Information Resources for Medical Students: Health Literacy

It's estimated that 36 percent of American adults have low or limited levels of Health Literacy (The Health Literacy of America's Adults, NAAL, 2003)  Populations at risk of low or limited Health Literacy include:

• older adults
• minorities
• those with limited English proficiency
• those with with less than a high school diplomas or equivalent.
• the uninsured, or those with Medicaid
• those who live below the federal poverty threshold

A patient with low HL might:

• not be able to describe his symptoms, understand a diagnosis or test results
• not be able to fill out insurance forms or a health history
• not be able to take medication correctly, read prescription labels or understand drug interactions and adverse effects
• not be able to manage a chronic condition
• not understand the connection between risky behavior and health effects
• not utilize preventive medicine
• not seek care until it is an emergency; or use emergency services for minor conditions

Low or limited levels of Health Literacy can be correlated to:

• poorer health outcomes, especially among the elderly
• higher medical costs due to lack of preventive care and use of higher cost emergency services
• poor medication adherence, resulting in inability to manage chronic conditions
• higher hospital admissions and readmissions
• higher mortality rates

The 2006 report, Low Health Literacy: Implications for National Health Policy, estimated that low health literacy costs the US economy in the range of $106 to 238 billion a year- enough to insure an additional 47 million Americans.

You might not be able to tell if a patient has low or limited health literacy. In fact, your patient can have high literacy or numeracy skills, yet low health literacy skills. Stress and anxiety about the medical setting may interfere with communication. Physicians routinely overestimate the HL skills of patients in the clinical setting, especially in minority populations. Consequently, the use of medical terminology and jargon increases while comprehension decreases, setting the patient up for poor outcomes.

Look for cues that a patient does not understand.  When presented with information, a patient with low HL might:

• Takes printed information to "read later" or claims he has forgotten his glasses.
• Misses appointments or arrives at the wrong time.
• Takes medication incorrectly or not at all.
• Has no questions
• Becomes visibility frustrated or shuts down
• Present as non-compliant

It's important to remember that patients with low literacy skills may not have told anyone about their difficulties.  Low or limited literacy might be a source of significant shame and embarrassment for the patient, and they may have developed coping mechanisms.

How to help patients

There are simple actions healthcare staff can take to help assess a patient's literacy level. 

• An assessment tool can be applied as a screening tool for all new patients.
• Front end staff can provide a private area where a patient can ask questions or receive assistance in filling out insurance forms and health histories.
• Physicians can minimize the use of medical terminology, acronyms and jargon.
• Physicians and nurses can also use literacy strategies like Teach Back and Ask me 3 to assess a patient's understanding of information.
• Provide plain language patient information or visual information.

Knowing which patients might be in the high risk for low literacy category can help the provider adjust the conversation for better communication.

Short Assessment of Health Literacy (SAHL) available in Spanish and English

The test contains 18 terms with related and distractor terms. It takes approximately 2-3 minutes to administer and evaluates both comprehension and pronunciation.

Rapid Estimate of Adult Literacy in Medicine (REALM)

REALM is available in short form (7 items) and long (66 items). Patient is given 5 seconds to read aloud medical terms such as "antibiotics". Scoring is based on a simple 0-7 word score.

Test of Functional Health Literacy in Adults (TOFHLA)

TOFHLA is available in both short and long forms. It contains both reading comprehension and numeracy, and is available in Spanish and English.

Newest Vital Sign (NVS)

NVS takes approximately three minutes to administer. It contains 6 questions based on a nutrition label. NVS is available free from Pfizer.

National Assessment of Adult Literacy (NAAL)

NAAL contains 28 questions that assess 3 areas of health related tasks-clinical, preventive and navigation.