The Importance of Health Literacy in Patient Education

Abstract

Low health literacy has a negative impact on a patient's health status and use of the health care system. Patients with low health literacy levels cannot make decisions regarding their health care or follow instructions on medications and health maintenance behaviors. It is the health care provider's responsibility to ensure that patients with low health literacy levels are identified and measures are taken to ensure those patients understand their options and instructions. To educate these patients, health care providers need to develop resources that are easily understood and interview skills that can ensure patient comprehension. This review discusses the prevalence of health literacy and its impact on patients and the health care system, and provides recommendations for creating supplemental literature at the appropriate level. The use of these tools and improved physician interview skills will establish a better physician/patient relationship and continue to encourage patient participation in the health care process.

Full text

WCHI #502021, VOL 14, ISS 3
The Importance of Health Literacy in
Patient Education
JOANNA DEMARCO and MEG NYSTROM
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The Importance of Health Literacy in Patient Education
Joanna DeMarco and Meg Nystrom

HEALTH LITERACY
Deborah Chiarella, Column Editor
5
The Importance of Health Literacy in
Patient Education
JOANNA DEMARCO and MEG NYSTROM
Cleveland Clinic, Cleveland, Ohio, USA
Low health literacy has a negative impact on a patient’s health
10
status and use of the health care system. Patients with low health
literacy levels cannot make decisions regarding their health care
or follow instructions on medications and health maintenance
behaviors. It is the health care provider’s responsibility to ensure
that patients with low health literacy levels are identified and
15
measures are taken to ensure those patients understand their
options and instructions. To educate these patients, health care
providers need to develop resources that are easily understood
and interview skills that can ensure patient comprehension. This
review discusses the prevalence of health literacy and its impact
20
on patients and the health care system, and provides recommenda-
tions for creating supplemental literature at the appropriate level.
The use of these tools and improved physician interview skills will
establish a better physician=patient relationship and continue to
encourage patient participation in the health care process.
25
KEYWORDS Health education, health literacy, Internet, patient
education
Comments and suggestions should be sent to the Column Editor: Deborah Chiarella
(dtc3@buffalo.edu).
Address correspondence to Joanna DeMarco, Cleveland Clinic, 9500 Euclid Avenue,
Cleveland, OH 44195. E-mail: Reidj2@ccf.org
Journal of Consumer Health on the Internet, 14:1–8, 2010
Copyright #Taylor & Francis Group, LLC
ISSN: 1539-8285 print=1539-8293 online
DOI: 10.1080/15398285.2010.502021
3b2 Version Number : 7.51c/W (Jun 11 2001)
File path : p:/Santype/Journals/TandF_Production/Wchi/v14n3/WCHI502021/wchi502021.3d
Date and Time : 15/07/10 and 15:16
1

INTRODUCTION
As defined by the National Institutes of Health (NIH), the term health literacy
is the ‘‘degree to which individuals have the capacity to obtain, process, and
30
understand basic health information and services needed to make appropri-
ate health decisions.’’
1
Individuals with low health literacy may be unable to
make the necessary decisions regarding their health or may not be able to
adhere to maintenance guidelines as prescribed by their physicians. This
can affect health care in a variety of ways.
35
Recent research has shown that patients with a low health literacy level
may be more likely to have problems following verbal or written medical
advice and medication instructions or understanding health-related materials.
These patients also have been shown to be less likely to use preventative
health services and have less knowledge of their condition. This often results
40
in a trip to the emergency room for their necessary care.
2
These limitations
can all lead to a higher rate of hospitalization and mortality.
3
The Joint Com-
mission on Accreditation of Healthcare Organizations (JCAHO) requires that
patients not only receive but also understand information that is relative to
their medical condition and care. Low levels of health literacy and the
45
inability to effectively communicate can interfere with the hospital’s com-
pliance level for these National Patient Safety Goals.
4
As materials are
developed to help educate patients about their condition, health literacy
levels must be taken into consideration in order to create education materials
that can be utilized and understood by a larger number of patients. By pro-
50
viding the patients with the basic knowledge to understand and adhere to the
instructions given to them and the confidence to communicate any questions
or concerns, the hospital is promoting a better patient-physician relationship.
LITERATURE REVIEW
Prevalence of Low Health Literacy
55
The findings of the 2003 National Assessment on Adult Literacy were released
in 2006. This assessment included a Health Literacy component that evalu-
ated patient’s health literacy in three main categories: clinical, preventative,
and navigation of the health care system. These categories were designed
to reflect things that patients would see or be asked to do in their daily lives.
60
Examples may include following medication instructions (clinical), schedul-
ing health screening tests such as a mammogram or colonoscopy (prevent-
ative), and finding one’s way to the appropriate location for a medical
appointment within a health care facility (navigation). The results of this
Assessment indicated that 36–38%of adults in the United States had a Basic
65
or Below Basic health literacy level or were not literate in English and could
2Health Literacy

not participate in the assessment.
5
Another 53%of U.S. adults reported
having a mid-range level of health literacy which showed room for
improvement.
6
Effect on Patients
70
Having a low health literacy level can have various negative effects on a
patient’s health and the care that they receive. Patients who have low health
literacy levels often cannot comprehend and follow the instructions on a
medication bottle, determine dosage information on over the counter medi-
cations, or understand how food labels relate to the dietary restrictions they
75
may be placed on by their physician.
7–9
Not only can a low health literacy
level affect the way that a patient cares for his or herself, but it can also affect
the access a patient may have to health care coverage and reimbursement.
The inability to understand the information requested on a health care form
can prevent an individual from having adequate health care coverage or hav-
80
ing access to care when it is needed.
5
If a patient does not have the ability to
identify when treatment is needed for a medical condition, make the
appointment, and navigate through the health care system to be treated,
his or her health can suffer. By not seeking medical attention at the beginning
of an illness or not accessing the appropriate point of entry in a health care
85
clinic, the patient is reducing the chance of having a positive health
outcome.
1
Effect on Health Care
People with lower health literacy may wait to seek medical attention rather
than utilizing preventative health services. These patients often have higher
90
rates of admission and use services that are designed for more critical patient
care. The increased rates of admission and inefficient use of specialized
hospital services are associated with higher health care costs to the
organization.
10,11
Utilization of Education Materials
95
When faced with a disease or health care condition, patients often turn to a
variety of places for health information. Cutilli and Bennet found that adults
with basic or below basic health literacy levels did not turn to print sources
(e.g., Internet, magazines, newspaper, books, literature) or nonprint sources
(e.g., family, friends, television, radio). This population reported the highest
100
number of persons not seeking information about their health or condition.
Of this population, patients who did report seeking information were
very reliant on the information from their health care provider. This
discovery of the utilization trends of health education materials highlights
Health Literacy 3

the importance for health care providers to be properly trained on how to
105
communicate health information to patients in the most efficient way.
12
Communication Barriers
Given the prevalence of patients with inadequate health literacy levels, it is
inevitable that physicians will treat a patient with this problem during their
career. Schillinger and colleagues report that patients recall and comprehend
110
as little as 50%of what their physicians or clinicians discuss with them at
appointments.
13
This inability to retain and utilize the information given to
them about their condition or health maintenance contributes to the inability
to care for oneself at home and prevent complications and subsequent
hospital admissions. Physicians are with a patient such a short amount of
115
time at each visit, yet they have so much critical information to communicate.
Schillinger and colleagues also found that physicians were introducing two
new concepts in an average outpatient appointment; more than half of those
concepts involved medications, introduction of a new medicine, discontin-
ued use of a current prescription, or a modification to the prescribed dose.
13
120
Higher rates of comprehension can be achieved when practitioners use plain
English to describe a condition or maintenance instructions and avoid using
medical jargon.
14
It is also of great importance to verify that a patient
understands what is being said to them. It is not sufficient to ask ‘‘do you
understand,’’ as patients will often answer ‘‘yes’’ regardless of actual compre-
125
hension.
14
Asking patients to demonstrate what they just heard is more
effective in gauging whether a patient understands the information. This con-
cept is termed ‘‘interactive communication loop’’ and allows a practitioner to
adjust patient instruction based on the interactive learning ability of the
patient.
13
Additional time can be spent with patients, or supplemental
130
materials can be provided to patients who have difficulty processing this
critical information.
Readability of Education Materials
According to the 2004 Institute of Medicine report, approximately 90 million
U.S. adults have literacy levels that fall below that of high school level; how-
135
ever, many health education materials and health care forms are written at
levels higher than this average. Consent forms were evaluated and found
to be written at scientific levels and contained much technical wording and
medical jargon. This has been found to leave patients confused and unable
to process what they read.
15
Health information, which is designed to assist
140
the patients in learning about their condition or provide instruction on how
to care for themselves at home, is most often written at a tenth grade reading
level.
16
Other factors that can have a negative impact on a person’s compre-
hension of health-related materials, include limited English language skills,
4Health Literacy

chronic health conditions, hearing problems, or vision problems. In order for
145
patients to be able to most effectively use these health education materials,
they should be written at lower reading levels using simple words and
pictures to emphasize points.
16
RECOMMENDATIONS
Patients with low health literacy levels are a population at high risk for nega-
150
tive health events. In order to more efficiently reach these patients and teach
them with the tools and communication styles that will reap the most benefits
for them, health care professionals need to get involved. Physicians and
nurses often have little time in an office visit to thoroughly discuss all of
the topics for which a patient may need information. Two areas that require
155
additional attention and revision are one-on-one communication with
patients during office visits and the readability level of supplemental health
information materials.
Improvement in Communication
Time is limited in an office visit. Patients have questions and clinicians have
160
vital information that they must communicate to the patient in order for the
patient to leave the visit able to care for him or herself. To make the most of
that short amount of time, it is essential for the clinician to communicate as
efficiently as possible by speaking slowly and using simple language rather
than medical words or technical jargon. This can assist greatly in a patient’s
165
ability to understand complex terms. When possible, the physician should
use pictures, illustrations, or diagrams to help explain the condition or treat-
ment at hand.
16
It is also equally important to confirm that the patient under-
stands the information and instructions discussed in the visit. One way to
check that the patient understands is to ask him or her to demonstrate the
170
instructions back to the clinician. By acknowledging the information that
was presented and asking the patient to communicate back what he or she
is to do at home, the physician can determine if the patient can carry out
the tasks or if additional instruction and materials are necessary. This type
of interactive conversation can also identify communication problems that
175
the physician may have been unaware of.
17
With ongoing practice and
continuous patient feedback, physicians can improve their communication
skills and increase their efficiency during office visits.
Effective Health Education Materials
Physicians use written health information to provide additional education to
180
patients on their condition or instructions that were provided during their
Health Literacy 5

visit. These materials are vital tools that can assist the patient in following the
instructions that are essential to health maintenance; however, these materi-
als are ineffective if the patient cannot understand the information. Safeer
and Keenan recommend writing health education materials at a sixth grade
185
or lower reading level to ensure that as many patients as possible understand
and use the information to help care for themselves.
16
The information
should be written in clear, simple language and, where necessary, provide
a definition of medical words that may be unfamiliar to a patient. To keep
the material short and efficient, developers should focus on the essential
190
information, such as: what is my condition, how do I take care of myself,
and why is it important to follow these instructions.
17
This information
should appear in the literature in order of importance.
18
The more simple
and to the point the information, the easier it will be to read, which will
increase the chances that a patient will actually read it. The use of headings
195
in brochures or pamphlets will provide visible breaks and indicate a change
in subject. These headings will also enable patients to find the information
they need more quickly. For lists of symptoms or instructions, bullet points
have been found to yield a higher rate of retention than the same list in para-
graph form.
18
Once a draft of each brochure is completed, it should be tested
200
for readability and literacy to ensure that it is appropriate for the general
patient population. The final step before implementing a piece of health edu-
cation is to test it within a sample group of the patient population. By allow-
ing patients who would be provided this information during an office visit to
read it and give feedback, the physician would be able to revise any confus-
205
ing information before placing it into use.
18
CONCLUSION
Low health literacy is a problem that continues to plague our patients and
health care system, contributing to a lack of or inefficient use of services,
often leading to negative health outcomes and increased costs. Hospitals
210
should focus attention on their forms and the health education materials they
are distributing to patients to ensure that these materials are appropriate for
all levels of health literacy. Having forms that are more easily understood
may increase a patient’s ability to access and utilize appropriate hospital ser-
vices. Giving patients more appropriate health education materials will
215
encourage them to become more actively involved in their care by providing
them with the confidence to make decisions about their treatment. Once
these tools are in place, the key to implementing them is having clinicians
who are able to identify patients who need additional information or assist-
ance in initiating a health care process. This step can only be done once
220
clinicians are made aware of the tools that are available to them and the
importance of utilizing these tools. As the individual relationship is built
6Health Literacy

between patient and care team, the trust will follow to ask questions about
information that is not clear and seek assistance when it is first needed
instead of when it is a critical situation. These are the essential pieces to
225
an efficient health care puzzle.
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ABOUT THE AUTHORS
Joanna DeMarco, MS, CHES (Reidj2@ccf.org) is a Doctoral Student at A.T.
Still University, Arizona School of Health Sciences, and a Health Educator at
Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. Meg Nystrom,
280
RN, MS (Nystrom@ccf.org) is a Health Educator at Cleveland Clinic, 9500
Euclid Avenue, Cleveland, OH 44195.
8Health Literacy