Health literacy disparities: Communication strategies to narrow the gap

There is a clear link between health literacy and health outcomes. Previous studies have shown an association between limited health literacy and decreased utilization of screening services, decreased medication adherence, and higher mortality rates.¹ However, interventions focused on improving patient-related communication can reduce health literacy disparities, highlighting it as a modifiable risk factor.²

In this issue of the American Journal of Surgery, Theiss et al. provide important data showing a link between health literacy and disparities in colorectal surgical outcomes.³ They leveraged strengths of their institution, including a racially diverse patient population and routine assessment of health literacy for patients undergoing elective colorectal surgery. Their data demonstrates a strong, independent association between limited health literacy and overall post-operative complications, (OR 2.03 95% CI 1.01–4.08, p=0.046) indicating 2-fold increased odds of complications.

One notable finding of the study was a significantly higher rate of open vs laparoscopic surgery in patients with limited health literacy (60.9% vs 42.7%, p=0.02). While this finding is consistent with prior literature,⁴ it does raise the question of why patients with low health literacy undergo open surgery at higher rates. There were no other significant differences in pre-operative factors between groups, suggesting surgeon bias may have played a role. However, other factors which were not included in the analysis, such as indication for surgery (beyond benign/malignant) and wound classification would have likely provided additional insight.

Focusing on health literacy remains important because there are clear, actionable communication strategies which have been demonstrated to improve patient understanding and adherence to treatment recommendations.² First, it should be noted that a patient’s health literacy cannot be assumed, and that clinicians should adopt a consistent approach to assess each patient’s baseline knowledge level and understanding.⁵ Often, information is delivered to patients as a long, complex lecture, without giving space for conversation or questions. Using the “ask-tell-ask” framework⁶ allows the patient to be included and for clarification of concepts. Specific attention should be given to avoiding and/or explaining jargon when necessary. For patients who are particularly at risk, it is important to focus on essential information, things they “need-to-know” and “need-to-do.”⁷ Another beneficial technique is using teach-back⁸ to assess and verify patient understanding and correct misunderstandings. Finally, supplemental resources including drawing pictures and providing brochures at an appropriate reading level can be helpful.⁹

Health literacy has a real impact on our surgical patients, and it is incumbent on us as surgeons to focus on mitigation strategies. Consistent implementation of effective communication can help improve care not only for our most vulnerable patients, but also universally, and ultimately strengthens the surgeon-patient relationship.