This discussion paper commissioned by the IOM Roundtable on Health Literacy was released
yesterday. I always watch for these papers by thought leaders in the field to see the evolution
of health literacy concept, measurement and intervention.
I am quite disappointed this time.
One statement of fact jumped out at me right away. The paper lists an increase in the
fertility rate among demographic trends behind the increasing size and diversity of the
population. But, according to the CDC the US fertility rate is at an all time low. Births
declined by 10% last year and the Census Bureau reports population growth has slowed
to its lowest rate in decades. The authors are correct that diversity continues to increase.
Pew reports the number of immigrants in the country doubled to 46 million between 1990
and 2013. (But the Pew Hispanic Center announced in April 2012 that immigration from
Mexico has stopped and perhaps even reversed.) Diversity of cultures and language is
indeed a challenge for the healthcare system that adds urgency to health literacy issues.
The concept of health literacy presented in the paper seems confused. First health literacy
is presented as a cognitive deficit that leaves patients “unable to understand and act on
health information”, placing the problem in patients and assuming it is intractable,
therefore requiring clinicians to over come or manage the problem. The approach is
necessarily information-centered and provider-centered, not patient-centered.
The authors also note that WHO considers health literacy a personal and community asset,
but seem not to notice this is contrary to their discussion focused on low health literacy as
a risk to patients and the system. Recommended universal precautions are not sufficiently
“on the ground” to change practice and represent long held heath education principles
(e.g. educate using plain language, do a learning needs assessment).There is an implied
assumption that universal precautions, overseen by a new office in healthcare organizations,
is the whole solution. These precautions are common sense, but they are insufficient to
address true cognitive impairment in the elderly population, or to overcome what
Doak Doak and Root described as gaps in logic, language and experience, the origin of
provider/patient communication problems with both native and foreign-born patients.
The authors suggest that efforts to develop an organization’s employees' health literacy skills
(knowledge of negative impacts of low health literacy in patients, employee-employee
communication) can "empower communities to be active partners in their care.” This is
faulty thinking. Establishing the attitude that patients are incapable of understanding and
acting on information, and so unable to learn and do what is needed to cope, recover, and
improve health, disempowers patients and providers alike, makes patients unnecessarily
dependent on professionals, and perpetuates the problem. The authors close with a call for
"trusted partnerships” between providers and patients; that requires providers to trust patients.
As long as we say that what we need to make the healthcare system work is a smarter patient,
we are stuck.
One more thing: Americans spend about one hour per year in a clinical setting. What about
health literacy in the other 8764 hours?