A 75-year-old woman with congestive heart failure fails to weigh herself daily and ends up in the hospital when her symptoms suddenly worsen. A 60-year-old man with hypertension misreads the instructions on his prescription bottle and suffers a dangerous elevation in blood pressure. An 82-year-old with mild cognitive impairment goes to the emergency room with stomach pain but can't remember what medications she's taking.
While each of these cases is hypothetical, the scenarios they describe are unfortunately common. They all involve "health literacy" -- how well someone understands and is able to act on medical advice, and how capable they are of navigating the medical system as a whole. If a patient fails to monitor symptoms, take medications as prescribed, or share important aspects of their medical history, then the medical profession's ability to keep them healthy is drastically impaired.
October is National Health Literacy Month -- a prime time to reignite discussion among professionals in the field about how we can boost health literacy, especially among our most vulnerable populations.
In practice, low health literacy has been linked to poorer management of chronic conditions, less use of preventive services, increased preventable hospitalizations, and worse overall health. Poor health literacy has also been estimated to account for at least 5 percent of the nation's overall health expenditures. By identifying people with low health literacy and working with them to bridge the knowledge gap, we can significantly improve our nation's health while substantially reducing avoidable medical expenses.
Poor Health Literacy: How Big a Problem Is It?
According to the Kaiser Foundation, nearly half of all American adults have difficulty understanding and acting upon health information. Similarly, a survey of Medicare recipients found that one out of three had low health literacy. A national assessment of health literacy conducted by the U.S. Department of Education found that just 12 percent of Americans had "proficient health literacy," meaning they were fully equipped to manage their health and prevent disease, while 14 percent had "below basic health literacy," meaning they lacked even a rudimentary ability to understand medical or preventive health instructions.
Taken together, these findings suggest that most Americans can benefit from improving their health literacy, and that addressing this issue can have a major impact on the health of individuals with low health literacy. It's also clear that the responsibility of improving health literacy rests predominantly with the medical profession. Making sure our recommendations are understood and followed must become a central part of the diagnosis and treatment process.
Approaches to Improving Health Literacy
My own organization, VNSNY CHOICE, administers Medicare plans and managed long-term care programs. Many of our members have one or more chronic medical conditions, and helping them manage their conditions effectively is one of our top priorities. In developing our education materials and protocols, we utilize a number of approaches that have been shown to be effective for communicating for people with limited health literacy. These include:
- Using plain, understandable language in written and spoken communications. This means avoiding medical jargon, breaking down complex concepts into small, easily understandable pieces, and keeping instructions clear and specific. For example, research shows that patients instructed to "take one pill in the morning and a second at 5 p.m." are more likely to take medication correctly than those told to "take two pills daily."
Other helpful approaches include combining verbal and written instructions, using visual illustrations, having the patient bring a family member to appointments, limiting information to a handful of key concepts, organizing communications so the most important information is contained at the very front, and repeating and summarizing key information.
Health Literacy Support in Action
A recent study that evaluated an intervention for CHF (Congestive Heart Failure) patients with low health literacy shows how these different approaches can be brought to bear successfully. In that study, patients had a one-hour session with a health educator in which they jointly went over an educational booklet written for a 6th-grade reading level. Using the "teach back" method, the educators taught them how to weigh themselves and log their weight in a notebook, detect when their symptoms were getting worse, and adjust their medications as needed. The educators then followed up with a series of scheduled phone calls to reinforce their patients' learning and provide motivational support. After 12 months, patients receiving the intervention had significantly lower rates of hospitalization and death, and were more than twice as likely to monitor their weight daily compared to a control group.
Resources for Better Health Literacy
To help doctors, nurses and other medical professionals connect better with all of their patients, the U.S. Agency for Healthcare Research and Quality has developed a toolkit with advice on how to improve communication between caregivers and patients, enhance patient self-management and empowerment, and establish better patient support systems. The toolkit is available here. I strongly recommend that clinicians review this toolkit -- you'll be a better caregiver because of it.
I also urge members of the public to let your doctor know if you don't understand a given instruction, are confused about how to take a medication, or have trouble reading a set of written guidelines. Your health -- and the health of our nation -- is too important to let any misunderstandings get in the way of your medical care. Good health is not just about blindly obeying doctors' orders, it's also about speaking up and asking when you're not sure.