Although the United States has a large, highly educated population, there is also a large segment of the population with limited skills. In 1993, the United States Department of Education (USDOE) conducted a survey of 26,000 individuals, a representative sample of adults in the United States, to profile English literacy. Users were tested in three areas and results placed them into one of five categories. The areas tested were prose (the ability to read and comprehend), document (the ability to read maps and follow directions), and quantitative (the ability to perform basic math computations). The study concluded 22% could perform only simple, routine tasks involving brief and uncomplicated texts. Moreover, the English Language Proficiency Survey (ELPS) of 1992 estimated 90 million, about half of the U.S. population, could perform tasks at Level 2. This means they could locate information in text, make low-level inferences using printed materials, and integrate easily identifiable pieces of information. When patients for whom English is a second language and those with hearing and/or visual problems are added to the group, physician-patient communications become far more difficult and complex.

Yet research reports the benefits of effective patient education as presented in recent articles...

• Illiteracy is a pervasive problem that this recent study found compromises quality healthcare, limits understanding of health information and potentially leads to poor health outcomes. A positive statistical relationship was found between educational material readability, client literacy, and client-perceived benefit and quality of care.
• Another randomized controlled trial conducted at the Grady Memorial Hospital in Atlanta, GA, tested use of a low literacy education tool with at-risk populations to determine if the tool would increase pneumococcal vaccination rates. Those patients receiving the education material were four times more likely to discuss the issue with their physician and five times more likely to get vaccinated.
• Lack of documented patient or family education was found to be a factor in unplanned hospital readmissions among patients 65 years of age and older in a managed care plan. Unplanned hospital readmission within 30 days of discharge is considered a "sentinel event" for poor quality.
• Chronic degenerative diseases all have one thing in common-the prolonged course of the disease. Patient education is key to helping client feel in control of the development of the disease. Through education, the patient can become his/her own advocate and an active participant in the doctor-patient relationship. This participation increases patient compliance for short- and long-term disease management.

These articles alone indicate patient education can increase immunization rates, decrease hospital readmissions, and empower patients to make better decisions about lifestyle and care. Ultimately, patients feel they receive better quality treatment when patient education is part of their care.

The Joint Commission on the Accreditation of Health Care Organizations (JCAHCO) requires that hospitals have a patient education program in place to be accredited. Although there is no literacy level recommended in the body of JCAHO’s handbook, The Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook states the basic requirement is hospitals should provide patient education that meets the literacy level of their patient population. This means education materials must meet the needs of the population’s low literacy segment. Education materials written at a lower literacy level are likely to be effective for a broader range of patients. The Keystone Center has introduced the "Action Plan for the Provision of Useful Prescription Medicine Information" that recommends a 6^th to 8^th grade reading level for medication materials distributed to patients.

An added dimension to the discussion is that literacy is hard to measure. Literacy at one time meant reading level. Now some tests attempt to measure recognition and comprehension. As the meaning of "literacy" has evolved, so has its description. The result is a wide a variety of "literacy" tests and just as wide variety in the results of these tests given the same document. In addition, these literacy tests do not and cannot take into account graphic elements meant to enhance comprehension. Because of differing meanings, inadequacy of tools to measure graphic enhancements, and lack of standardized tests and/or benchmarks for testing, publicized document literacy levels should be reviewed judiciously and used cautiously.

In a concerted effort to make the patient education documents in the Micromedex^® CareNotes™ System as accessible to patients as possible, without compromising content, our editorial team has developed a style sheet. All CareNotes clinical editors use this sheet when writing patient education leaflets. The style sheet has been compiled by reviewing the variety of literacy tests currently available. Among these were SMOG, FOG, Flesch Reading Ease, Flesch-Kincaid Grade Level, Coleman-Liau Grade Level, and Bormuth Grade Level. Utilizing the common features of the "literacy" tests, the style sheet has proven an effective foundation for creating documents that consistently test out at the 6^th to 8^th grade reading level. When medical terminology is removed from CareNotes documents, they test at even lower literacy levels. Micromedex believes the medical terminology should be included because these terms are central to the patient understanding the care being received. Instead of excluding these terms, phonetic pronunciation is given and the terms are described in low literacy language.

Micromedex encourages you to empower your patients with health information so they make the best health choices possible. For more information on how Micromedex can help in this effort, call (800) 525-9083.

The following bibliography lists articles on literacy and its effects on healthcare outcomes:

Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health literacy: report of the Council on Scientific Affairs. The Journal of the American Medical Association 1999.

Baker, DW. "Reading between the lines: deciphering connections between literacy and health." Journal of General Internal Medicine, May 14, 1999.

Bental, Diana S. et al. "Patient information systems that tailor to the individual." Patient Education and Counseling, 36 (1999)

Fisher, Evelyn. "Low literacy levels in adults: implications for patient education." The Journal of Continuing Education in Nursing, March/April 1999.

French, KS et al. "Relationships among educational material readability, client literacy, perceived beneficence, and perceived quality." Journal of Nursing Care Quality, August 1999.

Jacobsen, Terry A. et al. "Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates: a randomized controlled trial." The Journal of the American Medical Association, August 18, 1999.

Marcantonio, Edward R. et al. "Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan." The American Journal of Medicine, July 1999.

National Assessment of Adult Literacy. http://nces.ed.gov/naal/

United States Department of Education. Adult Literacy in America: National Adult Literacy Survey. Washing, D.C. 1993

van Eijk, J. Th. M. et al. "Care for the chronically ill: the future role of health care professionals and their patients." Patient Education and Counseling, 35 (1998)

Wiley, Terrence G. "Estimating literacy in the multilingual United States: issues and concerns" ERIC Digest: National Clearinghouse for ESL Literacy Education, September 1994.

Wilson, Feleta L. "Are Patient Information Materials Too Difficult to read?" Home Healthcare Nurse, vol. 18 no. 2/February 2000.

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