Of the many socioeconomic factors that predict health outcomes, health literacy may not be as well recognized as other factors such as race/ethnicity, education level, employment, and income. Yet data suggest that health literacy may be a stronger predictor than all these factors. Such data highlight the influence of poor health literacy on health outcomes, including increased mortality, lower patient satisfaction with care, lower quality of care, worse patient safety, higher healthcare costs, and overuse of the emergency department (ED).
“Health literacy skills are a social determinant of health and strong skills mitigate health problems and risks,” says Andrea Green, MD, FAAP, associate professor of Pediatrics and director of the Pediatric New American Clinic, University of Vermont, Burlington.
Defining health literacy as “the ability of people to get health information, understand it, and use it to make better decisions concerning their health,” Green emphasizes the need for pediatricians to recognize, identify, and improve health literacy in their patients and caregivers during a presentation she gave at the recent American Academy of Pediatrics (AAP) National Conference. As reflected in the title of her presentation, “Strategies to improve health literacy for diverse and underserved populations,” she spoke on the needs and challenges to improving health literacy in diverse and underserved populations while emphasizing that the scope of the problem extends to all populations.1 It is estimated that nearly one-half, or 90 million, adult Americans have difficulty understanding and acting on health information, she says.
As such, clinicians need to be aware that health illiteracy is a common problem that reaches into all socioeconomic and educational levels of society. However, its reach into diverse and underserved communities, such as immigrant and ethnic communities, can be particularly challenging given the extra burden of cultural and language barriers.
This article focuses on ways clinicians can identify and improve health literacy in their patients, with a particular emphasis on strategies to ensure patients of diverse and underserved populations are receiving sufficient help.
Identifying health illiteracy
Acknowledging that screening patients and/or their caregivers for health literacy may be uncomfortable for providers as well as patients, Green encourages clinicians to practice what she calls universal health literacy precautions. “Just as we wash our hands before and after every patient visit to protect all patients from communicable diseases, healthcare professionals should seek to promote better understanding for all patients, not just those we think need extra assistance,” she says.
For pediatricians, this means identifying patients and, importantly, their caregivers who have difficulty understanding the medical information and instructions imparted to them in the clinic. Improving health literacy in caregivers is particularly important. Data show that lower health literacy in caregivers is associated with increased rates of hospitalization for asthma; use of inappropriately dosed over-the-counter medications; less family-centered care; and increased incidence of child aggression and antisocial behavior.
To this end, Green describes a number of “red flags” that may indicate a patient and/or caregiver has poor health literacy: frequently missed appointments; incomplete registration forms; noncompliance with medications; inability to name medications or explain their purpose or dosing; identifying pills by looking at them versus reading the label; inability to give coherent history; asking fewer questions; and not following through on tests or referrals.
To assess health literacy in patients and/or caregivers, Green provides a list of standardized screening tests that can be employed.
For providers who prefer a simpler screening approach, she cites evidence showing the effectiveness of asking 3 simple questions to identify health literacy (Table 1).