Assessing and addressing low health literacy among surgical outpatients

AORN Journal, Sept, 2007 by Cindy L. Monachos

During a preoperative interview with a 23-year-old female patient, the nurse asked questions that he believed to be "routine." He listened carefully to the patient's responses and began to notice that the patient's body language was more expressive than her verbal responses. The patient avoided direct eye contact, and as she responded to more questions, she continually looked at the floor. The patient's mumbled and monosyllabic responses gave the nurse a gnawing sensation that something was not quite right.

The patient, a vulnerable young woman who was three days postpartum, was about to sign a surgical consent for a laparoscopic tubal ligation that would render her unable to conceive another child. Did she have any comprehension of the legal document she was signing? In an effort to avoid the embarrassment of admitting illiteracy or ignorance, was she just answering "yes" to everything? To preserve her self-respect and dignity, was she blindly trusting the medical system? Was this patient receiving quality care? The nurse realized that he might need to approach this patient with a more customized communication technique.

Perhaps it is time that medical professionals ask--and answer--some "routine" questions of their own. How does a patient's comprehension of his or her medical care fit into a care plan? As health care providers, how are nurses and other medical professionals assessing this crucial aspect of patient care? Are care providers accounting for low health literacy in determining "quality of care"?

HEALTH LITERACY

According to the World Health Organization,

   Health literacy represents the
   cognitive and social skills which
   determine the motivation and ability
   of individuals to gain access to,
   understand, and use information in
   ways that promote and maintain
   good health. (1(p10))

So in essence, health literacy is the ability to read, understand, and use health information to make appropriate health decisions. (2)

In a world of perfect health care, patients' procedures would have been fully explained to them in the physician's office before they were scheduled for surgery. Friends, relatives, and Internet resources might be consulted, but the patient would already have received and understood the information that is necessary for his or her care.

Many patients have adequate health literacy skills and have the ability, education, and knowledge to find answers to their medical questions. If they cannot find the answers, they know who to ask to obtain them. But what about the millions of people who do not know how to access health information resources or who cannot read a consent for treatment or surgery? What becomes of the patients who cannot understand their preoperative instructions or how to take their postoperative pain medications? One study found that 17% of Medicare recipients could not understand a standard Medicaid document and 24% could not interpret a blood glucose score. (3)

Low health literacy is a very broad term for a multidimensional problem that stems from a lack of education, communication breakdowns, educational materials that are not appropriately written, and medical jargon that is too difficult for patients to understand. How many providers in the health care field have read a statistical analysis of scientific material and had difficulty interpreting what the researcher was trying to say? Patients with low health literacy have equal difficulty understanding what health care providers may believe to be perfectly clear health care instructions or documents.

INCIDENCE OF ILLITERACY AND LOW HEALTH LITERACY

In 1992, results from the National Adult Literacy Survey showed that 40 million to 44 million Americans age 16 years and older, or approximately 23% of all adults in the United States, were functionally illiterate. In addition, 53.3 million Americans, or 28% of US adults, had only marginally better reading and computational skills. (4) These figures alone should make health care providers question whether the health care materials and communication techniques that they currently are using are adequate.

In addition, data from the 2003 National Assessment of Adult Literacy indicated that 30 million US adults had no more than the simplest and most concrete literacy skills, 63 million could perform simple everyday literacy activities, and 95 million could perform moderately challenging literacy activities. Only 28 million US adults could perform complex and challenging literacy activities. (5) This information suggests that more than 50% of all adults in the United States may have difficulties reading critical documents such as surgical consents, preoperative and postoperative instruction forms, prescriptions, health education forms, insurance forms, or even maps to locate a medical facility.

It is important, however, not to confuse illiteracy with low health literacy. Health literacy is more than just the ability to read written materials; it is the ability to comprehend information for managing one's own health. Some experts believe that low health literacy, when measured nationally, is statistically worse than illiteracy. (2)