HealthOctober 16, 2014

Health literacy: A barrier to preventive care

It’s not exactly a newsflash to say our medical system can be unfriendly to patients. But when you think about how the system looks to someone struggling with health literacy, the problems become even more glaring. As a result, people with low health literacy underuse preventive services and have higher rates of emergency use and hospitalizations.

By Emily Azari
Emily Azari is a health writer at Emmi Solutions, where she sorts through heaps of complex medical information and translates it into a language patients easily understand.

Consider the steps involved with something as simple as a routine check-up.

To start, many of us only go in for preventive care if we have health insurance. You’ve probably been through that fun drill of choosing a plan — trying to price out options, decipher deductibles, understand which medications will be covered, and so on. Of course, once the inevitable frustration sets in, you postpone the decision until your HR department gives the 24 hour warning, at which point you just pick the plan you had last year.

Brutal as it is for you, imagine that process for someone with low health literacy. In fact, let’s give him a name: Richard. Charts, calculations, and utterly foreign insurance lingo make the whole thing practically impossible for him to navigate. And that’s if he’s fortunate enough to afford a decent plan. After all, low health literacy is linked with less education and lower incomes.

Speaking of access to health insurance, let’s consider access to care. Going to the doctor often means taking time off work — a nuisance, at the very least, for many of us. Richard has the same issue, plus he needs a loved one to accompany him to help with paperwork and communication. That means two people now need to free up their schedules.

Cost and logistics aside, we need a spark of motivation to actually schedule the appointment. Folks with low health literacy have trouble understanding their health, and might not always realize when a preventive visit is in order. So maybe Richard’s cholesterol or A1C numbers aren't meaningful or motivating to him, or maybe he just doesn’t think there’s anything he can do about that nagging pain in his knee, anyway.

But once the appointment’s made, here we are in the waiting room. Many of us are nervous as we wait, feeling a little foolish as we fill out those forms. (Which is my group number, and which is my policy number, again?) Richard, meanwhile, is outright flummoxed by his paperwork, yet the front desk staff isn’t exactly expressing compassion. Fortunately, his daughter is there to help out, but even she isn’t confident about everything.

Onto the exam room. Even if you have a PhD in nuclear physics, you’re going to feel intimidated when you’re wearing a gown and saying “ahh” in the face of a physician. And what is it about that cold, bare room that makes your mind go blank? For Richard, it’s easy to see how overwhelming, even belittling, the experience might feel. The doctor might as well be speaking Swahili, and she can’t tell by looking at Richard that he has low health literacy. While he had a list of questions, it’s in the back pocket of his pants on the other side of the room. He doesn’t want to interrupt up to ask his daughter for help, though, so he nods along and mentally files this whole thing away as an experience he’d rather not repeat anytime soon.

Phew, the visit’s over. Richard heads to his car, almost instantly forgetting his doctor’s words. What he remembers most of all is the embarrassment. The visit might as well not have happened at all.

Of course, it did happen. The evidence arrives with the last step of his preventive encounter: the bill. Lovely — can’t wait to call that 800 number for help.

We’d all value a system that better speaks our language and adjusts to our needs, but populations with low health literacy would benefit even more — resulting, perhaps, in more appropriate use of preventive care and less reliance on the ER. In the meantime, it helps to keep the many complex issues facing this group in mind to provide compassionate care.

i. Scott TL, Gazmararian JA, Williams MV, Baker DW. (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care. 40(5):395-404.

ii. Bennett CL, Ferreira MR, Davis TC, et al. (1998). Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. Journal of Clinical Oncology. 16(9):3101-4.

iii. Agency for Healthcare Research and Quality. (2011). Health literacy interventions and outcomes: An updated systematic review (executive summary). Retrieved from:

iv. National Center for Education Statistics. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education.


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