Health literacy

You should know

• Inadequate literacy is the single best predictor of poor health status
• More than 90 million Americans have difficulty understanding and acting upon health information.¹
• While the majority of U.S. adults read at the eighth or ninth grade level, most health information today is written at or above a twelfth grade reading level.²
• Making health information easy to understand and improving patient-provider communication are two commonsense ways to address the effects of poor health literacy.

Background 

The American Medical Association defines health literacy as “the ability to read, understand and use health information to make appropriate health care decisions and follow instructions for treatment.” The fact that tens of millions of Americans lack this basic ability has numerous negative implications for the cost and quality of health care.

Across a wide spectrum of diseases, patients with low health literacy have greater difficulty managing chronic conditions. Among patients with type 2 diabetes, for example, low health literacy is associated with poorer control of blood sugar and higher risk of stroke. Patients with marginal health literacy are also less likely to seek out routine and preventive services. For instance, they are 40 percent more likely to never receive a flu shot.³ Low health literacy is associated with poorer adherence to drug warning labels, leading to increased safety risks.⁴ Most Americans also face serious challenges interpreting basic information required to choose a health plan and understand their health benefits. As a result, increasing attention has been devoted to the problem of health benefits literacy.

Though touching all segments of the population, rates of inadequate health literacy are nearly twice as high among African Americans (75 percent) and Hispanics (73 percent) as Whites (38 percent). Age is also a factor -- approximately 81 percent of adults age 65 and over have inadequate health literacy.⁵

Health care providers are just beginning to develop strategies to address and improve health literacy among patients. But a growing body of research shows that improved communication leads to better health outcomes. For example, a recent study of physician practices indicates that using “teach-back” methods -- which involve asking patients to repeat or otherwise demonstrate knowledge of the instructions they have received -- may improve glycemic control among patients with diabetes.⁶

The Aetna difference 

Aetna is engaged in numerous activities to address inadequate health literacy. Although raising levels of health and benefits literacy is a monumental challenge, we believe that targeted interventions can help to reduce the effects of inadequate literacy on health and well-being.

• As part of a physician awareness pilot program, Aetna has used text messaging to provide health literacy information to thousands of network physicians.
• Aetna has launched a nationwide education campaign called Plan for Your Health to help consumers better understand their health care options and the connection between health care and financial well-being.
• Aetna has created educational programs to improve understanding of health literacy issues among members and employees. Aetna has also delivered cultural competency training to its clinical staff.

Questions & answers: 

Q. Why is inadequate literacy so difficult to address in health care?
A. There are several reasons. One is the tendency to overestimate the average patient's ability to process information. Numerous studies demonstrate that even literate patients can recall few of the instructions they receive in the doctor's office. Another reason is that poor literacy is often hidden from plain view. Primary care providers often have difficulty identifying patients who are unable to comprehend instructions, and most patients who are not health literate are ashamed to admit it. Among those individuals who score at the lowest literacy levels, for example, only 29 percent admitted they could not read well and only 34 percent reported they could not write well.⁷ 

Q. How can health care providers, such as doctors and medical staff, better communicate with patients?
A. Patients at all literacy levels prefer clearer, simpler health information. Health care providers can improve comprehension by writing at or below a sixth grade reading level and using the active voice, short paragraphs, and words that are well-known to people without medical training. Improved oral communication practices can also promote understanding among patients with low health literacy. These practices include speaking slowly, taking time to assess patient literacy skills, using “living room” language and “teach-back”methods to confirm patient comprehension.

Q. Isn't literacy a problem primarily for people with low income and low education levels?
A. Absolutely not. Given that nearly half of all adults are either unable or only marginally able to comprehend health information needed to make basic health care decisions, it is a problem that affects every demographic group.

Q. Don't most people struggle to understand their health benefits as well?
A. Yes. Most Americans face serious challenges interpreting basic information required to choose a health plan and understand their insurance coverage. A 2004 poll of female consumers aged 24 to 44 found that 54 percent of respondents had difficulty choosing a health plan, citing "information that is confusing or hard to understand" as the single greatest challenge. At Aetna, we are constantly looking for ways to improve the way we communicate with our members. To that end, the company created a Health Literacy Workgroup in 2006 to raise awareness of health literacy and make member and patient communications easier to understand.

Q. Does poor health literacy contribute to the high health care costs?
A. There is ample evidence it does. A study commissioned by the Institute of Medicine found that the U.S. health care system spends an average of $993 every year in excess hospitalization expenses for every patient with inadequate health literacy.⁸ This accounts for tens of billions of dollars in annual health care costs. Inadequate health literacy also contributes to medication errors, a problem that results in approximately 7,000 deaths and costs the health care system $73 billion per year.⁹

¹ Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
² Rudd, R, BA Moeykens and TC Colton. “Health and literacy: a review of medical and public health literature.” Annual Review of Adult Learning and Literacy. 2000.
³ Scott, TL, JA Gazmararian, et al. “Health literacy and preventive health care use among Medicare enrollees in a managed care organization.” Medical Care. 2002; Vol. 40 (No. 5).
⁴ Wolf, MS, et al. “Misunderstanding of prescription drug warning labels among patients with low literacy.” American Journal of Health-System Pharmacists. June 2006;Vol. 63.
⁵ Rudd, R, I Kirsch and K Yamamoto. Literacy and Health in America. Princeton, NJ: Educational Testing Service; 2004.
⁶ Weiss, BD. Health Literacy: A Manual for Clinicians. Chicago, IL: AMA Foundation; 2003.
⁷ Institute of Medicine. Op cit.
⁸ Institute of Medicine. Op cit.
9 Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2004.