The Silent Epidemic: America's Struggle with Health Literacy

We live in a nation celebrated for its groundbreaking medical advancements, yet nearly 9 out of 10 adults can't fully grasp essential health information. A staggering 88% of American adults possess less-than-proficient health literacy skills—of which 36% struggle at basic or below-basic levels. Unfortunately, these measures are over 20 years old, since the last, and only nation-wide testing of health literacy was completed in 2003 by the National Assessment of Adult Literacy (NAAL). As we move from the broad picture of health literacy in America, we see its concrete effects in the research of Berkman et al. (2011), who demonstrated the link between low health literacy and poor health outcomes.

According to the landmark systematic review on health literacy and health outcomes, Berkman et al., (2011) concluded, “Low health literacy is associated with poorer health outcomes and poorer use of health care services.” While it is worth mentioning the variability of the studies' designs and strengths, the main takeaway is repeated by more recent studies, as well as the CDC. 

So, what exactly is 'health literacy' and why is it associated with poorer health outcomes? The Healthy People 2030 report divides health literacy into two definitions which is personal health literacy and organizational health literacy. 

Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

With so many Americans lacking the health literacy to navigate our backwards healthcare system, this has led to the development of several programs which are designed to assist administrators and physicians to improve the quality of educational materials provided to patients and the methods used within the office to improve patient-physician communication. 

The AHRQ's 21-step toolkit, aimed at helping physicians and administrators enhance health literacy, emphasizes several key strategies. It advocates for the use of plain language, recommending the replacement of medical jargon with words that are easy to understand and complemented by engaging visuals. The toolkit suggests keeping conversations with patients focused and concise, concentrating on a few essential points to avoid overwhelming them. It encourages healthcare providers to listen more and interrupt less, adapting their vocabulary to match the patient's when discussing their condition. Additionally, it underscores the importance of involving patients in their healthcare journey, urging providers to invite questions and verify that patients have comprehensively understood the information provided.

While the AHRQ’s toolkit is aimed to provide a framework for healthcare providers to improve the health literacy of their patients, they fail to address the time that is needed to follow the steps in their entirety. The time it takes to follow these guidelines is important because we are knee-deep in one of the worst doctor shortages this country has ever seen. Doctors are already sprinting through their day, going from patient to patient, with barely enough time to grab a cup of coffee. In this whirlwind, you think health education is a priority? Think again. Health education frequently takes a back seat in this high-pressure environment. 

Despite the actionable and time-intensive advice offered by the AHRQ's toolkit and recommendations from the CDC, NIH, and other organizations to enhance health education between physicians and patients, there is a notable omission in emphasizing the significance of post-office support for ongoing patient education. Patients forget 40-80% of medical information provided by healthcare providers immediately, with almost half of the information being remembered incorrectly. Hand-out materials could be effective to improve educational support beyond the office but according to 2022 US literacy statistics, 54% of adults have a literacy below sixth-grade level. With that said, there is great promise in the use of recording medical consultations in improving the communication between the doctor and the patient. According to "Teaching Patients with Low Literacy Skills" by Doak, Doak, and Root, the use of tape recorders has proven effective in the past for aiding patients with low literacy skills. However, there is a current reluctance to integrate this practice in clinical settings due to concerns over the recordings being potentially used in medical malpractice cases. 

In this complex landscape of healthcare, physicians face a daunting challenge: balancing the need for thorough patient education with the constraints of time and a growing doctor shortage. Techniques like the "teach-back" method have shown effectiveness in improving patient understanding, but we must acknowledge that forgetfulness remains a significant hurdle. This issue underscores the critical importance of enhancing both health literacy and general literacy from early education stages. As literacy levels decline in the United States, the future of health literacy appears grim. 

The need for more comprehensive, nationwide assessments of health literacy is evident, especially considering the association of poor health literacy with adverse health outcomes, as established by studies like those of Berkman et al. (2011). This situation calls for a multi-faceted approach that not only focuses on improving communication strategies in healthcare settings but also emphasizes the broader educational framework. It is essential that we address these challenges head-on, recognizing that the quality of healthcare and the ability to make informed health decisions should not be hindered by a lack of accessible, understandable information. The journey towards a more literate, health-aware society is not just a matter of policy and practice within the medical community, but a societal imperative that requires a collective effort across all levels of education and public awareness.