Komunikasi Dokter-Pasien
Komunikasi Dokter-Pasien
Komunikasi Dokter-Pasien
383
Background and Objectives: Patients health literacy is increasingly recognized as a critical factor affecting patient-physician communication and health outcomes. We reviewed research on health literacy, examined its impact on patient-physician communication, and offer recommendations to enhance communication with patients who have poor health literacy. Methods: We conducted a literature review using the
MEDLINE database for January 1966 through July 2001. The keywords literacy and health literacy
were searched independently and in combination with the medical subject headings (MeSH) physicianpatient communication, communication, and reading. Results: Poor health literacy is common,
especially among elderly patients. More than 33% of patients ages 65 and older have inadequate or
marginal health literacy, as do up to 80% of patients in public hospital settings. Patients with poor health
literacy have a complex array of communication difficulties, which may affect health outcomes. Such
patients report worse health status and have less understanding about their medical conditions and treatment; they may have increased hospitalization rates. Professional and public awareness of the health
literacy issue must be increased, beginning with education of medical students and physicians and improved patient-physician communication skills. Conclusions: Future research needs to address identification of optimal methods for communicating with patients who have low literacy skills. This should focus
on the effect of poor health literacy on patients ability to communicate their history and physicians
ability to solicit information, as well as identifying the most-effective techniques to educate patients.
(Fam Med 2002;34(5):383-9.)
With the number of Americans who have limited literacy estimated at more than 40 million,12 the ramifications of poor health literacy, and the associated lack
of understanding of written or oral health communication, are many. They include difficulties navigating the
health care system, inaccurate or incomplete histories,
missed doctors appointments, pills taken at incorrect
times or inappropriate dosages, and lack of informed
consent.3,9,13-18
This article reviews evidence documenting the prevalence of inadequate health literacy in America, the effect of limited literacy on patient-provider communication, identification of patients with low literacy, and
research on interventions to enhance the outcomes of
patients with inadequate health literacy. After a review
of research examining the issue, we provide recommendations for how clinicians can optimize communication with patients who have limited health literacy.
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May 2002
Methods
We searched MEDLINE for English-language articles published between October 1966 and July 2001.
The keywords literacy and health literacy were
searched independently and in combination with the
medical subject headings (MeSH) physician-patient
relations, communication, and reading. Subject
headings were exploded to expand the search. After
reviewing the title and abstract of all articles retrieved,
one author identified pertinent publications. The reference lists of the articles obtained through the MEDLINE
search were reviewed to identify additional articles.
Re sults from p re viously c onduc te d litera ture
searches10,11 and systematic reviews on patient-doctor
communication were also reviewed.1,2
These search strategies yield a total of 66 salient articles and books. In this paper, we categorized these
publications into those addressing (1) prevalence of the
problem, (2) effect of health literacy on patient-physician communication, (3) association of health literacy
to outcomes, and (4) interventions to enhance communication with patients who have inadequate or marginal
health literacy.
Results
Literacy and Health Literacy in
AmericaPrevalence of the Problem
According to the National Adult Literacy Survey
(NALS),12 considered the most accurate portrait of literacy in the United States, about one fourth of American do not have the ability to read, write, and speak in
English and compute and solve problems at levels of
proficiency necessary to function on the job and in society.12 Persons with inadequate literacy skills come
from a variety of backgrounds, including all races and
socioeconomic classes. These functionally illiterate
adults are more likely to have health problems, live in
poverty, and have fewer years of education.12 Of note,
lack of adequate literacy is twice as common for older
Americans and inner-city minorities, the primary users
of Medicare and Medicaid.
The findings of the NALS have been corroborated
in health care settings. For example, an evaluation of
more than 2,500 patients at two public hospitals, using
the patients native language (English or Spanish), revealed that 42% could not understand directions for
taking medication on a empty stomach, 26% could not
understand an appointment slip, and 60% could not understand a standard informed consent document.9 The
prevalence of inadequate or marginal functional health
literacy was more pronounced among older persons,
with more than 80% of those older than 60 having inadequate health literacy.9 Similar finding were noted
in a cross-sectional survey of 3,260 community-dwelling Medicare enrollees in a managed care plan from
three different states. That study revealed that 34% of
Family Medicine
English-speaking and 54% of Spanish-speaking respondents had inadequate or marginal health literacy.19
Effect of Health Literacy on PatientProvider Communication
Understanding the Physicians Vocabulary. The terminology or language that health care providers use
to communicate with patients is a barrier for patients
with inadequate health literacy. Multiple studies document that physicians use of medical terms, combined
with patients limited health vocabulary, results in inadequate and even confusing communication,3-5,20,21 and
patients commonly complain that physicians do not
explain their illness or treatment options to them in
terms they can understand.3 An older, yet still relevant,
study assessed 125 hospitalized patients comprehension of 50 of the most common health words found in
transcripts of physician-patient interviews.20 While almost all (98%) understood the word vomit, only 35%
of patients understood the word orally, 22% understood nerve, 18% comprehended malignant, and
just 13% understood terminal.
A more recent study revealed confusion and lack of
understanding of medical terms used in describing colon cancer screening. Many participants did not know
the meaning of commonly used terms such as polyp,
tumor, lesion, screening, or blood in the stool. None
knew what or where the colon or bowel was, and many
were not clear about the rectum.5
(1) Understanding Patient Education Pamphlets. Patients ignorance of medical terms interferes with the
usefulness of written patient education pamphlets. Numerous studies have documented that standard patient
education materials are frequently written at levels exceeding patients literacy skills.22 Studies in the mid1990s found that only 19% of health education pamphlets written for parents of pediatric patients were
written below a ninth-grade level, and only 2% were
written below a seventh-grade levelplacing them
beyond the reading comprehension of most US adults,
for whom average reading skills are at the eighth-grade
level.23
In the last few years, some health education materials have been written in simpler language. Yet, current
studies show that much health educational material is
still written with wording too difficult for patients with
inadequate or marginal health literacy.24-26
(2)Understanding On-line Information. The Internet
is a potentially attractive method for patients to get specific health information. However, current formats are
not suitable for audiences with low literacy skills. A
recent study conducted by Rand found that 100% of
the English-language Web sites evaluated presented
health information at a ninth-grade level or higher, and
six of seven Spanish-language sites presented information on at least a high-school level.27 Additionally, the
385
General Health Outcomes and Costs. In a study involving low-level readers enrolled in adult basic education classes, 52 subjects with the lowest reading skills
had poorer physical and psychological health than those
with better reading skills. These relationships persisted,
even after statistic al a djustments for confounding
sociodemographic factors. A study of 2,659 patients at
two public hospitals found that those with inadequate
functional health literacy were more than twice as likely
to have poor self-reported health status than subjects
with adequate literacy.53 Literacy was a stronger correlate of health status than education level and other
sociodemographic variables. In fact, after adjustment
for literacy, education level had no significant association with health status.19,22,53
Patients with limited literacy skills may also have
higher health care costs. A study of English- and Spanish-speaking Medicaid participants revealed that among
those enrolled in Medicaid because of medical need or
indigence, those reading at the lowest grade levels
(grades 02) had average annual health care costs of
$12,974, compared with $2,969 for the overall population studied.54,55 Finally, in a study of 958 low-income
patients followed for 2 years, patients with inadequate
literacy were nearly twice as likely to have been hospitalized during the previous year (31.5% versus 14.9%),
a relationship that persisted after adjustment for health
status and various socioeconomic indicators.56 Inadequate health literacy has also been confirmed as an
independent risk factor for hospital admission among
elderly managed care enrollees.57
Validity of Medical Tests. Low health literacy may interfere with the validity of instruments used to screen
for cognitive impairment. In particular, scores on the
Mini-mental State Examination (MMSE)48 are influenced by a patients literacy skills.49-51 Patients may
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Family Medicine
Discussion
A marked expansion in patient education requirements has paralleled the recent growth in medical technology. For example, patients with an acute myocardial infarction are now typically hospitalized for just 2
to 4 days (compared to 4 weeks about 30 years ago),
will probably be discharged on five or more medications ( blocker, aspirin, anti-platelet agent, ACE inhibitor, lipid-lowering agent), and given detailed dietary
and exercise instructions.76,77
Such demands on patients medical knowledge, combined with their limited health vocabulary and frequent
use by physicians of medical terms, represent a major
source of miscommunication between patients and physicians. Although physicians frequently believe they
speak to patients in laymans terms, patients and nurses
do not perceive this. 78 Indeed, Waitzkin found that physicians used nontechnical language in only 12% of explanations to patients. 79 Not surprisingly, therefore,
patientsespecially those with limited health literacy
commonly report that physicians do not adequately
explain illness or treatments in understandable terms.3
Identifying Patients With Limited Health Literacy
Unfortunately, it is difficult to identify patients with
low health literacy skills because they do not fit a
steroptype.12 Many well-groomed, articulate, intelligent-sounding individuals have limited health literacy.
Further, most individuals with limited literacy try to
hide this limitation from others because of shame.80 A
previous study found that 67% of patients with low literacy had not told their spouse, more than half had not
told their children, and 19% never told anyone.80
Clinicians often attempt to assess patients literacy
by asking how far they went in school, but there is a
poor correlation between educational attainment and
literacy skills. A study of five family practices in a southern city found that more than 60% of patients had reading skills at least three levels below the highest school
grade they attended.20 The previously mentioned survey of Medicare managed care enrollees found that 27%
of those who graduated from high school had inadequate
or marginal health literacy, as did 17% of those with
some college education.19 Thus, one cannot predict literacy level simply by inquiring about a patients education level.
Tests such as the Rapid Estimate of Adult Literacy
in Medicine (REALM)81 and the Test of Functional
Health Literacy in Adults (TOFHLA)82 can identify
patients with low literacy skills, the former in as little
as 90 seconds. The literature does not, however, support using these instruments to test patients literacy
skills unless health care providers are willing to tailor
communication and health education to the needs of
low-literacy patients identified by testing.83
Table 1
Six Steps to Enhance Understanding
Among Patients with Low Health Literacy
Slow down and take time to assess patients health literacy skills.
Use living room language instead of medical terminology.
Show or draw pictures to enhance understanding and subsequent recall
Limit information given at each interaction and repeat instructions
Use a teach back or show me approach to confirm understanding.
This approach involves having clinicians take responsibility for adequate
teaching by asking patients to demonstrate what they have been told (ie,
teach back to you how to take their medications) to ensure that education
has been adequate.
Be respectful, caring, and sensitive, thereby empowering patients to
participate in their own health care.
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Conclusions
Poor health literacy is common, especially among
poor and elderly patients. Patients with poor health literacy have a complex array of communications difficulties that may affect health outcomes. Such patients
report worse health status and have less understanding
about their medical conditions and treatments; they may
have increased hospitalization rates.
While a variety of methods have been recommended
and studied for communicating with patients who have
limited literacy skills, our search of the literature found
little experimental researc h to determine which
method(s) is optimal and leads to the best health outcomes. Such research is needed.
Corresponding Author: Address correspondence to Dr Williams, Emory
University, School of Medicine, 69 Butler Street, SE, Atlanta, GA 30303.
404-616-5287. Fax: 404-616-0747. mwillia@emory.edu
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