Committee Opinion
Number 585, February 2014
(Replaces Committee Opinion Number 491, May 2011)


Committee on Patient Safety and Quality Improvement
Committee on Health Care for Underserved Women

This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Health Literacy

ABSTRACT: According to the Institute of Medicine of the National Academies, health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. The American College of Obstetricians and Gynecologists is committed to the promotion of health literacy for all. Responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care arena—from the system level to the health care professional.


Each day, patients encounter the challenges of interpreting health information presented by health care providers and making decisions based on their understanding of that information. According to the Institute of Medicine of the National Academies’ report, Health Literacy: A Prescription to End Confusion, nearly one half of all Americans have difficulty understanding health information (1). Engaging patients in difficult health care decisions requires that patients listen, understand, read, and analyze information about their health; in essence, patients are expected to be health literate. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (1). Because situations regarding an individual’s health are often complex and the language used to explain them is often specialized, years of education or reading ability do not necessarily translate into adequate health literacy. Health care professionals often use technical language specific to their areas of expertise with the expectation that individuals who are not familiar with the professional jargon will understand the meaning of complex ideas and terms. Even individuals highly trained in other fields may have difficulty understanding health information and instructions about their care.

The problem of limited health literacy is widespread. Multiple studies have demonstrated the seriousness of the problem, with an increasing body of research demonstrating a correlation between health literacy levels and health outcomes (1). Adults with low health literacy are at increased risk of hospitalization, encounter more barriers to receiving necessary health care services, and are less likely to understand medical advice that can affect disease progression (2–5). In addition, individuals with limited health literacy skills have poorer health status than the rest of the population, which, even after controlling for a variety of sociodemographic variables, is associated with worse health outcomes (6). Given the scope of the problem, the U.S. Department of Health and Human Services identified several objectives within the Healthy People 2020 topic area on health communication and health information technology, including improving the health literacy of the population, increasing the proportion of individuals who use electronic personal health management tools, and increasing the proportion of individuals who report that their health care providers always involved them in decisions about their health care as much as they wanted (7).

Additionally, three recent federal policy initiatives have pushed health literacy to the mainstream of health care practice, which stresses the need for system-level changes for both the health care professional and the setting in which care is delivered. The Affordable Care Act incorporates health literacy into professional training and streamlines the procedures for enrollment into federal and state insurance programs. The Affordable Care Act requires health plans and insurers to provide patient-oriented summaries that give consumers clear, consistent, and comparable health information in a standardized summary of benefits (8). The National Action Plan to Improve Health Literacy states that, “(1) everyone has the right to health information that helps them make informed decisions and (2) health services should be delivered in ways that are understandable and beneficial to health, longevity, and quality of life” (9). The Plain Writing Act of 2010 requires federal agencies to write documents clearly so that the public can understand and use them. These federal policies related to health literacy all have the goal of improving health care access and quality (10).

The current health care delivery system assumes a high level of health literacy. Health literacy includes three components: 1) print literacy (writing and reading), 2) oral literacy (listening and speaking), and 3) numeracy (using and understanding numbers). Individuals are expected to understand and apply verbal information pertaining to consent, diagnosis, medical advice, and treatment; have access to and use a computer, the Internet, cell phone texts, and other smart phone capabilities; calculate and interpret numeric data; and interpret graphs and visual information. Patients are expected to be articulate and accurate about their conditions and symptoms, as well as to have sophisticated decision-making skills. Often, those individuals with the greatest health care needs have limited skills to synthesize and interpret health information (11).

Patients with specific educational or linguistic challenges also may have limited health literacy. Not adhering to therapeutic and medication recommendations, often construed as “noncompliance,” can lead to poor outcomes and may be more related to limited health literacy than to patients’ indifference toward their health. It may be that nonadherent patients are not following recommendations because they do not understand what is expected of them. This is often the case with older patients and those with limited English proficiency or no English proficiency. In the United States, individuals aged 65 years and older use 30% of prescription drugs and 40% of over-the-counter drugs (12). Senior citizens often have low health literacy skills and, therefore, poor comprehension of information on medication labels (13). Low health literacy also may be a problem for immigrant populations for whom English is a second language (14). According to a survey conducted by the American College of Obstetricians and Gynecologists that focused on language access solutions in California, 25% of Fellows reported that one quarter of their patients have limited English proficiency and 38% reported an increase in patients with limited English proficiency during the past 5 years (15).

When the concept of health literacy is taken into consideration, all facets of the medical encounter, including patient education and the informed consent process, are important to improving the patient’s and the public’s health. Individuals with low health literacy are vulnerable to receiving poor-quality care and to being exposed to medical errors because of communication barriers (16). Patient health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, patient education brochures, and consent forms, as well as the ability to negotiate complex health care systems.

Multiple factors affect a patient’s understanding of health information, including the physician’s health knowledge and communication skills, the demands of the situation in which the health information is being conveyed, the medium in which the health information is being conveyed, and time constraints for delivering the information. Other factors include the patient’s ability to communicate effectively with the health care team, to manage and commit to her own health care, and to comprehend complex concepts such as probability and risk. Understanding the unique capabilities of the individual patient will make the information provided by the health care team more accessible for both the patient and her family members. When patients can obtain, process, and understand basic health information, they are more likely to make the most appropriate health decisions.

Responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care profession, from the primary health care team to public health care systems. Making information understandable and accessible to all patients involves a systematic approach toward health literacy in physicians’ offices, hospitals, clinics, national organizations, local health organizations, advocacy organizations, medical and allied health professional schools, residency training programs, and continuing medical education programs. Because nursing and support staff are often the ones identifying the level of health literacy among patients, it is extremely important to also provide them with the appropriate training and resources so they can help navigate these patients through the health care system. Community-based partnerships to help understand and address the needs of the local community and consumer health information organizations to focus on the issue of health literacy are needed in the effort to improve health literacy.

The American College of Obstetricians and Gynecologists is committed to providing patients with clear, understandable, and actionable science-based health information to address the challenges of limited health literacy and supports the following guidelines (adapted from the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion’s Quick Guide to Health Literacy [17]):

  • Tailor speaking and listening skills to individual patients. —Ask open-ended questions using the words “what” or “how” to start the sentence. (For example: “What questions do you have for me?” rather than “Do you have any questions?”)
    —Use medically trained interpreters, when necessary (eg, to assist in the informed consent process).
    —Check for comprehension by asking patients to restate the health information given in their own words. (For example: “Tell me how you are going to take this medication.”) This is particularly useful during the informed consent process.
    — Encourage staff and colleagues to use plain language that is culturally sensitive and to obtain training in improving communication with patients (18). (For more information please refer to the American College of Obstetricians and Gynecologists’ Committee Opinion Number 587, Effective Patient–Physician Communication [19]).
  • Tailor health information to the intended user. —When developing health information, make sure it reflects the target group’s age, social and cultural diversity, language, and literacy skills.
    —When developing information and services, include the target group in the development (pretest) and implementation (posttest) phases of the process to ensure the program is effective.
    —In preparing health information, consider cultural factors and the influence of culture on health, including race, ethnicity, language, nationality, religion, age, gender, sexual orientation, income level, and occupation (18).
  • Develop written materials. —Keep the messages simple.
    —Limit the number of messages (general guideline is four main messages).
    —Focus on action. Give specific recommendations based on behavior rather than the medical principle. (For example, “Take a warm water bath two times a day” instead of “Sitz baths may help healing.”)
    —Use the active voice instead of the passive voice. (For example, “These pills can make you sick to your stomach” instead of “Nausea may be caused by this medication.”)
    —Use familiar language and avoid jargon. (For example, “You may have itching” instead of “You may experience pruritus.”)
    —Use visual aids such as drawings or models for key points. Make sure the visual messages are culturally relevant.
    —Use at least a 12-point type size to make the messages easy to read.
    —Leave plenty of white space around margins and between sections.

Because of the potential effect of health literacy on patient outcomes, obstetrician–gynecologists should take the appropriate steps to ensure that they communicate with their patients so that they can understand and make informed decisions about their health care.

The American College of Obstetricians and Gynecologists’ Resource

American College of Obstetricians and Gynecologists: For patients. Available at: acog.org/For_Patients. Retrieved August 1, 2013.

Resources

The following resources are for information purposes only. Referral to these sources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. These resources are not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.

The Joint Commission. “What did the doctor say?” Improving health literacy to protect patient safety. Oakbrook Terrace (IL): Joint Commission; 2007. Available at: http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf. Retrieved August 5, 2013.

Agency for Healthcare Research and Quality. Health literacy universal precautions toolkit. AHRQ Publication No. 10-0046-EF. Rockville (MD): AHRQ; 2010. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/literacy-toolkit/healthliteracytoolkit.pdf. Retrieved August 5, 2013.

National Center for Education Statistics. National Assessment of Adult Literacy (NAAL): a first look at the literacy of America’s adults in the 21st century. Washington, DC: NCES; 2005. Available at: http://nces.ed.gov/NAAL/PDF/2006470.pdf. Retrieved August 5, 2013.

Centers for Disease Control and Prevention. Health literacy: accurate, accessible and actionable health information for all. Available at: http://www.cdc.gov/healthliteracy/index.html. Retrieved August 1, 2013.

References

  1. Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004.
  2. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791–8. [PubMed] [Full Text] 
  3. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274: 1677–82. [PubMed]
  4. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166–72. [PubMed] [Full Text] 
  5. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545–51. [PubMed] [Full Text] 
  6. Weiss BD, Health literacy and patient safety: help patients understand. Manual for clinicians. Chicago (IL): American Medical Association; 2007, Available at http://www.ama-assn.org/resources/doc/ama-foundation/healthlitclinicians.pdf. Retrieved August 5, 2013.
  7. Department of Health and Human Services. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Retrieved August 5, 2013.
  8. Center for Health Care Strategies. Health literacy implications of the Affordable Care Act. Hamilton (NJ): CHCS; 2010. Available at: http://www.chcs.org/usr_doc/Health_Literacy_Implications_of_the_Affordable_Care_Act.pdf. Retrieved August 5, 2013.
  9. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National action plan to improve health literacy. Washington, DC: HHS; 2010. Available at http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. Retrieved August 5, 2013.
  10. Koh HK, Berwick DM, Clancy CM, Baur C, Brach C, Harris LM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly ‘crisis care.’ Health Aff 2012;31:434–43. [PubMed] [Full Text] 
  11. Parker RM, Gazmararian JA. Health literacy: essential for health communication. J Health Commun 2003;8 (suppl 1): 116–8. [PubMed] 
  12. Salom IL, Davis K. Prescribing for older patients: how to avoid toxic drug reactions. Geriatrics 1995;50:37–40, 43; discussion 44–5. [PubMed] 
  13. Morrell RW, Park DC, Poon LW. Effects of labeling techniques on memory and comprehension of prescription information in young and old adults. J Gerontol 1990; 45:P166–72. [PubMed] 
  14. Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. J Health Care Poor Underserved 2005;16:152–66. [PubMed]
  15. American College of Obstetricians and Gynecologists. Strengthening communication capacity: California’s OB/GYNs enhance language access for limited English proficient patients. Sacramento (CA): ACOG District IX; 2006. Available at: acog.org/http://www.acog.org/-/media/Districts/District%20IX/2006LanguageAccessSolutionsReport.pdf?dmc=1&ts=20130801T1642187019 . Retrieved August 5, 2013.
  16. National Quality Forum. Improving patient safety through informed consent for patients with limited health literacy: an implementation report. Washington, DC: NQF; 2005. Available at: http://www.qualityforum.org/Publications/2005/09/Improving_Patient_Safety_Through_Informed
    _Consent_for_Patients_with_Limited_Health_Literacy.aspx
    . Retrieved August 5, 2013.
  17. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Quick guide to health literacy. Available at: http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf. Retrieved August 5, 2013.
  18. Cultural sensitivity and awareness in the delivery of health care. Committee Opinion No. 493. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 117:1258–61. [PubMed] [Obstetrics & Gynecology] 
  19. Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014:123:389–93.

Copyright February 2014 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Health literacy. Committee Opinion No. 585. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:380–3