The 2003 National Assessment of Adult Literacy reported that only 12% of American adults have proficient health literacy. Possessing limited health literacy can lead to poorer health outcomes, including earlier death, and suboptimal use of health care services. A debate exists as to whether health care organizations should use a “universal precautions” approach to health literacy where simplified information is presented to everyone undergoing a health intervention versus tailoring patient interventions based on the results of validated health literacy screening tools.
Due to the biology of aging, the potential presence of a life-limiting chronic illness and individuals who have completed a high school education or less, there is ample opportunity for widespread patient misunderstanding of their disease, their medication, how to self-manage their condition and how to appropriately access medical services.
Additionally, patients who have limited English proficiency are also at an increased risk for misunderstanding critical health care information. A recent report from Angela G. Brega and colleagues in HLRP: Health Literacy Research and Practice suggested a framework that organizations can use to become more health literate, which can also serve as a useful guide for an individual practitioner working in an outpatient setting.
Clear, concise communication in both the written and oral format is essential for your message to be adequately understood. It is recommended that any patient-related material that is being given to patients be written at the sixth grade reading level or lower, preferably accompanied with pictures and illustrations.
One easy way to assess whether print materials are written at the appropriate reading level is to put the text into an Automatic Readability Checker. This free resource analyzes text and converts it into a reading grade formula.
Although there is not a recording feature on the site, I have occasionally analyzed the information I give about a particular disease, medication or self-management plan after recording it as a voice memo on my smartphone, transcribing it and then pasting it into the calculator to assess whether my verbal communication is similarly commensurate with the recommended sixth grade reading level.
However, delivering information in a clear, concise manner is necessary but not sufficient to ensure patient understanding. After communicating an important piece of information you should ask patients to “Teach Back” what you have just said or demonstrated. This ensures that your message has been heard and understood as prior research has indicated that patients comprehend as little as half of what physicians convey during an outpatient encounter.
Patients who have limited English proficiency should be offered the opportunity to have an interpreter, whether in-person or remotely, that can help facilitate crucial information transmittal and assess understanding in the patients’ preferred language.
Ease of navigation
Navigation doesn’t necessarily mean how patients manage to get to your office, or find your health system’s phlebotomy lab, radiology department, or outpatient testing area. Although some health systems have navigation apps that can be downloaded and utilized, patients should not be expected to be proficient in digital strategies in order to have a successful visit.
Although having people assist with wayfinding in large institutions and having prominent, easy-to-understand signs that are updated when changes to service offerings occur is critical to engender trust, loyalty and satisfaction, ease of navigation should be thought of as how patients and their data move within and across organizations. These transitions are critical for minimizing patient frustration and poor patient outcomes. For example, monitoring whether patients have timely scheduled follow-up visits for primary and specialty care, especially if they were recently discharged from the hospital. Also, monitoring whether follow-up information from referrals are received by the practice in a timely manner.
Unfortunately, I have witnessed patients being the source of information that should have come from the consulting physicians directly back to the requesting physician. This is particularly problematic if patient-provided consultant information is used to facilitate further diagnostic and treatment planning.
Patient engagement & self-management support
The most important quality a health care provider can possess in helping patients with limited health literacy is empathy. Trying to intuit the experience of a patient who has limited health literacy and is attempting to navigate the health care system with a potentially life-limiting illness and who may also have other challenging social determinants of health in the context of a modern office or hospital visit can provide the resilience and understanding that is needed to form an effective relationship.
It has taken providers decades of experiential and formal knowledge to gain expertise and confidence in the medical conditions patients present to them with. If only a few minutes every few months is spent teaching in a direct face-to-face setting, how can we expect patients to master the skills needed to manage something providers need years to master? Having this perspective allows one to be creative in trying to convey necessary information, provides hope, encouragement and builds trust that you and your practice will always be there to holistically care for the patient.
Enlisting specialized programs like congestive heart failure or pulmonary rehab clinics, for example, can allow patients to have different opportunities to practice their understanding and skills in disease self-management. When appropriate, support groups may add additional opportunity to share stories and strategies on how to cope with living with a particular condition.
Finally, engaging patients on what goals they would like to achieve despite their health condition(s) and working with them collaboratively to break down any barriers in achieving them allows patients to understand that doing the things necessary to improve their health allows them to lead fuller and richer lives.
Fortunately, there are community resources that can assist in breaking down those barriers (social services, food, transportation, etc.) and the perceptive provider working in an office or hospital setting can leverage those assets so he or she doesn’t feel overwhelmed with the complexity of trying to manage limited health literacy on their own.
But none of this is possible unless providers, offices and health systems demonstrate collective leadership when it comes to providing effective structures and polices aimed at improving communication, navigation and self-management.
Joseph M. Geskey is the Vice President of Medical Affairs at OhioHealth Doctors Hospital in Columbus, OH. He is currently working on a book about the healthcare experiences of patients with limited health literacy and challenging social determinants of health in the digital and technological era medicine is embracing.