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Assessing Health Literacy in Clinical Practice


Implications of Limited Health Literacy

The importance of limited health literacy rests with its strong independent association with a variety of adverse health indicators. Specifically, people with limited health literacy have limited health knowledge, and they often misunderstand how to take medications. As a result of these and likely other factors, they also have worse health status, more hospitalizations, and higher healthcare costs -- even after controlling and adjusting for potentially confounding sociodemographic factors such as ethnic/racial group, income, education level, and others.

Limited Health Knowledge

People with limited health literacy have less health knowledge than their more literate counterparts. To cite just a few examples, individuals with limited health literacy are less aware of the need for preventive health measures such as cancer screening, [17,18] and in many cases don't even know what a screening test is. [19] Those with chronic diseases have less knowledge about their conditions -- a finding shown in studies of patients with asthma, [20,21] heart failure, [22] hypertension and diabetes, [23] HIV infection, [24] and other chronic disorders. People with limited health literacy are also less apt to understand the content of consent forms [25] and less likely to understand how to correctly use birth control methods. [26]

Attempts by clinicians and health systems to educate patients with limited health literacy are often unsuccessful. This could partly be because patients with limited health literacy are less likely to ask questions of clinicians. [27] But perhaps more importantly, most health education information for patients -- both oral instructions and written information -- is too complex for the average person to understand. [28-37] For individuals with limited literacy skills, such information can be incomprehensible.

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Copyright 2007: American Medical Association and American Medical Association Foundation

Misunderstanding How to Take Medication

Just as with patient education handouts, prescription labels and the written instructions that accompany both prescription and nonprescription medications are often complex and written at a reading difficulty level that exceeds the literacy skills of the average American. [34,36,38-42] Even highlighted warning labels on prescription bottles are difficult for individuals with limited literacy to understand. [43]

The result is that patients -- especially those with limited literacy -- do not understand medication instructions and often take medications incorrectly. The problem is greatest in elderly patients -- the age group that NAAL data indicate has the highest reported rate of limited health literacy. [5]

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Republished with permission of Terry C. Davis, PhD

Worse Health Status

Studies conducted in different settings using different methods and studying different medical conditions have all concluded that people with limited health literacy skills have worse status than those with adequate literacy skills -- even after controlling and adjusting for potentially confounding sociodemographic factors. [44-48] One recent study found that all-cause mortality rates are 52% higher among Medicare managed care enrollees who have limited health literacy compared with those with adequate literacy, even after adjusting for baseline health and socioeconomic factors, including education. [49]

The difference in health status applies not just to overall health, but also to health status of those with specific chronic illnesses. For example, HIV-infected individuals with limited health literacy report worse health status than those with adequate health literacy. [47] Men with limited health literacy who develop prostate cancer have later-stage disease at the time of diagnosis. [50] And several, though not all, studies have shown that patients who have diabetes and limited health literacy skills have worse glucose control than those with better literacy skills; literacy itself is thought to be the likely mediating factor. [48,51,52]

More Hospitalizations

The worse health status of individuals with limited literacy translates into higher hospitalization rates and higher healthcare costs. For example, Medicare managed care enrollees (mostly older individuals) followed over a 3-year period were 29% more likely to be hospitalized if they have limited health literacy skills. [53] In another study, patients with limited health literacy receiving care at public hospitals had a 2-year hospitalization rate that was 69% higher than it was among patients at the same hospitals who had adequate literacy. [54]

Higher Healthcare Costs

The poor health knowledge, incorrect medication use, poorer health status, and higher hospitalization rates of people with limited health literacy translate into higher healthcare costs. One early study of the association between limited literacy and costs in a sample of Medicaid managed care enrollees found that those with limited literacy skills had mean annual healthcare costs of $10,688 per year, while the average per-patient cost for the entire managed care plan was only $2891, a difference largely driven by higher costs for hospital care. [55]

Another study, this one involving Medicare enrollees in sites across the United States, also found higher costs for those with limited health literacy. Costs for emergency care, prescription drugs, and inpatient care were all higher among patients who had limited health literacy, even after statistical adjustments for a variety of confounding socioeconomic variables. [56]

Finally, 2 reports have estimated the economic effects of limited health literacy on overall medical expenditures in the United States. The first study, reported in 1998, estimated that excess healthcare costs due to limited health literacy totaled $50-70 billion per year. [57] A more recent report, issued in 2007, that used a more sophisticated economic analysis estimated the annual costs to be more than $100 billion. [58]