Health literacy is generally considered to have two components: the ability understand health information and the ability to use that information to make good decisions about your own health (see here and here for definitions). Health literacy has been found to be a key indicator of all kinds of healthy behaviors, including eating nutritious foods, exercising, and scheduling regular physicals. It just makes sense that higher health literacy would also have some impact on whether patients end up in the emergency room or ambulance.
Interestingly, though, there appears to be something of a paradox in the relationship between health literacy and emergency services use. Health literacy appears to significantly reduce the number of potentially preventable hospital admissions and overall use of emergency services–except when it does the exact opposite.
More Health Literacy, More Health
One of the most consistent findings about the relationship between health literacy and emergency services or emergency department use is that limited health literacy leads to fewer doctor visits, which in the end translates to more “potentially preventable hospital admissions,” as one study put it. It makes sense: if you go to the doctor less often, you’re less likely to catch chronic or terminal diseases in their early stages. Diabetes, cancer, and heart disease–three of the biggest killers in all Western countries–are much more likely to require emergency care if not properly managed through regular doctor visits.
Overall, those with lower health literacy have also been found to have higher risk of death, according to the U.S. Agency for Healthcare Research and Quality (AHRQ). Those with low health literacy have difficulty reading medication labels, are less likely to get screened for major diseases, and are less likely to seek out preventive interventions such as flu shots. Compounding the issue is that minorities and those in poverty, groups with poorer health outcomes on average, tend to have lower health literacy as well (although of course this is not universal).
Fortunately, a number of programs exist to help patients improve their health literacy, even in the ED. One such program, for example, educated parents who came to the ED about mild health complaints and where to take their children first when they got sick. The program was highly effective, reducing the study group’s visits to the ED by 30% (an outcome that not only reduces ED overcrowding but saves the parents money as well).
Except . . .
At least one study, though, has found that some education programs can have exactly the opposite effect. The Keep Well at Home Project, initiated in West London, screened older adults and provided them with at-home care and health education to reduce hospital admissions—an intervention that makes total intuitive sense.
What happened? “There was an increase of 51%” in emergency admissions among patients involved in the program. As the authors put it in a wonderful phrasing, “the KWAH Project reveals that there can be a major gap between what seems to be a sensible national initiative and what actually occurs when attempts are made to apply the policy.”
To be fair, the KWAH Project may have done its patients more good than if it had reduced their emergency admissions as planned. The screening may well have identified serious problems that would otherwise have gone unnoticed or helped patients better recognized changes in their own symptoms. The outcomes of their hospital visits aren’t known, so it’s hard to tell whether those visits were necessary.
What is important to remember about all of these studies, though, is that the effects of educational interventions to change health behaviors—especially the often rushed, emotional choices that patients make about seeking emergency care—are not straightforward cause-and-effect. Interventions to increase health literacy in our communities clearly lead to improved health outcomes. Whether they lead to reduced emergency services use is less clear.
And perhaps most complicated of all is the question of whether we want them to. If increased health literacy means, for example, that patients recognize a heart attack or stroke earlier, then we should be happy to see more of these patients in the emergency room. The key, in future research, will be to tease out which patients (like the parents of children with minor concerns) can be safely educated out of the ED, and which should be educated in.