What Did You Just Say?: Health Literacy in the Information Age

MDNG PsychiatryJuly 2008
Volume 8
Issue 7

Health literacy requires more than just knowing how to read. It involves a number of additional skills, including listening, analyzing, and decisionmaking.

Health literacy requires more than just knowing how to read. It involves a number of additional skills, including listening, analyzing, and decisionmaking. Patients are called on to demonstrate health literacy skills in a variety of situations when interacting with the healthcare system, including deciphering appointment slips; comprehending written and verbal instructions for prescription and OTC medications and supplements; understanding information in health brochures and other instructional and educational materials; comprehending and acting on instructions from healthcare professionals; filling out consent forms; and maneuvering through the often-complex modern healthcare system.

Literacy problems are not rare, nor are they trivial. The 2003 National Assessment of Adult Literacy found that 43% of adults read at basic or below basic levels, which can translate into poor health outcomes. The Agency for Healthcare Research and Quality (AHRQ) found that for a number of health and healthcare topics, patients with low literacy had a worse prognosis than those with high literacy. Populations with sizeable percentages of people who have poor health literacy include the elderly, minorities, immigrants, low-income groups, and people with chronic mental and/ or physical health problems. Reasons for poor health literacy include lack of higher education, learning disability, cognitive decline among the elderly, and lack of regular reading resulting in diminishing ability over time.


It can be challenging to identify people with low health literacy, as these individuals will not necessarily volunteer their limitations. Th ey often can be ashamed of their limitations and are very protective of them. Th ere is no particular “look” for someone with low health literacy; these individuals can be well-groomed, articulate, and appear quite intelligent (http:// caonline.amcancersoc.org/cgi/content/ abstract/52/3/134).

Formal tests of health literacy include the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA). However, these are not one-size-fi ts-all tools—the lead author of the article on the REALM test only recommends using these formal instruments in clinical practice if the physician is willing to take the time to tailor the communication to the particular patient to be assessed with the formal test.

Physicians and other healthcare professionals must always be on the alert for patients with low health literacy. Beyond merely assuming that patients who are of older age or have limited formal education are at risk, there are several signs that may indicate a patient has low health literacy: claiming they forgot their glasses and therefore cannot read brochures or other print pieces received from your staff , always bringing family members with them to explain instructions and other information, and failing to properly or accurately complete patient intake forms or research surveys.


INTERNET-BASED COMMUNICATION With so many patients relying on the Internet as their main source of healthcare information, the diffi culty of the language used to present medical information can pose a major challenge. One study found that 100% of the English-language websites evaluated off ered health information at the ninth-grade reading level or higher. Even the language used by physicians in written and oral communications with their patients may be confusing or unfamiliar. Davis and colleagues and Manning and Dickens offer a number of practical suggestions for clinicians to promote effective communication with patients.


When you are recommending websites to patients or printing pages from websites to distribute to patients, consider whether they are written for people with low health literacy. If you are not aware of specifi c websites that meet this criterion, then recommend those with lower grade reading levels. The typical website is often written at a tenth-grade reading level or higher. The National Work Group on Cancer and Literacy recommends that essential written communication for patients should be written at a fifth-grade reading level or lower.

How can you determine if a particular webpage is written at a lower grade reading level? One way is to copy and paste the text into Microsoft Word and calculate the Flesch-Kincaid grade level. To do this, click “Tools” and select “Options” from the drop-down list (a), click the “Spelling and Grammar” tab (b), and then click the “Show Readability Statistics” checkbox ©. Then click “Tools” again and select “Spelling and Grammar” from the drop-down menu (d). Word will highlight all spelling and grammar mistakes, off ering you the chance to correct or ignore them, and then display the readability statistics, including the Flesch-Kincaid grade level (e).

Keep in mind that Word recognizes every occurrence of a period as a sentence. Thus it will count abbreviations such as “Dr.,” numerical expressions with decimal points, and bulleted lists as very short sentences, which may lower the reading grade level. If necessary, edit those parts from the document to allow for a more accurate readability estimate. When creating a page on a practice website, consider the grade level of the information and other content you plan to include.

Pictures and stories have been shown to be effective means of communicating with patients with low literacy levels. Research has also shown that video content increases comprehension among patients with low health literacy.


Some physicians embrace e-mail as a way to communicate with their patients. It may be helpful to determine the two or three key messages of clinical importance you wish to convey and include only those in e-mails to patients; anything more than that may be too much content and potentially overwhelm patients with poor health literacy skills. It is also important to use non-technical medical language, or “living room” language, when possible. Keep in mind that the patient may not be the one opening and reading the e-mail—a friend, family member, or caregiver may be opening and printing the content for the patient to read at a later time.

Instant Messaging

In addition to the e-mail recommendations, there are several useful strategies you can employ to promote understanding if you are communicating with your patient via instant message. Avoid asking, “Do you understand?” as many patients will respond “yes” regardless of whether they truly understand. Instead, use a “teach back” approach, in which you ask patients to state in their own words the information and instructions you have communicated to them.

Poor reading comprehension and defi ciencies in other health literacy skills are common and often diffi cult to detect in patients. Failure to accommodate the needs of patients with low health literacy can result in poor communication, leading patients to misunderstand or ignore your instructions to the detriment of their health. By following the suggestions outlined above, you can help your patients understand and retain the information they need to make better decisions and experience better outcomes.

Dr. Fogel is an Oncology Net Guide editorial board member and an assistant professor in the department of economics at Brooklyn College of the City University of New York. He can be reached at joshua.fogel@gmail.com.

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