ACCEL Classics

Take-Home Messages

  • As medical treatment decisions become more complex and chronic diseases become more prevalent, the issue of health literacy has become an urgent issue.
  • Low health literacy is surprisingly widespread and can be found in some people with college degrees and even graduate degrees.
  • There are universal precautions that can be taken to improve patient communications and these can be used by clinicians and their staff.

In recent years, there has been a growing interest in the silent CV risk factor: low health literacy.

Health literacy is defined as the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. This is problematic for many people.

  • Forty million Americans cannot read complex texts like these at all.
  • Nearly half of American adults—90 million people—have difficulty understanding and acting upon health information.
  • There is a higher rate of hospitalization and use of emergency services among patients with limited health literacy.
  • Limited health literacy contributes to billions of dollars in avoidable health care costs.
  • —Source: Institute of Medicine (IOM), Health Literacy:
    A Prescription to End Confusion

More than a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. In daily life, different types of literacy are required; any one of which can make understanding a challenge. They include: 1) prose literacy—understanding text such as newspapers and magazines; 2) document literacy—understanding tables, forms, graphs, maps, etc; and 3) quantitative literacy—understanding measurements and other numeric information.

At some point, most individuals will encounter health information they cannot understand. Even well-educated people with strong reading and writing skills may have trouble obtaining, understanding, and using complex health information. For example:

  • A surgeon may have trouble helping a family member with Medicare forms.
  • A science teacher may not understand information sent by a doctor about a brain function test.
  • An accountant may not know when to get a coronary imaging test.

These well-educated people have plenty of company. The National Center for Health Statistics estimates that 13% of college graduates and 11% of people who have undergone graduate studies or obtained a graduate degree operate at a basic or below basic level of health literacy. Clearly, a diploma is no guarantee an individual can understand complex information and navigate the health care system.

So What?

According to the National Patient Safety Foundation:

  • Annual healthcare costs for those with low literacy skills are four times higher than those with higher literacy skills.
  • Poor patient compliance and medical errors may be based on poor understanding of healthcare information.
  • Patients with low health literacy and chronic disease have less knowledge of their disease and their treatment options, as well as fewer correct self-management skills than literate patients.
  • Patients with low literacy skills have a 50% increased risk of hospitalization than patients with adequate literacy skills.

Recognizing low health literacy is the first step. You can’t tell by looking, but you can recognize red flags in patients:

  • Seeking help only when illness is advanced
  • Making excuses
  • Becoming angry/demanding or quiet/passive
  • Difficulty explaining concerns or no questions
  • Frequently missed appointments, tests
  • Non-compliance
  • Statements such as “I forgot my glasses” or “I’ll bring this home so I can discuss it with my family”
  • Intake forms incomplete
  • Medication review marked by looking versus reading

Also, literacy declines with age, regardless of education.

There are a number of office strategies that can be employed to help patients:

  • All staff should be made aware of literacy issues
  • Speak slowly to foster a patient-centered approach
  • Use plain, nonmedical language
  • Use supplemental materials with visual images to improve both understanding and recall
  • Limit the amount of information and repeat it
  • Use teach-back to confirm patient understanding
  • Reinforce education with follow-up phone calls/visits
  • Create a collaborative environment to encourage questions
  • Enlist the aid of the patient’s family or friends—a second pair of eyes and ears who can reinforce and clarify later


“The main problem with communication is the assumption it has occurred.”
George Bernard Shaw


Keywords: Universal Precautions, Medical Errors, Confusion, Health Literacy, Health Care Costs, Risk Factors, Patient Safety, Hospitalization, Communication, Patient Compliance

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