Health Literacy

The ability to use and correctly interpret health information is important for people who contend with one or more chronic diseases.  Often, those with chronic illness have complex medical management needs, and likely take multiple prescription drugs.  The oral or written instructions for medication management may be insufficient or confusing. 
This is a patient safety issue: non-adherence or misuse of medications can result if patients do not understand their prescriptions.  A study by Davis and colleagues demonstrated that patients with lower literacy levels and those who take a greater number of medications were less able to understand their medication labels.  The study found that even if patients understood the words on the label, most could not correctly demonstrate how to take the medication -- suggesting the importance of communicating clear directions and assisting with any skill-building necessary to take the the medication as directed. 

While medication management is an important aspect of health literacy, the consequences of low health literacy can have a wider impact.  These may include failure to recognize signs and symptoms of illness, inattention to preventive care or self-management, and unwillingness to talk with medical providers out of fear or shame. 

Confirming patients' understanding, regardless of the relative complexity of medical information, has been suggested as a universal precaution for health care providers.  Plain communication in the medical context would benefit persons at every education level, because any interaction with the health care system carries at least some degree of stress.  This stress may in turn reduce ability to process and recall information.  Because patients with chronic disease are often in the position of having to self-monitor their condition and adjust their therapy, teaching them self-care behaviors and helping them master the needs of their condition can be a relevant approach.  This is often a stepped and tailored process, with periodic refreshers to ensure that patients sustain their self-management skills over time.

A thoughtful look at your health care system can turn up many ideas for paperwork reduction, streamlined or standardized processes, and clear, simple communication -- all elements of truly patient-centered care.    
Health Literacy Universal Precautions Toolkit
The federal Agency for Healthcare Research and Quality has released the “Health Literacy Universal Precautions Toolkit,” prepared by the the University of North Carolina at Chapel Hill.

The toolkit outlines a six-step path to improvement for primary care practices to follow and provides a wide variety of tools for them to use to achieve this objective, including videos, posters and sample clinic forms.  By implementing the tools, a practice will be able to support their patients’ needs in ways the patients can understand.
Authors of the toolkit include Darren A. DeWalt, MD, MPH, an assistant professor in the UNC School of Medicine and research fellow at UNC’s Cecil G. Sheps Center for Health Services Research, Leigh F. Callahan, Victoria H. Hawk, Kimberly A. Broucksou and Ashley Hink, all from UNC; and Rima Rudd from the Harvard School of Public Health.
Resources for Readability
Readability of written materials is part of addressing the overall issue of health literacy.  The Group Health Research Institute (GHRI) Readability Toolkit, now in its third edition, was created to help researchers, patient educators, clinicians and health plan administrators create materials that patients and health care consumers can understand.  This Readability Toolkit was developed as part of PRISM, the Project to Review and Improve Study Materials. In addition to helping users craft materials at a level appropriate to their audience, the Toolkit offers tips and guidance for layout and formatting, as well as plain language alternatives for common medical terms. 
Please note that while the PRISM Toolkit is copyright-protected, it is a freely usable resource.  GHRI asks users to register so that the uptake of this resource can be tracked; the registration link is available on page 2 of the document. 
Key Citations
Bennett IM, Chen J, Soroui JS, et al. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009 May-Jun;7(3):204-11. [Link]
Cho YI, Lee SY, Arozullah AM, et al. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med. 2008 Apr;66(8):1809-16. [Link]
DeWalt DA, Dilling MH, Rosenthal MS, et al. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr. 2007 Jan-Feb;7(1):25-31. [Link]
Hope CJ, Wu J, Tu W, et al. Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure. Am J Health Syst Pharm. 2004 Oct 1;61(19):2043-9. [Link]
Kalichman SC, Pope H, White D, et al. Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care (Chic Ill). 2008 Nov-Dec;7(6):317-23. [Link]
Kripalani S, Henderson LE, Chiu EY, et al. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med. 2006 Aug;21(8):852-6. [Link]
Laramee AS, Morris N, Littenberg B. Relationship of literacy and heart failure in adults with diabetes. BMC Health Serv Res. 2007;7:98. [Link]
Morris NS, MacLean CD, Littenberg B. Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes. BMC Fam Pract. 2006;7:49. [Link]
Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ. 2007 Jan-Feb;33(1):144-51. [Link]
Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006 May;54(5):770-6. [Link]
Tang YH, Pang SM, Chan MF, et al. Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. J Adv Nurs. 2008 Apr;62(1):74-83. [Link]
Cavanaugh K, Huizinga MM, Wallston KA, et al. Association of numeracy and diabetes control. Ann Intern Med. 2008 May 20;148(10):737-46. [Link]
Rudd RE, Blanch DC, Gall V, et al. A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management. Patient Educ Couns. 2009 Jun;75(3):334-9. [Link]
Wallace AS, Seligman HK, Davis TC, et al. Literacy-appropriate educational materials and brief counseling improve diabetes self-management. Patient Educ Couns. 2009 Jun;75(3):328-33. [Link]
Weiss BD, Francis L, Senf JH, et al. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med. 2006 Aug;21(8):823-8. [Link]