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Health Literacy The Missing Link in Patient-Physician Communication. AMA-MSS Subcommittee on Health Literacy Community Service Committee. Do you know?. Which of the following is the strongest predictors of an individual’s health status? A) Age B) Income C) Literacy skills

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Health Literacy The Missing Link in Patient-Physician Communication

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Health LiteracyThe Missing Link in Patient-Physician Communication

AMA-MSS Subcommittee on Health Literacy

Community Service Committee

Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) Age

B) Income

C) Literacy skills

D) Education level

E) Racial or ethnic group

F) Average Beer Intake at Metro

Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) Age

B) Income

C) Literacy skills

D) Education level

E) Racial or ethnic group

F) Average Beer Intake at Metro

The Problem:

Low Health Literacy


  • Illiteracy: total inability to read and write

  • Functional Illiteracy: ability to only read/write/understand below 5th grade level

  • Marginal Literacy: ability to only read/write/understand between the 5th and 8th grade level

  • Literacy: ability to read/write/understand at the 8th grade level and above

Health Literacy

  • The ability to read, understand, and use healthcare information to make effective healthcare decisions and follow instructions for treatment

  • “… half of our adult population has deficiencies in reading or computational skills.” (AMA Council on Scientific Affairs, JAMA 1999)

  • Do your patients understand what you are telling them?

Basic information about a colonoscopy, as perceived by a patient with limited literacy skills

Scope of the Problem

  • 22% of adult Americans are functionally illiterate; an additional 27.5% are marginally literate

  • Therefore, nearly half of American adults (90 million patients) do not have sufficient literacy skills to fully function in society

  • All segments of the population are affected

  • Percent of physicians who know about Health Literacy:


  • Percent of physicians who make changes in patient communications after learning about health literacy:


Education as an Unreliable Indicator of Literacy Level

  • Number of years of education not equal to amount learned

  • 24% of Functionally Illiterate (NALS Level 1) people actually completed high school

Health People 2010 Focus Areas

  • Access to Quality Health Services*

  • Arthritis, Osteoporosis, and

    Chronic Back Conditions

  • Cancer

  • Chronic Kidney Disease

  • Diabetes

  • Disability and Secondary Conditions

  • Educational and Community-Based


  • Environmental Health*

  • Family Planning

  • Food Safety


  • Heart Disease and Stroke

  • HIV

  • Immunization and Infectious Diseases*

  • Injury and Violence Prevention*

  • Maternal, Infant, and Child Health

  • Medical Product Safety

  • Mental Health and Mental Disorders*

  • Nutrition and Overweight*

  • Occupational Safety and Health

  • Oral Health

  • Physical Activities and Fitness*

  • Public Health Infrastructure

  • Respiratory Diseases

  • Sexually Transmitted Diseases*

  • Substance Abuse*

  • Tobacco Use*

  • Vision and Hearing

National Adult Literacy Survey (NALS)

  • Provides the most comprehensive view of general literacy skills of American adults (1992)

  • 5 Levels

Summary of NALS Levels

  • Level 1: Functionally Illiterate

    • CANNOT:

      • use bus schedule, find intersection on map

      • read a simple story to a child

      • fill out social security application

  • Level 2: Marginally Literate

    • CANNOT:

      • use bus schedule

      • read a bar graph

      • write a letter of complaint

  • Level 3 & 4: Functionally Literate

  • Level 5: High-Level Literacy

Results of the NALS

  • Level 1: 22%

  • Level 2: 27.5%

  • Level 3: 31.5%

  • Level 4: 16%

  • Level 5: 3%

Increased costs of low literacy

  • Average annual cost of all Medicaid enrollees: $3,000

  • Average annual cost of low literacy enrollees: $13,000

Sources of Increased Costs

  • Low literacy patients have:

    • more medication errors

    • excess hospitalizations

    • longer hospital stays

    • more E.D. visits

    • generally higher level of illness

  • RESULT: An excess cost of $50-73 billion per year to the US healthcare system

Limited Literacy in Healthcare Setting

  • Trouble understanding:

    • when next appt was scheduled

    • medical vocabulary (bowel, polyp, colon, etc.)

    • basic disease concepts

    • how to use medical devices (asthma inhaler)

Low Literacy translates into poor health outcomes

  • Health Knowledge Deficits:

    • Diabetic patients less likely to know symptoms of hypoglycemia

    • Patients with low literacy are less likely to maintain tight control of their diabetes

  • Less healthy behaviors:

    • more smoking, including during pregnancy

    • more exposure to violence

    • less breastfeeding

  • High Risk Groups

    • Elderly

    • People with limited education

    • Ethnic Minorities (Hispanic, AA)

    • Recent Immigrants to the US

    • People born in the US but English is a second language

    • Low income

Red Flags

  • Behaviors

    • registration forms incomplete or inaccurate

    • frequently missed appointments

    • noncompliance with medication

    • lack of follow-through with tests or referrals

    • eyes wandering over a page

    • very slow to finish

    • sounding out words

    • looking confused

  • Responses

    • “I forgot my glasses”

    • “Let me take this home so I can discuss it with my children”

Can you expect your patient to tell you?

  • Shame and Stigma

    • 68% have never told their spouse

    • 75% have never told their healthcare provider

    • 19% have never told anyone

  • may bring decoy reading materials

  • 66-75% of adults in NALS Level 1 say they read “well” or “very well”

  • 33.6% of low literacy patients do not admit to having reading trouble

Overview of Implications

  • Poor Health Outcomes

  • Over-utilization of health services

  • Limited effectiveness of treatment

  • Higher patient dissatisfaction

  • Higher provider frustration

How can you find out?

  • Do social history first in patient evaluation, adding questions about literacy skills in a sensitive manner

    • “How happy are you with the way you read?”

    • “What do you like to read?”

  • Ask questions in a safe and supportive environment and in a neutral, nonjudgmental fashion

  • Brown-bag medication review

    • “When was the last time you took one of these pills?”

    • “When was the time before that?”

    • Do they read the label or look at the pill?


  • Not stupid

  • All social classes

  • Amazingly able to function

  • The majority of people with low literacy skills are white, native-born Americans

    • Health providers should not have racial/ ethnic bias


What can we do?

  • Make your practice patient-friendly

  • Communicating in an easy-to-understand language

  • Creating and using patient-friendly written materials

What can we do?

  • Make your practice patient-friendly

    • Attitude of helpfulness from clinicians and staff

    • Help with office check-in and scheduling appointments

    • Repeat important instructions

  • Communicating in an easy-to-understand language

  • 6 Steps to improve communication with patients

    • slow down

    • use plain, non-medical language

    • limit the amount of information provided, and repeat it

    • show or draw pictures

    • use teach-back or show-me technique

    • create a shame-free environment

Use plain, non-medical “living room” language

  • Creating and using patient-friendly written materials

  • Written consent forms/ patient education handouts

    • most forms written 10th grade to graduate level

    • average US adult reads at 8th grade level

2. Principles for creating patient-friendly written materials

  • 5th or 6th grade level

  • clear statements of instruction

  • avoid unnecessary background info

  • avoid lengthy review of anatomy or physiology

  • short sentences

  • large text

  • Non-written patient education materials

    • Graphic Illustrations



      • Models

    • Audiotapes and compact disks

    • Videotapes

Patient Empowerment

  • 3 Important Questions:

    • What is my main problem?

    • What do I need to do?

      • How do I take my medicine?

      • When do I need to be seen again?

    • Why is it important for me to do this?

  • These questions can help patients take their medications properly and take care of their health.

PowerPoint prepared by:

Anupama Kathiresan, Jeremiah Johnson, David Newton

Medical College of Georgia

Augusta, GA


Health Literacy Subcommittee, Anupama Kathiresan, Chair

Community Service Committee, Stephen Patrick, Chair

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