by Hope Ruiz, PhD
People today are bombarded with words. With technology’s availability and apparent ease of use, accessing needed information would seem to be a simple task. However, in the United States, one in seven people – more than 40 million people – can barely read a job offer or utility bill.
In 2003, the National Assessment of Adult Literacy conducted by the U.S. Department of Education, found that 14% of American adults scored below the basic level in prose literacy. More than half of that group lacked high school diplomas or GEDs, but not even college students fared much better. In 2003, fewer than one-third of all college graduates and fewer than one-half of all graduates with advanced degrees could score at the national assessment’s highest proficiency level.
Health literacy falls within the domain of literacy, but also involves one’s ability to obtain, process, understand, and act upon basic health information and services to make appropriate health decisions. More than half of all American adults – 147,867,067 people – have difficulty understanding and complying with health information, including prescription medication instructions.
For persons lacking skills in health literacy, reading, and use of numbers and/or mathematic concepts, serious consequences impact not only the individual, but also the entire country because of the high monetary cost. The nonprofit Intercultural Development Research Association in 1994 reported that the national cost of illiteracy ranged from $25 billion to $30 billion per year in lost productivity, errors, and accidents. Today, national annual healthcare costs attributed to low health literacy alone is estimated to be $73 billion.
Texas’ population of 22.1 million is expected to increase to 50 million by 2040, an increase of 127%. The illiteracy rate in Texas – 10.74% or 1.3 million people – is twice as large as the nation’s average and is greater than that of either California or Kentucky. Bexar County’s 12.4% illiteracy rate also is generally higher than the state average and nearly matches that of Houston at 14.13% and Dallas at 13.88% (Montes & Johnson, 2005). For the San Antonio area, that translates to more than 90,000 people.
Limited or low health literacy skills have been linked to:
• poorer health, health outcomes, control of chronic diseases, knowledge regarding one’s health conditions, and self-reported health;
• greater noncompliance rates for medications and treatment plans;
• lowered use of preventative services;
• increased visits to the emergency room;
• increased hospitalizations;
• limited access to health care;
• higher healthcare costs; and premature death.
Recent studies indicate most physicians (> 50%) could not identify their patients with poor health literacy skills. Healthcare providers and health service managers then face two basic problems: recognizing situations when a patient does not understand written words and knowing how to communicate in ways that make sense to the patient. Further complicating the problem, even providers who do identify a patient with low health literacy may fail to address the problem because of patient confidentiality, the potential of embarrassing a patient, a perceived lack of effective interventions, and/or a lack of time.
Whether anecdotally or based on first-hand experience, you may already realize that patients employ a number of strategies to either cover up or compensate for their health literacy limitations. For example, you may have a patient who:
• asks the staff for assistance with filling out forms; brings someone to help with the forms;
• uses excuses such as, “I forgot my glasses,” or, “I have a headache. Would you read (or complete) these forms to me?” or “I’ll complete (read) these forms at home;”
• submits forms with missing information or reports misplaced data;
• consistently fails to comply with or adhere to taking medication(s), following instructions, and/or keeping appointments;
• memorizes the size, shape, and color of his/her medications instead of reading printed instructions and labels; and/or
• asks questions about information covered in provided literature or instruction sheets.
More than 300 studies indicate that health materials are not understood by most of the people for whom they are intended. The average American reads at the eighth to ninth grade level, and the average Medicaid recipient reads at the fifth grade level. Despite these daunting facts, there actually are several simple, effective, and worthy strategies you and your staff can employ to improve patient-provider and patient-staff communication:
• Create a receptive, friendly office environment, starting with the office staff.
• Foster a patient-centered approach in provider-patient interactions.
• Use plain, simple, language (no acronyms, no jargon, no complicated medical terms).
• Start with what the patient already knows and move forward from there.
• Limit the amount of information you give at any one time.
• Use a “say, then show” technique that uses pictures, illustrations, visual aids, and simple charts.
• Repeat instructions; if necessary restate different ways.
• Use a “teach back” approach – ask the patient to restate or explain (but not “parrot”) what must be done and/or demonstrate steps or procedures they need to perform.
• Slow your rate of speech.
• Explain what the patient should expect at the next appointment.
• Use the patient’s preferred learning style (i.e., auditory, visual, kinesthetic) to promote self-directed learning and understanding).
• Remember, many people lack basic math skills; it may be more effective to tell your patient to take one pill every eight hours vs. take one pill three times a day).
• Improve the appearance of your office/medical forms:
o Simplify and limit the needed information.
o Use medium/large text fonts (12-point or larger).
o Use a simple font style and keep the font size and style consistent.
o Use the active voice.
o Use headings.
o Use illustrations/pictures.
o Leave white space between sections.
o Use bulleted lists instead of long paragraphs.
o Subdivide long lists into smaller sections.
o Use upper and lower cased lettering. ALL CAPS IS DIFFICULT TO READ.
o Target materials to a sixth grade reading level.
Stakeholders – the U.S. health system, pharmaceutical companies, adult educators, healthcare providers, healthcare staff, and consumers – have a vested interest in collaborating toward solutions in assessing patients with low health literacy skills and developing health-related materials that provide clear, simple, and complete information regarding:
• basic health and treatment(s);
• medical forms;
• treatment instructions;
• medications and medication safety;
• the healthcare system and access to it;
• self-advocacy and self-education; and
• self-education.
Bridging this gap requires awareness and action. Communities across the country must work together by creating coalitions to find the most appropriate solutions in their particular situations, probably using their own resources. The San Antonio Health Literacy Initiative is one such volunteer or-ganization with members from several community-based organizations, local colleges, and universities. Its mission is to create a positive change in health literacy for the city of San Antonio. For more information, visit its web site: www.sahealthlit.org.
Dr. Ruiz earned her doctorate in educational human resources development from Texas A&M University and is currently an assistant professor with the Army-Baylor graduate program in health and business administration at Ft. Sam Houston. She is a member of SAHLI.
Resources
Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press.
Montecel, M., Supik, F., Montes, & Adame-Reyna, N. (1994). The state of literacy in San Antonio in the 1990s. San Antonio, TX: Intercultural Development Research Association.
Montes, F., & Johnson, R. L. (2005). The new state of literacy in San Antonio and in the nation.
San Antonio, TX: Intercultural Development Research Association
National Center for Education Statistics. (1993). Adult literacy in America: A first look at the results of the national literacy survey. Washington, D.C: Office of Educational Research and Improve-ment, U.S. Department of Education.
Osborne, H. (2005). Health literacy from A to Z: Practical ways to communicate your health message. Boston: Jones & Bartlett.
Texas Department of State Health Services. (March 3, 2005). Demographic and health trends. Retrieved July 10, 2006, from www.dshs.state.tx.us
U.S. Census Bureau. 2004 ACS congressional toolkit. (2004). Wash-ington, DC: Author.
