The Impact of Illiteracy

Recognizing Patients with Literacy Problems

What Can Providers Do?

Literacy and Language Resources

Millions of workers have literacy or language barriers that interfere with their ability to understand medical forms, prescriptions, and written or oral instructions. This, in turn, significantly impacts their health and health-related behaviors. The American Medical Association (AMA) estimates that 90 million Americans have difficulty comprehending medical information and acting on it. The AMA further concludes that this costs the healthcare system $73 billion per year due to unnecessary doctor visits, hospitalizations, and failure to comply with treatment plans and preventive efforts. Besides higher rates of utilization and poorer health, individuals with low literacy rates are more likely to have problems accessing the healthcare system, understanding treatment and appointment slips, comprehending medical labels, and understanding consent forms, medication instructions, and health education materials. While costs to the health system are enormous, the impact of this problem has largely gone unnoticed by the provider community.

Results from the National Adult Literacy Survey reveal that of the 90 million Americans who have difficulty comprehending medical information, 47% have low or limited literacy skills. Of these, 25% (40–44 million) are immigrants from non-English language backgrounds who often have to rely on interpreters to communicate with health professionals. Another 20% of this population is functionally illiterate, which impacts not only their health, but also their ability to perform their jobs and follow training and safety instructions correctly. In general, workers with literacy and language problems:

• Perform their jobs less adequately

• Cannot read warnings, safety manuals, or instructions for operating machinery

• Are more likely to cause damage to equipment

• Are more likely to be injured on the job

Individuals with limited English proficiency represent a significant portion of the U.S. workforce. Numerous studies have confirmed that literacy and language problems impact health, health behaviors, safety, and the ability of health providers to maximize treatment or outcomes. Because of this, the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and AHA (American Hospital Association) have increasingly placed emphasis on organizations’ and providers’ ability to meet the needs of those with literacy/language problems.

Even though these two issues—literacy problems and English as a second language—produce similar problems, recognizing and dealing with each generally requires different approaches. While a patient’s accent and appearance might identify him or her as being foreign, these are not necessarily indicators of language comprehension or communication problems. On the other hand, a patient who is illiterate (regardless of native language) can be more difficult to identify, since such individuals often conceal their problem and may appear angry, aloof, or overly anxious. Perhaps one of the easiest approaches physicians and other healthcare professionals can take is to make themselves non-intimidating, conveying to patients that it is okay to ask for assistance in completing forms or understanding instructions.

Most providers need to improve their ability to recognize patients with language problems and make a determination of the patient’s literacy level so they can tailor their patient communication and education accordingly. Several different readability tests can be used to determine a patient’s literacy level or the reading level/readability of a particular document that you would like to use. These tests include the Fry Readability Graph, Flesch-Kincaid Formula (the one utilized by Microsoft® Word to provide readability statistics), McLaughlin SMOG Formula, and Rapid Estimate of Adult Literacy in Medicine (REALM).

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The following chart identifies the implications for patient comprehension and education based on their grade equivalent reading level:

Fortunately, some employers do recognize literacy problems among their non-English speaking employees and provide translators to accompany current or prospective employees on their medical appointments. In addition, many programs have started to provide forms and patient education/instructions in Spanish. While this is one of the most prominent non-English languages in the U.S., it is probably not the only ethnic community and language prevalent in your market. Ethical as well as current accreditation standards obligate providers to identify and meet the needs of all patients entering the practice, regardless of services that may be provided by an employer. And addressing the needs of those with low levels of literacy is just as important as addressing the needs of patients for whom English is a second language.

Here are key areas to address in overcoming communications barriers:

Educate your physicians and staff. Make sure all employees have a heightened awareness of the potential problems posed by illiteracy and language barriers. All physicians and staff should have a demonstrated proficiency in how to recognize problems, how to approach patients with courtesy and compassion, and how to effectively communicate with these patients.

Educate employers. Raise employers’ awareness of the true impact of these problems on the health, safety, and productivity of the workforce.

Evaluate your print materials. Identify what forms, patient instructions, and patient education materials could benefit from translation into non-English languages that are prevalent in your community and get them translated. What is the readability and grade level of all patient information? Is it above the 5th grade reading level? How will you effectively communicate with patients whose reading and comprehension levels are lower than this?

Bilingual staff. If necessary, start screening and hiring physicians and staff who are bilingual, or identify current employees who have this ability. Language classes specifically geared towards medical professionals are also becoming increasingly available. Physician extenders, supervisors, or other key players should be encouraged to expand their language skills if you have a dominant, non-English speaking patient base.

Availability of interpreters. Identify and establish a relationship with an Interpreter Service, if you have not done so already. You should also have access to resources for the hearing and visually impaired patient.

Sell new services. You may be able to turn the language barrier into a new product line, again depending on the types of employers and the prevalence of non-English speaking employees in your market. Some programs are developing diction and pronunciation services in tandem with their Speech and Hearing Department as a new service that is sold to employers who want to improve their employees’ pronunciation of the English language.

Patients with inadequate literacy often have a complex array of communication difficulties that interact and influence their health and health outcomes. These patients generally report worse health status and have significantly less understanding about their medical conditions and treatment. Professional and public awareness of literacy issues and their impact on health, safety, and medical outcomes must be increased, beginning with the education of physicians, other healthcare providers, and the employer community. Providers who improve their ability to effectively communicate with these patients will undoubtedly enjoy improved outcomes, improved relationships with patients and employers, and significantly enhanced satisfaction levels across the board. 

Literacy and Language Resources

Health Literacy: Report of the Council on Scientific Affairs, American Medical Association, 1998." Council Report on Health Literacy," JAMA, 1999; 281: 552-557.

Channing Bete Company
800.477.4776
www.channing-bete.com

Krames/Stay Well Communication
800.333.3032
www.krames.com

Parlay International
800.457.2752
www.parlay.com

Language Line Services
800.752.0093
www.languageline.com

Long Island Productions
800.397.5215
www.trainingntwrk.com

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