How Well Do Patients Understand Written Instructions?

The aim of this study was to assess health literacy (word recognition and comprehension) in patients at a rural rheumatology practice and to compare this to health literacy levels in patients from an urban rheumatology practice. Inclusion criteria for this cross-sectional study were as follows: 18-year-old patients at a rural rheumatology practice (Mid-North Coast Arthritis Clinic, Coffs Harbour, Australia) and an urban Sydney rheumatology practice (Combined Rheumatology Practice, Kogarah, Australia). Exclusion criteria were as follows: ill-health precluding participation; poor vision/hearing, non-English primary language. Word recognition was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). Comprehension was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Practical comprehension and numeracy were assessed by asking patients to follow prescribing instructions for 5 common rheumatology medications. At the rural practice (Mid-North Coast Arthritis Clinic), 124/160 patients agreed to participate (F:M 83:41, mean age 60.3 12.2) whereas the corresponding number at the urban practice (Combined Rheumatology Practice) was 99/119 (F:M 69:30, mean age 60.7 17.5). Urban patients were more likely to be born overseas, speak another language at home, and be employed. There was no difference in REALM or TOFHLA scores between the 2 sites, and so data were pooled. REALM scores indicated 15% (33/223) of patients had a reading level Grade 8 whereas 8% (18/223) had marginal or inadequate functional health literacy as assessed by the TOFHLA. Dosing instructions for ibuprofen and methotrexate were incorrectly understood by 32% (72/223) and 21% (46/223) of patients, respectively. , FRACP, Paul Bir P, Hanish Bagga, BMed, FRACP There was no significant difference in word recognition, functional health literacy, and numeracy between rural and urban rheumatology (Medicine 93(25):e129) INTRODUCTION L iteracy is defined as ‘‘the ability to read and use written information and to write appropriately in a range of contexts.’’ Health literacy is a more specialized aspect of literacy and is ‘‘the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.’’ The National Assessment of Adult Literacy (NAAL) in the United States (US) found that 5% of 19,000 participants were nonliterate and 43% of participants had either basic or below basic English literacy. The Adult Literacy and Life Skills Survey found that up to 60% of Australians ages 15 to 74 years achieved scores below Level 3 for the health literacy domain, where Level 3 is the ‘‘minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy.’’ Similar results were reported from Canada. Low literacy is associated with poorer health outcomes, for example, increased asthma morbidity, poorer diabetic control, less stable anticoagulation, and increased mortality. Those accessing health care require adequate health literacy and numeracy (the ability to use and understand numbers in daily life) skills to understand written instructions regarding medication, appointments with health care professionals and to calculate correct medication doses. Patient self-reported reading skills correlated poorly with actual reading scores. Limited health literacy is associated with medication noncompliance and misunderstanding of instructions on medication prescription labels. Patients with poorer health literacy were less likely to keep appointments with health care professionals, participate in health screening programs or seek medical assistance. Poor health literacy has also been linked to less health knowledge and fewer self-care behaviors. Limited health literacy affects use of health care resources and expenditure. Poor health literacy also raises questions regarding informed consent, the right to quality care, and antidiscrimination. Limited health literacy can be a significant source of shame and embarrassment. Large rural populations exist in countries such as the and Australia. Thirty percent of people n 22 million) reside outside a capital have poorer health outcomes for many www.md-journal.com | 1 conditions, such as coronary heart disease, colorectal cancer, stroke, and HIV. An important factor affecting health outcomes may be health literacy, yet there are limited data regarding health literacy in rural residents. The largest published study addressing this examined 3850 rural residents (population centre <50,000 people) and 14,260 urban dwellers from the NAAL database. Rural residents performed worse in all domains of literacy and health literacy. However, there was no difference in health literacy between the 2 groups once age, sex, ethnicity, education, and income were corrected for. Ten percent of patients with rheumatoid arthritis attending a community-based Australian Rheumatology practice had inadequate or marginal functional health literacy or a reading age at or below the US high school grade equivalent of seventh– eighth grade. However, as that practice was located in an affluent suburb of a major capital city, these findings may not be generalizable to other demographic areas. Up to 24% of rheumatology patients at an academic US medical centre had a reading level of eighth grade or less. One in 6 rheumatology patients at a Scottish hospital were illiterate and struggled to understand education materials and prescription labels. These findings are concerning, as rheumatologists often use medications such as methotrexate (MTX) or biologic therapies with severe adverse effects if taken incorrectly. Given the lack of data regarding health literacy in rural patients we sought to determine the level of health literacy (word recognition, comprehension, and numeracy) in outpatients attending a rural rheumatology practice; compare the health literacy of these patients to those attending an urban rheumatology practice; and determine whether patients could follow written dosing instructions for common medications used in rheumatology practice. PATIENTS AND METHODS