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

,; ,

Applied Evidence

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

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

PDF Download

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.

Routinely using an HL assessment tool is an important first step. There are several screening tests that reliably assess HL, but they vary in their approach and the time needed to administer them. (See TABLE 1 for details on the most widely used screening tools.^17-21)

Assessing time and cost. The Newest Vital Sign (NVS), a screening tool in which patients are asked to use a sample product label to determine things like fat content, calories, and serving size, was included in a study assessing the time and cost of HL interventions. Distributing the NVS and explaining how to complete it added <30 seconds to the patient intake process. Scoring the test and recording the results in the patient’s electronic medical record, tasks completed by the front office staff, took <2 minutes. The office visit itself took 2 to 5 minutes more than it otherwise would have—the extra time needed for the clinician to adapt his or her communication style to the patient’s documented HL level and to assess patient recall and understanding.²²

Implementation added up to $8,000 in start-up and training costs, plus costs for refresher training and system maintenance.²² Using free materials, such as the Agency for Healthcare Research and Quality (AHRQ)’s Health Literacy Universal Precautions Toolkit (detailed in a bit),²³ limiting training fees, and relying on existing staff members to do the training could significantly cut the cost of an HL intervention.²²

Table 1
Health literacy assessment: Validated screening tools^17-21

Assessment tool	Description	Administration time	Scoring	Advantages
Newest Vital Sign (NVS) http://www.annfammed.org/content/3/6/514.figures-only	6-question test of ability to interpret an ice cream nutrition label	<3 minutes	0-1 correct=high likelihood of limited HL; 2-3 correct=possibility of limited HL; ≥4 correct= adequate health literacy	Quick, widely accepted; available in English and Spanish
Rapid Estimate of Adult Literacy in Medicine, Short Form (REALM-SF) http://www.ahrq.gov/populations/sahlsatool.html	7-item health word recognition test	2-3 minutes	0 correct=≤3rd grade;* 1-3 correct=4th-6th grade; 4-6 correct= 7th-8th grade; 7 correct=high school	Quick; large font available
Test of Functional Health Literacy in Adults (TOFHLA) http://www.peppercornbooks.com/catalog/information.php?info_id=5	Timed reading comprehension test^†	18-22 minutes (7 minutes for S-TOFHLA)	75-100=adequate HL; 60-74=marginal HL; 0-59= inadequate HL	Available in short version, very short version, and in Spanish
*≤3rd grade: unable to read most low-literacy materials; 4th-6th grades: needs low-literacy material and may be unable to read prescription labels; 7th-8th grades: will struggle with most patient education material; high school: able to read most patient education material. ^†Uses modified Cloze procedure (every 5th to 7th word is replaced with a blank space and the patient selects the word from 4 multiple choice options). HL, health literacy; S-TOFHLA, Short Test of Functional Health Literacy in Adults.

Tools to help boost your communication skills

A number of online resources are available to help health care professionals address HL. Take a look at the following examples to see which might be most helpful to you:

AHRQ Health Literacy Toolkit. Available at http://www.ahrq.gov/qual/literacy/index.html, the AHRQ’s HL toolkit starts with the assumption that most patients have difficulty understanding health information at times. It outlines a systematic approach to assessing clinical practices, evaluating patients’ HL, improving provider-patient communication, and teaching patients self-management skills. AHRQ provides 20 tools, specific implementation steps, worksheets, and sample forms, among other resources.

Communication course for providers. The Health Resources and Services Administration (HRSA) is another valuable resource. Noting that ensuring effective health communication is a shared responsibility, HRSA offers a free online course (http://www.hrsa.gov/publichealth/healthliteracy/) titled “Effective Communication Tools for Healthcare Professionals.” The curriculum incorporates HL, cultural competence, and LEP.

“Ask Me 3” campaign. Developed by the National Patient Safety Foundation, this program (available at http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/) is designed to promote provider-patient communication by encouraging patients to ask 3 questions at each visit:

What is my main problem?
What do I need to do?
Why is it important for me to do this?

The role of providers is to ensure that patients understand the answers. Ask Me 3 brochures, posters, and patient handouts, which can be purchased on the foundation’s Web site, are designed to remind patients to speak up.

Assess comprehension and recall

Studies suggest that up to 80% of medical information received is forgotten by patients immediately, and nearly half of the content that’s retained is incorrect.²⁴ Prioritizing information you wish to provide and limiting yourself to 3 to 5 key points per visit is one way to increase the likelihood that patients will remember what you said. Using open-ended questions (eg, “Tell me what you’ll do when you get home”) and the “teach back” method—that is, asking patients to repeat in their own words what you’ve taught them about their medications and treatment plan—helps to reinforce key take-home points.