter into the electronic medical record the patient’s highest grade level achieved, preferred language, and preferred learning method.

Speak clearly. Avoid using medical terminology. Many patients do not understand what hypertension is, but do know they have high blood pressure.

Evaluate patient understanding before, during, and after. Try the “teach-back” method by having the patient repeat in their own words what you have just taught them. This can also be useful when consenting patients for surgery.

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Use pictures, graphs, and easy-to-read text in handout materials.

Next: Use technology


Use technology. Videos may be easier to understand for some patients, especially if available in multiple languages. Pay close attention to the ease of use of your website. Easy-to-read text is also important here.

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Follow-up. If able, have nurse follow-up visits or call patients at risk for low health literacy to follow up on their recent visit. Send reminder letters.

Inform patients of available community resources. Support groups, educational classes, etc. are often available in the community for little or no cost to the patient.

Create a shame-free environment. Admitting limited literacy can be very difficult. I quickly realized that many of my patients are unable to fill out AUA symptom scores due to low literacy skills. When returning to the room and collecting a blank form, many patients say they forgot their glasses or simply do not address the issue at all. Now, I offer to fill out the form with the patient, to avoid forcing the patient to admit they cannot read or write. For my patient population, all forms are also in Spanish.

Regardless of practice type or location, we all have patients with low health literacy. When looking at your schedule, take a moment to identify who may be at risk for low health literacy and consider implementing some of the above techniques for improved patient understanding and care. The scope of this issue encompasses the individual patient’s health all the way to our national finances and warrants a closer look.

For more information about health literacy in American adults, please visit the National Assessment of Adult Literacy published studies.

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