Monday, October 29, 2012

Does my patient have low health literacy?

While it’s easy to make a diagnosis of jaundice by examining the patient , there are no visual signs to tell doctors who is health literate and who is not. There are many myths about who has limited literacy skills, such as:

•    They have a low IQ and are slow learners
•    They look different from people with high literacy skills
•    Years of schooling correlates with literacy skills
•    They are from ethnic minority populations
•    They will admit that they have limited literacy skills

Doctors often make mistakes when estimating a patient’s health literacy. They may assume poor patients are stupid, or that rich patients understand everything. Both of these stereotypes are incorrect. However, there are clues that can help you know if your patient might need extra help, if you pay attention. For example, if your patients complete their forms incorrectly, or have left many blanks, it may be due to limited literacy skills. Taking medications incorrectly can also be a clue to their lack of understanding of medical terms. Poor communication has many side effects, and your low-literate patients may:

•    Miss appointments frequently
•    Not be able to explain their symptoms clearly
•    Have difficulty complying with treatment instructions
•    Not follow through with tests or referrals to other providers
•    Not read the patient educational materials you provide
•    Not be able to explain what a medication is for

Despite these clues, limited health literacy is often a hidden problem. Most people with low literacy skills go undetected by their doctors, because they go to great lengths to hide their literacy problems. They are ashamed and carry a lot of emotional baggage from many years of feeling stupid. This is a very touchy issue for them, and they will often clam up because of humiliation and frustration. Many low-literate patients are surprisingly smart and have figured out ways to hide their limited literacy skills from others by memorising things they have read before or making intelligent guesses that cleverly camouflage their lack of understanding. Patients often wish to be amiable and a smile and a nod should not be mistaken for agreement or comprehension. Ironically , they may also not know enough English to tell you that they don’t understand what you are saying. Remember that even people with proficient literacy skills can fail to understand complex instructions and health information when they are ill; and many patients are reluctant to ask questions so as not to appear stupid, or because they do not want to annoy a busy physician.

One simple way to assess whether patients have adequate health literacy skills is to conduct a “brown bag medication review”. Ask patients to bring in all the medications they take (both prescription and non-prescription) to their next appointment and to name each of them one by one; explain what each is for; and how often they take them. You may suspect low literacy skills if the patient struggles to read the label on the bottle or if they pour out the pills in their hand to look at them in order to identify them.

There are several formal assessment tools available for use in the clinic, such as the following:

Newest Vital Sign (@

Rapid assessment of health literacy in medicine

Short assessment of health literacy for Spanish speaking adults

While these resources can help you assess your patient’s level of health literacy scientifically, their major limitation is that they only give an approximation of reading skills and are incapable of assessing other important aspects of health literacy, such as understanding, motivation and the ability of individuals to access or use information concerning health and healthcare.

Universal Precautions

It’s safest to assume that everyone can have difficulty understanding health information. Universal Precautions are a method of minimising risk for ALL patients, because you do not know which patients have trouble understanding. The idea is similar to taking universal precautions against the transmission of blood borne infectious diseases when providing medical care, because you do not know which patients are HIV or hepatitis positive.

Many healthcare professionals find it challenging to practice Universal Precautions, because they have to change the way they think and talk to their patients. They also may fear they are “dumbing down” the information, or that patients will be insulted by their use of “ simple language”. However, patient surveys have shown this not to be true. All patients prefer simple and clear communication and plain language resources provide the means to moving up the ladder of health literacy.

In brief, universal precautions include 4 main areas:

1.    Improving spoken communication
2.    Improving written communication
3.    Improving self-management and empowerment
4.    Improving support systems

Improving spoken communication includes using “plain language” and the “teach-back” technique for clear verbal communication. Improving written communication involves selecting, and creating written materials that patients can understand and make use of easily. Improving self-management and empowerment means increasing self-efficacy and self-care, thus improving adherence to treatment. Improving support systems involves collaborating with professionals and organisations inside and outside the healthcare system to help patients carry out the advice of healthcare professionals. We will address each of these issues individually in this book.

To help healthcare practices implement health literacy universal precautions, The Agency for Healthcare Research and Quality has created a Health Literacy Universal Precautions Toolkit (@ for health professionals. This provides step-by-step instructions for healthcare practices and offers a systematic approach to simplifying medical care and helping patients get the right medical care.

For there to be a solution, the problem must be recognised. This is not an easy task, because illiterate patients are masters at hiding their inability to read – after all, this isn’t something that they want to be advertised. With all of our progress and technology, people are still slipping through the school system unable to read. The educational system has failed them; does the health care system have to fail them as well?

HELP is organizing a conference on “ Putting Patients First Through Health Literacy  “. This will be on Sunday, 2nd December’12 at Nehru Center at 10.30a.m. to 1.p.m.  The website is

The conference will be followed by a health literacy workshop in the afternoon. Helen Osborne, President, Health Literacy, a world renowned  Consultant from US , will be delivering the keynote and conducting the workshop.  Her website is at

At this time, we will be releasing the book, Deciphering Medical Gobbledygook: Promoting Health Literacy to Put Patients First , authored by Dr Aniruddha Malpani and Juliette Siegfried. This is Chapter 4 from that book

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