Health Literacy

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, 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, and to use such information and services in ways that are health enhancing (1, 2). 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 people 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. Whereas approximately 10% of Americans have low general literacy (skills necessary to perform simple and everyday literacy activities), 50% of adults are estimated to have marginal health literacy skills to low health literacy skills (3, 4). Multiple studies have demonstrated theseriousness of the problem. 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 their disease progression (5–8). Given the scope of the problem, the U.S. Department of Health and Human Services identified several target areas in the Healthy People 2010 objectives to improve health communication, which incorporated goals related to health literacy and cultural competency (9). These target areas also are included in the goals and objectives for Healthy People 2020.

Our current health care delivery system assumes a high level of health literacy. Individuals are expected to understand and apply verbal information pertaining to consent, diagnosis, medical advice, and treatment; have access to and use a computer and the Internet; calculate and interpret numerical 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 (10).

Patients with specific educational or linguistic challenges also may have limited health literacy. Nonadherence to therapeutic and medication recommendations, often pejoratively labeled “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, people 65 years and older consume 30% of prescriptions and 40% of over-the-counter drugs (11). Senior citizens often have low health literacy skills and, therefore, poor comprehension of information on medication labels (3, 12). Low health literacy also may be a problem for immigrant populations for whom English is a second language (13). According to a project conducted by the American College of Obstetricians and Gynecologists, which 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 (14).

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 (15). 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, 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 Gyne-cologists 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 [16]):

1. 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.
   • 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 (15).
   • Encourage staff and colleagues to use plain language that is culturally sensitive and to obtain training in improving communication with patients (17). (For more information please refer to the American College of Obstetricians and Gynecologists' Committee Opinion on "Effective Patient–Physician Communication" [18]).

2. 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 (17).

3. 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 on your genitalia.")
   • 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.

ACOG Resource

The following online resource may be helpful to physicians in finding resources for patients:

American College of Obstetricians and Gynecologists www.acog.org/goto/patients

Resources

The resources listed here are for information purposes only. Referral to these resources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. Further, the American College of Obstetricians and Gynecologists does not endorse any commercial products that may be advertised or available from these organizations or on these web sites. This list is 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 and URLs are subject to change without notice.

American Academy of Family Physicians
http://www.familydoctor.org

National Center for Farmworker Health, Inc.
http://www.ncfh.org/?sid=40

Oregon Health and Science University: Low-literacy handouts in English
http://www.ohsu.edu/library/patiented/links.shtml#lowlit

U.S. Department of Health and Human Services, Office on Women's Health: Womenshealth.gov in Spanish
http://www.womenshealth.gov/espanol

University of Washington, Harborview Medical Center: Ethnomed
http://ethnomed.org

References

1. Institute of Medicine (US). Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004.
2. Joint Committee on National Health Education Standards. National Health Education Standards: achieving excellence. 2nd ed. Atlanta (GA): American Cancer Society; 2007.
3. 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 November 5, 2010.
4. Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175–84.
5. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791–8.
6. 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.
7. 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.
8. 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.
9. U.S. Department of Health and Human Services. Health communication. In: Healthy People 2010. 2nd ed. With understanding and improving health and objectives for improving health. Washington, DC: U.S. Government Printing Office; 2000. p. 11-3–11-25. Available at http://www.healthypeople.gov/Document/pdf/Volume1/11HealthCom.pdf. Retrieved January 25, 2011.
10. Parker RM, Gazmararian JA. Health literacy: essential for health communication. J Health Commun 2003;8 Suppl 1:116–8.
11. Salom IL, Davis K. Prescribing for older patients: how to avoid toxic drug reactions. Geriatrics 1995;50:37, 40, 43; discussion 44–5.
12. 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.
13. 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.
14. 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: http://www.acog.org/~/media/Districts/District%20IX/2006LanguageAccessSolutionsReport.ashx. Retrieved January 25, 2011.
15. 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/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=22090. Retrieved January 25, 2011.
16. U.S. Department of Health and Human Services. Quick guide to health literacy. Washington, DC: HHS; 2006. Available at: http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf. Retrieved January 25, 2011.
17. 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.
18. Effective patient–physician communication. Committee Opinion No. 492. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011:117:1254–7.