I read with interest the article by Rangachari and colleagues, "Using the "Customer Service Framework" to Successfully Implement Patient- and Family-Centered Care," on applying a well-established theoretical perspective, that is, the service quality model (also known as the "customer service framework") to the health care context to reconcile the debate in relation to patient involvement.1

I agree with Rangachari and colleagues that the organizational literature has remained divided on the effectiveness of patient involvement in care delivery and safety.1 Furthermore, use of the customer service model appears to have significant merit in the health care setting.

Rangachari and colleagues referred to "low health literacy" without adequately defining this term. The most widely accepted and cited definition of Western World health literacy is "the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions."2 To illustrate the extent of health literacy problems, Rangachari and colleagues should have included information about the prevalence of low health literacy in the Western World populations. Figures published on New Zealand's Health Literacy Web site3 indicate significant prevalence of low health literacy. In the United States, 21% of the population is functionally illiterate (ie, below fifth-grade level), and in Australia, 59% have low health literacy. Furthermore 56%, 46%, and 60% of adults have poor health literacy in New Zealand, the United Kingdom, and Canada, respectively. These alarming rates highlight the need for strategies to improve health literacy.

As noted by Rangachari and colleagues, people with low health literacy (a) are hospitalized more frequently and for longer periods, (b) use emergency departments more frequently, and (c) self-manage asthma and diabetes less proficiently.1 Therefore, people with low health literacy are likely to represent a large proportion of the overall population utilizing health care. Moreover, the high incidence of serious adverse events (among patients with low health literacy) may have been significantly reduced through patient involvement.1 This suggests that health care professionals should invest considerable time and training treating patients with low health literacy. Doing so will improve patient involvement, decrease the gap between expected and perceived care, and prevent adverse events.

Rangachari and colleagues called for the universal adoption of strategies to successfully implement patient- and family-centered care.1 Applied globally, this framework has the potential to decrease adverse events and improve safety and quality of health care for patients and not a select few. In the absence of improved patient involvement, the gap between the health illiterate and health literate will widen. Societies are becoming more culturally diverse, suggesting that health care services need to become more culturally versatile, by offering information in a range of languages, communicating sensitively, and involving patients in all areas of their health care regardless of their level of health literacy. In turn, this will lead to improved quality, safety, and access to appropriate and timely health care for all.

-Jacinta Baker

Melbourne Health

Parkville, Victoria, Australia 3052

([email protected])

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