Translate the following statement into plain English:*
“It is fruitless to become lachrymose over precipitately departed lacteal fluid.”1
If these words made you pause—even for a moment—you now have an inkling of what people of limited literacy confront when they deal with the healthcare system.
Health literacy is best defined as a patient’s ability to read, comprehend, and act on medical instructions and to make appropriate health-related decisions.2,3 It is closely related to, although not absolutely dependent upon, one’s overall level of literacy—and literacy problems are surprisingly widespread. According to the National Assessment of Adult Literacy (NAAL), a survey of more than 19,000 adults conducted in 2003 by the National Center for Educational Statistics and published in 2006, 36% of American adults have nothing more than basic or below basic literacy. People in these two categories might be able to sign their names, decipher a bus schedule, or read very simple instructions telling them what they can and cannot eat before a medical test, but they cannot read a juror information pamphlet, much less an informed consent form. Another recent survey suggested that about one-third of adults in public hospitals read at or below a sixth-grade level.4
Components of Health Literacy
Several components figure into a person’s ability to manage his health and engage the healthcare system. Literacy limitations can impair any or all of these factors, which include:
- Health promotion: reading and understanding product labels or articles in newspapers;
- Health protection: reading and understanding applications for insurance or following sanitary precautions in the workplace;
- Disease prevention and screening: obtaining information about flu shots and blood pressure maintenance;
- Ability to access care and navigate the system: determining the most appropriate healthcare provider to call when a problem arises or filling out forms correctly; and
- Routine care and maintenance: testing blood glucose and getting regular checkups.1
Health literacy is further complicated by the fact that it can fluctuate in the same individual at different times and under different circumstances. For example, you might have no trouble deciphering the sentence at the beginning of this article if you feel well and are reading it in your office, living room, study, or some other familiar and comfortable environment. Now imagine that you’re ill and sitting in a noisy, chaotic emergency department, with a sheaf of other forms and papers to plow through. Suddenly the statement above may not be as easy to interpret.
“We must leave behind the notion of ‘illiterates,’ ” says Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM. “A person may not normally have a literacy problem, but they may be overwhelmed by the medical terminology, or they simply may not feel well enough to comprehend immediately everything the doctor says to them.”
The changing nature of healthcare may exacerbate the problem. Thirty years ago, only 650 drugs were available, and the average hospital stay for a myocardial infarction was four to six weeks. Today, there are more than 10,000 prescription drugs alone, and the typical stay for a heart attack is two to four days. As healthcare grows increasingly fragmented and complex, doctors have less time than ever to explain things and answer questions for their patients. Nevertheless, patients are expected to shoulder an ever-greater portion of the responsibility for their care and to live with conditions like diabetes or congestive heart failure, which require aggressive and detailed management.5 This is a challenge for even the most highly educated person; for someone whose literacy skills are fragile, the task can seem hopeless.