Tina Simpson, JD, MSPH
Principal
Today (September 8th) is International Literacy Day. Here at Atrómitos, we are taking the opportunity to reflect on how literacy intersects with health outcomes and introduce the importance of health literacy. Because we are consistent that way – and all roads lead back to health.
But first, let me set the stage with a few literacy statistics for context:
- According to a 2015 Department of Education study, an estimated 32 million American adults cannot read or write with sufficient fluency to navigate modern life.
- Compared to other industrialized countries, the United States has a higher proportion of adults with low literacy levels, amounting to approximately 1 in 6 adults, or 17% of the adult population.
- Population literacy rates vary significantly by race and income, with blacks and Hispanics being three to four times more likely to have poor reading or numeracy skills than whites. Half of the population estimated to have no literacy are Hispanic. This discrepancy in literacy rates exacerbates and perpetuates economic disparities across and between communities.
- Low US adult literacy rates are associated with an estimated loss of $2.2 trillion annually in the United States.
The adult literacy gap is an under-recognized and underfunded issue in our society. Literacy is critical to effectively navigate and thrive in our modern (not to mention digital) world. Little is more limiting – or more vital in expanding or experiencing opportunities or innovation – than the lack of literacy.
LITERACY AND HEALTH
This brings us to today’s topic: health literacy. Literacy skills are (at least in the United States) strongly correlated with health outcomes. An estimated 90 million people in the United States lack the basic skills and proficiency necessary to understand and use health information. This is a problem, particularly given the emerging predominance of chronic health conditions where patient self-management is so critical. However, health literacy is more than technical reading comprehension skills and understanding discharge instructions or a care management plan. Health literacy is defined, by the CDC, as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”
THE COST OF LOW HEALTH LITERACY
The cost and impact health literacy has on care delivery and outcomes is profound and evident. The Center for Health Policy Research found that the lack of health literacy costs the US economy between $106 – $236 billion annually (a figure we are sure has increased since the report’s publication in 2007). The individual cost associated with low health literacy is also high. Even when controlling for socioeconomic status, health status, and health behaviors, lack of health literacy is associated with a 29% to 52% higher hospitalization rate. Additionally, patients with lower health literacy experience higher mortality rates following cardiovascular events.
The impact of health literacy is most easily measured by the patient outcome – a state of health resulting from the patient’s ability to navigate an extraordinarily complex and fragmented system. (Let’s be honest: our health system generally defies understanding and even those who are “experts” in health care face [serious] challenges in navigating the system.) Improving the ability for patients to access, understand and participate in their care decisions is critical to improved care quality, equity, and efficiency.
That is why, if we really care about Health Literacy (and, relatedly, Patient-Centered Care), we need to think about health literacy as an exercise in more than just bolstering a patient’s literacy skills (although that is an essential component of the solution). Instead, we need to think more about health care communication and engagement generally.
WHAT I MEAN BY THIS
Over the past twenty or so years, there has been a paradigm shift happening (it is slow but inevitable – and it is gaining momentum). I see it as the flattening of the medical care hierarchy: We are moving away from healthcare as a good received from healthcare professionals in discrete doses and interactions to a process of exchanges. In this new paradigm, the patient is not just a recipient but also an active and informed participant, and care is characterized by shared decision-making and is aligned with the patient’s stated goals.
That is why “literacy,” insofar as it is understood as the ability to process received information in a written, static and formal manner, is not enough if we are genuinely thinking about health communication and collaboration. It is more than a case of the 10 commandments in discharge paper form: (1) Thou shalt not eat processed food; (2) Thou shalt not forget to take your medicines, etc. It is an understanding that effective care delivery is an exercise in communication, driven by a patient’s health literacy skills. And this communication is a two-way street: providers have a role to play in promoting, supporting, and developing their patients’ health literacy.
THE ROLE OF THE PROVIDER
Much as factors impact literacy outside of an individual’s control, so is a patient’s health literacy influenced by the behaviors of the health care system. To promote the paradigm shift from health literacy on its own to health literacy as a component of effective health communication, health care providers and stakeholders must:
- Utilize multiple communication strategies and mediums to engage patients, particularly when it comes to providing care management.
- Train your care team members to ensure they have effective communication skills.
- Use “plain language” with patients. To paraphrase Mark Twain, don’t use a five-dollar word when a fifty-cent one will do. Expertise and efficacy are measured by our ability to provide simplicity within complexity.
- Create space for patients to ask questions.
- Expand your care team’s cultural competence to know how to engage with patients of varying literacy and communication skills.
I want to reemphasize this last point: Invest in your care team’s communication capabilities. I have observed throughout my career that providers will focus on the hard skills or clinical competencies of their care management team. This focus, at times, excludes other “softer” skill competencies, including communication, cultural competency, psychology, and behavior change management. This is a very natural and understandable impulse, as we tend to recreate what we know and understand.
But consider the data: over 70% of health outcomes are related to health behaviors and social determinants of health (as we talked about earlier this month). If we want to “move the needle” on these outcomes, we need to think differently and intervene in a manner that addresses the root causes. This includes creating environments that promote health (including addressing unmet social determinants of health), meeting the patient where they are at, and providing patients with the tools, resources, and skills to make positive changes in their lives. Much of this work requires effective health communication from both the patient and the provider(s). Those who facilitate access to care (including administrators and providers) must begin (or continue, for those ahead of the curve in this area) establishing systems and teams of care that know how to share with and receive from patients necessary health-related information. This may require adding new members to your team, including Community Health Workers and Behavior Change Specialists.
The takeaway is this: patients cannot overcome challenges to health literacy on their own, and the impact of those challenges continuing to exist negatively impacts us all. In recognition of International Literacy Day (with our own “health literacy” spin to it), we call on our healthcare infrastructure to lean into its role in addressing patient literacy.