benefits magazine september 201114

The growing disparity in health care literacy levels must be addressed if plan participants are to become more responsible for their own health and controlling costs of health care.

by | Thomas A. Curtin Jr.

Our Health Care Literacy Dilemma: How to Ensure Understanding

Benefits Magazine v 48 no 9 Sep 2011 pp 14-19

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Language as simple as A-B-C to those of us working in the health care industry is often foreign to most Americans. Both the com-plexity and sheer volume of information that defines health care today is accelerat-

ing a literacy disparity with direct impact on patient health, care delivery system efficiency and, of course, cost.

Unless we commit to increasing literacy, we can’t hope to build a fully participatory health care system where patients and other participants are informed and engaged. A widening lack of clarity and under-standing will have an increasingly negative impact on the physical and economic health of individuals, the organizations they work for and their communities.

This article explores factors impacting literacy and opportunities and practical strategies for improving literacy by answering key questions:

• What does literacy encompass and who is at risk for low health literacy?

• How do we help people become educated and confident consumers of health care?

• What tools work in different environments and for organizations at different stages of maturity?

Defining Health Care LiteracyAt its most basic, health literacy is a person’s ability

to gather, process and understand health information in order to make sound health care decisions.

From a functional perspective, literacy is the abil-ity to read prescription bottles, appointment slips, informed consent documents, insurance forms and health education materials.

Culturally, health literacy is influenced by lan-guage, belief systems, traditions and alternative med-ical practices, each of which can hamper or help ef-fective communication and patient education.

At the individual level, health literacy encom-passes the educational, social and cultural factors that influence the expectations and preferences of the individual, and the extent to which those providing

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health care services can meet those ex-pectations and preferences.

Always complex, health and medi-cal language in the 21st century has be-come increasingly difficult to decipher. The volume of information increases exponentially as science and technol-ogy give us more to learn and under-stand. The explosion of Web-based re-sources and social media give us instant access to more information than we can possibly digest.

Advances in medicine have made treatment decisions more complex. Obesity can now be treated with gastric bypass surgery. However, treatment success (and subsequent avoidance of greater health risks) is dependent on extensive patient education and follow-through. Managing chronic diseas-es—which continue to become more prevalent—requires constant vigilance incongruent with shrinking doctor-patient face time.

Together, these factors impact health literacy and can affect anyone, regardless of education level or socio-economic status.

Sizing the GapMany consider a person’s health liter-

acy to be as important a vital sign as his or her heartbeat or pulse. Yet millions of adults are not considered proficient. A recent Washington Post article refer-enced a 2006 U.S. Department of Educa-tion study that found that 36% of adults have only basic or below-basic skills for dealing with health material. That trans-lates to 90 million Americans who can’t understand discharge instructions writ-ten at a fifth-grade level or lower.1

Nearly as astounding, only 12% are considered proficient.2

When mainstream media is writ-

Test Your Health Literacy IQ

1. True or False: People with high incomes and education are not at risk for low health literacy.

2. What percentage of patients forget what the doctor tells them as soon as they leave the office?*(a) 80%(b) 25%(c) 45%

3. What is the average adult reading level in the United States?**(a) 10th grade or above(b) 8th to 9th grade(c) 6th to 7th grade(d) 5th grade or below

4. If your doctor says you have a case of dyspepsia, you should:(a) Monitor your temperature.(b) Treat with a pain reliever like Tylenol.(c) Take Pepto Bismol or other antacid.(d) Go to the hospital.

5. It’s important to understand what contraindication means because it’s a signal that:(a) You should do the opposite of what you had been doing for treatment.(b) A drug or procedure may be dangerous given your other prescrip-

tions or treatment.(c) Positive test results are really negative.(d) You have a condition for which there is special treatment.

6. How many adults have difficulty following routine medical advice?(a) One out of ten(b) Five out of ten(c) Nine out of ten(d) None of the above

How did you score? If you quizzed 100 of your employees or plan partici-pants, what would they score?

*Source for Question 2: “Patients’ memory for medical information,” Journal of the Royal Society of Medicine 2003:96:219-222.

**Source for Question 3: “Adult Literacy in America (NALS),” National Center for Education Statistics, U.S. Department of Education, Office of Educational Research and Improvement (NCES 1993-275), April 2002.

(1) False (2) a (3) b (4) c (5) b (6) c

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benefits literacy

ten at the eighth-grade level, and anything over that level is considered difficult to read, how can we expect patients to navigate health and medical information? Further compli-cating the issue is the rise in the number of Americans who are innumerate (unable to understand numbers and quanti-ties)—for example, being unable to rate something on a scale of one to ten, or to determine whether a symptom occurred a third of the time.

Studies show that people from all demographics—age, race, income and education levels—are challenged by this problem. And while health literacy problems affect people from all backgrounds, they especially impact those with chronic health problems. Low literacy severely limits access to appropriate services and impacts the health care system’s ability to appropriately care for these patients who need care most. That, in turn, worsens patient outcomes and drives up costs (see the figure).

Individuals with limited health literacy incur medical expenses resulting from unnecessary doctor visits and hos-pital stays that are up to four times greater than patients with adequate literacy skills.3 In starker terms: Elderly pa-tients with limited health literacy are almost twice as likely to die before those who are fully literate.4 Costs to the U.S. health care system stemming from health literacy deficien-cies were estimated to amount to $238 billion annually (as of 2007).5

Raising health care literacy levels can seem daunting. The impact any one doctor, hospital, company or health care or-ganization can have depends on multiple variables: resourc-es, available channels, stakeholder, executive buy-in and more. However, the good news is that there are many small ways to begin to make stronger connections.

Replacing the Amiable NodEducation is clearly a vital component to improving lit-

eracy, and it begins with the doctor-patient relationship. Because it is a highly deferential relationship, many patients hide confusion. They may feel too intimidated or ashamed to ask for help. Pride can be another factor.

Delivering and receiving information in a way that can be processed by the patient helps to improve literacy. Physicians are being encouraged to teach back, where they ask the pa-tient to explain things back to them to ensure understanding. For example: “I’ve just said a lot of things and want to make sure I’ve explained things clearly to you. Can you explain

things back to me, so I know you understand?” Questions like these can bring up red flags that can be further discussed and/or monitored.

Patients can take the proactive role and “say it back.” For example: “What I’m hearing you say is this. . . . Did I get that right?” Or, “You just gave me this new drug, but I’m still sup-posed to take my other medications. Is that right?”

Ask Me 3™6 is a program designed to promote commu-nication between health care providers and patients in order to improve health outcomes. Three simple questions at every point of care empower people to get the information they need in a way that makes sense to them:

1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this?

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takeaways >>•  Health literacy is influenced by language, belief systems,

traditions and alternative medical practices, as well as educational, social and cultural factors.

•  Ninety million Americans can’t understand discharge instructions written at a fifth-grade level or lower.

•  Deficiencies in health literacy cost the U.S. health care system an estimated $238 billion annually.

•  Using a variety of tactics such as mail, e-mail, telephone and multimedia helps educate more people.

•  Using plain language and simpler forms will increase understanding.

FIGURE >>

Hospitalization Emergency servicesTreatment delaysCondition severityProductivityMortality

Literacy Costs

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Making Connections, Inspiring ActionRepeated reinforcement using multiple communications

channels is another way to educate and keep people actively in-volved in their health. No one single lever is likely to make the connection, so using a variety of tactics such as mail, e-mail, telephone and multimedia increases how many people we can reach. Posters in workplaces, articles in company newsletters and stuffers in payroll envelopes are a few options that compa-nies and funds can use to connect with participants.

Online content via both websites and intranets are key in-formation channels for many people. However, it would be a mistake to rely on the Internet and e-mail for populations whose work doesn’t provide easy access to a computer. It’s also important to note that searching the Internet requires high-level literacy skills, which puts poor readers at a disadvantage.

Supplementing written material with conversation, video and audio sources increases how many people we can reach and connect with. For example, at Kaiser Permanente, we use radio to communicate our thrive messages. Technically, these are ads but our purpose is to, in a very short amount of time, give listeners a health tip or idea (e.g., take the stairs, walk a few minutes every day) that they can implement right away—something easy that will help them thrive.

Understandably, a big radio campaign isn’t practical for all organizations but the idea can be adapted in a different form. For example, a plan sponsor might create an Ask Me 3™ wallet-sized card with the three questions, and have them available in workrooms or included with annual open enroll-ment materials—a simple yet incredibly efficient tactic.

Keeping It SimpleThe U.S. health system is papered with material, which

makes the way information is written and presented vital to improving health literacy. It’s not about dumbing down the information but using styles and formats that are easier to understand.

Using plain language is the place to start. Language is plain when people can read or listen to the information, comprehend it and have the ability to apply it in a reasonable amount of time. For example, a patient consent form warn-ing of hyperpyrexia after a procedure could be translated to an abnormally high fever. Instead of hypoglycemia, we can say dangerously low blood sugar. We can replace hyperlip-idemia7 with a high level of fats in the blood; and prevents osteoporosis with keeps bones strong.

Thomas A. Curtin Jr. is senior vice president, national sales and account management, at Kaiser Permanente, where he leads the company’s initia-tives related to the national employer

and labor and trust business segments, including the company’s engagement efforts with national consulting firms. He earned his B.A. degree from St. Anselm College in Manchester, New Hampshire and completed M.B.A. degree coursework at Northeast-ern University in Boston, Massachusetts. He can be reached at thomas.a.curtin@kp.org.

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bio

Checklist for Literacy-Friendly Communications

4 Are you using plain language? Consider: Can you replace complex terms with commonly understood words? Use shorter sentences? Give examples?

4 Have you limited the piece to one or two key mes-sages? Restrict content to what your audience needs to know now.

4 Is the material written in the active voice and in a conversational style?

4 Is the reading level of the material appropriate for your audience?

4 Are you emphasizing the desired behavior instead of medical facts?

4 Can the communication be easily scanned or navi-gated? Easy ways to increase readability:• Bullet points instead of dense paragraphs• Larger font size• Pictures and diagrams in place of text• Clear headings• White space (area around the page)• Short sentences.

4 When you use technical terms, are they clearly explained with helpful examples? Could you replace terms with commonly understood words?

4 Example: Use “keeps bones strong” instead of “pre-vents osteoporosis.”

4 Is it very clear what, if anything, the reader has to do?4 If you received this communication at home or work,

would you read it? If not, what can you change to make it more inviting?

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Through plain language, we can begin to reverse driv-ers that impact higher costs. For example, simplified patient consent forms can help reduce the risk of malpractice suits from patients who might feel that they weren’t fully informed or made to understand the risks before undergoing a recom-mended procedure.

Stylistic techniques that increase readability and under-standing are fairly easy to adopt and include:

• Breaking up dense paragraphs of text with bullet points

• Using pictures and examples to illustrate important ex-amples

• Limiting footnotes, which disrupt the reading flow• Using a larger font size• Leaving room for white space—the space on a page

where there is no text or graphics.

Enabling UnderstandingWhen people don’t understand basic health information,

they won’t use their health plan benefits. When they don’t use their benefits, they can’t optimize their health. Health lit-eracy is, therefore, a better forecaster of health status than age, income, employment, ethnicity or education level.

Investing in health literacy is, unquestionably, an invest-ment in our collective bottom line: Individual health im-proves, medical costs go down, productivity goes up and absenteeism goes down. Our collective recognition and work toward resolving our health care literacy dilemma can effectively enable and enhance the understanding of health care information for everyone and as a result make a vital improvement to our sustained health and well-being.

Endnotes 1. “Many Americans have poor health literacy,” The Washington Post, February 28, 2011. 2. M. Kutner, E. Greenberg, Y. Jin and C. Paulsen. 2006. The Health Lit-eracy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483), U.S. Department of Education, Washington, DC: National Center for Education Statistics. 3. “Health Literacy,” American Medical Association, www.ama-assn.org, October 25, 2010. 4. “Do You Know What the Doctor Is Talking About?,” The New York Times, April 2, 2009. 5. “Taking Medical Jargon out of Doctor Visits,” Wall Street Journal, July 6, 2010. 6. The National Patient Safety Foundation: Ask Me 3 is trademark li-censed to the Partnership for Clear Health Communication. 7. “Taking Medical Jargon out of Doctor Visits,” Wall Street Journal, July 6, 2010.

ReferencesHealth Literacy Fact Sheets, Center for Health Care Strategies, www.chcs

.org.“Doctors Often Overestimate Patients’ Health Literacy,” U.S. News &

World Report on USNews.com, October 17, 2008.Health Literacy: A Toolkit for Communicators, The Association of Health

Insurance Plans, available at www.ahip.org/healthliteracy/toolkit.

Health Care Literacy ResourcesA wealth of credible health care literacy toolkits and other resources are available in the public domain.• The Association of Health Insurance Plans (AHIP)

has developed a toolkit for organizations to use to develop health literacy programs. Visit www.ahip .org/healthliteracy/toolkit.

• Healthy People 2010 encourages individuals, communi-ties and professionals to take specific steps in helping ensure good health is enjoyed by all. Available at www.healthypeople.gov.

• The American Medical Association was the first national medical organization to adopt policy rec-ognizing that limited patient literacy affects medical diagnosis and treatment. Available at www.ama-assn.org.

• U.S. Dept. of Health and Human Services’ Quick Guide to Health Literacy has facts, definitions, helpful tips, checklists and resources. Available at www.health.gov/communication/literacy/ quickguide/quickguide.pdf.

• The National Patient Safety Foundation houses in-formation on Ask Me 3™ and other literacy resourc-es for patients, providers and the media. Ask Me 3™ is a trademark licensed to the Partnership for Clear Health Communication. Available at www.npsf.org/askme3/.

Also take advantage of the materials and support offered by your health care partners, universities and local community organizations.

learn more >>Education57th Annual Employee Benefit Conference October 30-November 2 New Orleans, LouisianaFor more information, visit www.ifebp.org/usannual.

benefits literacy