Help your patient “get” what you just said: A health literacy guide

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Applied Evidence

Help your patient “get” what you just said: A health literacy guide

J Fam Pract. 2012 April;61(4):190-196

By

Lois Wessel, FNP

Michelle A. Roett, MD, MPH, FAAFP

These simple strategies can help patients with limited health literacy grasp—and retain—vital information about chronic conditions, medications, and more.

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References

1. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.

2. Kutner M, Greenburg E, Jin Y. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education Statistics; 2006.

3. Vernon JA, Trujillo A, Rosenbaum S, et al. Low health literacy: implications for national health policy. National Patient Safety Foundation; 2007. Available at: http://www.npsf.org/askme3/pdfs/Case_Report_10_07.pdf. Accessed March 21, 2011.

4. Schillinger D, Machtinger EL, Wang F, et al. Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment. J Health Commun. 2006;11:651-664.

5. Adams RJ, Appleton SL, Hill CL, et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol. 2009;124:601-602.

6. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.

7. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57:334-345.

8. Kirsch I, Jungeblut A, Jenkins L, et al. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. 3rd ed. Washington, DC: National Center for Education, US Department of Education; 2002:201.

9. Davis T, Crouch M, Wills G, et al. The gap between patient reading and comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533-538.

10. Brach CP, Cheyarley FM. Research findings #28: Demographics and health care access and utilization of limited-English-proficient and English-proficient Hispanics. 2008. Agency for Healthcare Research and Quality. Available at: http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf28/rf28.pdf. Accessed May 20, 2011.

11. Ngo-Metzger Q, Telfair J, Sorkin DH, et al. Cultural Competency and Quality of Care: Obtaining the Patient’s Perspective. New York, NY: The Commonwealth Fund; 2006:963.

12. Bass PF, Wilson JF, Griffith CH, et al. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039-1041.

13. Schwartzberg JG, Van Geest JB, Wang CC. eds. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, Ill: American Medical Association Press; 2005.

14. Kripalani S, Henderson LE, Chiu EY, et al. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med. 2006;21:852-856.

15. US Department of Health and Human Services. National Healthcare Disparities Report. 2010. Available at: http//www.ahrq.gov/qual/nhdr10/nhdr10.pdf. Accessed March 9, 2011.

16. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-594.

17. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391-395.

18. Parker RM, Baker DW, Williams MV, et al. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537-541.

19. Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.

20. Shah LC, West P, Bremmeyr K, et al. Health literacy instrument in family medicine: the “Newest Vital Sign” ease of use and correlates. J Am Board Fam Med. 2010;23:195-203.

21. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the Newest Vital Sign. Ann Fam Med. 2005;3:514-522.

22. Welch VL, VanGeest JB, Caskey R. Time, costs, and clinical utilization of screening for health literacy: a case study using the Newest Vital Sign (NVS) instrument. J Am Board Fam Med. 2011;24:281-289.

23. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; April 2010. 10-0046-EF. Available at: http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf. Accessed March 21, 2011.

24. Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96:219-222.

25. Shillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.

26. Wolf M, Bailey S, You W, et al. Improving patient understanding of preeclampsia, a randomized controlled trial. Am J Obstet Gynecol. 2011;206(suppl 1):S312.-

27. Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns. 2007;66:368-377.

28. Clancy DE, Huang P, Okonofua E, et al. Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med. 2007;22:620-624.

29. McLean S, Chandler D, Nurmatov U, et al. Telehealthcare for asthma. Cochrane Database Syst Rev. 2011;(1):CD007717.-

30. Liang X, Wang Q, Yang X, et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabet Med. 2011;28:455-463.

31. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achieving cardiovascular health (COACH): a multicenter randomized trial in patients with coronary heart disease. Arch Intern Med. 2003;163:2775-2783.

32. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48:923-933.

PRACTICE RECOMMENDATIONS

• Prioritize patient teaching, and present no more than 3 to 5 key points per visit. C

• Confirm that patients understand what you’ve told them by asking them to explain it to you (the “teach back” method). B

• Whenever possible, use simple visual aids—eg, draw pictures, use illustrations, or show a video—to get your point across. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Half of all adults are unable to understand basic health information and services needed well enough to make appropriate health decisions, according to the Institute of Medicine.¹ Findings from the 2003 National Assessment of Adult Literacy (NAAL), the National Center for Education Statistics’ only study of Americans’ ability to understand health-related information, painted a similarly grim picture. Although 53% of US adults had “intermediate” health literacy (HL), the NAAL found that up to 90% lacked the skills needed to manage their health and prevent disease.²

The National Patient Safety Foundation reports that low HL is associated with an additional $106 to $238 billion in health care costs per year.³ Among the reasons:

Up to half of all prescription and over-the-counter medications are taken incorrectly,⁴ which helps explain why roughly 1.5 million preventable adverse drug reactions occur each year.¹
Chronically ill patients incur higher health care costs as a result of low HL. Consider, for instance, that patients with asthma have more frequent hospitalizations,⁵ and patients with diabetes have higher glycohemoglobin (HbA1c) and a higher incidence of nephropathy and retinopathy.⁶
Elderly patients with low HL are more likely to use the emergency department, and have significantly worse mental health and greater all-cause mortality than their counterparts with higher HL.⁷

Clearly, this is a problem primary care physicians cannot afford to ignore. The strategies discussed in the text and tables that follow will increase your awareness of the effects of limited HL—and help you take positive steps to address them.

Put health literacy on your radar screen

Anyone can have trouble comprehending medical information at times, but patients who are elderly (≥65 years), cognitively impaired, or have limited education face the highest risk.⁸ Half of adults who never completed high school have “below basic” HL, compared with 15% of high school graduates.²

FAST TRACK

The reading comprehension of many adults—especially low-income minorities—is 2 to 5 grade levels below the education level attained.

Education alone is not an accurate measure of HL, however. Reading comprehension is often 2 to 5 grade levels lower than an individual’s actual educational level. Socioeconomic status, race, and age affect the extent of the discrepancy, with the largest gap found among low-income minority patients.⁹

HL status is not shaped by reading comprehension alone, however. It also depends on the ability to decode symbols and charts and to formulate decisions and subsequent actions related to health. Thus, limited English proficiency (LEP) is a key risk factor for low HL, as well.¹⁰

Among Hispanic adults, those with LEP have higher rates of unemployment and are less likely to have health insurance or to have a usual source of health care.¹⁰ Compared with English-speaking patients with higher HL, those with lower HL and LEP are less likely to use health services or to adhere to clinicians’ recommendations—and more likely to have worse outcomes.¹¹

FAST TRACK

Patients with low health literacy may have trouble filling out forms or submit forms that are incomplete or have multiple misspellings.

While behavioral markers for low HL may be evident, clinicians often fail to recognize them.^12,13 Patients with low HL may ask for help with forms they’re asked to fill out, submit incomplete forms, or fill out the forms with multiple misspellings. In the exam room, patients with limited HL are likely to identify a drug by its appearance—“the little yellow pill”—rather than by the name on the label. In one study, patients with limited HL were 10 to 18 times less likely than those with higher HL to correctly identify their medications.¹⁴ Rather than request clarification, however, such individuals are frequently ashamed of their lack of understanding and attempt to mask it by asking few questions.

Incorporate an HL assessment tool
According to the National Healthcare Disparities Report, poor HL contributes not only to differences in access to care, but also to provider bias and to poor patient-provider communication,¹⁵ which directly affects patients’ understanding of, and adherence to, medications and treatment plans. But in a busy practice setting, clinicians may have limited time to screen for HL or to devote to patient education. They may also be concerned about embarrassing patients who have low HL and unsure of how to appropriately address the issue.¹⁶