Health literacy expert Sunil Kripalani, MD, MSc, assistant professor in the Division of General Medicine at the Emory University School of Medicine and internist at Grady Memorial Hospital, is featured as a lead author and co-editor of a special August issue of the Journal of General Internal Medicine (JGIM) dedicated to health literacy. Another Emory faculty member known for her expertise in health literacy, Ruth M. Parker, MD, also served as co-editor.
The August issue of JGIM is the first journal issue specifically devoted to health literacy. The issue features 12 original research articles, as well as education and policy pieces that address important issues such as whether differences in literacy contribute to racial and socioeconomic disparities in health and health care; medication adherence; comprehension of informed consent; and patient mortality. Dr. Kripalani served as lead author on the introduction, as well as two articles about medication self-management skills and how to teach physicians and medical students about health literacy and clear communication. U.S. Surgeon General Richard Carmona, MD, MPH, wrote the foreword.
"Our goal was to help the field continue to move forward by bringing together the latest work in health literacy research, education and policy," Dr. Kripalani says. "We were very pleased to get the support of the entire health literacy research community as well as the Surgeon General. Health literacy has been one of his key public health platforms and he has served as one of its strongest national advocates."
Health literacy is an individual's ability to read, understand and act on health information. According to 2006 results of the National Assessment of Adult Literacy, more than 90 million adults lack the literacy skills needed to effectively function in the present health care environment. Low health literacy is associated with less medical knowledge, infrequent receipt of preventive services, increased hospitalization and use of emergency care, and worse control of chronic diseases. An article in the JGIM special issue demonstrates for the first time that low health literacy also predicts higher patient mortality.
In 2004, the Institute of Medicine (IOM) called for additional research into the associations and consequences of low health literacy. The IOM highlighted the need to develop new measures of health literacy, approaches to improve health communication in diverse populations, interventions to reduce the negative health effect of low literacy, and ways to address health literacy in graduate medical education and the health system.
"This special issue was intended to serve as a response to the IOM report by encouraging researchers to continue to address those priority areas," Dr. Kripalani explains.
In one article, Dr. Kripalani and colleagues, including Terry A. Jacobson, MD, professor of medicine at Emory and director of Health Promotion and Disease Prevention for the Grady Health System, describe the challenges low-literacy patients face when trying to manage their own medicines. The team individually interviewed 152 patients who brought their medications to an appointment in the Primary Care Center at Grady. The patients' medicine bottles were lined up on a table, and the interviewer named a medication, asking the patient to pick it out of the line-up, either by reading the label or opening the bottle to look at the pills themselves.
Overall, 57 of 152 patients (38 percent) were unable to identify all of their medications. Patients had greater difficulty identifying their medications if they were age 65 or older, had not completed high school, or were cognitively impaired. Over half (57 percent) of patients with inadequate literacy skills were unable to identify all of their medications, compared with 25 percent of those with marginal literacy and 7 percent of those with adequate literacy skills.
"When we controlled for all of these factors together, the patients with the lowest literacy skills had 10 to 18 times the odds of being unable to identify all of their medicines," Dr. Kripalani says.
"What that means for physicians is that low-literacy patients will likely have difficulty taking medicines correctly or responding to changes in their medication regimen because they often can't distinguish one medication from another," Dr. Kripalani adds. "Patients tend to hide these difficulties, and unless we assess them specifically, we may never know they exist. The best thing that physicians can do when communicating instructions to patients is to ask the patient to repeat back the information, and demonstrate it if possible, to ensure that the physician communicated the information clearly.
"For example, it is not enough to simply tell the patient that he should increase his dose of atenolol from 50mg to 100mg. According to the results of our study, the patient may not know which medication the physician is referring to. A better exchange would involve the physician saying to the patient, 'I always ask my patients to repeat back important instructions to help me make sure I have explained them clearly. Tell me (or show me) how you are going to take the atenolol now.' If the patient is unable to select the correct medication or demonstrate the new dosage, it provides the physician an immediate opportunity to reinforce the medication change and reassess the patient's understanding."
In another article, Dr. Kripalani and co-author Barry D. Weiss, MD, a professor at the University of Arizona College of Medicine, provide methods for teaching medical students and residents how to communicate more clearly with patients. The strategies he recommends include: assessing patients' baseline understanding before providing extensive information; explaining things clearly using plain language; emphasizing one to three key points; encouraging patients to ask questions; using a teach-back technique to confirm patient understanding; writing down important instructions; and providing useful educational materials. He also suggests structured small group exercises for skill development and videotaping residents interacting with a standardized patient who has been trained to play the role of an adult with low health literacy.
"The average adult in the United States reads at the eighth-grade level," Dr. Kripalani says. "National studies have shown that, while only one percent of the U.S. population is illiterate, about 45 percent have difficulty reading and comprehending moderately difficult information like they find in the health care setting. It's wrong to assume that low health literacy is a problem that only affects inner-city or underserved populations. Physicians should be aware that, regardless of where they are practicing medicine, a very large percentage of their patients has limited literacy skills."
The articles in the August JGIM special issue provide guidance for all healthcare professionals about how to approach the challenges of low health literacy. The full issue is available online at http://www.blackwell-synergy.com/toc/jgi/21/8. Funding for the issue was provided by Pfizer Inc., through an unrestricted grant.