Health Literacy and a Patient's Right to Understand

By Schwartzberg, Joanne G. | Aging Today, March/April 2006 | Go to article overview

Health Literacy and a Patient's Right to Understand

Schwartzberg, Joanne G., Aging Today

The 2005 White House Conference on Aging (WHCOA) Mini-Conference on Health Literacy and Health Disparities focused on the role of limited literacy and low understanding of health information as a cause at the root of health disparities and poor health outcomes in the United States.

In their executive summary, the conferees stated: "Patients have the right to understand Healthcare information that is necessary for them to safely care for themselves and to choose among available alternatives. Healthcare providers have a duty to provide information in simple, clear and plain language and to check that the patients have understood the information before ending the conversation'.'


In the last quarter-century, research has repeatedly shown that patients leaving a physician's office are unable to recall or explain between 46% and 63% of the medical information they have been given. These misunderstandings have been shown to lead to adverse clinical outcomes. The early responses to these distressing studies were to concentrate on the patients-exhorting them to become more involved and activated, ask questions, participate, share in decision making and manage their own care. Only after the publication of the National Adult Literacy Survey (NALS) in 1993, with its startling revelations of the functional literacy levels of Americans, did educational and health researchers begin to look more deeply into the effectiveness of oral and written healthcare communications and the barriers poor communication created for patients.

Although the average American reads at the eighth-grade level (at or below level two of the five-level NALS scale), most Healthcare information has been written at a college level. Also, most informed-consent documents are written at a 17th-grade level. Of particular concern are the difficulties encountered with numeracy: The approximately one-half of Americans falling into the NALS level-one and level-two categories (around 90 million adults in the United States) demonstrated great difficulty in answering questions based on their reading and interpretation of bar graphs or charts, such as train or bus schedules.

All Healthcare directions involve numeracy. For example, "Take I teaspoon four times a day." Directions that use simple words and seem very clear to the health professional can be very confusing to people who try to carry them out and realize at home that they do not have enough information to confidently follow the instructions correctly. In this case, how do you divide a 24-hour day by 4? Do you count night as "day"? Do the instructions mean to take the medicine every six hours, or every three-and-a-half hours while awake? Does the interval have to be spaced out? Could one take two teaspoons in the morning and two at night, or one dose every hour? And is a teaspoon a regular spoon or a soup spoon?

In addition, what happens to older adults who take multiple medications with differing instructions and schedules throughout the day? Over the years, many studies have reported that up to 30% of hospital admissions for people 65 or older are caused by "medication misadventures."


According to the Institute of Medicine 2004 report "Health Literacy: A Prescription to End Confusion," 90 million Americans are at risk for medical misunderstandings, errors, poorer health outcomes and higher medical costs because of their limited literacy skills.

While the majority of those people are white, native born and educated in American schools, minority populations face additional barriers. More than 10% of the U.S. population has limited English proficiency, but more than 50% of the patients who enter healthcare facilities in New York City, for example, don't speak English. In some situations, English speakers are the minority.

Most of the studies looking at low literacy and limited English proficiency have concentrated on the Latino population. …

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