Practice Management
Health Literacy and Surgical Informed Consent
Hammil S, Helitzer D, Rogers RG
The Female Patient. 2011;36(3):51-55

Health literacy is an important but poorly understood topic in health care. Inadequate health literacy is common and can have important consequences for affected individuals.

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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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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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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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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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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  1. US Department of Education. National Center for Education Statistics. National Assessment of Adult Literacy (NAAL). 2006. Available at: http://nces PageId=133. Accessed June 3, 2010.
  2. Ratzan SC, Parker RM. Introduction. In: Selden C, Zorn M, Ratzan SC, Parker RM, compilers. Health literacy [bibliography online]. Bethesda, MD: National Library of Medicine; 2000. Available at: www.nlm.nih .gov/archive//20061214/pubs/cbm/hliteracy.html. Accessed June 3, 2010.
  3. Carpenter ES. Children's health care and the changing role of women. Med Care. 1980;18(12):1208-1218.
  4. Wyn R, Ojeda V, Ranji U, Salganicoff A. Issue Brief: Update on Women's Health Policy: Women, work, and family health: a balancing act. Kaiser Women's Health Survey. April 2003. Available at: shealth/loader.cfm?url=/commonspot/security/ getfile.cfm&PageID=14293. Accessed June 3, 2010.
  5. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588-594.
  6. Salovey P, Schneider TR, Apanovitch AM. Persuasion for the purpose of cancer risk reduction: a discussion. J Natl Cancer Inst Monogr. 1999;(25):119-122.
  7. Lidz CW. The therapeutic misconception and our models of competency and informed consent. Behav Sci Law. 2006;24(4):535-546.
  8. Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Improving Patient Safety Through Informed Consent for Patients With Limited Health Literacy: An Implementation Report. 2005. Washington, DC: National Quality Forum. Available at: /Publications/2005/09/Improving_Patient_Safety_ Through_Informed_Consent_for_Patients_with_ Limited_Health_Literacy.aspx. Accessed January 19, 2011.
  9. Wadey V, Frank C. The effectiveness of patient verbalization on informed consent. Can J Surg. 1997;40(2): 124-128.



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