The inability to read and understand basic medical instructions "may be an important barrier to receiving proper health care," conclude Georgia and California researchers in the December issue of the Journal of the American Medical Association.
These findings from The Robert Wood Johnson Literacy and Health Care Project provide the most comprehensive view of how often English- and Spanish-speaking patients at two public hospitals have difficulty with reading tasks routinely required to function in the health care setting, the authors reported.
More than one-third (35.1 percent) of 1,892 English-speaking patients and more than one-half (61.7 percent) of 767 Spanish-speaking patients who participated in the study "had inadequate or marginal functional health literacy," reported researchers from the Emory School of Medicine, Georgia State University and Harbor-UCLA Medical Center.
The researchers measured the functional health literacy of 2,659 patients seeking medical care in the emergency departments of two urban, public hospitals: Grady Hospital in Atlanta, and Harbor-UCLA Medical Center in Torrance, Calif. Functional health literacy as described in the paper is the ability to understand written information in the health care setting, including directions on prescription bottles, appointment slips, Medicaid forms and informed consents.
The study is the first to employ a standardized instrument designed specifically to measure patients' literacy levels regarding basic reading and computational tasks encountered in the health care environment. Called the Test of Functional Health Literacy in Adults (TOFHLA), it measures reading skills and has provided investigators the first data collected on numeracy comprehension in the health care setting. The TOFHLA was designed by four of the study authors: Joanne R. Nurss of the Center for the Study of Adult Literacy, Georgia State University; Mark V. Williams (first author) Ruth M. Parker and David W. Baker, all assistant professors of general medicine in Emory's Department of Medicine.
Their research indicates that significant proportions of patients are unable to read and understand the following:
* How to take medication on an empty stomach (41.6 percent of patients did not read and understand instructions);
* When their next appointment was scheduled (26 percent);
* Standardized informed consent (59.5 percent);
* Medicaid Rights and Responsibilities section of Medicaid application (36.9 percent).
"Patients are frequently discharged from a clinic with prescription and appointment slips and given only brief oral instructions," the authors said. "Assuming patients can read these materials may result in decreased compliance, poorer health outcomes or adverse reactions among patients with low literacy levels.
"The higher prevalence of inadequate health literacy skills among the elderly is noteworthy. Between 47.9 percent and 80.5 percent of patients aged 60 years or older had inadequate functional health literacy... Since the elderly have a greater burden of chronic medical problems and are more likely to need health care services, their higher prevalence of low functional health literacy takes on even greater significance. Many hospitalizations and adverse drug reactions may be due to patients incorrectly taking medications because of their inability to read prescription bottles or other self-care instructions correctly."
The authors also noted that lack of literacy skills may be a barrier to obtaining health insurance.
"The inability of patients to understand the informed consent sections of the Medicaid application (Medicaid Rights and Responsibilities) raises concerns that low literacy may be an access barrier to receiving Medicaid," they said.
To enhance the understanding of health care information among low-literate patients, the authors suggest using surrogate readers (such as literate family members), using symbols rather than words whenever possible, and using video and audio forms of communication rather than printed presentations.
"Much can be done to mitigate the negative effects of low literacy on health care," the authors reported. "The first step toward solving the problem of caring for low-literate patients is to acknowledge its existence.
"... The fact that reading is so basic and taken for granted by so many may be why those who cannot read well feel embarrassed and inadequate. Consequently, low literacy remains an occult, silent disability. Clinicians must learn to identify these individuals compassionately and overcome communication barriers to ensure that patients with inadequate literacy skills receive high quality health care."
-- Lorri Preston