The results of the 2003 National Assessment
of Adult Literacy (NAAL)
indicate that 93 million US adults
function at or below a basic level of
overall literacy.1 On a component of the
NAAL specifically designed to evaluate the
ability to read and understand health-related
information, most adults tested (53%) had
intermediate health literacy, and only 12%
scored in the proficient range. The remaining
36% had basic or below basic literacy on
health-related items.
Health literacy has been defined by the Institute
of Medicine and Healthy People 2010
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."
2 Health literacy capabilities are not
just individual in nature but are affected by
family, social, and systemic factors. Culture,
ethnicity, education, language, the mass
media, assimilation, characteristics of health
care settings, and socioeconomic status are
all important factors in a given patient's
health literacy.
The effect of inadequate health literacy is
far-reaching. It can impact the ability of affected
individuals to understand the need for
regular and preventive health care, as well as
their ability to access the health care system.
Patients with inadequate health literacy may
have difficulty comprehending instructions
and applying recommendations made to
them by clinicians. Although assessment of
health literacy is fundamental to good patient
care, most practitioners have no training in or
awareness of methods to assess health literacy
and how to tailor their care to the health
literacy level of individual patients.
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HEALTH LITERACY IN THE OUTPATIENT SETTING
Women with low health literacy may face
great difficulty when navigating the health
care system.3,4 In the outpatient setting, this
deficiency can be particularly problematic.
Women may be unable to understand the
details of their anatomy and may have difficulty
reading or understanding patient education
materials. They may also have difficulty
comprehending their diagnosis and
subsequently struggle to understand the options
presented to them for treatment.
Several valid instruments are available to
screen patients for their level of health literacy.
The Test of Functional Health Literacy in
Adults (TOFHLA) and the Rapid Estimate of
Adult Literacy in Medicine (REALM) questionnaires
are commonly used in health literacy
research. Chew and colleagues published
a series of brief questions to identify
patients with inadequate, marginal, and adequate
health literacy.5 The Chew instrument
uses 3 questions to assess health literacy
in a manner comparable with the short
form of the TOFHLA (Figure). These brief
questions could be easily added to routine
intake paperwork and reviewed prior to beginning
the patient's visit.
Screening patients in the clinic allows a
practitioner to identify patients with low
health literacy. These patients could then be
targeted for further formal health literacy
assessment and special methods of communication
and assistance.5 It may be
worthwhile to train support staff to observe
patients as they fill out forms in the waiting
area or examination room so that they may
alert the provider to those having difficulty
completing the forms. It is important not to
stigmatize or embarrass patients who have
low health literacy, because they are likely
to be uncomfortable about their challenges
with reading and understanding health
information.
Given that patient satisfaction with treatment
tends to be related to their expectations,
which are at least in part determined
by understanding, it is important to involve
the patient in the decision-making process.
Framing the information for patients by focusing
discussion on either the positive or
negative consequences of a proposed intervention
and tailoring the message for the
person's readiness for change are powerful
techniques to affect patient decisions regarding
their treatment options.6 This cannot be
successfully accomplished without an appreciation
of the patient's ability to understand
what is explained.
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HEALTH LITERACY AND INFORMED CONSENT
Helping a patient with low or marginal health
literacy understand surgical procedures,
risks and benefits, and alternatives to surgical
interventions also creates special challenges
for clinicians during the informed
consent process. Informed consent is the
process by which health care professionals
provide patients with information necessary
to make a knowledgeable decision about
their health care. Valid informed consent includes
the principles of voluntarism, capacity,
disclosure, understanding, and decision
making.7
From the medicolegal perspective, informed
surgical consent focuses on the provision
of factual information from health care
providers to patients. In contrast, ethicists
emphasize the importance of patient autonomy
and collaboration in the decision-making
process. As such, an ideal informed consent
session is a shared process between
health care professionals and patients that
allows clinicians to meet their duty to fully
inform patients of the risks, benefits, and alternatives
of a particular intervention, while
still maintaining patient autonomy.
It is vitally important that patients understand
the nature of a surgical intervention,
as well as its attendant risks, benefits, and
alternatives. Patients with low health literacy
may be particularly challenged to understand
the details provided during the
informed consent session and may be unable
to successfully navigate a consent form
and make appropriate decisions regarding
proposed surgery. Those patients with low
health literacy may also experience difficulty
following detailed postoperative instructions,
resulting in a more complicated
postoperative course.
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COMMUNICATION METHODS
Several methods have been advocated to improve
the process of communicating information
to obtain informed surgical consent.
These methods include the use of visual aids,
simulators, computer-assisted technology,
and provision of written preoperative
information.
The "teach-back method" has also been
proposed as a technique for improving informed
consent. In the teach-back method
of surgical consent, patients are asked to verbalize
their understanding of the operative
procedure, as well as its benefits, risks, and
alternatives, prior to giving surgical consent.8
The National Quality Forum, a private notfor-
profit organization created to develop
and implement a national strategy for health
care quality measurement and reporting, has
recommended the teach-back method. Patients
who recount information have greater
recall and comprehension of the risks and
benefits of proposed therapies than those
who are not asked to "teach back."9
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CONCLUSION
In order to mitigate the potential negative
impact of low health literacy, medical professionals
must first be aware of the strong likelihood
that patients in their practice may
have inadequate health literacy. Satisfactory
care of these patients will require practitioners
to be knowledgeable regarding health literacy
barriers and responsive in their communication
with these patients. Successful
communication of health information will
empower patients in preventive, therapeutic,
and surgical situations that necessitate collaboration
in care.
Drs Hammil and Helitzer report no actual or
potential conflicts of interest in relation to
this article. Dr Rogers is a consultant to
Pfizer.
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