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Risk of Death Greater With Low Literacy Levels

chronic disease is on the rise, and we know that the socioeconomic disparities associated with poor health and death persist into old age. Is there any better reason to redesign our health care system so that our patients actually understand health related information and are empowered to manage their disease processes?"

The study was part of an actual trial of advance directives, the name given to the forms that allow patients to state their wishes ahead of time with regard to medical treatment and end-of-life care.

"We did not design the modified consent process in order to write a paper, but because we wanted to protect patients who were enrolling in our trial," says Sudore. "Studies have shown that up to 80 percent of patients don't understand some aspect of consent information, and that low literacy is probably a factor. Most consent forms are written at a 12th grade level or beyond. We were concerned that a vulnerable, possibly illiterate patient population would not be able to understand the sensitive nature of end-of-life issues associated with our trial if we used conventional consent forms."

The researchers recruited 204 adult subjects, fluent in English or Spanish, with a mean age of 61 years. Forty percent had limited literacy. The subjects were given a consent form written in English or Spanish at a sixth grade-reading level, and asked to read along slowly while native speakers read the form aloud to them. The speakers stopped frequently to ask if the subjects understood what was being read to them. They then asked the subjects seven true-or-false questions designed to probe comprehension.

"If they missed any of the seven questions, we'd go back to the form, read aloud the sections of the consent form they misunderstood, then go back to the questions they missed and ask a second time," recounts Sudore. "We did this until they got all the questions right, or until they required more than six passes t
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