Low health literacy is pervasive barrier to care

Washington -- How hard can it be to select the proper spoon to administer medicine? Surprisingly difficult, actually. The Institute of Medicine found that very few people could pick out the one that holds a traditional 5 mL of liquid.

This test is one of the ways the IOM panel illustrated its point that nearly half of all American adults, or 90 million people, have difficulty understanding and using the health information that is dispensed in physicians' offices and in hospital discharge instructions.

A companion report, "Literacy and Health Outcomes," written by the Agency for Healthcare Research and Quality and requested by the AMA, confirmed that low reading skills and poor health are clearly related.

"Limited health literacy is a huge obstacle standing between millions of America's patients and the health care they need and that physicians wish to deliver," said AMA President-elect John C. Nelson, MD, at an April 8 briefing to release the two reports.

Low health literacy is a pervasive problem that can result in patients being unable to understand basic information presented by their doctor, the studies concluded.

"Tens of millions of U.S. adults are unable to read complex texts, including many health-related materials. Arcane language and jargon that become second nature to doctors and nurses are inscrutable to many patients," according to the IOM report "Health Literacy: A Prescription to End Confusion."

However, the AMA has been aware of the problem for some time and has developed several approaches for physicians to use when communicating to patients.

Among them: Use simple language; ask a patient to paraphrase what has just been said; and suggest they bring a friend or relative to sit in on a counseling session.

The AMA and its philanthropic arm, the AMA Foundation, began the effort to provide physicians the means to overcome patients' low health literacy in 1998, said Dr. Nelson. A kit, "Health Literacy: Help Your Patients Understand," is available at the AMA Foundation's Web site. The AMA has also brought speakers to physicians in hospitals and clinics and is offering continuing medical education credit to physicians who commit to reading and learning the materials. "We think it's that important," said Dr. Nelson.

And the tips are working.

"Most of us are slowing down when we speak to allow patients time to understand what they're hearing. We're saying 'high blood pressure' instead of 'hypertension.' And more of us are asking patients to repeat the information we give them, in their own words," he said.

Instructions vital to patients' health go well beyond medication instructions. "Patients with low literacy don't just have prescription problems," he added. "They also tend to have a lower estimation of their own health status, and they are right. The reports released today say people with low health literacy are less healthy -- physically and psychologically."

Complex decisions ahead

Health literacy is more than a measurement of reading skills, according to the IOM report. It includes listening, speaking, having adequate background information and being able to advocate for oneself in the health system. A person who has finished high school and knows how to read may still not be able to navigate the health system.

Low literacy also plays an important role in health disparities and may contribute to lower quality care and even medical errors, said AHRQ Director Carolyn M. Clancy, MD.

Americans with lower-than-average reading skills are less likely than other Americans to get potentially lifesaving screening tests such as mammograms and Pap tests, to get flu and pneumonia vaccines and to take their children for well-child visits, the AHRQ report found.

The report also provides a roadmap for the research that still needs to be done, including how to improve health literacy, said Dr. Clancy. To this end the Dept. of Health and Human Services, the AMA and the American Hospital Assn. have produced a five-step program intended to help patients become better health consumers.

Among the steps: Ask questions if you have doubts or concerns; bring a list of all medications to appointments; get the results of any tests; talk to your physician about which hospital is best for a particular procedure; and make sure you understand what will happen if you need surgery.

Improving health literacy is even more important as patients are called upon to negotiate their way through an increasingly complex treatment world.

In recent years, patients have had to assume more responsibility for their own health, said U.S. Surgeon General Richard H. Carmona, MD, MPH. "But do people know how many grams of fat to eat in a day? Or how much of a drug is too much? Even if they don't ask the questions, we need to provide the answers."