A recent article in American Medical News reports that one in three patients has basic or below basic health literacy, “meaning he or she struggles with tasks such as completing health insurance forms or understanding a short set of instructions about what liquids to avoid drinking before a medical test.” The lengthy piece says low health literacy leads to poor health outcomes and proposes steps physicians can take to identify patients who have it and to overcome the associated risks.
The report raises more questions than it answers.
The sender is responsible for the message
How does this conceptualization of health literacy as a cognitive deficit in patients that doctors need to overcome square with the basic tenet of communications that says “the sender is responsible for the message”. In healthcare, this principle has long been legislated through federal and state civil rights laws, Medicare/Medicaid regulations and accreditation requirements.
Is health literacy really about filling out forms?
If patients were better at filling out forms, would they have better outcomes? Would disparities be equalized?
For discussion, let’s just assume, for a minute, that they would....
The report assumes patients’ difficulty with insurance forms is due to low literacy (which is understood and tested as reading ability). What other explanations have been investigated? Could it be illness, medications, or stress is reducing usual cognitive abilities? Could it be the form is full of words a person needs and uses only if they become an actuary or a medical transcriptionist, or develop a raft of chronic ailments? Maybe, not having had occasion to learn the vocabulary of disease is an indicator of good health literacy, suggesting ability to effectively use health information and services.
When a third of patients have trouble with a form or instructions, that says at east as much about the form and the instructions as it does about the person trying to use them. In a patient-centered system, or any system, doesn’t it make more sense to simplify the forms and the instructions than to expect everyone to learn medical and insurance vocabulary?
And what about people who are not patients; do they have health literacy?
These conceptual questions are about to become very practical and critical. In 2014, millions of people previously excluded from the healthcare system will gain access. Do we want to make fluency in medicalese and insurance-speak a pre-requisite to care?
Now is the time to fix the forms and instructions, stop blaming failures in communication on the receivers’ reading skill, and ask: What supports people in using health information and services to cope, recover and maintain or enhance health?
O’Reilly, KB. (March 19, 2012) The ABCs of health literacy. Amednews.com http://www.ama-assn.org/amednews/2012/03/19/prsa0319.htm
Smith, Sandra (2001) Patient Education and Literacy in Labus and Lauber, (Editors) Preventive Medicine and Patient Education, WB Saunders, Philadelphia PA