Avenues explored for improving health literacy

A conference focuses on the scope of the problem and on ways physicians and others can help patients who have trouble understanding instructions and information.

By Susan J. Landers — Posted Dec. 17, 2007

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Complexity in the health care system is widely acknowledged as a barrier to effective care for many people, and now it's time to simplify, simplify, simplify, said participants at a recent conference, Advancesin Health Literacy.

With researchers having already demonstrated some serious problems associated with poor health literacy -- more emergency department visits and hospitalizations, and patients' inability to follow physicians' directions -- they are now shifting their focus to finding solutions. Several were presented at the conference, co-sponsored by the American College of Physicians Foundation and the Institute of Medicine and held Nov. 28 in Washington, D.C.

It was the IOM's 2004 report, "Health Literacy: A Prescription to End Confusion," that found that nearly half of all American adults -- 90 million people -- have difficulty understanding and using health information.

Health literacy goes beyond just reading to include writing, listening, speaking and mathematical skills, noted the report. Those skill sets come into play even before patients set foot in a physician's office; without such skills, patients may not even be able to find the office.

The situation is likely to worsen in coming years, said Rose Martinez, ScD, director of the IOM's Board on Population Health and Public Health Practice. She presented information assembled by the IOM Roundtable on Health Literacy showing that as immigration increases, accompanied by lower English language proficiency, unemployment also will grow, along with the number of uninsured. Health literacy issues likely will be most severe among those older than 65.

Congress has taken note of the problem and is working on legislation to establish federal and state health literacy resource centers. A bill is expected soon.

The AMA also is engaged in finding solutions to the health literacy problem and encourages the development of patient education materials and medical education programs that include ways to communicate more effectively with patients who have limited literacy skills.

Meanwhile, community-based programs in New York City have established partnerships with hospitals and physicians. These Health Literacy Study Circles, developed by Rima Rudd, ScD, MSPH, a senior lecturer at the Harvard School of Public Health, are taught in 200 literacy programs where 20% of class time is devoted to health issues.

Topics covered include navigation skills, oriented to hospitals, labs or pharmacies; the importance of screening and prevention; and management of chronic diseases, said Elyse Barbell Rudolph, executive director of New York City's Literacy Assistance Center.

"We use real-life materials," she said. Encountering registration forms for the first time in the less-threatening classroom can help diminish the fear some students experience when they visit a physician's office or hospital. "It's terrifying to students to go through all the steps they must take before they see the doctor."

The program helps demystify the health care system by bringing entire classes to participating hospitals where they receive health screenings and explanations from physicians on such troubling experiences as long emergency department waits.

The program has led to increased health insurance enrollment, proper emergency department use, increased health screening rates and stronger connections with primary care physicians, said Rudolph. "The gains from this have been tremendous."

Physicians also have roles to play and may in fact be unwittingly contributing to the problem, said George Isham, MD, chair of the IOM Health Literacy Roundtable. Although 80% of physicians believe that their patients understand what they are saying, a mere 37% of patients agree that this is the case, he said.

One way to confuse patients less is to simplify prescription drug labels, said Dr. Alastair J.J. Wood, managing director of Symphony Capital LLC, a private equity firm that invests in novel biopharmaceuticals.

A recent study found that 46% of adults misunderstood at least one drug label, said Dr. Wood, who spoke at the conference. He is the former chair of the Food and Drug Administration's Nonprescription Drugs Advisory Committee. He advocates the standardization of medication dosing times so patients are instructed to take their medicines at the same times each day, such as breakfast, lunch, dinner and bedtime.

The ACP Foundation also stepped into the information breach, releasing a simply written, lavishly illustrated diabetes guide produced as a patient handout. Although physicians want to teach patients how to manage their diabetes, they often don't have the time, said Terry Davis, PhD, professor of medicine and pediatrics at the Louisiana State University Health Sciences Center in Shreveport.

Physicians may provide diabetes patients with too much information, information that isn't useful, or not enough information, Dr. Davis said. Plus, she said, young physicians often use scare tactics, and older physicians may be fatalistic about the disease. The guide, which is also produced in Spanish, is limited to the topics most patients find important. These include eating, exercise, monitoring blood sugar, insulin and keeping track of medications, she said.

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More deaths, too

Low health literacy is not just associated with poorer health. Researchers at Northwestern University's Feinberg School of Medicine in Chicago found it also leads to higher death rates among older people. They concluded that inadequate health literacy, measured by reading fluency, was an independent risk factor for higher mortality from all diseases and particularly from cardiovascular disease. Researchers followed more than 3,000 Medicare managed-care enrollees in four cities for six years. They determined that 2,094 had adequate literacy, 366 had marginal literacy and 800 had inadequate literacy.

deaths (380)
deaths (309)
Adequate literacy 7.9% 5.8%
Marginal literacy 16.7% 4.6%
Inadequate literacy 19.3% 8.8%

Note: When adjusted for other factors, participants with inadequate health literacy did not have higher cancer death rates. Study authors speculated that cancer treatment generally follows an established course of surgery or chemotherapy; cardiovascular conditions usually require more patient self-care.

Source: Archives of Internal Medicine, July 23

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External links

American College of Physicians Foundation resources on health literacy (link)

Institute of Medicine Roundtable on Health Literacy (link)

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