November 2005, Volume 27, No. 11
Editorial

Are you looking after patients with low literacy level?

Tai-Pong Lam 林大邦

"This is a pamphlet on your illness condition. It contains all the information that you need to know. Take it home and read it." says doctor. "Okay." replies the patient.

The above scenario should be very familiar to many family doctors. However, is the patient going to be able to read it? For those of us who can read, we may not realize that there are still many citizens in Hong Kong who have difficulties understanding the simplest form of written information. They also may not disclose their low literacy level readily, unless specifically asked.

In the 2001 Hong Kong Population Census,1 8.4% of the population aged 15 and over had either no schooling or only kindergarten level of education. This is particularly so among the females with 12.0% of them belonging to that category versus 4.6% of the males within the same age group. Low literacy is also found to be more common among the older populations. Among the 55 and over, 31.2% had either no schooling or only kindergarten level of education.

This shows that a significant number of the population had no or minimal level of education, particularly among the females and the elderly. The latter also tend to suffer from more chronic illnesses. This group of low literacy people is also more likely to belong to the population of the lower socio-economic groups. The ways these people utilize the health care facilities will have a major impact on the efficiency of the system.

Low literacy can be an important barrier to receiving adequate health care, because patients must be able to understand appointment slips, medicine labels, directions for self-care, informed consent forms, and health education material.2 In the US, it was showed that low literacy is associated with worse health according to the Sickness Impact Profile, although the reasons for this are unclear.3 Many other studies in the US have also showed that the medical information routinely given to patients is often above their reading level.4-6 In 1999, a Committee of the American Medical Association stated that patients with the greatest health care needs might have the least ability to read and comprehend information needed to function successfully as patients.7 However, there is little information available on how low literacy affects the ability of patients to obtain adequate medical care and comply with the recommendations of health professionals.8-9

In Hong Kong, we have little knowledge on the relationship between low literacy and health outcomes, despite the large number of people with low literacy in our community. Our recent local qualitative study10 has however showed that patients with poor literacy have diverse views on how they perceived their literacy problem. Some thought they were handicapped by it but other felt it was not a problem, even in urban environment like Hong Kong. For this reason, it is quite possible that we could be looking after patients with low literacy and do not know it because these patients may not readily reveal their low literacy level to us.

A previous study in the US has showed that patient educational status is not a valid indicator of reading ability.11 Appearance is also an unreliable basis on which to judge ability to read and understand health instructions.12 Patients with poor literacy may not follow instructions. But, as family physicians, we all know that compliance is vital to good medical care.13,14

Our recent qualitative study also revealed the coping strategies that some of the participants adopted; for example, drawing simple symbols or recognizing simple numbers to help with the timing of taking the medications and the dosages. However, the most important help to these patients with low literacy was better explanation by health care workers. This once again confirms the importance of effective communication between patients and health professionals.10

In conclusion, it is highly relevant for health care workers to be aware of the low literacy status of their patients and to explain information so that patients understand it.

Tai-Pong Lam, PhD, FRACGP, FHKAM (Family Medicine)
Associate Professor,
Family Medicine Unit, Department of Medicine, The University of Hong Kong.

Correspondence to : Dr Tai-Pong Lam, Family Medicine Unit, Department of Medicine, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.

References
  1. Hong Kong Census and Statistics Department. 2001 Population Census. Main Report - Volume I. Hong Kong: Printing Department, Hong Kong SAR Government. 2001
  2. Baker DW, Parker RM, Williams MD, et al. The health care experience of patients with low literacy. Arch Fam Med 1996;5:329-334.
  3. .Weiss BD, Hart G, McGee DL, et al. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1988;17:124-126.
  4. Powers RD. Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med 1988;17:124-126.
  5. Jaycox S. Smoking literature and literacy and the readability of smoking education literature. Am J Public Health 1989;79:204-206.
  6. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among medicare enrolees in a managed care organization. JAMA 1999;281:545-551.
  7. . American Medical Association. Ad hoc committee on health literacy for the Council on Scientific Affairs. Health Literacy Report of the Council on Scientific Affairs. JAMA 1999;281:552-557.
  8. Boisaubin EV, Dresser R. Informed consent in emergency care: illusion and reform. Ann Emerg Med 1987;16:62-67.
  9. Rossof AH. Noncompliant, or illiterate? Lancet 1989;1:362.
  10. Lam TP, Cheng YH, Chan YL. Low literacy Chinese patients: how are they affected and how do they cope with health matters? A qualitative study. BMC Public Health 2004;4:14.
  11. Davis TC, Crouch MA, Long SW, et al. Rapid Assessment of literacy levels of adult primary care patients. Fam Med 1991;23:433-435.
  12. Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. Philadelphia, JB Lipincott 1985.
  13. Sands D, Holman E. Does knowledge enhance patient compliance? J Gerontol Nurs 1985;11:23-29.
  14. Vermeire E, Hearnshaw H, Van Royen P, et al. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharmacy and Therapeutics 2001; 26: 331-342.