Editorials

The Role of Literacy in Health and Health Care



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Am Fam Physician. 2005 Aug 1;72(3):387-388.

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Up to 40 percent of American adults have fair to poor literacy skills, which can make it difficult for them to function proficiently in the health care system.1 Studies have shown that patients with inadequate literacy have less health-related knowledge, receive less preventive care, have poorer control of their chronic illnesses, and are hospitalized more frequently than other patients.2 In this issue of American Family Physician, Safeer and Keenan3 raise awareness of patient literacy problems and suggest practical strategies for identifying and addressing the needs of patients who have inadequate literacy.

Health literacy is defined as the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions.4 As described in a report by the Institute of Medicine, health literacy also may require medical knowledge, navigational skills, cultural competency, and initiative. Thus defined, inadequate health literacy can affect patients beyond those with poor reading skills.

There is no proven method to measure health literacy. Previous research has measured the relationship between reading ability and health outcomes2,5; such measures are highly correlated with measures of general reading ability.68

Identifying a clear relationship between health outcomes and literacy is important because physicians may be able to mitigate the effects of low literacy by communicating more clearly with patients and reducing the complexity of care for these patients. For example, patients with heart failure are frequently told to avoid salt, measure their weight daily, change their diuretic dose based on weight, and call the doctor for a variety of reasons. Many patients with inadequate literacy have difficulty learning all these strategies—particularly when they are recommended all at once and in the context of a routine office visit when their diabetes and blood pressure medications also have been changed.

Inadequate literacy is associated with less formal education, lower socioeconomic status, and certain racial and ethnic backgrounds. Addressing literacy-related barriers also may help reduce disparities in health outcomes related to these other markers. Healthy People 2010 and the Institute of Medicine identify health literacy as a priority area for improving health in the United States.9,10

Physicians and patients must cooperate in the outpatient setting to manage multiple chronic diseases. Physicians can do this by providing appropriate self-management support via oral and written communication. By using the spoken word to convey information, physicians have an advantage because verbal literacy usually is greater than written literacy. However, when physicians expect patients to learn and remember more than one or two ideas, they will need reinforcement after they leave the office. Physicians can rely on clear written materials for patients with adequate literacy skills, yet may need to offer further oral instruction in the form of follow-up calls to the home or frequent follow-up visits until the patient masters the necessary skills. Physicians have found that patients with low literacy can learn complicated tasks if given enough instruction.11

To supplement self-management support, Safeer and Keenan3 offer several guidelines for improving written communication. They also note that patients who read at higher levels often prefer information written at a lower grade level and presented in plain language.12 It also has been shown that patients would rather receive directly relevant information about how to care for themselves than explanations of disease pathophysiology. Emphasizing only the two or three highest yield recommendations for any given visit can help ensure understanding and implementation by the patient, regardless of literacy level. Some patients may request more detailed explanations or background information, but our default should be to focus on key behaviors or tasks.

Although better self-care instructions, in oral or written form, can help address disparities according to literacy status, we must not forget about the rest of the health care setting. Patients with low health literacy skills can become frustrated and overwhelmed by having to interact with insurance companies, Medicare or Medicaid, hospitals, and physician offices. The current trend toward more consumer-driven health care also will increase the literacy demands on patients who already struggle to keep up. Helping physician office staff to recognize this common barrier faced by many patients can improve our effectiveness. Organized systems of care, sensitized to the needs of patients with low literacy skills, can mitigate disparities related to literacy.13 One model that has been effective uses mid-level providers and health educators to help patients learn effective self-management behaviors, overcome common barriers to care, and ensure the appropriate intensity of care to reach targets.13

The Institute of Medicine has defined quality health care as safe, timely, effective, efficient, equitable, and patient-centered.14 Addressing the needs of patients who have low literacy is an opportunity we cannot afford to waste.

The Authors

DARREN A. DEWALT, M.D., M.P.H., is assistant professor of medicine at the University of North Carolina at Chapel Hill.

MICHAEL P. PIGNONE, M.D., M.P.H., is associate professor of medicine and associate chief of general internal medicine at the University of North Carolina at Chapel Hill.

Address correspondence to Darren A. DeWalt, M.D., M.P.H., University of North Carolina at Chapel Hill, 5039 Old Clinic Building, CB# 7110, Chapel Hill, NC 27599 (e-mail:dewaltd@med.unc.edu). Reprints are not available from the authors.

Author disclosure: Drs. DeWalt and Pignone have received grant support and honoria from Pfizer, Inc. for work related to health literacy. Pfizer had no roll in the preparation or funding of the manuscript.

REFERENCES

1. Comings J, Reder S, Sum A. Building a level playing field: the need to expand and improve the national and state adult education and literacy systems. Cambridge, Mass.: National Center for the Study of Adult Learning and Literacy, 2001.

2. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228-39.

3. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72:463-8.

4. Selden CR, Zorn M, Ratzan SC. Health literacy. Accessed online February 24, 2005, at:http://www.nlm.nih.gov/pubs/cbm/hliteracy.html.

5. Nielsen-Bohlman L, Panzer AM, Kindig DA, Committee on health literacy. Health literacy: a prescription to end confusion. Washington, D.C.: National Academies Press, 2004.

6. Rudd RE, Kirsch IS, Yamamoto K. Literacy and health in America. Princeton, N.J.: Center for Global Assessment, Policy Information Center, Research and Development, Educational Testing Service, 2004.

7. Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391-5.

8. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537-41.

9. U.S. Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2d ed. Washington, D.C.: U.S. Dept. of Health and Human Services, 2000.

10. Adams KM, Corrigan J. Priority areas for national action: transforming health care quality. Washington, D.C.: National Academies Press, 2003.

11. DeWalt DA, Pignone M, Malone R, Rawls C, Kosnar MC, George G, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns. 2004;55:78-86.

12. Davis TC, Crouch MA, Wills G, Miller S, Abdehou DM. The gap between patient reading comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533-8.

13. Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, Crigler B, et al. The influence of patient literacy on the effectiveness of a primary-care based diabetes disease management program. JAMA. 2004;292:1711-6.

14. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press, 2001.



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