Optimize patient health by treating literacy and language barriers

AORN Journal,  Feb, 2002  by Vicki Dreger,  Thomas Trembeck

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The nurse tried not to take Mr B's abrupt behavior personally--he was very ill, in pain, and awaiting emergency bowel surgery. When Mr B hesitated to add his initials to the adjusted consent, the nurse asked if he needed glasses to see the form. He gave the nurse "a look" as he took the pen and initialed the changes on the consent. A colleague suggested that perhaps the patient could not read. The nurse responded that Mr B had signed the original consent form already, but the nurse realized that a signature alone does not guarantee the ability to read. The nurse further recognized that few patients voluntarily acknowledge that they are unable to read.

WHAT IS HEALTH LITERACY?

"Health literacy is a huge national problem that demands immediate action." (1) Nationally and internationally, nursing and other health care professions are focusing on this growing problem.

The term literacy is defined as the ability to read and write. The National Literacy Act of 1991 extends this definition to "the ability to read, write, and speak English and solve problems at levels necessary to function in jobs and society." (2) According to this standard, many people who can perform basic literacy tasks (eg, signing one's name) nevertheless may lack the skills needed to function in society as workers, citizens, or patients.

The term illiteracy means the complete inability to read or write. Less than 5% of US residents are illiterate. (3) The term functional illiteracy applies to adults who read, write, and understand material at less than the fifth grade level. These adults are unable to comprehend and interpret what is written, but, more importantly, they cannot use or apply written words correctly in their daily existence. The phrase low literacy describes adults who are able to read, write, and understand information but only between the fifth and eighth grade levels, which makes functioning in society difficult. (4)

One author of several articles on literacy and patient education has divided literacy into three dimensions:

* prose literacy (ie, the ability to understand written news stores, poems, editorials);

* document literacy (ie, the ability to understand bus or train schedules, charts, maps, graphs); and

* quantitative literacy (ie, the ability to use numbers, balance a checkbook, understand fractions). (5)

All three dimensions of literacy are required to understand most of the brochures and other written information that patients receive during health care visits. Patients should be able to read and understand such things as how to use the food exchange list from a diabetic diet, read a thermometer, comply with childhood immunization schedules, and understand proper medication administration. (6)

Illiteracy and low literacy affects not just patients and family members but also health care providers. "More than 90 million Americans have limited literacy skills, a burden that profoundly affects the quality of their health care." (7) The US Department of Education's national adult literacy survey results reveal that:

* approximately 21% to 23% of adults (ie, 40 to 44 million people) perform at the lowest of five skill levels on literacy tasks related to activities of daily living;

* another 25% to 28% of adults (ie, 50 million people) have marginally functional literacy, performing at the second lowest of the five proficiency levels, and only 3% to 4% are at the fifth or highest level;

* older adults are overrepresented among those with low literacy because they comprise approximately 33% of the low literacy groups, even though they represent just 16% of the US population; and

* an estimated 15% of recent, high school graduates read at less than a sixth grade level. (8)

Presently, the average American reads at the seventh grade level, with 40 million American adults reading below that level. (9) The effect of reading below the seventh grade level is significant, particularly in regard to health care. Unfortunately, most patient educational materials are written above the eighth grade level, which interferes with patients' ability to use the information intended to help them. (10) Officials at the Chicago American Medical Foundation cite a recent public hospital study, which reveals that 42% of hospitals' English-speaking patients did not understand the details of their prescriptions, and 27% were unable to read their appointment slips. (11)

Forty-eight percent of adults cannot follow a bus schedule, and 21% cannot read the front page of a newspaper, according to a national adult literacy study. Additionally, 60% of English-speaking patients at public hospitals could not comprehend a standard consent form. The same study also determined that the mean-reading level for Medicaid enrollees was grade 5.3. (12) Another report suggests that patients with the least ability to read and comprehend medical information needed to adhere successfully to their plan of care often have the greatest health care needs. (13) Patients who do not understand the information provided by health care practitioners cannot make informed health care decisions. (14) Nurses must identify which patients are in the 60% that cannot comprehend a standard consent form before those patients are allowed to sign. Identifying the prevalence and scope of the problem may be the first step toward intervention.