Risks associated with low functional health literacy in an Australian population

To the Editor: A recent editorial about health literacy and a research article on the prevalence of low health literacy in a South Australian population sample2 highlight the potential negative impact of low health literacy on treatment outcomes. Adams and colleagues also suggest a need to assess health literacy in clinical practice.2 Although calls for the introduction of screening to identify patients with low health literacy appear frequently in such articles, we urge caution in taking such a step at this time, because of a lack of sound evidence to support such a recommendation.

High-level evidence related to health literacy screening is scarce. One randomised controlled trial found that making physicians aware of patients’ health literacy status led to greater use of recommended strategies, but did not translate to expected improvements in patient self-efficacy.3 An unanticipated outcome was that physicians who received advice about their patients’ health literacy status reported significantly lower satisfaction with the consultation and felt marginally less effective than those not given such information. The authors caution against health literacy screening in clinical practice unless system-wide training and support for both health practitioners and patients is in place.

A fundamental principle of screening is that it should not be introduced without an effective intervention — to do so offers no advantage to patients and may be harmful.4,5 Health literacy screening raises the potential for harm due to high levels of stigma and shame that may be experienced by those with poor literacy.

In Australia at this time, it is uncertain whether effective intervention strategies suitable for use in clinical settings are readily available. Moreover, we do not have reliable information about the skill levels of practitioners to address low health literacy.

Published studies consistently show that 40%–60% of clinical and population samples have low or marginal levels of health literacy. This means that one of every two people attending a medical consultation can be expected to have suboptimal health literacy. Therefore, a universal approach to the assurance of comprehension in every consultation, supported by practitioner training in health literacy communication and evidence-based tools to enhance patients’ encounters with health services, may offer a more effective and efficient alternative to screening.