Mind the Gap: Overcoming Health Inequities – With Health Literacy. Healthcare Organizations, It’s on You

Contributor: Talya Miron-Shatz, PhD 
To learn more about Talya, click here.


From my perspective as a behavioral economist and social psychologist, there are several things you can do and several areas you can tackle in order to improve patient choices, empowerment, and satisfaction. This will lead to reduced costs for the healthcare system. A win-win.  These areas are presenting probabilities, formulating choice, enabling doctor-patient relationships, and improving communication on end-of-life issues. But let’s start with health literacy. 

Imagine the following scenario: you’re visiting your elderly mother at home. She’s not feeling well and then she collapses. You realize she’s in cardiac arrest and you freak out because, even if you are an educated person and should be able to follow professional instructions, this is your own mother lying there.

You dial 911. But, in your freaked out state, how well can you understand what they’re saying? Let’s hope you can, because they are telling you to start CPR as soon as possible, which will increase her chances of survival.

Now imagine it’s not you this is happening to. It’s someone who barely finished high school. Maybe someone for whom English is not a first language. How well do they understand what the medical dispatch is saying? And if they don’t understand them well, what does this mean for their mother’s chances of survival?

An intervention at the LA Police Department examined this scenario. Realizing that delayed CPR was reducing survival rates among cardiac arrest victims, they tried a new protocol for caller communication. They gave their existing staff minimal training with using simplified language and examined the effect it had.

Among callers with limited English proficiency, 69% now did CPR, as opposed to 28% before. Out of every 100 people who had a cardiac arrest, 69 now got CPR, instead of just 29. I keep wanting to write that it’s an astounding difference, but the truth is – it’s not. This jump in the ability to follow the 911 recommendation to resuscitate makes plenty of sense given how we’re communicated to, especially when under extreme stress, influences our comprehension. A simple "press on the chest, now!’ is easier to follow than ‘start compression.’

The effect on people who did have English proficiency was smaller, shifting from 55% to 67%. Still meaningful, still life-saving, helping an additional 12 people out of every 100. And what a lesson in understanding that clear communication makes all the difference.

LAPD’s accomplishment is huge in and of itself, but more so when we acknowledge it pertains to a substantial proportion of the U.S. population. Nearly 36% of American adults have low health literacy. It is more likely to be found among lower-income Americans eligible for Medicaid. This trend leads to health inequities.

You may not care about health inequities or the toll they take on low-income populations (though you should), but you will certainly care about bottom lines. Low health literacy comes with a price tag: The Center for Healthcare Strategies reports individuals with low health literacy experience greater use of the healthcare system (because things go wrong more often) and higher costs compared to those with proficient health literacy.  

The U.S. spends an additional $600 billion annually due to low health literacy. Mid-sized community hospitals spend an additional 1.8 million dollars covering the costs associated with low health literacy. In fact, the health literacy level of a city’s population is one of the key indicators of a healthy city.

As healthcare organizations aim to lower costs, they struggle to create behavior change. This is especially difficult among older and less literate populations. One way they can affect behavior change is by changing the way they communicate with these groups, both in times of crisis and in routine interactions.

The problem of health literacy is not a new one. There’s a paper I wrote about it ten years ago with Sir David Spiegelhalter, Ben Goldacre, and others. We proposed using a tiered approach, where you first deliver information in its most simplified form, then allow people to drill down through increased levels of complexity, all the way to the academic papers that medical knowledge is based upon.

This solution, which I also elaborate on in my book ‘Your Life Depends On It: What You Can Do to Make Better Choices about Your Health’ (Basic Books, Hachette), explores individuals’ health literacy –  their ability to understand health information, question it, and act upon it. But I do not stop there. What I propose in this book, and what the LAPD did, was to make health information more accessible. Patients need their doctors to do this, but pointing a blaming finger at overworked doctors, who aren’t trained in accessible, tiered communication, is not the way.

Doctors need to help patients overcome health literacy issues, and I propose take-aways to this effect. Here are three of them, but there’s more where they came from:

  1. Speak clearly and allow for your patients to drill down to the scientific terms, if they want.
  2. Provide your patients with opportunities to ask questions, to clarify, and repair.
  3. Write down or print out relevant medical terms for your patients. Help them so they don’t have to rely on memory. Have them write down what they think they hear, and spell it out for them.  

Just like blaming low health literacy on patients would be unfair, it is also unfair to expect doctors to solve the problem on their own.

This is where healthcare systems come in. This is where it’s worth their while to promote increased readability of texts and accessibility of spoken instructions. These actions increase patients’ adherence, satisfaction, and health. This, in turn, lowers expenses – the bottom line.

Here are three of the take-aways I propose for the healthcare system:

  1. Make it a habit to create accessible information. Tailor materials to the reading level of a 5th grader.
  2. When creating materials, give the option to drill down for higher level terms so the patient can feel up to par with their doctor’s knowledge when explaining what they have learned.
  3. Create institutional invitations, norms and training around tools like ‘Repair’ (where doctor and/or patient verify what the other said), or ‘Ask Me about What Matters’ (which I developed: What are the risks? What are the benefits? What are the alternatives?).

If the LAPD could do it, so can you, and I am more than happy to help.


Contact Talya at:
[email protected]