Only 12 percent of adults in the United States have a high level of health literacy, according to the National Assessment of Adult Literacy. In other words, nearly nine out of 10 adults lack the skills needed to fully manage their health care and prevent disease. These adults are more likely to report their health as poor, and are more likely to lack health insurance. Low literacy has been linked to poor health outcomes, higher rates of hospitalization, less use of preventive services, minimal prescription and care plan adherence, and death. Additionally, these all lead to higher health care costs.

What is health literacy?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information to make appropriate health decisions. 

With literacy skills developed through basic education and personal experiences, patients can better understand their conditions, provide consent, effectively communicate with their health care providers, and apply health information to different situations. They can read and understand directions on prescription bottles, consent forms, brochures, and appointment information. These basic skills enable patients to apply the major components of health literacy:

• print literacy – writing and reading
• oral literacy – listening and speaking 
• numeracy – using and understanding numbers, such as medication doses, calculating premiums, copays, and deductibles

Numerous studies have determined that there is in fact a correlation between low literacy and the overall self-care and health decline of patients. 

Here are four facts about individuals with low health literacy:

1. Less Likely to Engage in Health Care

Many health care organizations assume patients understand and can manage their own health care. To achieve optimal health care, patients must engage with their health care. If a patient doesn’t have the literacy skills necessary to comprehend basic words, it is unlikely that he or she will be able to engage with their care, which is typically made up of complex directions and complicated terminology. 

Engagement is the ability of a patient to play an important role in his or her health care. This is achieved through: 

• health literacy – the ability to read, understand, and act on health information
• shared decision making – the ability to engage with health care professionals and select appropriate treatment and management options
• quality improvement – assessing health care processes and outcomes

In addition to low health literacy affecting a patient’s own care, it can also affect the care of others.  For example, a parent unable to read or understand directions may struggle to determine the necessary dosage of medicine for their child. Likewise, patients of all ages with numerous complex conditions have trouble managing their care or of others in their household due to low health literacy.

Dealing with complicated forms, complex medical verbiage, multiple health care providers, and insurance premiums that can be difficult to understand, individuals with low health literacy face many complications that hinder the progress of their health. 

In 2010, three initiatives stressed the consequences of low health literacy: the Affordable Care Act, the National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010. The initiatives resulted in the requirement for health care forms and publicly distributed documents to be clearer and more concise.

Another initiative of the National Action Plan to Improve Health Literacy focuses on two essential principles: 

• All people have the right to health information that helps them make informed decisions
• Health services should be delivered in ways that are easy to understand and that improve health, longevity, and quality of life

Ultimately, access to correct and accurate health information and usable health services needs to be improved for individuals with low health literacy.

2. Prescription Labels Often Misread

As anyone who takes multiple medications knows, taking the right medication at the right time is crucial to treatment and can prevent dangerous outcomes.

More than a third of adults are in the “basic” or “below basic” health literacy groups, which means they are more susceptible to failing to properly read and understand warnings on prescription and over-the-counter medicine labels. 

A study on the common causes for misunderstanding prescription drug warning labels (PWLs) among adults with low literacy was conducted at the Louisiana State University Health Sciences Center in Shreveport. Seventy-four patients reading at or below the sixth-grade level and receiving care at the clinic were recruited to participate. After interpreting and commenting on eight commonly used warning labels found on prescription medications, an expert panel reviewed the patients’ responses and determined the different levels of interpretation.

Patients with low literacy skills demonstrated a lower rate of correct interpretation of the PWLs than those with higher literacy skills. It was identified that the most common causes of misinterpretation were:

• multiple-step instructions
• reading level of the text
• use of icons
• use of color
• message clarity 

A similar study was conducted by Michael Wolf, Ph.D., assistant professor of medicine at Northwestern University’s Feinberg School of Medicine. He concluded that nearly half of the total low-income and low-literate patients examined during the study misinterpreted at least one out of the five average prescription labels they were tested on. Additionally, patients with low literacy made the most mistakes and were unable to understand four out of five of the label instructions.

“Just being able to read the label doesn’t mean you’ll be able to interpret it. Patients reading at a sixth-grade level or below could read it back. But if you ask them what it means to take two tablets twice daily, only one-third of the patients with limited literacy skills got that correct,” Wolf noted.

It is important that our health care system continues efforts to redesign and standardize the text and format of prescription medication labels to reduce the highly dangerous, and even deadly, outcomes for patients.

3. Increased Visits to the Emergency Room

Patients with low health literacy are 2.3 times more likely to visit the emergency room. 

In The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study, published in Academic Emergency Medicine, researchers assessed the association between health literacy and emergency department (ED) admissions. It was determined that education is a critical factor in reducing hospital admissions and health care costs. 

The study was led by Meenakshi P. Balakrishnan MPH, Ph.D., clinical research manager in the department of emergency medicine at the University of Florida. Balakrishnan and her research team conducted a study of potentially preventable ED visits among adults 18 years and older in an urban community. A total of 1,201 participants were enrolled and 4,444 ED visits were reviewed.

The results of the study indicated that 33 percent of the participants had low health literacy, and 9.5 percent of ED visits were potentially preventable and 61 percent resulted in a hospital admission. Furthermore, patients with low health literacy were 2.3 times more likely to visit the ED.

“Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the health care system,” said Harrison Alter, MD, MS, executive director of the Andrew Levitt Center for Social Emergency Medicine.

Health care professionals need to both recognize and address health literacy related problems in order to prevent avoidable hospital admissions. This means ensuring that patients understand instructions and are able to navigate the health care system. 

4. Higher Mortality Rate

Lower health literacy has been associated with a higher prevalence of depressive symptoms, physical limitations, and chronic diseases; specifically heart disease, diabetes, stroke, and asthma. 

Individuals with low health literacy have less knowledge about chronic diseases, poorer mental and physical health, limited use of preventive services, and higher rates of hospital admissions. Given the complex nature of managing chronic diseases and age related health decline, low-literate individuals who fall into these categories, especially low literate older adults, are at a much higher risk of death.

A study in England concluded that one in three older adults were unable to understand basic usage instructions on a medicine label. The study was based on the results of 7,857 patients and an in-depth scoring system to determine level of health literacy. Adults with low health literacy, with scores in the lowest 12.5 percent, were more than twice as likely to pass away within five years, and those with moderate health literacy showed an intermediate pattern.

A study led by Pamela N. Peterson, MD, MSPH, of the Denver Health Medical Center, to determine the association between low health literacy and mortality and hospitalization of patients with heart failure concluded that nearly one in five patients with heart failure have low health literacy.

Conclusion

Health care providers are challenged with learning how to best share information with people of varying literacy levels, and to recognize when a patient doesn’t understand. Many patients feel pressure to act as if they understand, even when they do not. It is important for health care providers to identify patients who are at high risk for not comprehending the health information they are provided. 

The quality of communication between the patient and provider, and materials that are easy to understand, such as forms, prescription labels, and health care instructions, is key. These factors can help increase patient engagement, improve adherence of medicine and care plans, reduce hospital admissions, and ultimately, decrease low literacy related deaths.