Addressing Low Health Literacy Inside and Outside the Exam Room

As this headline in The Washington Post points out, “Health illiteracy is nothing new in America, but the pandemic magnifies how troubling it is.” In fact, according to an expert cited by Eve Glicksman in the article, “One in five people struggle with health information.” Considered in those terms, most physicians and other healthcare providers likely encounter patients with limited health literacy every day. Increasing awareness of this across medical practices and hospitals and improving patient education efforts can mitigate its impact on health outcomes and patient safety – and reduce liability risk.   

Definition of health literacy

The federal government has adopted a standard definition for health literacy. As posted by the National Institutes of Health (NIH), health literacy is “the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others.” In addition, the NIH offers the following:

• Health literacy encompasses the materials, environments and challenges specifically associated with disease prevention and health promotion.
• Health literacy incorporates a range of abilities: reading, comprehending and analyzing information; decoding instructions, symbols, charts and diagrams; weighing risks and benefits; and, ultimately, making decisions and taking an action.

NIH also notes, “Everyone, no matter how educated, is at risk for misunderstanding health information if the topic is emotionally charged or complex.” However, as reported by Glicksman, “The people most likely to have low health literacy include those dying in greater numbers from COVID-19: older adults, racial and ethnic minorities, nonnative English speakers and people with low income and education levels.”

The impact of low health literacy on health outcomes

As a factor in patient engagement and patient safety, low health literacy increases the risk of poor health outcomes. Glicksman’s article in The Washington Post provides some context: “Health literacy is the best predictor of someone’s health status… Decades of research consistently link low health literacy to poorer medical outcomes, more hospitalizations and emergency room visits and higher health-care costs. The less literate often experience higher mortality rates for heart disease and more foot amputations if diabetic. And you are less likely to wear sunscreen, maintain an optimal weight and take other health-preventive measures if your health literacy is low.” Recent research highlights a couple of examples, including health literacy’s role in poorer maternal/neonatal outcomes and higher risk of death associated with heart failure.

The risks posed are so numerous and significant, health literacy appears on past ECRI lists of the most urgent patient safety concerns and a current list of the federal government’s objectives for Healthy People 2030, which informs healthcare priorities nationwide.

Addressing low health literacy during patient encounters

Conversations and materials that patients absorb and understand are critical pieces of “successful” healthcare visits for both patients and their physicians. As we detail in a Risk Management Tip on Communicating With Low Health Literacy Patients, “Effective communication with patients may improve compliance with treatment regimens, enhance the informed consent process and increase safe medication use.” To improve the patient experience and reduce potential liability exposure, the tip (available here as a PDF) offers several recommendations, including:

• Use lay terminology whenever possible.
• Define technical terms with simple language.
• Write patient education materials in plain language, avoiding use of medical jargon.
• Reinforce verbal instructions with visual aids and printed materials that are easy to read and include pictures, models and illustrations. Consider using non-printed materials, such as videos and audio recordings, as indicated.
• Provide interpreters for patients who are not fluent in English.
• Use open ended questions to assess patient understanding.
• Utilize the “teach back method” when reviewing new medications or treatment plans.

Where is low health literacy a factor? (Hint: It’s not just the office visit.)

Whenever and wherever a patient interacts with the healthcare system, there is an opportunity for health literacy to be an issue. While communicating effectively and confirming patient comprehension during office visits is critical, it’s not the only place health literacy challenges exist. Here are some important areas to keep in mind:

Websites
Many of the recommendations above also apply to the online presence of physicians, medical practices, hospitals and other healthcare facilities. (The Office of Disease Prevention and Health Promotion offers these additional guidelines for addressing health literacy by simplifying the user experience.)

Language barriers in print materials
A recent Scientific American opinion piece stresses the importance of assessing interpreter services and translating print materials, including signage, brochures and care instructions. Another urges greater “support for non-English speakers throughout the healthcare continuum,” in the form of “language appropriate materials and care.”

Digital health tools and access
Healthcare IT News reports on digital health literacy as a social determinant of health and the call for providers to “develop linguistically and culturally tailored digital health tools to engage diverse populations.” It’s also critical to consider the digital divide as a factor, since it can limit access to care (like use of telehealth), points of contact (like patient portals) and digital health (like remote patient monitoring).

Critical encounters
Health literacy takes on heightened importance during specific points of care. This includes time periods with heightened risk to patient health and safety (like hospital or post-op discharge) and conversations involving critical considerations (like informed consent or shared decision making on treatment options).

Chronic disease management
Health literacy can be a factor in patient noncompliance with chronic disease management. For example, according to the NIH, “Evidence suggests that people with limited health literacy are less likely to follow diabetes self-care instructions and to seek care early in the course of the disease, which makes them more likely to experience complications.”

Public health
Healthcare Finance describes health literacy as “a continuum that starts with getting information, understanding it and making a decision based on that information.” With that chain of events in mind, it’s easy to see how overly complicated information on COVID-19 puts individual patient safety – along with public health – at risk. Similarly, those with low health literacy may not be able to spot misinformation, which creates confusion or, in the case of the current pandemic, leads to vaccine hesitancy.

Low health literacy can be situational.
Consider this reminder from the Centers for Disease Control and Prevention (CDC): “Even people who read well and are comfortable using numbers can face health literacy issues when they aren’t familiar with medical terms or how their bodies work, they have to interpret statistics and evaluate risks and benefits, they are scared and confused or they have health conditions that require complicated self-care.”

Additional information on health literacy

MLMIC encourages policyholders to consult our Risk Management Tip on Communicating With Low Health Literacy Patients. The CDC has also published a guide for developing a plan for your organization to improve health literacy.