This Fact Sheet is used with the permission of the Center for Health Care Strategies, Inc. All CHCS Health Literacy Fact Sheets are available in pdf form at www.chcs.org.

Health literacy is the ability to read, understand, and act on health care information.

Healthy People 2010 defines health literacy 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

The AMA Council of Scientific Affairs more specifically defines functional health literacy as "the ability to read and comprehend prescription bottles, appointment slips, and the other essential health related materials required to successfully function as a patient." ²

• A study of 483 asthma patients found that although two-thirds reported graduating from high school, only 60% could read above the sixth-grade level. Reading ability was the single strongest predictor of asthma knowledge. Twice as many patients reading below the third-grade level had poor metered-dose inhaler technique as patients reading at high-school level (89% vs. 48%). ³

People with low functional health literacy are less likely to: ^{5, 6, 7}

• Understand written and oral information given by physicians, nurses, pharmacists, and insurers.
• Act upon necessary procedures and directions such as medication and appointment schedules.
• Be able to navigate the health system to obtain needed services.

People with low functional health literacy are more likely to: ^{8, 9, 10}

• Receive health care services through publicly financed programs, even after controlling for such factors as age, education, or socioeconomic status.
• Incur higher health care costs. A study of Medicaid patients found those reading below third-grade level had average annual health care costs four times those of the overall Medicaid population.

Several studies have indicated poor health status is disproportionately high among patients with low functional health literacy. For example:

• A study of 212 low-income men found that low literacy is a better predictor than race or age of advanced prostate cancer. ¹¹
• A study of 182 HIV-positive adults found that those with low functional health literacy were more likely to miss treatment doses than those with high health literacy because of confusion about the instructions. ¹²

References

This Fact Sheet is used with the permission of the Center for Health Care Strategies, Inc. All CHCS Health Literacy Fact Sheets are available in pdf form at www.chcs.org.

Health literacy problems affect people from all backgrounds, especially those with chronic health problems.

Older people, non-whites, immigrants, and those with low incomes are disproportionately more likely to have trouble reading and understanding health-related information.

• According to the National Adult Literacy Survey (NALS): ¹
  • 66% of U.S. adults age 60 and over have inadequate or marginal literacy skills.
  • 50% of welfare recipients read below fifthgrade level.
  • 50% of Hispanic Americans and 40% of African Americans have reading problems.
• Inadequate literacy was an independent risk factor for hospital admission among 3,260 elderly managed care enrollees. ²
• Health literacy problems were independently associated with worse glycemic control among 408 English- and Spanish-speaking patients with diabetes. ³

Those with poor health literacy are more likely to have a chronic disease and less likely to get the health care they need.

• According to the NALS¹, 75% of Americans who reported having a long-term illness (six months or more) had limited literacy. This may mean they know less about their conditions or how to handle symptoms.
• Emergency room patients with inadequate literacy are twice as likely to be hospitalized as those with adequate literacy — even after adjusting for self-reported health, health insurance, and socioeconomic characteristics (32% vs. 15% in a study of 979 patients). ⁴

But “You can't tell by looking.”

Even practitioners who have worked with low-literacy patients for years are often surprised at the poor reading skills of some of their most poised and articulate patients. ⁶

• Two-thirds of 58 patients who admitted having reading difficulties had never told their spouse. Nine of them had told no one. ⁷
• Physicians at a women's health clinic could identify only 20% of their patients who were at the lowest literacy level (third grade). ⁸

References

This Fact Sheet is used with the permission of the Center for Health Care Strategies, Inc. All CHCS Health Literacy Fact Sheets are available in pdf form at www.chcs.org.

Poor health literacy can have profound financial consequences. In 2001, low functional literacy resulted in an estimated $32 to $58 billion in additional health care costs.

According to the National Adult Literacy Survey (NALS), as many as 44 million people (age 16 and older), or 23% of all adults in the United States are functionally illiterate. An additional 28% of all adults — 53.5 million people — had only marginally better reading and computational skills. This suggests that nearly 50% of all adults may have problems understanding prescriptions, appointment slips, informed consent documents, insurance forms, and health education materials. ¹

After adjusting for health status, education level, socio-economic status, and other demographic factors, people with low functional literacy have less ability to care for chronic conditions and use more health care services. In 1998, for example:

• Adults whose functional literacy was in the bottom 20% were more than 1.5 times more likely to visit a physician than adults with higher functional literacy. ²
• Adults whose functional literacy was in the bottom 20% were likely to have 3 times as many prescriptions filled than adults with higher functional literacy. ³

This finding was recently confirmed by modeling the probability of low functional literacy skills using data from NALS and applying those probabilities to people in the 1998 Medical Expenditure Panel Survey (MEPS). ⁴ A model was estimated, using information that was similar in both NALS and MEPS that would predict the observed literacy scores in the NALS. This model included age, educational attainment, race, gender, marital status, and employment status. The study found that people whose estimated level of functional literacy was in the lowest 20% used substantially more health care services, resulting in greater health care expenditures. The study controlled for age, gender, health status, income, and type of insurance coverage.

The following tables show average expenditures per person by health status and family income among people whose estimated functional literacy is in the bottom 20% compared to the rest of the population. Average per person expenditures were greater among those most likely to have low functional literacy.

The direct medical costs of low functional literacy are financed through additional hospital and office visits, longer hospital stays, extra tests, procedures, and prescriptions. While all payers fund these additional resources, taxpayers finance a disproportionate share:

• Medicaid finances 47% of the additional health care expenditures.
• Medicare finances 19% of the expenditures.
• Employers may be financing as much as 14% of the additional health care expenditures for their employees and their employees' dependents.
• The patients who have the poorest health literacy skills finance 14% of these additional health care expenditures as out-of-pocket co-payments and deductibles.



References

1. Kirsch I.S., et al. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. National Center for Education Statistics, Department of Education, 1993. ↑
2. Center on an Aging Society tabulations from the Medical Expenditure Panel Survey, 1998. ↑
3. Center on an Aging Society tabulations from the Medical Expenditure Panel Survey, 1998. ↑
4. Funding for this research was provided by Pfizer Inc to the Center on an Aging Society. ↑

This Fact Sheet is used with the permission of the Center for Health Care Strategies, Inc. All CHCS Health Literacy Fact Sheets are available in pdf form at www.chcs.org.

Patients with poor health literacy skills struggle to understand basic medical forms and instructions.

“… [W]hen they give you papers to fill out ... you want to know what it means before you sign it … [but it's] sign this, sign that. I don't know what that means.” — A patient ¹

• It is especially difficult for less literate patients to fill out intake forms, enroll in insurance programs for which they may be eligible, get services once enrolled, follow medical instructions, or give informed consent.
• Most informed consent and insurance forms, and most medication package inserts, are written at high school level or higher. ^{2, 3}
• Of 979 emergency department patients with inadequate health literacy: ⁴
  • 81% could not read the rights and responsibilities section of a Medicaid application.
  • 74% did not know if they were eligible for free care.

Prescription labels and self-care instructions are among the most important written materials patients receive.

Poor compliance with medication and care regimens can be dangerous. Yet serious mistakes may occur because the patient cannot read the instructions.

• Among 659 public hospital patients, those with poor health literacy skills were five times more likely to misinterpret their prescriptions than those with adequate skills. ⁵
• Reading skill was the strongest predictor of asthma knowledge in a study of 483 patients. Only 11% of those reading below a third-grade reading level could use their metered dose inhaler correctly. ⁶
• HIV-positive adults with low functional health literacy missed more treatment doses than patients with high health literacy because they were confused by the instructions in a study of 182 patients. ⁷

Poor health literacy has legal ramifications for health care professionals.

It is up to the health care system to be sure patients understand the information they receive well enough to apply it.

• The Food and Drug Administration, Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance all require that health care institutions be able to document evidence of patient understanding of the medical information provided to them. ^{8, 9, 10, 11}
• But none of these can document whether a particular patient understands the one form they need at the moment. This leaves it up to the person requesting the data, the provider conducting the procedure or writing the prescription, or the practitioner providing the instructions to ask the patient what s/he under stands.

References

Since it was first published. Teaching Patients with Low Literacy Skills by Doak, Doak, & Root has become a major resource book for health information providers who know that their patients aren't getting the message. It addresses the mismatch between the literacy skills of Americans and the literacy demands of healthcare instruction.

This book is provided here as a series of PDF files with permission of the authors Ceci and Len Doak.

To read or download each section, click or right-click the following links:

   Doak.1.Intro.pdf   436.0 KB   
   Doak.2.Chap1-4.pdf   5,554.5 KB   
   Doak.3.Chap5-7.pdf   6,178.6 KB   
   Doak.4.Chap8-10.pdf   4,349.2 KB   
   Doak.5.Appendices.pdf   1,267.0 KB   

Health Literacy & Plain Language                      Resource Guide

Thank you for your interest in the Health Literacy & Plain Language Resource Guide, created by Health Literacy Innovations with support from the AmeriHealth Mercy Family of Companies.

Download   HLI_Resources_Guide.pdf   748.9 KB   

In late 2007, Health Literacy Innovations conducted the first national survey on Medicaid guidelines for health literacy. The results of the survey, including state reading level requirements for printed material, is available as a FREE download:

Download   HLI_Medicaid_Survey.pdf   77.8 KB   

Of the many solutions for health literacy, one is to improve health communication. To help writers understand and best use readability indices to simplify information for health care consumers, Health Literacy Innovations launches its newsletter, with the first issue dedicated exclusively to readability indices.

Download   HLI_Newsletter_Vol_1_Iss_1.pdf   643.8 KB   

http://guides.lib.umich.edu/content.php?pid=30712&sid=224563

http://www.nphic.org/members-area/tools/linklibrary/164-health-literacy.html

Download   HealthLiteracyWebResources03-09.pdf   75.3 KB