Health Literacy and Diabetes: Now for the Good News

AADE General Session
Saturday, August 14, 2004
8:00 AM - 9:30 AM

Health literacy, or the ability to comprehend medical information, has been operationally defined in a variety of different ways. According to the AMA Council on Scientific Affairs, health literacy is the ability to read and comprehend prescription bottles and other medical information and related materials. This definition focuses heavily on the ability to read, but others have proposed a broader definition that includes a constellation of skills, both reading and numeric, required to function in a medical care environment. This definition is more relevant to diabetes, which has a very heavy numeric component. Although health literacy is correlated with certain demographic factors, it does not include payment problems, sensory deficits, presence of comorbid conditions, or speaking a language other than English. Rather, health literacy is better defined as a mediator between sociodemographic factors and poor diabetes outcomes.

Empirically, health literacy is strongly correlated with health beliefs, performance of self-care behaviors, medical outcomes, and medical costs. One recent study demonstrated that patients with low health literacy (measured by self-report) had poorer glycemic control, were 2.3 times more likely to have retinopathy, and were 2.7 times more likely to have a stroke, as compared with patients with higher health literacy. Further, only half of patients with low health literacy could identify the symptoms of hypoglycemia, as compared with nearly all of the patients with higher health literacy. Patients with lower health literacy also had higher health care costs.

The most important thing about health literacy is that it is an addressable problem. The first step is to identify patients with deficits in health literacy. Psychometrically validated research instruments, such as the Test of Functional Health Literacy in Adults- Short Form (S-TOFHLA), are inexpensive and easy-to-administer self-report scales. Although this scale only takes 12 minutes to complete on average, many physicians and patients do not have the time to do so. As an alternative, single questions, such as "How often do you have a family member or someone else help you fill out medical forms?" or "How comfortable are you with filling out medical forms?" can be used to identify patients with health literacy deficits, although more false positives and false negatives will occur using this approach.

Once patients with health literacy deficits have been identified, a variety of strategies can be undertaken to address the problem. Physicians can be instructed to communicate more clearly with patients who have known health literacy difficulties. One strategy that has been shown to be effective is "closing the educational loop." This strategy involves training physicians to be more attentive to patient learning needs when new information is presented.  Specifically, the physician can ask the patient to reflect back on the recommendations given and what they mean.  If the patient is unable to accurately characterize the medical recommendations, the physician then provides more information.  This process is repeated until the patient has demonstrated comprehension. Research using this strategy has shown that when new information was given, physicians tried to close the loop only 20% of the time. However, when the loop was closed, A1C decreased without a concomitant increase in visit time. Another strategy for augmenting communication is to make use of technological advances, such as kiosks in waiting rooms or automated telephone calls and assessments between visits. Additionally, use of simple graphics and other visual tools can also be away to present information to patients with deficits in health literacy.

In short, there are a variety of strategies available to identify patients with health literacy and to intervene to address the situation. Interventions to augment patient-physician communication and to improve health literacy can have an important impact on diabetes outcomes.