JAMA: Health literacy lacking among elderly

Many people 65 and older have significant difficulty reading and comprehending medical information that is pertinent to their health, according to a recent article in The Journal of the American Medical Association (JAMA).

Julie Gazmararian, M.P.H., Ph.D., from the Prudential Center for Health Care Research, Atlanta, and colleagues studied the ability of 3,260 new Medicare enrollees from Cleveland, Houston, south Florida and Tampa to read and understand written medical information. They discovered that overall, 33.9 percent of English-speaking and 53.9 percent of Spanish-speaking respondents had inadequate or marginal health literacy.

Respondents with inadequate functional health literacy often misread simple prescription instructions, information regarding the results of blood sugar tests, and simple instructions for preparation for an upper gastrointestinal tract radiographic procedure.

Those with marginal health literacy performed better on all these tasks but showed poor comprehension of blood glucose tests, instructions for taking medication on an empty stomach, and a passage from the Medicaid rights and responsibilities.

The authors write that patients with low health literacy and chronic diseases, such as diabetes, asthma, or hypertension, have less knowledge of their disease and its treatment and fewer correct self-management skills than literate patients. They say these factors may explain why patients with inadequate functional health literacy are more likely to be hospitalized than those with adequate healthy literacy.

“The relationship between age and health literacy showed a strong trend, with the prevalence of inadequate health literacy steadily increasing from 15.6 percent of individuals aged 65 to 69 years to 58 percent of those aged 85 years or older. Individuals who rated their health as fair/poor were twice as likely to have inadequate health literacy compared with individuals who rated their health as good/excellent - 38.7 percent vs. 19.2 percent respectively,” the authors write.

The authors explain that the participants in this study were all enrolled in Prudential HealthCare Medicare managed care plans and that while the study has many implications for the entire health care delivery system it also has implications for managed care. “Patients entering managed care settings have certain responsibilities that they may not have experienced with traditional fee-for-service plans, such as selecting their primary care physician, determining how to obtain a referral, and using designated pharmacies for discounted services. An individual's health literacy may directly affect his/her ability to negotiate the system, and thus health outcomes.”

According to the researchers, among the implications of the study is that clinicians need to be aware of the prevalence of health literacy problems and need to identify patients with poor health literacy skills, and health care organizations should be aware that inadequate health literacy may adversely affect costs and delivery of care.

The authors conclude: “Managed care organizations provide an ideal setting to address many of the health literacy-related issues that affect the various levels of the health care delivery system. For instance, the results from this study could be used to help design an intervention program for elderly enrollees, specifically targeting certain subgroups that are at high risk (eg, older age, less education). Possible intervention strategies include use of audio and video tape recorders with medical instructions or providing instructions with visual cues rather than written instructions.”

AMA issue health literacy recommendations

Recognizing that poor literacy is both common and complex, the American Medical Association (AMA) Council on Scientific Affairs asked an ad hoc committee of experts to investigate the subject.

The investigation included a review of 20 years worth of medical literature on the subject and resulted in the following recommendations that were adopted as AMA policy at the AMA Annual Meeting in June 1998:

  • The AMA recognizes that limited patient literacy is a barrier to effective medical diagnosis and treatment.
  • The AMA will work with members of the federation (ie specialty, state and local medical societies) and other relevant medical and nonmedical organizations to make the health care community aware that approximately one-fourth of the adult population has limited literacy and difficulty understanding both oral and written health care information.
  • The AMA encourages development of undergraduate, graduate and continuing medical education programs that train physicians to communicate with patients who have limited literacy skills.
  • The AMA encourages the U.S. Department of Education to include questions regarding health status, health behaviors, and difficulties communicating with health care professionals in the National Adult Literacy Survey of 2002.
  • The AMA encourages the allocation of federal and private funds for research on health literacy.

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