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Literacy can affect health, compliance
(Feb. 1, 2002)
Imagine living in a world where you speak the same language as those around you but you can't read signs, newspapers, books, recipes or medication labels.
For about 20 percent of the American population, it's not something to imagine. They can't read, write or do basic math.
"The new civil right in today's society is literacy," said Dr. Mark Williams, associate professor of medicine and director of the Hospital Medicine Unit at Emory University School of Medicine in Atlanta, during a recent East Carolina University Department of Medicine grand rounds lecture on health literacy.
"Imagine that in the world's greatest nation seven out of 10 fourth graders can't read at grade level," he said. "Maybe that patient isn't noncompliant; maybe he can't read the appointment slip."
Health literacy is defined by the National Library of Medicine as "the degree to which people can obtain, process and understand basic health information and services they need to make appropriate health decisions."
At the Brody School of Medicine, Dr. Carlos Estrada of the Department of Internal Medicine has been researching health literacy and its impact on his patients in an anticoagulation clinic for about four years.
"Patients must take an exact amount of Coumadin," an anticoagulant, Estrada said. "A few years ago, we were thinking, "Do these patients really follow the directions?"
Over four months, Estrada and his nurses assessed that 30 percent of the patients didn't have formal education past the sixth grade; 30 percent had between sixth- and ninth-grade educations; and 30 percent had more than a ninth-grade education. And they know some patients can't read at all, but they don't ask and often the patients don't tell. They also reviewed the standard clinic materials patients were given.
In an article published in "Stroke" magazine in 2000, Estrada and his colleagues reported 88 percent of most patient information materials regarding the use of anticoagulants is written at the ninth-grade level or higher.
"The readability level of patient information material contrasts with the observed patients' abilities to read. One-third to one-half of English-speaking patients have difficulty reading material at the 10th-grade level," they wrote in their article.
Almost all the patient information material is above the head of patients in this town," Estrada said. "Everything's at a great level, so much that 80 percent of our patients can't understand the materials."
He shakes his head when he said that some free company provided materials for medical clinics across the country were written on ninth- to 18th-grade level when analyzed. An 18th-grade level would be post-master's degree. "We recommended that patient materials be written at the sixth-grade level or lower," Estrada said.
Another hurdle for patients with low literacy levels and their health care providers is that often the patients' educational level doesn't mean proficiency at that level. Estrada said that patients' observed reading abilities are usually three-to-five grade levels below what they report as the last grade completed.
In addition to reading, Estrada and his team assessed whether the patient could do simple math. "A significant number of patients couldn't figure out if you take one-and-a-half tablets per day and you have nine pills, do you have enough pills for one week," he said. "It's not surprising the patients with the highest percentage of noncompliance are the same ones who couldn't read and write."
Estrada received a $60,000 grant from the American College of Physicians Society for Internal Medicine to set up an electronic medical record to note literacy of the patient and a Web site to educate physicians about dosing issues for patients with low literacy levels.
Now that the patients' paper medical records at the Brody