Health literacy requires more than just knowing how to read. It involves a number of additional skills, including listening, analyzing, and decisionmaking. Patients are called on to demonstrate health literacy skills in a variety of situations when interacting with the healthcare system, including deciphering appointment slips; comprehending written and verbal instructions for prescription and OTC medications and supplements; understanding information in health brochures and other instructional and educational materials; comprehending and acting on instructions from healthcare professionals; filling out consent forms; and maneuvering through the often-complex modern healthcare system.
Literacy problems are not rare, nor are they trivial. The 2003 National Assessment of Adult Literacy
found that 43% of adults read at basic or below basic levels, which can translate into poor health outcomes. The Agency for Healthcare Research and Quality
(AHRQ) found that for a number of health and healthcare topics, patients with low literacy had a worse prognosis than those with high literacy
. Populations with sizeable percentages of people who have poor health literacy include the elderly, minorities, immigrants, low-income groups, and people with chronic mental and/ or physical health problems. Reasons for poor health literacy
include lack of higher education, learning disability, cognitive decline among the elderly, and lack of regular reading resulting in diminishing ability over time.IDENTIFYING LOW HEALTH LITERACY
It can be challenging to identify people with low health literacy, as these individuals will not necessarily volunteer their limitations. Th ey often can be ashamed of their limitations and are very protective of them. Th ere is no particular “look” for someone with low health literacy; these individuals can be well-groomed, articulate, and appear quite intelligent (http:// caonline.amcancersoc.org/cgi/content/ abstract/52/3/134).
Formal tests of health literacy include the Rapid Estimate of Adult Literacy in Medicine
(REALM) and the Test of Functional Health Literacy in Adults
(TOFHLA). However, these are not one-size-fi ts-all tools—the lead author of the article on the REALM test only recommends using these formal instruments in clinical practice if the physician is willing to take the time to tailor the communication to the particular patient to be assessed with the formal test.
Physicians and other healthcare professionals must always be on the alert for patients with low health literacy. Beyond merely assuming that patients who are of older age or have limited formal education are at risk, there are several signs that may indicate a patient has low health literacy: claiming they forgot their glasses and therefore cannot read brochures or other print pieces received from your staff , always bringing family members with them to explain instructions and other information, and failing to properly or accurately complete patient intake forms or research surveys.PRACTICAL TIPS FOR IMPROVING
INTERNET-BASED COMMUNICATION With so many patients relying on the Internet as their main source of healthcare information, the diffi culty of the language used to present medical information can pose a major challenge. One study
found that 100% of the English-language websites evaluated off ered health information at the ninth-grade reading level or higher. Even the language used by physicians in written and oral communications with their patients may be confusing or unfamiliar. Davis and colleagues
and Manning and Dickens
offer a number of practical suggestions for clinicians to promote effective communication with patients.Websites
When you are recommending websites to patients or printing pages from websites to distribute to patients, consider whether they are written for people with low health literacy. If you are not aware of specifi c websites that meet this criterion, then recommend those with lower grade reading levels. The typical website is often written at a tenth-grade reading level
. The National Work Group on Cancer and Literacy
recommends that essential written communication for patients should be written at a fifth-grade reading level or lower.