One issue in health care that is rarely discussed in the public domain, but which deserves significant attention, is health literacy. Health literacy is not the same as the general ability to read and write, although it is often related. Health literacy specifically refers to an individual’s capacity to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (Institute of Medicine 2004)
Health literacy comes into play whenever a person purchases or administers a medication, reads an article about a health topic, fills out an insurance form, or discusses treatment with a doctor. It can impact the way parents care for a sick child or how adult children manage the health care of an ailing parent. It influences how an individual selects insurance coverage or how a person without insurance makes health decisions. In fact, health literacy contributes to almost every aspect of a person’s interactions with their own health, the health of those around them, and the healthcare system.
In 2003, the National Center for Education Statistics (NCES) conducted the National Assessment of Adult Literacy (NAAL). In additional to measuring general population literacy, they included a health-specific section of tasks to test individuals’ abilities to understand health texts (such as pamphlets), to utilize health forms in various formats, and to complete basic health care computations. These areas of ability were used to create a health literacy scale with four levels of performance: Below Basic, Basic, Intermediate, or Proficient.
The results of the testing showed that 12% of adults were proficient, 53% were at the intermediate level, 22% had basic skills, and 14% had below basic health literacy.
The results varied by several demographics. For example, women had higher average health literacy than men. White and Asian/Pacific Islander adults had higher average health literacy than adults of other racial/ethnic groups. Hispanic adults had lower average health literacy than adults in any other racial/ethnic group. Adults over age 65 had lower health literacy, on average, than younger adults. Literacy level also varied based on socioeconomic status, native language, media/internet access, and insurance status.
In addition, the NAAL showed that health literacy varied widely with education level. Among adults who never completed high school, approximately 49% had below basic health literacy. By contrast, 15% of adults who ended their formal education with a high school diploma and 3% of adults with a bachelor’s degree had below basic health literacy.
The real importance of all this information is that, as one might expect, individuals with higher health literacy also self-reported better overall health.
When a woman struggles to understand directions from her physician, the chances of successfully managing a chronic illness are lower. When a man is unable to read a chart showing the healthy weight for his height and age, he may not realize he is moderately overweight and will be less likely to consider lifestyle changes. When a mother does not understand the dosage instructions for her child’s medication, she is less likely to foster a quick recovery and may even make a grave error. When a young man does not understand his insurance plan, he may not realize that he will pay significantly more to get a couple of stitches at the emergency room as compared to a local urgent care clinic.
Provider-patient interaction, disease prevention, and navigation of the health care system all contribute significantly to the health outcomes of individuals, as well as the cost of our overall health care system.
So how should we respond to these results about health literacy? What can be done to improve the health literacy of our population and to make navigation of the health care system more manageable?
One step that has already been taken by President Obama is the Plain Writing Act, which was signed into law on October 13. This act requires federal agencies to write all public documents in a “clear, concise, well-organized” manner. This includes Medicare and Medicaid forms! (Although I supposed "clear, concise, and well-organized" is mainly in the eyes of the writer.)
Many non-federal agencies, such as pharmaceutical and insurance companies, are also encouraging the use of plain language. This does not mean that the company “dumbs down” concepts, but that it uses common vocabulary and more streamlined structures of communication to state the same information.
Compare the following:
A. The Dietary Guidelines for Americans recommends a half hour or more of moderate physical activity on most days, preferably every day. The activity can include brisk walking, calisthenics, home care, gardening, moderate sports exercise, and dancing.
B. Do at least 30 minutes of exercise, like brisk walking, most days of the week.
Option B is clearly in plain language compared to option A, and they communicate the same essential point.
Another idea to improve health literacy is to incorporate additional skills into existing health education classes (such as those that cover sexual health in middle and high school.) These could include the basic skills of reading health-related articles, filling out health forms, understanding medication instructions, and learning basic insurance terms, like “deductible” and “copay.”
It may also be helpful to provide more extensive literature and/or classes for health care professionals on communicating with health literacy in mind. Since I am not a health care provider, I do not actually know what sort of training physicians, pharmacists, and other providers receive in this area already. It might even be helpful to train the secretary or office manager at the front desk of a doctors’ office.
Many hospitals and insurance companies may also benefit from amplifying the role of personal phone calls from nurses in following up with patients. A three minute call may reveal that a patient is not following post-operation instructions or has questions about medication side effects that can be answered right away, which may or may not have come up before the patient returned home. This sort of pro-active approach offers a patient the opportunity to get further clarification on any instructions or ideas they did not understand originally. And it can prevent unnecessary complications or readmissions to the hospital.
Some communities already have nonprofit organizations, which help individuals navigate the health care system, particularly the application processes for Medicare and Medicaid. If the government, doctors, hospitals, and insurance companies collaborated with these organizations, they could potentially support classes that introduce members to basic health literacy concepts. Or they could more generally glean information from the nonprofit’s experience about the most common areas of difficulty and use the information to make document and process changes.
I am very interested to know if others have ideas that they think would improve health literacy or that would make the health care system easier to navigate. Please share!