Limited health literacy has been linked to poor outcomes in many chronic medical conditions. Among surgical populations, over one third of patients may be impacted by limited health literacy. Our study focused on colorectal surgery, known for its high risk of poor surgical outcomes, racially diverse population in the Deep South, and low national literacy ranking. Our objective was to characterize factors contributing to lower health literacy.

The 4-item Brief Health Literacy Screen (BRIEF) instrument is a well-validated screening tool ranging from 4 to 20, interpreted as limited(4-12), marginal(13-16), and adequate(17-20). It was administered by clinic staff during routine intake at a high volume, tertiary care colorectal surgery clinic in Birmingham, AL since 2018. Changes in health literacy over time for each patient were compared by age, race, sex, and median income by ZIP code.

Among all charted scores (n=2,163), the mean was 18 (SD=3.3) with 83.4% scoring “Adequate” (n=1,586), 6.7% scoring “Limited” (n=127), and 9.9% scoring Marginal (n=188). On unadjusted analysis, BRIEF score was negatively associated with age (p<0.001) with a correlation of -0.12, and higher among female (n=682, mean=18.2, SD=0.13) compared to male (n=577, mean=17.8, SD=0.14) (p=0.02) patients. By race, health literacy was highest among white (n=879, mean=18.2, SD=0.11) and Black (n=329, mean=17.8, SD=0.19) patients and lowest among Asian (n=20, mean=16.3, SD=0.75) and Native American (n=8, mean=13.9, SD=1.2) patients (p<0.0001). Median income of the patient’s ZIP code had a positive correlation with BRIEF score by 0.077 (p<0.0001). Among patients who had multiple BRIEF scores (n=1,208), 5.5% had a decrease in score (n=66), 85% had no change (n=1,028), and 9.4% had an increase (n=114). Patients whose scores increased were younger (mean=51.6yr, SD=15.6) than those without change (mean=54.2yr, SD=16.1). Both were younger than those whose score decreased (mean=60.8, SD=13.8) (p<0.001).

Low health literacy has been shown to lead to high rates of complications and readmissions after surgery. This study shows that health literacy is lower among Asian, Native American, lower income area, and older patients. With literacy declining significantly with age, this calls for multi-level interventions targeting elderly patients to improve their understanding and interaction with the healthcare system.

Health literacy and older adults

Health literacy and clinical healthcare settings