Health Literacy:
A Crisis In Health Care
Minnesota Rural Health Conference
July 19, 2005
Duluth, MN
Developed by Stratis Health with the Permission of the American Medical Association
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Foundation and the American
Medical Association
Definitions
General Literacy:
“ An individual’s ability to read, write, and speak in English,
and compute and solve problems at levels of proficiency
necessary to function on the job and in society, to achieve
one’s goals, and develop one’s knowledge and potential.”
National Literacy Act of 1991
Health Literacy:
“The degree to which individuals have the capacity to
obtain, process, and understand basic health information
and services needed to make appropriate health
decisions.”
Healthy People 2010
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Implications of low health
literacy on patient care
33% Unable to read basic health care materials
42% Unable to comprehend directions for taking
medication on an empty stomach
26% Unable to understand information on appointment slip
43% Unable to understand rights and responsibilities
section of Medicaid application
60% Unable to understand standard informed consent
Williams et al., JAMA 12/6/95
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Cost of poor health literacy:
Estimate >$50 billion annually*
We all pay!
 39% paid by Medicare (FICA taxes on workers)
 17% paid by employers
 16% paid by patients, out-of-pocket
 14% paid by Medicaid
 14% from other public and private sources
*Estimated by National Academy on an Aging Society using 1998 figures
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National Adult Literacy Survey (NALS)
 Conducted in 1992
 N=26,000
 Most accurate portrait of literacy in the US
 Scored on 5 levels
 Not accounted for:
 Patients who have adequate language skills, but
do not have adequate health literacy
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Results:
National Adult Literacy Survey (NALS)
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31.5%
27.5%
30
25
21%
20
16%
15
10
3%
5
0
1
2
Level
3
(Kirsh I, Jungeblut A, 1993)
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NALS: Results
 48%, or 90 million, US adults have inadequate or
marginal literacy skills
 Does not account for patients who have adequate
language skills, but do not have adequate health
literacy
 Only 25% of those in Level 1 were new
immigrants.
 Those at levels 1 and 2 did not necessarily
perceive themselves as being ‘at risk’
(Kirsh I, Jungeblut A, 1993)
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Why are patients at risk?
 Reliance on written word for patient instruction
 Increasingly complex health care system
 More medications
 More tests and procedures
 Growing self-care requirements
 Esoteric language
 Aging population
 More culturally diverse patient population
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Understanding the problem
What is it like?
The following passage simulates what a
reader with low general literacy sees on
the printed page
Read the entire passage out loud
You have 1 minute to read
(Hint: words are written backwards and
the first word is “cleaning”)
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GNINAELC – Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna natspac
revenehw uoy eciton na noitalumucca fo tsud
dna nworb-der edixo selcitrap. Esu a nottoc
baws denetsiom htiw lyporposi lohocla. Eb erus
on lohocla sehcuot eht rebbur strap, sa ti sdnet
ot yrd dna yllautneve kcarc eht rebbur. Esu a
pmad tholc ro egnops ot naelc eht tenibac. A
dlim paos, ekil gnihsawhsid tnegreted, lliw pleh
evomer esaerg ro lio.
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Understanding the problem
Hear a few examples from:
“As Patients See It”
 A video created in 2003 by AMA
 Real patients and real physicians talking
about literacy issues
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Mr. Day
 Diagnosed with
hypertension
 Reads at
second-grade
level
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Mr. Bell
 Reads at fifthgrade level
 Gets agitated
filling out
paperwork
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Mrs. Cordell-Seiple
 Film maker
 Graduated from
high school
reading at a
fifth-grade level
 Didn’t know she
had undergone
a hysterectomy
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What do we know?
Low Health Literacy (LHL) is prevalent
LHL leads to:
 Lower health knowledge and less healthy
behaviors
 Greater health costs
 Poorer health outcomes
Techniques and approaches may be
used to address health literacy
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Three strategies
I.
II.
III.
Create a “shame-free” environment
Improve interpersonal communication
Use patient-friendly educational
materials and forms
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Strategy: Create a
shame-free environment
 Recognize red flags:
 “I forgot my glasses…”
 Incomplete forms
 Seeking help only when illness is advanced
 Convey an attitude of helpfulness, caring, and
respect (by all staff):
 What is it like being a patient in your setting?
 Are there forms or instructions that could be
confusing?
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Strategy: Improve
interpersonal communication
 Slow down
 Use plain “living room” language
 Focus on key messages (www.askme3.org):
What is my main problem?
What do I need to do?
Why is it important for me to do this?
 Use “teach back” techniques
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Strategy II
Improve interpersonal communication
 Mrs. Greigar (reads
at third-grade level)
 Dr. Alvarez
 Slow down
 Use analogies
 Use plain “living
room” language
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Strategy II (continued)
 Brown bag review
 Mrs. Tilsley reads at
seventh-grade level
 Dr. Williams
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Strategy III
Develop patient-friendly materials/forms
Keep content concise and focused:




Focus only on key points
Emphasize what the patient should do
Keep anatomy and physiology basic
Show or draw simple pictures to
enhance interaction
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Strategy III
Tips for easy-to-read materials:
 Simple words (1-2 syllables)




Short sentences (4-6 words)
Short paragraphs (2-3 sentences)
Limit medical jargon
Use headings, bullets, and lots of white
space
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What can you do by next week?
1. Explain things clearly in plain non-medical
language/analogies.
2. Focus on the key messages using
“Ask Me 3”.
3. Use a “teach back” or “show me” technique
to check for understanding.
4. Use patient-friendly educational materials to
enhance interaction.
5. Create a shame-free environment.
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What can you do in the future?
 Form a team to determine a long-term strategy
 Develop a plan to educate all staff about low
health literacy
 Discuss methods for improving communication
skills with providers and staff
 Do role play and/or identify key terms/messages
commonly encountered in your practice
 Incorporate “Ask Me 3” components into patient
information
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“Understanding
is a two-way street.”
Eleanor Roosevelt
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For more information:
 www.amafoundation.org
 www.askme3.org
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Karla Weng, MPH, CPHQ
Project Manager
(952) 853-8570
kweng@mnqio.sdps.org
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Brought to you by Stratis Health
Minnesota’s Medicare Quality Improvement Organization
Stratis Health is a non-profit independent quality improvement organization
that collaborates with providers and consumers to improve health care.
This presentation was created by Stratis Health under a contract with
the Centers for Medicare & Medicaid Services (CMS).
The contents do not necessarily reflect CMS policy.
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