The Challenge of Low Health Literacy Among Patients and Caregivers of ALL Cultures

by | Jan 5, 2013

Recognizing the impact of low health literacy on patient compliance and health outcomes is extremely important. A strong body of evidence points directly to the importance of caregiver health literacy as a factor in child health outcomes specifically. Education, written literacy, numerical literacy, socio-economic status, limited English proficiency and culturally-based understanding of illness causation are some of the major factors that affect a person’s ability to understand and perform health-related tasks. Providers can employ a few effective verbal and print strategies, along with tangible action plans for follow-up to better ensure effective communication.  

What is health literacy?

The institute of Medicine defines health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions.”1 At some point, most individuals will encounter health information they cannot understand. Even well-educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor’s instructions regarding a drug or procedure. In 2003, the National Association of Adult Literacy ( NAAL Report) surveyed 19,000 people and found that only 11% of adults have proficient health literacy skills, and 14% of adults have below-basic health literacy.2 What do these statistics really mean? Well, for example, basic awareness of available services and the ability to locate and gain access to such services requires basic health literacy. The ability to follow through on physician recommendations requires reading and writing skills as well as listening and speaking skills. Taking prescription drugs appropriately requires the ability to understand and use numbers. Cultural knowledge is also important. Patients who do not understand the western medical culture will have a harder time knowing what they should expect of physicians. They are also less likely to understand the concepts of self-care and chronic disease management and won’t demonstrate the degree of self-sufficiency health care professionals may expect of them. They also may be unwilling to ask questions for clarification because they see providers as authority figures not to be questioned. Participating in open dialogue about their health may be something they don’t have experience doing.  

Patients and caregivers with low health literacy may struggle with the following:

  • Reading pamphlets and handouts from a provider’s office
  • Selecting proper OTC medications
  • Reading prescription fact sheets – warnings, side-effects, etc.
  • Dosing medications correctly
  • Remembering the names of medications they are taking or have taken in the past
  • Filling out forms with information like known allergies
  • Completing insurance forms
  • Understanding self-management of chronic disease – being a-symptomatic is not the same as being “cured.”
 

Three key factors associated with the health literacy of children’s caregivers are:

When looking at caregivers of children specifically, three key factors associated with health literacy are: 1. Having less than a high school education: Parents with less than a high school education are 8 times more likely to have low health literacy. 2. Having limited English proficiency: Parents with limited English proficiency are 18 times more likely to have low health literacy. 3. Having parents who were born outside the United States. 3 Analysis of data from the 2003 NAAL survey revealed the following statistics: 2
  • Of approximately 6,100 parents, nearly 70% of parents were unable to enter names and birth dates correctly on a health insurance forms
  • 36% of parents were unable to determine what time a person could take a prescription medication based on drug label information.
  • 40% of parents were unable to determine when a child should receive the third hepatitis B vaccination using a chart showing recommended childhood vaccines.
  • Only 47% of caregivers could correctly describe how to mix infant formula.
  • Only 73% of caregivers could correctly give the dose for liquid amoxicillin.
  • Just 69% of caregivers could interpret a digital thermometer correctly.
  • Most parents had difficulty understanding over-the-counter cough and cold medication labels, and most would give such a medication to a 13 month-old child, against the recommended age indications on the products.

 

Effective communication techniques are critical to minimizing the effects of low health literacy.

Providers need to tailor information to the health literacy level of patients/parents, focusing their efforts on 3 communication domains: Verbal communication; Print materials; Action Plans. Providers also need to be aware of realistic retention rates, limiting information to what patients and caregivers NEED to know. Communicating too much information, especially if it is technical in nature, creates a shut-down effect in people’s ability to absorb new information. The following lists appeared in “Mastering the Language” (April 12 issue of Contemporary Pediatrics). It offers strategies that can be very useful in communicating with low health literacy patients.
  • Use print materials to enhance health education.
  • Use print materials in the appropriate language for the family.
  • Ideally use materials at the 4th-6th grade reading level.
  • Use materials that have pictures to help explain text.
  • Use materials to summarize key points.
  • Avoid materials with dense areas of text. Long lists of bullets also.
  • Include families in any action steps.
  • Set concrete, realistic goals.
  • Assess family’s confidence in meeting the goals and adjust accordingly.
  • Set a time frame for accomplishing the steps/goals and review at a follow-up visit.
  • Ackknowledge challenges/barriers (socioeconomic, cultural, etc).

  • Use plain language.
  • Avoid jargon/acronyms.
  • Partition information to avoid overwhelming families.
  • Use interpreter services for limited English families.
  • Encourage families to ask questions.
  • Summarize key points at the end of each visit.
  • Use the teach-back technique to confirm understanding.
  • Make information culturally relevant and personal.
  

Summary:

According the the NAAL findings, a concerted effort by the public health and health care systems, the education system, the media, and health care consumers is needed to improve the nation’s health literacy. If patients cannot comprehend needed health information, attempts to improve the quality of care and reduce health care costs and disparities may fail.

 

“The Challenge of Low Health Literacy Among Patients and Caregivers of ALL Cultures” by Marcia Carteret, Copyright © 2013. All rights reserved.
Additional Links for More Information HHS National Plan to Improve Health Literacy http://www.hhs.gov/ash/news/20100527.html Institute of Medicine Brief Report http://www.hhs.gov/ash/news/20100527.html Powerpoint presentation with statistics from National Association of Adult Literacy. Slides 15-25 particularly http://www.calpro-online.org/researchtopractice/MoM2ppt/markKutnerPlenary.pdf Resources Cited In this Article 1. http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx 2. Kutner M, Greenberg E, Baer J; National Assessment of Adult Literacy (NAAL). A First Look at the Literacy of America’s Adults in the 21st Century. Washington, DC: National Center for Education Statistics; 2006 3. Sanders LM, Thompson VT, Wilkinson JD. Caregiver Health Literacy and the Use of Child Health Services. Pediatrics. 2007; 119(1):e86-e92