What would you say if I told you there is a problem in the United States that affects up to 50% of the adult population, adds more than $70 billion to the cost of health care each year, but goes unrecognized by most health care workers every day? Impossible! Outrageous! How can we be ignoring something this important?

Literacy Level Predicts Health Status

Recent studies have shown that literacy skills are the single strongest predictor of health status--stronger than age, racial or ethnic group, income, employment status, or educational level. A recent study reported that among 3200 new Medicare enrollees at an HMO, patients with inadequate literacy had an increased frequency of arthritis, diabetes, hypertension, and heart failure. Based on a functional survey (SF-36), they also had decreased physical function, poorer mental health, increased limitations in activity due to physical health and increased pain that interfered with normal work activities.

One study of patients with diabetes reported that 36% of patients with inadequate literacy had the diagnosis of retinopathy, where only 19% of patients with adequate literacy have retinopathy. Diabetic retinopathy is the leading cause of blindness in the United States. Low literacy clearly has a significant association with poorer health.

Definition of Literacy

Literacy can be defined in many ways. A recent nationwide federal survey of adult literacy defined literacy as "Using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential." The National Assessment of Adult Literacy (NAAL) evaluated three areas of literacy in 2003:

• Prose literacy is the ability to find pieces of information in written text like patient instructions.
• Document literacy is the ability to find information in short forms or graphically displayed information found in everyday life like a prescription label or a bus schedule.
• Quantitative literacy is the ability to perform arithmetic using numbers imbedded in print.

The NAAL study reported that up to 50% of adults in the United States have inadequate or marginal literacy.

What Does 'Health Literacy' Mean?

You will also hear about "health literacy" and as you might guess, there are many definitions of health literacy. The Institute of Medicine (IOM) published a comprehensive report about literacy and its effect on health in 2004. The IOM definition of health literacy is "The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health." The key concept is understanding information needed to make good decisions about health habits and health care.

Survey of Family Doctors about Literacy

Jon Temte, MD, PhD recently completed a preliminary analysis of 462 responses to a survey of Wisconsin family physicians about literacy and healthcare. Approximately 85% of the physicians thought that low literacy had some impact on health outcomes and quality of care. However they estimated that only 17% of their patients had low literacy, and only 7% of physicians were screening patients for literacy level. Overall clinicians recognize the importance of low literacy in the health of their patients, but underestimate its prevalence, and few employ screening.

People with Low Literacy Often are Ashamed and Hide their Problem

Many people with low literacy are ashamed of their problem and are very good at keeping it hidden. A group of low literate adults were asked who they had told about their reading difficulties. Less than 50% had told their children and only 25% had told their doctor. Even though patients hide their low literacy well, there are groups of people you can identify who are more likely to have low literacy:

• People who are older
• Immigrants
• Non-white
• Those who did not graduate from high school
• Those with low incomes and on Medicaid

Unfortunately, education level alone is not a reliable predictor of literacy level with about 20% of high school graduates being functionally illiterate. Keep in mind that less than 4% of Wisconsin's population is foreign born and 89% is white, so the majority of Wisconsin's low literacy population are white and native born.

Patient Handouts Often Written at Reading Levels Too High

Twenty percent of American adults read at or below the 5th grade level. A recent study of the American Academy of Family Physicians Patient Education Handouts available at http://familydoctor.org/ found that 76% were written at a 9th grade level or higher. More than 300 studies have reported that most printed patient materials are written at a reading level that is too high. Many are written at a 12th grade level or higher.

OK, Literacy Is a Big Problem, But What Can I Do About It?

I probably have convinced you that low literacy is a big problem. The next question is what can you do?

1. You can learn more about health literacy by reading an excellent summary at: http://odphp.osophs.dhhs.gov/pubs/prevrpt/Archives/Default.htm.
2. You can download and watch a video about health literacy from the American Medical Association Foundation called "Low Health Literacy: You Can't Tell By Looking" (18 min.) at http://www.ama-assn.org/ama/pub/category/8035.html.
3. You can download and watch a video about how to improve communication from the American Medical Association Foundation called "Health Literacy: Help Your Patients Understand" (23 min) at http://www.ama-assn.org/ama/pub/category/8035.html.
4. You can refer your low literate adults for tutoring at the Madison Area Literacy Council located at 1118 South Park Street, or call 244-3911.
5. You can volunteer to tutor adult literacy or English as a second language (ESL) students at the Madison Area Literacy Council. They have over 100 students on a waiting list for tutors. The most need is for ESL tutors. You do not have to speak any foreign language to be an ESL tutor. The tutor training takes 10 hours and they ask you to commit to 2 hours a week for 4-6 months. Hours can be flexible. For more information or to volunteer call 244-3911, or go to their website at: http://www./www.litnetwork.org/index.html.
6. Don't have time to volunteer? You can donate money to Wisconsin Literacy, a non-profit organization that supports adult, family, and workplace literacy programs statewide through program and resource development, training, and advocacy at: http://www.www.wisconsinliteracy.org/donate.php.
7. Review your clinic's patient educational materials for reading level. Contact Paul Smith, MD (mailto:paul.smith@fammed.wisc.edu) for more information about how to do this, and for resources on documents written for people with low literacy.