Experts debate value of assessing health literacy

Should physicians adjust the communication level for each patient, or are comprehension difficulties so common that simpler language should be used with everyone?

By Victoria Stagg Elliott — Posted June 2, 2008

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A patient's health literacy can be measured quickly, according to a study published in the May-June Journal of the American Board of Family Medicine, but many experts question whether this information is necessary to guide medical care.

"This is fine for research, but it's not appropriate for clinical practice," said Joanne G. Schwartzberg, MD, director of aging and community health at the American Medical Association. "Clinicians can better spend their time ensuring that all their patients understand the medical information they need to know to care for themselves."

Researchers administered the tool that uses comprehension of an ice cream nutrition label to measure health literacy to 78 consecutive patients presenting at an outpatient primary care clinic. The activity took an average of 2.9 minutes per person to complete, and the authors suggest this may be a good way to perform literacy screening in clinical practice.

"As a physician, you want to know how much of what you are telling a patient is getting through. This gives some guidance on how to tailor your message," said Kristen Johnson, MD, lead author and a family physician at The Polyclinic in Seattle.

Those behind this tool add, however, that there is not enough evidence to support routine use. Rather, they would like to see physicians use it to raise their own awareness of health literacy in their practices.

"Some people are arguing with some justification that screening every patient really doesn't make sense," said Barry D. Weiss, MD, the paper's co-author and professor of family and community medicine at the University of Arizona College of Medicine in Tucson. "But, if physicians used this on the next 200 people in their practice, they would be universally surprised. There's a problem in everybody's practice because low literacy is very prevalent, and most clinicians don't know about it."

Many experts, though, wondered if this kind of assessment should be performed. They cite concerns about stigmatizing patients and a lack of evidence that performing this screening affects outcomes. They also note that factors such as anxiety or information overload may be interfering with a patient's ability to understand.

"It has not been shown to benefit patients for doctors to know that they have limited literacy," said Michael Paasche-Orlow, MD, MPH, an internist and assistant professor of medicine at Boston University School of Medicine. "A fair portion of folks with limited literacy are ashamed when asked about this. And, even if the testing can be done in a nonjudgmental fashion, they would still very much not want this information included in their medical record."

In addition, many argue that since health literacy is problematic in many patients, a broad approach should be taken, with an across-the-board lowering of the level of education required to understand communication in a health setting.

"We don't insult people by doing that. All people are grateful for clarity," said Ruth Parker, MD, professor of medicine at Emory University School of Medicine in Atlanta and a member of the Institute of Medicine's Roundtable on Health Literacy.

For example, according to data released last month by the Agency for Healthcare Research and Quality, only 12% of adults have the skills to proficiently manage their own medical care. About 53% had intermediate skills and were able to determine the right time to take a medication based on label information. Another 22% had basic skills, meaning they could read a pamphlet and understand two reasons why a test might be appropriate despite a lack of symptoms. Lastly, 14% could only comprehend short sets of instructions, such as what they are allowed to drink before a medical test.

The AMA recognized low health literacy as barrier to effective medical diagnosis and treatment in 1998, and, through the AMA Foundation, has organized numerous educational opportunities for physicians, including videos, which are available online (link).

A Foundation report, "Assessing the Nation's Health Literacy," is expected to be released in July.

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External links

Health Literacy, AMA Foundation (link)

"How Long Does It Take to Assess Literacy Skills in Clinical Practice?" Journal of the American Board of Family Medicine, May-June (link)

"The Newest Vital Sign: A New Health Literacy Assessment Tool for Health Care Providers," Pfizer Clear Health Communication Initiative (link)

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