How to improve our patients’ health literacy

“ Health literacy is the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. But health literacy goes beyond the individual. It also depends upon the skills, preferences, and expectations of those health information providers: our doctors, nurses, administrators, home health workers, the media, and many others. Health literacy arises from a convergence of education, health services, and social and cultural factors, and brings together research and practice from diverse fields.” —Health Literacy: A Prescription to End Confusion Institutes of Medicine (2004)

A major part of our day is spent providing information to pa­tients and families—in other words—teaching. The word “doctor” is from the Latin word “docre” which is “to teach.” All of us can remember being at the mercy of teachers who could not teach. They mumbled, used jargon, assumed too much, and would not answer questions. We also re­member the excellent teachers—their explanations were understandable and they used metaphors that we could relate to. Following their direction was easy. 

Are you a good teacher?

Have you wondered why a patient did not take your advice? Or didn’t complete the prescription? Or decided to opt for ongoing treatment that has little likelihood to succeed? While there are many factors that influence patient decision making, health literacy is a major one.

Health literacy is a stronger predictor of health status than age, income, education level, employment status, and race. Health status differences associated with differing levels of health literacy are large enough to imply that significant improvements in overall levels of population health might be realized if a way could be found to raise adult health-literacy levels. Health literacy is independently related to a patient’s knowledge about their disease and is also related to their mortality.

The economic costs of low health literacy include staying in hospital up to 2 days longer, fewer doctor visits but more emergency and hospital visits, and an estimated $7.3 billion (1998 US dollars) in extra medical costs.

Overwhelming and consistent evidence suggests that taking steps to raise health-literacy skills while decreasing the challenges of navigating our health care system would be low-cost approaches to improving overall health and well-being. This approach would result in better understanding and more effective use of health care tools that already exist, rather than funding new health care technology. 

A 2007 health literacy report for Canada found that:
• 60% of adult Canadians (ages 16 and older) lack the capacity to obtain, understand, and act upon health in­formation and services and make appropriate health decisions on their own.
• The proportion of adults with low levels of health literacy is significantly higher among certain groups: older adults, non-English/French speakers, Aboriginal groups, and those with chronic illness and stress.
• Seniors tend to have the lowest level of health literacy, suggesting that the aging process amplifies initial levels of education-based inequality.

What can a physician do? 

First, be aware that you cannot know a person’s health literacy by looks or risk factors. Patients may be verbally articulate and quite knowledgeable but unable to grasp disease concepts or understand treatment regimens. Some common tip-offs to low health literacy are noncompliance with treatment, tests, and appointments; being unable to name medications, understand what they are for, and when to take them; and avoiding reading information in your presence. Adults with low health literacy tell their children of their difficultly only 48% of the time and their health care providers only 25% of the time. Asking patients “What is the best way for you to learn new things?” or “How confident are you filling out medical forms by yourself” may result in disclosure of a problem with literacy.

Second, you can improve adherence to your treatment and improve patient outcomes through the following six steps:
• Slow down when speaking to patients.
• Use plain, non-medical language. 
• Show or draw pictures—visual pictures with an explanation is best.
• Limit the amount of information provided and repeat it.
• Confirm that patients understand by asking them to repeat instructions to you.
• Be open to patients asking questions. 

The third thing you can do to improve your patients’ health literacy is to look for information pamphlets that provide essential information only and is written at a grade 6 level. Ideally, before using it in your office present it to a few patients to test read it for you and explain what it says. Look on the Internet for videos or diagrams that can be used with an explanation.

At the end of a visit a patient should be able to answer the following questions: What is my main problem? What do I need to do about it? Why is it important for me to do this? If they can, you have been successful in your teaching, and that makes a good doctor.

—Romayne Gallagher, MD Chair, Geriatrics Committee