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Low health literacy is costing the health care system more than $300 billion annually, according to the American Medical Association. When almost one third of patients can't understand basic health information, can't read the labels on their prescriptions, and can't comply with doctors' instructions, it not only affects their health outcomes, but it carries a huge economic impact.
Untreated chronic diseases, unnecessary repeat hospitalizations and doctors' visits, and the costs of improperly taken medications all contribute to the price tag. The additional costs incurred by patients who can't process basic health information — whether from a language barrier, limited education, or problems associated with aging — amount to a significant percentage of the $1.3 trillion spent annually on hospital care and physician services, as reported in 2010 by the Kaiser Family Foundation.
To attack the problem at its root, the AMA has given out millions of dollars in resource materials to promote health literacy in areas with demonstrated need. Williamsburg and James City County are among the targeted areas in Virginia. Community health groups are tackling the issue through the Williamsburg nonprofit Literacy for Life, which has started a HEAL (Health Education and Literacy) program. It takes the message to physicians' offices to encourage them to identify patients who need help. As a complement, the literacy group now offers a series of free health literacy classes for both native and non-native English speakers.
Alerting doctors' offices
A former pharmaceutical rep, literacy tutor Sandy Menaquale uses her sales background to motivate the staff at physicians' offices to identify patients who may need help navigating their health care. "Health literacy" refers to how well people understand and process health information, she explained. She cited the National Assessment for Adult Literacy, conducted by the U.S. Department of Education every 10 years, which found that 29 percent of U.S. adults could not understand basic health questions. In Virginia, where 18 percent of the population is foreign-born — compared to 14 percent nationally — the number is slightly higher, at 31 percent. "Given a card showing their next doctor's appointment on Nov. 17, one-third was unable to circle it on a calendar," said Menaquale. "We're talking about more than 90 million adults."
Addressing the staff at Sentara Williamsburg Pediatrics at New Town, Menaquale hammered on. "At the intermediate literacy level, when shown a chart, half couldn't determine the age at which their child should have a vaccine. Is that important to your practice?"
Pediatrician Maurice E. Graham first encountered the problem 30 years ago, when a Filipino woman, whose husband was deployed, brought in their severely dehydrated baby for its two-week-old checkup. She had been feeding the baby concentrated formula since birth, putting it at risk of life-threatening convulsions. He likened the barriers to care for her to Americans abroad. "Say you were in Russia, trying desperately to get medical help. It causes a lot of anxiety. It's quite frightening," he said. "Someone didn't understand that that mother didn't understand."
The pediatric practice has multiple patients for whom English is not their first language. "As small as Williamsburg is it's an international city — we have a lot of Middle Eastern patients, from Japan, South America and Slavic countries," Graham added. "There are so many things about a medical visit. They might have only 30 percent recall because they're distracted by a 3-year-old." To counter that, the office gives out lots of handouts and reminders to parents.
Patients often ask for medical assistant Emily Carrillo, whose family is from Mexico. "I use my language skills every day. I will write down instructions in Spanish. Often they don't understand insurance, how to take a prescription to a pharmacy, or the concept of refills," she said, noting that medical customs differ from country to country.
Failure to understand
The HEAL program is not just for non-English speakers, but for all with low health literacy, or difficulty following doctors' instructions. Menaquale told of an elderly patient who revealed to his physician, after seven years, that he only took his blood pressure medication if he felt "hyper" when he woke up. Seniors age 65 and older make up the largest proportion of the noncompliant, with problems often caused by failing memory and vision, according to the AMA. However, they're far from alone.
Graham has encountered cases in which young parents administered the thrice-daily oral antibiotic amoxycillin, prescribed for ear infections, directly into a child's ear instead of by mouth. "Up to 78 percent don't understand prescription labels," said Menaquale, citing common misunderstandings with phrases such as "don't take with dairy" or "take on an empty stomach." Asthmatics frequently don't know how to use an inhaler, and many diabetics have problems monitoring their blood sugar levels.
To conclude her presentation, Menaquale invited staff members to wear a button, "Ask me if I can help?" as a way to encourage patients to self-identify. "Many times people go to the ER because it's all verbal," she said, as she advised office staff to watch for those struggling with paperwork. She identified trigger responses, such as "I don't have my glasses," "I don't know," or "I'll talk to my family." She urged them to give out a "prescription" for the free health literacy classes being offered by Literacy for Life. Further, she said, starting in 2013, there will be new billing codes so that physicians can charge for spending time on patient education, such as for diabetes care.
In the classroom
Students in the pilot health literacy classes in Williamsburg reflect a typical cross-section of those who are daunted by the health care system. They're from a dozen countries, mostly in Asia, along with a few native English speakers.
"There are a lot of English speakers who don't feel comfortable asking doctors questions," said Joan Peterson, executive director of Literacy for Life. "Others will put off going until it's a crisis, knowing that they'll have to fill out forms."
Instructor Tisha Sawyer, who speaks some French, Arabic, Spanish and Italian, understands the problems they face. With a Moroccan husband, she's seen the problems firsthand on doctor visits where she translated for him. "I understand the processes and barriers," she said. Her presentation mixed lecture, demonstration, pictures and interactive games as she introduced basic health vocabulary with all its nuances — the differences between aches and pains, fatigue and drowsiness, nausea and vomiting. She talked about duration and intensity of symptoms, when to go to the doctor and when to wait — and just as importantly, where to go.
The students read and discussed and played interactive Body bingo to label body parts. For some, the information helped to relieve anxiety. "I have a lot of pronunciation problems," said Falguni Patel from India, who cared for her mother-in-law through breast cancer. "Sometimes when the doctor speaks, I don't understand." Yuko Sato and Yoshi Wakabayashi, both from Japan, were pleased to be learning more about correct terminology. "After this class, I will be more secure," said Sato, who came to the U.S. six months ago. Wakabayashi wanted to be sure he understood correctly on visits to the doctor with his two children.
For Charles Brooks of Williamsburg, the class was an opportunity to learn more about what contributes to general good health. He learned how stress can produce physical symptoms. "I was surprised how it can hurt you. I didn't realize that," he said.
Free health literacy classes
What: Classes on health education and health literacy, HEAL, for English and foreign language speakers
Where: Literacy for Life, William & Mary School of Education, 301 Monticello Ave., Williamsburg
When: 9:30 a.m. to 11:30 a.m. Thursdays through Dec. 13; new 8-week session starts in January. Take one class or all. They're free but registration is requested in advance.