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Health Literacy, Communication, and Treatment Decision-Making in Older Cancer Patients

Health Literacy, Communication, and Treatment Decision-Making in Older Cancer Patients

ABSTRACT:  Abstract: Inadequate health literacy and physician-patient communication are associated with poor health outcomes and appear to limit quality of medical decision-making. This review presents and consolidates data concerning health literacy, physician-patient communication, and their impact on medical treatment decisions in elderly cancer patients. This population faces increasingly complex management options, cognitive and sensory deficits, and intergenerational barriers. As a result of these and other factors, older cancer patients have among the lowest health literacy and numeracy rates and often suffer from suboptimal physician-patient communication. These deficiencies impair elderly cancer patients’ ability to understand, recall, and act upon information concerning treatment risk and benefit. This situation also makes it difficult for patients to have self-confidence in communicating with their provider and sharing in the decision-making. Moreover, since older cancer patients usually bring a companion to medical appointments, the positive and negative role of a companion in the context of communication and decision-making needs to be considered. Future research should center on developing ways to identify and overcome health communication barriers to improve geriatric cancer care.

Literature from the past 2 decades widely acknowledges both inadequate health literacy and poor physician-patient communication as major health-care challenges. Deficient health literacy contributes to poor treatment compliance, uncontrolled chronic disease, and high health-care costs.[1,2] Similarly, quality of physician-patient communication correlates strongly with patient satisfaction and positive health outcomes.[3] Patient health literacy, through its influence on physician-patient communication, has profound impact on the effectiveness and quality of medical treatment decisions, especially in the older cancer patient.[4]

Several major health-care policy organizations in the United States have made addressing these issues a high priority. For example, a 2004 report by the Agency for Healthcare Research and Quality found “confidence in the conclusion that low reading skills and poor health are clearly related.”[5] Furthermore, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has added health-care benchmarks for hospitals to achieve and improve health literacy as one of the Department of Health and Human Services’ Healthy People 2010 goals.[6] Correspondingly, the Institute of Medicine of the National Academy of Sciences recently added health literacy to its list of areas for quality improvement.[1]

In regard to physician-patient communication, JCAHO annually releases National Patient Safety Goals that include recommendations for improving patient communication and autonomy in treatment decisions.[7] Moreover, the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) recognize interpersonal and communication skills as a core competency for medical trainees in medical education.[8]

However, despite the significant amount of attention these topics receive in relation to the general population, they remain relatively unstudied in subpopulations of patients that may in fact have the poorest health literacy and be subject to the least effective communication. One such subpopulation is comprised of elderly cancer patients.[9] These individuals face increasingly complex cancer management options and may be hindered by issues such as impaired memory, language deficits, and intergenerational and cultural barriers.[10] As such, we review the current trends in health literacy, patient-physician communication, and the medical treatment decision process, focusing attention on the older cancer patient population.

Health Literacy

Definition of Health Literacy
The American Medical Association defined health literacy in 1999 as “a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment.”[11] A patient’s health literacy level, which includes such skills as the ability to comprehend prescription bottle labels, follow written and oral health instructions, and understand physician dialogue, may be significantly lower than their general literacy level.[12] Health literacy level in today’s complicated medical environment can be conceptualized as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.[13]

Epidemiology of Health Literacy
Most health-care material is written at a 10th grade reading level or higher and most adults read between the 8th and 9th grade levels.[14] The National Adult Health Literacy Survey (NALS) published in 1993 reported that almost 50% of the US population was either functionally illiterate or possessed marginal literacy skills. Almost 25% of adults read at the lowest level, approximately 5th grade or lower.[14] The 2003 National Assessment of Adult Literacy (NAAL) conducted by the US Department of Education found no significant improvement in the percentage of adults with below basic or basic literacy ability.[15]

Furthermore, these health literacy statistics are subject to disparities based on sociodemographic characteristics such as race, income, education, language, and age. Specifically, black race, low income, low rate of high school completion, Spanish language, and advancing age are all associated with lower levels of literacy.[16,17] The problem of inadequate health literacy is especially significant in older patients. The majority of patients over 60 years of age perform at the lowest levels of literacy, and 80% have poor document literacy, limiting their ability to complete basic health forms employed by many physicians.[9]

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