American College of Physicians: Internal Medicine — Doctors for Adults ®


Low health literacy can be harmful to patients' health

From the October ACP Observer, copyright 2006 by the American College of Physicians.

By Lynn Kirk, FACP

As many as 50% of our patients do not have the “capacity to obtain, process, and understand basic health information and services needed to make appropriate medical decisions”. This is the definition of health literacy as laid out by Parker and Ratzan in a National Library of Medicine bibliography on health literacy. Most of us relate health literacy to patients’ abilities to read, but it also means how well they understand spoken instructions to carry out the often-complex tasks necessary to treat and control their acute and chronic diseases. Compounding these factors can be cultural and conceptual differences in understanding of health and illness.

A recent issue of the Journal of General Internal Medicine (JGIM) devoted to health literacy includes several articles about the adverse outcomes of low health literacy. People with lowered health literacy have more problems controlling their chronic diseases, receive fewer clinical prevention interventions, and are less likely to follow up on abnormal screening tests. They also perceive their health as poorer than do adults with adequate health literacy. In the elderly, lower health literacy is independently associated with increased mortality, according to Sudore and colleagues in JGIM. Low health literacy also contributes to some of the health disparities evident in the U.S.

Prescription bottle labels are a particular challenge for people with low health literacy. If patients don't understand instructions for taking medications or prescription label warnings, they are at risk for poor health outcomes. Internists manage an increasingly aging population suffering from multiple chronic diseases. These patients are often taking many different medications, putting them at even greater risk of suffering potentially significant complications if they take their medicines incorrectly.

The ACP Foundation has identified health literacy as its sole focus in its mission to improve the health of the public. The Foundation has committed to developing resources for internists to assist in increasing their patients’ abilities to obtain, process and understand the basic health information needed to make appropriate decisions that impact their health. The Foundation’s objectives include:

  • Promote shared understanding and informed decision making
  • Reduce medical errors and improve health care quality
  • Improve health outcomes
  • Reduce waste and inefficiency
  • Reduce cultural and language barriers to improve health literacy

The Foundation’s Prescription Bottle Labeling Project is working to improve container labeling. Research suggests that using lists, bullets, headers, white space and a logical organization of concepts improves patient comprehension. The Foundation is continuing to work on labeling improvements and the regulatory changes necessary to assure their implementation.

The Foundation has also developed many resources to improve patients’ understanding of common diseases that are available to ACP members on the ACP Foundation Web site. These include HEALTH TiPS, prescription-sized education materials on common topics such as hypertension and smoking cessation. A variety of tools for patients with diabetes is under development and will be available in the next few months.

The Committee on Health Literacy at the Institute of Medicine pointed out in a 2004 monograph that health literacy must be understood in the context of culture and society (National Academies Press, 2004). Both health systems and educational systems (especially K-12 education) need to work to improve health literacy. As internists, we can have a major impact on improving health literacy by being aware of this problem and attempting to identify it in our patients. There is a significant stigma associated with poor health literacy, causing some patients to attribute their lack of understanding to other factors. In the health literacy issue of JGIM, Wallace and colleagues identified a single screening question that could detect low health literacy—“How confident are you in filling out medical forms yourself?”

Several approaches show promise for increasing patients’ understanding of health information in health care settings. These include:

  • Assuring all forms and written information are at an appropriate reading level for patients.
  • Using pictures and graphics to transmit information.
  • Offering materials in patients' native languages.
  • Training staff on the cues that signal low literacy and lack of understanding.
  • Having patients 'teach back' the instructions.

No matter how skilled we are at diagnosing and prescribing treatment for our patients’ problems, we cannot successfully help them improve or maintain their health unless they cannot carry out the treatment plan. By detecting health literacy problems and employing tools to help our patients overcome them, we can improve our success in maintaining health and treating disease in our patients—which is the reason we do this work in the first place.


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