Download - Health care literacy in the adult 10215
Running head: HEALTH CARE LITERACY IN THE ADULT 1
Health Care Literacy In The Adult
Sherri Boseski RN,APN-C
Health Care Associates of NJ LLC
September 7, 2015
HEALTH CARE LITERACY IN THE ADULT 2
Abstract
Low health care literacy is an independent risk factor for morbidity and mortality.
Ninety million Americans have limited health literacy and cannot perform their own self-care
due to their inability to decipher health care information. (Institute of Medicine [IOM], 2004,
pp. 1) Health care providers have an obligation to ensure that their patients are able to take an
active role in their own care, and receive health information that is accessible, actionable,
understandable, and effective, utilizing many evidence-based learning modalities which have
proven effective. The most common modality of learning for the patient is oral and aural. The
Teach-Back Method has proven to be the most efficient and effective learning modality and has
been recommended to be utilized in each health care learning encounter. Reading materials
and other health related learning modalities need to be at the appropriate health care literacy
level for each patient, in order to ensure that the patient can decipher and utilize its content.
This will improve patient outcomes, increase reimbursement, and decrease the overall health
expenditure in the United States of America .(Weiss, 2007).
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Health Care Literacy In The Adult
Literature Search
Two data bases Pub Med and CINHAL were searched utilizing the search terms “health
care” and “literacy”. Pub Med retrieved 790 articles with the limitations of being peer reviewed.
Pub Med retrieved 196 articles, utilizing time constraints of being published within the past ten
years. Then abstracts were reviewed for the terms health literacy as a main theme; 15 articles
were retrieved and utilized from PubMed. The CINHAL data base was searched using the
Boolean Phrases “health & literacy”, and were limited to peer-reviewed, evidence-based,
research articles, English, full text articles, human, all sexes, all adults, and articles published
within the last ten years. I retrieved 125 articles from CINHAL. Then each abstract, was
reviewed and limiters were set to include the term ‘health literacy’ in the abstract and then 5
articles were abstracted from the CINHAL database. From those 20 articles their references
were hand reviewed. I was able to review and choose articles from the articles references. A
total of 106 articles were reviewed. I reviewed one dissertation from Proquest using the search
term “Health Care Literacy” and I reviewed 2 books on health care literacy and one book on
patient education and one monograph on utilization of TOFHLA in preparation for writing this
manuscript on Health Care Literacy in the Adult. I also performed a google and bing and Ask
search utilizing the terms health care literacy; and reviewed 20 websites pertaining to “Health
Care Literacy”.
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Objectives
I. Define Health Care Literacy
II. Define Scope of the Problem of Health Care Literacy
III. Explain How To Measure Health Care Literacy
IV. Give Examples How to Improve Health Care Literacy
V. Summarize Findings related to Health Care Literacy
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Health Literacy in the Adult
Objective I; Define Health Care Literacy
According to the U.S. Department of Health and Human Services Office of Disease
Prevention and Health Promotion; Health literacy is defined as; “The degree to which individuals
have the capacity to obtain, process, and understand basic health information and services,
needed to make appropriate health care decisions.” (U.S. Department of Health and Human
Services,[HHS] 2014) Health literacy is a concept, which values that all people have access to
health information, which assists them in making informed health decisions. (National Institute of
Health, [NIH], 2014) According to the United States Department of Health; health literacy, is
needed to improve the health of the nation. (Health Resources and Services Administration,
[HRSA],(2015).
Nine out of ten American adults have difficulty reading prescriptions, following their
health care providers’ instructions and keeping appointments; all of these activities represent
health information utilization. The National Action Plan to Improve Health Literacy, (HRSA,
2015), research has demonstrated with over two decades of study; that health information is
proven, not to be usable by most Americans. People with health literacy difficulties are more
likely to utilize emergency services and hospitals because they cannot manage their own chronic
diseases.( HHS, 2010) This increases the suffering and cost for each patient. According to
Healthy People (2010) the American population cannot utilize health information in ways that
are understandable and benificial to health, longevity, and quality of life.
Health literacy has been given increasing importance due to decades of research; which
demonstrated health literacy levels directly correspond with health outcomes and costs. (Ownby
R. & Waldrop-Valverde, 2013) In order to achieve proficient health literacy it must be defined,
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and be universal to all health care providers with objectives that are clear, measurable, and
obtainable.
Healthy People 2010 delineates health literacy as;
1. Patient-physician communication
2. Drug labeling, medical instructions and medical compliance
3. Health information publications and resources
4. Informed consent
5. Responding to medical and insurance forms
6. Giving patient history’s
7. Public health training
8. Assesment of all health literacy programs.
Healthy People, 2020, goes further explaining rational objectives which will provide
greater health care literacy and information to include;
-Supported shared decision-making between patients and providers
- Providing personalized self-management tools and resources
-Building social support networks
-Delivering accurate, accessible, and actionable health information that is targeted and
tailored to the meaningful use of health.
-Facilitating the meaningful use of health IT and exchange of health information among
health care and public health professionals.
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The need to assess health literacy was deemed important enough to be investigated by
Congress, who alloted funds to assess trends and problems in literacy. Congress defined and
investigated health literacy in addition to other literacy problems. This effort summerized the
difficulties in literacy and health literacy in the American population. The task was given to; The
US Department of Education and The National Literacy Act, which was enacted to perform the
research. Literacy was defined by the National Literacy Act, in 1992 as; an individual’s ability to
read, write, speak in English, compute and solve problems; at a level of proficiency necessary to
function on the job and in society, to achieve one’s goals, and develop one’s knowledge and
potential. (Kirsch I, et al. 2002) Since 1992 literacy skills have improved vastly to include
technology.
According to Healthy People, 2020, health literacy skills have increased, to include the
ability to use technology to access knowledge. Three skills lacking by health care providers
determined by the Department of Education; National Assesment of Adult Literacy or NAALS,
(2006) includes;
1- The ability to provide access to accurate and actionable health information.
2- The ability to deliver person centered services and health information.
3-The ability to support lifelong learning and skills to promote good health.
The Afforable Care Act (ACA) provides authorization, for community outreach programs
to expand; these three skill sets amongst providers and the use of technology, such as the web
portal healthfinder.gov. (Wizemann, 2011) There are a number of provisions of the ACA, that
pertain to CMS including;
Supporting informed consumer decision making.
Standardizing prescription drug information and insurance plan information.
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Improving communications with diverse, low literacy patients.
According to Section 3507, of the Affordable Care Act, which addresses patient
information on risks and benefits provided at the point of prescribing rather than dispensing, is
recommended for each health care provider. (Wizemann, 2011) Utilizing Electronic Medical
Records, can help the prescriber review a patient’s medication with greater ease and cross-
referrence medications, prescribed by other providers, in order, to identify any contraindication,
while the patient is still in the examination room. Patients should bring in all medications and
supplements they take from every prescriber, to each appointment in order to keep the
medication record up to date. This allows real-time review of the medication list prescribed by
the medical provider and real-time feed-back from the patient regarding compliance and side-
effects of prescriptions.
The use of many different tools to improve health literacy through technology has
grown by leaps and bounds. The NIH, HHS, AHQR, and others all have websites addressing the
needs of improved health literacy and utilization of technology. Substantial benefit would be
derived from coordination in developing standardization, easy to use, and easy to obtain
materials, regarding health literacy. (Wizemann, 2011) Using possibly one web-based portal to
access all the web sites and tools could reduce redundacy and ease accessibility.
The National Action Plan to Improve Health Literacy (2006) incorporates the findings
from NAALS and has two basic principles; (1) everyone has the right to health information
which helps them make good decisions and (2) health services should be delivered in a manner
appropriate to the patients needs, beneficial to health, long life and quality of life.
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The Seven Goals of the National Action Plan to Improve Health Literacy (2006)
include;
1-Developing and disseminating health and safety information that is accurate, accessible
and actionable.
2- Promoting changes in the health care system which improves health information,
communication, informed decision making, and access to health services.
3- Incorporating accurate, standard-based, and developmentally appropriate health and
science information in curricula in child care and education through the university level.
4- Supporting and expanding local efforts to provide adult education, including English
language instruction for foreign speaking clients, which is culturally and linguisticly
appropriate, for the health information services in the community.
5- Building partnerships, developing guidance and changing policies.
6- Increasing basic research which includes the development, implementation, and
evaluation of practices and interventions to improve health literacy.
7- Increasing the dissemination and use of evidence-based health literacy practices and
interventions.
Low health care literacy is defined as the inability to obtain patient safety and the
desired outcomes, due to decreased knowledge of one’s medical condition. Poor medication
adherence, non-adherence to treatment plans, lack of self-care behaviors which decreases
physical and mental health, increasing the risk of hospitalization and mortality, all are signs of
poor health care literacy.(Evangelista L.S., et.al.2010) Timely recognition of low health literacy
can prevent deaths, increased costs, and is mandatory by most regulatory bodies. (AMA, 2007)
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Health literacy is considered a dynamic concept. Thus multiple measurements must be
taken during a patient’s lifespan. Due to aging, changes in cognition, and possible learning, each
intervention could effect one’s health literacy score. Measuring health literacy once, would be
sufficient to improve health literacy skills if it was a stagnant concept, which it is not. Health
literacy requires minimal effort to improve scores and decrease health care costs, sufferring, and
morbidity. People are capable of changing their score by increasing their understanding of their
diseases and decreasing their score with cognitive dysfunction such as dementia. A person
asserting modest effort such as attending an adult education class, can significantly improve their
health literacy. Which in turn has proven to improve patient outcomes, decrease health costs, and
decrease morbidity. (Weiss and Palmer, 2007) Thus saving the person afflicted with chronic
disease, great suffering. In addition, the American tax payer saves millions of dollars in health
care expenditure, due to preventable admissions to the hospital and disease complications;
related to misunderstanding of a person’s chronic disease progression, symptomology and
exacerbation avoidance.
Health Literacy Tests
National Assessment of Adult Literacy or NAAL measures, prose literacy; which is the
knowledge and skills needed to search, comprehend, and use information from non-continuance
texts in various formats; the quantitative scale measures: the knowledge and skills needed to
identify and perform computations using numbers embedded in printed materials, and document
literacy scales; measuring knowledge and skills needed to search, comprehend, and use
information from noncontinuance texts in various formats. (NAAL, 2006)
Health Literacy was only one component of the, 2003 National Assesment of Adult Literacy
(NAAL), which was the first ever national assesment designed specifically to measure adult’s
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ability to utilize health literacy skills to read and understand health related information. The U.S.
Department of Health and Human Services (HHS) used these findings to set goals for Healthy
People, 2010. The NAAL, is the second recent attempt to assess literacy by Congress in the
United States, and is the outgrowth of the 1992 assessment of adult literacy which was titled
National Adult Literacy Survey or NALS. The health literacy component of NAAL assesed
adult literacy and surveyed data, helping policymakers, health communicators, and literacy
practitioners to; (1) identify the literacy skills to target audiences; (2) develop health information
tailored to the literacy strengths and weaknesses of target audiences; and (3) develop programs to
improve the health literacy skills of specific audiences. The NAAL performed in 2003 health
literacy component, assessed responses to health-related tasks presented in written form. These
tasks fall into three categories: clinical, prevention, and navigating the health system. Examples
of test questions administered by the NAAL; include determining the right dose of a prescribed
medication from a prescription label; understanding the health risks of smoking and determining
benefits of a health insurance plan.
Health literacy scores were derived from the respondents’ score on 28 health related prose,
document, and quantitative tasks embedded in a NAAL assesment of 152 tasks. Two tasks are
from a previous assement called National Adult Literacy Survey (NALS) conducted in 1992, the
remaining 26 were newly created for NAAL or National Assessment of Adult Literacy. Utilizing
NAAL survey in every day practice is impractical, cumbersome and time-consuming. The
NAAL data however is frequently cited in the literature, as well as the scale utilized to define
health literacy therefore it is relevant and must be understood.
The NAAL, study provided a cross-section of American adults’ability; to use literacy skills
to read and understand health related information. NAAL’s reported health literacy scores for
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all-adults including vulnerable populations such as the elderly, minorities, low-income persons,
immigrants, the less educated, and the nation’s prison population. NAAL’s provided the
following information to Congress;
The relationship of other NAAL scores compared to other health literacy scores
The health literacy skills of adults with below average literacy skills
The relationship of health literacy scores with newly developed skills in literacy
Comparison of health literacy tasks amongst adults scoring different percentiles and
scale scores which one can and cannot perform
Percentage of the population answering each of the 28 health literacy tasks correctly
The general literacy skills required to complete health literacy tasks and the deficits in
literacy that prevent health literacy successful completion.
Statewide health literacy scores for states that chose to participate in a separate state
assessment conducted by NAAL (six states in 2003: Kentucky, Maryland,
Massachusetts, Missouri, New York and Oklahoma). These States have specific data
pertaining to their own state because they were studied separately.
The National Assesment of Adult Literacy or NAAL and the American Association or AMA,
have assigned levels of health care literacy that allow people to categorize and assess health care
literacy. Both the AMA and the U.S. Department of Health and Human Services utilize this
standard, which is four levels and have been assigned values including proficient, intermediate,
basic, and below basic.
Proficient Health Care Literacy is defined as the following; an individual who can read and
comprehend virtually all text and numerical information, that one might encounter in the health
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care setting. This segment of the population is approximately 13 % of the American population.
For example;
1. The ability to find and calculate an employee’s share of health insurance costs for a
year. (AMA, 2007)
2. The ability to find the information required to define a medical term by searching
through a complex document. (AMA, 2007)
3. The ability to evaluate information to determine which legal document is applicable to a
specific health care situation. (AMA, 2007)
Intermediate Health Care Literacy is defined as; a person who can decipher text and
numerical information in a health care setting and can decipher most text and numerical
information. This segment of the American population comprises about 53% of the population.
For example the skill set in this population comprises;
1. The ability to determine a healthy weight range for a person of a specific height, based
on a graph that relates height and weight to body mass index. (AMA, 2007)
2. The ability to find the age range during which children should receive a particular
vaccine using a chart that shows all the childhood vaccines and the age’s children should
receive them. (AMA, 2007)
3. The ability to determine what time a person can take a prescription medication, based on
information on the prescription drug label that relates the timing of medication to eating.
(AMA, 2007)
4. The ability to identify three substances that may interact with an over-the counter drug
label. (AMA, 2007)
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Basic Health Care Literacy is defined as; people who can perform basic tasks; such as reading
and understanding, a short pamphlet that explains the importance of a screening test. People with
basic health literacy would not be able to consistently perform these tasks such as reading
different graph types. People having basic health care literacy, comprises about 22% of the U.S.
population. For example patients’ with this skill set have the ability to;
1. Explain two reasons why a person with no symptoms of a specific disease should be
treated for the disease, based on information written in a pamphlet. (AMA, 2007)
2. Explain why it is difficult for people to know if they have a specific chronic medical
condition, based on information in a two-page article about a medical condition. (AMA,
2007)
Below Basic Health Care Literacy is defined as; reading and understanding a short pamphlet,
that explains the importance of a screening test. Most persons in this population would have
difficulty understanding typical patient education handouts and/or filling out health insurance
forms. This segment of the population with below basic health literacy, consists of about 14 % of
the U.S. population. Examples of the skill sets of people in the below basic health literacy
population are;
1. The ability to identify how often a person should have a specific medical test, based on
information in a clearly written pamphlet. (AMA, 2007)
2. The ability to identify what is permissible to drink before a medical test, based on a set
of short instructions. (AMA, 2007)
3. The ability to identify and circle the date of a medical appointment on the hospital
appointment slip. (AMA, 2007)
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The main components of NAALS frequently cited in health literacy literature include;
(1) reports on health literacy skills of target audiences, (2) sheds light on the relationship
between health literacy and background variables such as educational attainment, age,
race/ethnicity, where adults get information about health issues, and health insurance
coverage,(3) examines how health literacy is related to prose, document, and qualitative
literacy, (4) provides information that is useful in the development of effective policies and
customized programs that address deficiencies in health literacy skills, and (5) guides the
development of health information tailored to the strengths and weaknesses of the target
audience.
NAAL’s found that people with below basic health care literacy receive their health care
information primarily from mass media such as television and radio. Local News
broadcasts and radio shows even when presented by a health care provider, are not always
sufficient to explain a health topic in its entirety, not allowing the public to make informed
decisions. Despite many times having a doctor explain the findings of a study on television,
the information lacks substance and is many times given out of context. Easily giving the
public alarm messages which can scare and misinform the public due to the manner in
which the studies are presented.
The NAAL health literacy component is designed to provide objective data on health literacy
but does not measure other aspects such as (1) the ability to orally consult about a condition or
treatment; (2) knowledge of health issues, such as how to prevent hypertension; and (3) the
ability to understand health materials containing medical jargon and scientific terms. Such skills
are essential to improving health literacy because they are effective means of communication
which a patient encounters with each health care intervention.
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The communication received during treatement from a health care provider is person specific
and essential for the patient to utilize and understand. This communication is usually oral,
specific to the patient’s disease, and can include health handouts or explainations of medication
or treatments to alleviate the suffering from the disease. For this reason NAAL literacy
assessment may be impractical for every day use.
Lawsuites, approximately 75% of all malpractice suits are due to provider communication
style. (AMA,2007) If the patient does not understand the explanation of the diagnosis, or it was
inadequately explained. If the patient does not understand the treatment, or the teach-back
method was not utilized to ensure understanding. If the patient feels ignored, if the clinician fails
to understand the patient’s perspective or discounts the views of the patient or family members,
or the patient feels rushed, they are more likely to sue. (AMA, 2007) The Joint Commission and
the National Committee for Quality Assurance have both adopted guidelines specifying the need
for patient education information and documentation. Failure to provide understandable
information may have a negative factor on accreditation. (AMA, 2007)
II. Define The Scope of the Health Care Literacy Problem
Decreased health literacy increases a patient’s morbidity by 2 times; then that of a person
with good health literacy. (Evangelista L.S.,et.al. 2010) Abilities which are associated with
health literacy include; the ability to read, comprehend, and analyze instructions, symbols,
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charts, and diagrams; weighing risks and benefits; and ultimately, making decisions to take
action. Enabling the patient to actively participate in managing their own care. (Evangelista L.S.,
et. al. 2010)
Medication adherence is a high level of self-care and self-care management. Patients
with low literacy were 3 times as likely to misinterprete medication labels. Patients who read at
low levels are 1.5 to 3 times more likely to have adverse outcomes than those with higher
reading levels. (Evangelista L.S., et al. 2010) Adherence to medication is estimated to be as low
as 40-50%. Polypharmacy from multiple providers makes adherence to medication regimes more
fragmented. (Hawkins L.A. & Firek C.J., 2014) Many pharmacies attempt to coordinate a
person’s medication’s with pamphlets and warnings. According to the NIH (2014) health literacy
extends to patient education materials such as written patient pamphletes. A poorly written
patient pamphlet for the elderly would have small font. (NIH, 2014) Similar to the font on
medication labels and the explanation of medications, many pharmacies attach to the
prescription. The font is extremely small on medication packaging and it’s inserts and is difficult
for the elderly to read due to changes in vision.
A health care provider needs to look for signs of decreased literacy as well as administer
health literacy tests which can be given in a timely and effective manner during the medical
encounter. Misfilled out health forms, with multiple errors is a red flag for decreased health
literacy. Patient’s not taking medications as prescribed or patient’s being unable to explain
medical concepts in their own words related to their disease is another significant sign of limited
health care literacy. Behaviors that indicate limited literacy include; frequently missed
appointments, non-compliance with medical regimes, lack of follow-through with laboratory
tests, imaging tests, or referrals, patients who state they are taking their medications but the
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physiologic parameters such as lab tests, do not change in the expected fashion, patient
registrations that are inaccurately completed. (AMA, 2007) If a patient is unable to name their
medications, unable to explain what they are for, and unable to explain the time of day that they
take them this is evidence of a health care literacy deficit.
Common statements of patients with low health care literacy according to the AMA,
2007 are;
“ I forgot my glasses. I’ll read it when I get home.” or “ I forgot my glasses can you read
it to me.”, or “ Let me bring this home so I can discuss it with my children.” (pp.17, AMA,2007)
These are all signs that the patient has difficulty reading health information possibly due to being
unfamiliar with medical jargon. A clinician must then intervene to assess how great the deficit
of knowledge is and is liable if they ignore the obvious signs of deficient health care literacy
regarding their patient’s treatment.
Poor understanding of basic medical vocabulary is another symptom of poor health
literacy. Medical providers use words in their everyday practice that may be unfamiliar to those
even with the highest reading level ability, but who have no medical training. (AMA, 2007)
Common words to a medical provider such as analgesic, anti-inflamatory, benign, carcinoma,
heart failure, all need to be put in to terms the lay person would understand. For example,
instead of analgesic, say pain killer, anti-inflamatory can be replaced with the words less
swelling and irritation, begnign can be replaced with not cancer, carcinoma can be replaced with
cancer, and heart failure can be stated simply that the heart is not pumping well.
Costs of Low Health Care Literacy
Adverse health outcomes and low health care literacy increase cost per
patient. (Weiss, 2007) According to the Center for Health Care Strategies low
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health literacy is estimated to cost, the U.S. economy up to $236 billion
every year. (CHCS, 2014) Poor outcomes of patients with low health literacy
increase the cost for the health care system. According to the AMA, two
studies cited in the article; Removing barriers to better, safe care Health
literacy and patient safety: Help patients understand Manual for Clinicians 2 nd
Edition (2009); costs for both Medicare and Medicaid patients increase as
health care literacy decreases. The average health costs for all Medicaid
enrollees was $2,891 per enrollee but the annual cost for enrollees with
limited health literacy was $10,688. This is a substantial difference. This
Medicare study, found that patients with low health care literacy had higher
health care costs, had higher emergency room visits, and higher inpatient
care and medical costs than patients with higher health literacy scores.
(Weiss and Palmer,2004)
People who are insured through private insurance have higher health literacy than those who
have Medicare and Medicaid. People with Medicare had below basic health literacy 27% of the
time and those with Medicaid had 30% of their population with below basic health care literacy.
(Volandes A.E. , Passche-Orlow M., & Michael K.,2007) Medicare patients are 29% more
likely to be hospitalized if they have limited health care literacy, this ends up to be millions of
dollars expended that most likely could have been avoided with proper communication at the
appropriate health care literacy level for the individual. (AMA, 2007) Limited health care
literacy is greatest in those with lower education levels, the elderly, minorities, and those with
chronic diseases. (Volandes & Paasche-Orlow, & Michael K., 2007) The problem of health care
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literacy being unexplored by the health provider costs the United States $50 billion to $73 billion
a year. (AMA, 2007)
Literacy is a stronger predictor of health status than income, employment status, education
level, and racial and ethnic groups. A person’s educational achievement is only determined by
the number of years they spent in school not how much knowledge they retained that can be
utilized in everyday life.(AMA, 2007) For this reason effective medical education cannot take
place unless the provider assesses the patient’s level of health care literacy and provides the
patient with appropriate learning modalities at the level of literacy the patient demonstrates. A
person with an MBA in economics may not understand the word endoscopy but may feel
embarrassed to ask, or may wrongfully assume the definition. Thus the educational level alone
cannot determine one’s understanding of medical jargon.
III. Explaining How to Measure Health Care Literacy
Health Literacy Tests/Tools Useful in the Clinical Setting
Health literacy assessment tools that are more commonly used in the clinical setting, are
usually less time consuming and easier to administer with simple answer keys which derive a
score quickly. These literacy scores provide immediate assessment of the health care literacy
level. The health literacy score can then be applied to the health literacy needs of the patient
within minutes. Communication and written materials should represent the score derived in the
health care literacy assessment to ensure teaching is at a level which is adequate and appropriate.
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This ensures the communication is on the same level of understanding, that the patient can
properly decipher.
Health education needs to be assessed as efficiently as possible to be effective. The health
care provider can fit the assessment into their routine by utilizing themselves or having another
staff member utilize these assessment tools which have proven, effective, simple, and easy to
administer. Health Practitioners need to manage their time appropriately, and ensure that their
communication to the patient is effective and not rush through teaching efforts. One instrument
designed to gauge the level of health literacy of a patient is the Newest Vital Sign, NVS. This
tool utilizes an ice cream label and is only six questions which can be easily administered prior
to the patient being seen by the health care provider, who can then utilize the results and prepare
his or her teaching accordingly.
The NVS was correlated with the Test of Functional Health Literacy in Adults, (TOLHFA),
which is the most commonly utilized assessment of health care literacy in the literature. Analysis
of the psychometric properties of both English and Spanish versions of the NVS and TOLHFA
were conducted separately using identical methods. Reliability of the NVS was assessed using
Cronbach alpha, which measures internal consistency.
The NVS, English and Spanish speaking versions were compared to the results of the
TOLHFA, before and after adjustment for sex and education. The English score had a
significantly higher score than the Spanish samples before and after adjustment for sex and
educational level and the differences could not be explained by differences in sex and education
level.
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The time required to administer the NVS was approximately 2.9 minutes (SD 1.2 minutes;
range= 1.5-6.2 minutes. There was no significant difference between men and women utilizing
the NVS as compared with the results for the TOLHFA.
Using the NVS is a quick an efficient tool that correlates with the most commonly used
TOLFHA, in scientific inquiry of health literacy. The development of the NVS involved
surveying 1,000 candidates, this tool has good internal consistency, and can accurately measure
literacy levels of those who participate in using the tool for literacy assessment purposes. It can
be administered in three minutes and will allow the clinician to rapidly assess literacy in their
patients.
Two other instruments used repeatedly in health literacy literature are the TOLFHLA; Test of
Functional Health Literacy and the REALM; Rapid Estimate of Adult Literacy in Medicine. The
TOLFHA comes in English and Spanish and can be administered in 22 minutes for the full
version and 7 to 10 minutes for the short version. The TOLHFA has a two –part assessment. The
first part provides participants with medical information or instruction (e.g. Instructions on a
prescription label or instructions about preparation for a diagnostic procedure.). Participants
review the information and then answer questions that test their understanding of provided
information. The second part is based on the Cloze method, where participants are given
passages of text about medical topics with certain words replaced in the blank spaces. The
participants must fill in the blank spaces using words selected from a multiple choice list.
The Short Test of Functional Health Literacy in Adults (S-TOFLHA) is the TOFLHA reduced
by 2 reading comprehension passages with missing words, based on the Cloze method. The first
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passage is at a 4th grade reading level and the second is at a 10th grade reading level. Average
administration time is 12 minutes. By comparison the REALM and REALM-SF can be is only
available in English. The REALM can has 66 item instrument and the Realm-SF is a 7 item
instrument, which can be administered in 3 minutes. (LSU Shreveport, n.d.)
Participants must fill in the blank spaces with words from a multiple choice list in the
TOFHLA. The TOFHLA is scored from 0-100, higher scores indicate better health literacy;
1. Scores < 60 represent inadequate health literacy
2. Score 60-74 represent marginal literacy
3. Scores > 75 represent adequate literacy.
Individuals with TOFHLA scores in the inadequate or marginal range would likely have
trouble understanding written material that requires a reading level greater then 7th grade or
higher, and often need assistance to understand completely the instructions for their medical
care. Scores on the TOFHLA correlate with the Revised Wide Range Achievement Test and
with scores on the REALM. (Weiss, B.D. et al., 2005)
The S- TOFHLA includes two reading passages (36 items, 2 points each) and four “numeracy
items (7 points each). The S-TOFLHA scores range from 0-100 and is also divided into three
categories;
1. 0-55 represents inadequate literacy
2. 56-66 represents marginal literacy
3. 67-100 represents adequate literacy
Inadequate literacy on the S-TOFLHA represents the inability to read and comprehend,
everyday material including prescription bottles and appointment slips. A marginal literacy
rating, describes people who can usually read the simplest material but struggle with more
HEALTH CARE LITERACY IN THE ADULT 24
complex material. A rating of adequate literacy demonstrates one can successfully complete
most reading materials but may misread materials which are very complex with much
numerical information. (Wolf, M.S., Feinberg J., Thompson J., & Baker D.W., 2010) The
short length S-TOFHLA is used to screen patients in a medical clinic, determine literacy
levels for a health education program, and include literacy as a descriptive variable in
research.
The Realm-SF or Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) is
a 7 item word recognition test to provide clinicians with a fast assessment of literacy. The
clinician supplies the patient with a laminated copy of the Realm-SF and scores the patients
responses. The health provider asks the patient to read the words on the laminated copy of the
Realm-SF. If they cannot read a word or sound it out they say blank and go to the next word. If
a patient takes greater than 5 seconds to say a word, go to the next word.
The Scores for the Realm-SF are as follows;
0- Represents a third grade and below reading level; will not be able to read most low
literacy materials; will need repeated oral instruction, materials composed primarily of
illustrations, or audio or video tapes.
1-3 Represents a fourth to sixth grade reading level; this patient will need low-literacy
materials. A patient in this range may not be able to read prescription labels.
4-6 Represents a seventh to eighth grade; this patient will struggle with the most patient
education materials..
7- Represents a high school reading level; this patient will be able to read most patient
education materials. (Schonlau, Martin, Hass, Pitkin Derose, & Rudd, 2012)
HEALTH CARE LITERACY IN THE ADULT 25
For Spanish Speaking Adults there is the (SAHLSA-50) Short Assessment of Health
Literacy for Spanish Speaking Adults. The Short Assessment of Health Literacy for
Spanish Adults (SAHLSA-50) is a validated health literacy assessment tool containing
items designed to assess a Spanish speaking adult’s ability to understand written common
medical terms. Administration takes 3-6 minutes. The SAHLSA is based on the
REALM, which is known to be the most easily administered tool for assessing health
literacy in English. Although the SAHLSA was developed utilizing the REALM the
results are not comparable. If the reader is interested in comparing the health literacy
ability between English and Spanish speakers they are advised to adopt the SAHL-S&E.
When administering the SAHLSA, the clinician can write one of the 50 words on a 4x 5
index card and the two associated words; one word is the key and the other is the
distractor. A score between 0-37 suggests the examinee has inadequate health literacy.
Culture and Health Literacy
Cultural background, socioeconomic background, ability to understand, read
and speak in English, and educational background are all factors of one’s ability to retain health
care information provided in the United States. (AMA, 2007) According to the Center for Health
Care Strategies (2013) a large number of minorities and immigrants have literacy problems.
Patient beliefs and values are formed in part by their culture including their racial identity,
ethnic, religious, social and linguist communities. A person’s personal and collective values are
defined as a culture, which impacts a patient’s health care literacy.
According to the Center for Health Care Strategies (2006) a persons’ culture can be defined by;
1- What they define as a health care problem.
2- How they express concerns about the problem and report symptoms.
HEALTH CARE LITERACY IN THE ADULT 26
3- How they decide what type of service they should obtain and from whom.
4- How they determine how they should respond to treatment guidance.
According to NCES (2006) health literacy disparities existed between racial groups. White
and Asian/Pacific Islander adults who had a higher health literacy scores than Black, Hispanic,
American Indian/Alaska Native, and multiracial adults. Hispanics had the lowest health care
literacy scores of all groups measured by the NCES. Fifty-eight percent of Whites and 52 percent
of Asians and 59 percent of multiracial adults had intermediate literacy compared with 41
percent of Blacks and 31 percent of Hispanics.
According to NAALS (2006) adults who spoke only English before starting school had higher
health literacy than adults who spoke only another language; other than English before starting
school. Average health literacy score of adults who spoke only English was Intermediate. Those
who spoke English and Spanish and another language before starting school had Intermediate
health literacy ratings. Which is the same as for English only speakers. Adults who only spoke
Spanish before starting school had the lowest health literacy rating, which was below basic.
Adults who graduated from high school or obtained a GED, had average health literacy scores;
health literacy scores increased with higher educational attainment. Adults who had not
completed High School and were not currently enrolled in school had lower health literacy than
those with higher education or than those currently attending school.
Immigrant populations’ language skills may be lacking such as those who, English is a second
language. (U.S. Department of Health and Human Services, Office of Disease Prevention and
Health Promotion [HHS], 2010)
HEALTH CARE LITERACY IN THE ADULT 27
Use of English as a Second Language or ESL instructors utilize methods and pictures
in explaining health care concepts to new immigrant populations, which can be helpful.
ESL learning for health care topics focus on vocabulary, body parts, symptoms, and risk
factors. (M.Santos et al., 2014) Some of the basic components of the reading process
included in ESL are:
1. Alphabetics (phonemic awareness and phonological decoding) the ability to detect
and manipulate phonemes (the smallest unit of language sound).
2. Phoeneme sequencing- Helping students recognize and sequence the individual
sounds in a word such as sat has 3 phonemes:/s/ /a//t/
3. Phenological Decoding (phonics) is the ability to use letters-sounds to correspond to a
recognized word.
4. Fluency which refers to the ease of the learner with reading aloud to the instructor.
This should be encouraged to assess and improve skills.
5. Vocabulary refers to knowledge of the word meaning- including oral vocabulary and
reading vocabulary. Vocabulary differs from not knowing a word, to recognizing a
word, to knowing something about the word and relating it to a situation, to knowing
a word well enough to use it in conversation.
6. Comprehension refers to actually understanding what you read. Good readers are
actively engaged in reading and derive meaning from the text. Comprehension
involves interaction with the text. (M.Santos et al., 2014)
When the ESL teacher and the health care provider, such as nurses collaborate to
integrate the fundamentals of health care literacy has a positive impact on health literacy
functioning. High prevalence diseases entities such as diabetes and use ESL, to enhance
HEALTH CARE LITERACY IN THE ADULT 28
language skills; with trained providers in each subject area include several studies such
as, ESL Participation as a Mechanism for Advancing Health Literacy in Immigrant
Communities. This has demonstrated a positive impact on functional literacy skills.
(M.Santos et al., 2014)
Printed materials
Handouts are material that provide detailed expansion or reiteration of the
presentation. When communicating health information to an audience. Make sure the
handouts are at the appropriate reading level for the audience. Handouts should be written
at or below sixth grade reading level with two key teaching objectives, using mono-
syllabic words, active voice, and short paragraphs. (Traumura, 2013) A large font no
smaller than 12 point serifs with upper and lower case letters. Limit content to what
patients really want and need to know. Avoid information overload, use only words that
are well known to individuals without medical training. Make content appropriate for age
and culture. Use short paragraphs. Use an active voice, Use upper and lower case words.
Use subheadings. Do not clutter the page. Avoid complex graphs and anatomical
diagrams. (AMA, 2007)
The PILL Study, conducted by Pharmacies of Grand Memorial Hospital in Atlanta, GA,
serves primarily indigent population with low health care literacy skills. The pharmacist
provided pictorial prescriptions that represented the appearance, indication, and daily dosing of
each medication given to the patient. During the intervention which included phone-calls the
group given pictorial prescriptions had increased adherence to medications. Other studies have
shown an increase in medication adherence when utilizing pictures and calendars to increase
HEALTH CARE LITERACY IN THE ADULT 29
adherence. Medication adherence improved with pictorial representation in Heart Failure
patients with mild cognitive impairment. (Firek et al., 2014 ) A medication sheet was made using
medication images and a color printer and the time of day the medication was to be taken. So the
use of pictorial representation for improved health care literacy has proven effective for both
English speaking and non-english speaking, as well as for patient’s with mild cognitive
impairment.
Assessment of health education materials for patients included in health literacy are, health
education, suitability, readability and assessment. One method to evaluate printed materials
which is used, is the SAM or suitability of materials, this evaluates the appropriateness,
presentation of printed adult health related materials, which were developed for people with
limited literacy skills. A rater trained in health literacy establishes validity, and then repeats the
assessment by the trained rater to establish inter-rater reliability.
Readings allow detailed expansion of material but must be at the reader’s grade level and
have appropriate font to make reading easy. Reading level can be assessed using the Flesch
Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledgook test (SMOG),
Coleman-Liau Index, Gunning Fog Index, New Fog Count, New Dale-Chall Readability
Formula, Forcast Scale, Raygor Readability estimate Graph, and Fry Readability Graph. The
Flesh Reading Ease (FRE) uses sentence length and syllables to calculate a score from 0-100,
with higher scores indicating greater reading ease and a score of 30 indicates a level of difficulty.
The Flesh Kincaid Grade Level assessment uses the same variables to determine reading grade
level. The SMOG, uses sentence length and number of complex words (words greater than 3
syllables). The Coleman- Liau Index or CLI, uses sentence and word counts to determine grade
level, The Gunning Fog Index or GFI uses the total number of words and 3 syllable words. The
HEALTH CARE LITERACY IN THE ADULT 30
New Fog Count or NFC uses the number of complex words, number of easy words, and number
of sentences to calculate reading difficulty. The New Dale Chall Readability or NDC, considers
sentence length and frequency of unfamiliar words. There are 30,000 common words recognized
by the common fourth grader and the NDC utilizes this list. The Forcast counts the number of
single syllable words in 150 word sample and estimates the reading grade level, and the Raygor
readability estimate Graph or RRE, and the FRY Readability Graph use visual display of the
reading grade level. The REE calculates grade level based on average number of sentences and
long words greater than 6 characters per word per 100 words. The Fry uses the average number
of sentences and syllables per 100 words. (Huang B.S. et al., 2015)
Methods to Improve Health Care Literacy
Computer-assisted learning; allows the learner to employ technology and supports
learning. One can learn with a two way responsive flow of information and go at their
own pace. (Babcock & Miller, 1994, pp.201)
Field Trips or Tours; aid learning by; allowing for environmental interaction which has
meaning to the subject matter. This reinforces group motivation and communal support,
which initiates conversation amongst peers. Disadvantages to field trips include
transportation costs and advanced planning for any complications a patient may
encounter throughout the trip. (Babcock & Miller, 1994,pp.201)
Simulations and Role Playing; helps client stimulate greatest transfer of knowledge.
Helps to learn if patient needs to manage a specific problem or environment. Facilitates
unpredictable occurrences. Disadvantages to simulation and role playing include
simulation can be intimidating to patients. Both activities take a lot of time, which makes
realizing outcomes more difficult. (Babcock & Miller, 1994, pp. 201)
HEALTH CARE LITERACY IN THE ADULT 31
Case Studies; include a detailed account real or hypothetical problems and has the
advantage of allowing the participants to breakdown, discuss and create an action plans to
solve the problems. Disadvantages of a case study; may be that they are too complex;
because real representations may have complex co-morbidities confounding the scenario.
(Janson S., 1996)
Open-Ended Discussions; include allowing continual feed-back, with the advantage of
developing attitudes, and making adjustments to the conversation as necessary to achieve
objectives. Also open-ended conversations may pick up statements that helps resolve
difficulties. Serves as a vehicle for networking. Disadvantages to open-ended
conversation include; increased chance of getting off focus, making it easy for discussion
to become purposeless, allowing some participants to be dominate and others to be
passive, another disadvantage is this method takes a lot of time. (Babcock & Miller,
1994, pp. 201)
Action Plans; describe who, when, where, and how to treat symptoms; advantages
include proper identification of symptoms, use of other tools to measure symptoms, (i.e.
peak flow meters in asthma), and outline of proper interventions for each level of
deterioration or improvement in symptoms. (Action Plans are recommended to be utilized
for asthma at the first visit with physician or during first ER visit for asthma. The Asthma
action plan uses green, yellow, and red color codes to specify danger zones.) Action plans
are specifically geared toward each patient’s manifestation of symptoms. Advantages of
action plans include avoiding excessive hospitalizations and ER visits, and are cost
effective. Disadvantages include the increased time in teaching. Patient needs to learn to
HEALTH CARE LITERACY IN THE ADULT 32
use equipment properly and interpret results properly, patients may wrongfully adjust
medications while learning plan. (Janson S., 1996)
Demonstrations; activates many senses and clarifies the why of the principle.
Advantages include commanding interest and correlating theory with practice and
allowing the teacher to see learning and diagnose the problem. Demonstration helps
learner get well practiced, facilitates affective learning, bypasses learner’s defenses and
proves effective with children. Disadvantages include time for preparation and supplies
needed. (Babcock & Miller, 1994, pp.201)
Modeling; facilitates effective learning. The advantages include bypassing a person’s
defenses. Modeling proves effective with children. Disadvantages include it is ineffective
without rapport. Does not always make what is learned apparent. (Babcock & Miller,
1994, pp.201)
Programmed Instruction; allows students to go at their own speed and refer to a section
at leisure, breaks material down into manageable increments. Saves the teacher time.
Disadvantages to programmed learning include possible lack of motivation of the learner,
and does not account for unplanned feedback, which can distance clients. (Babcock &
Miller, 1994, pp.201)
Teach Back Method; ensures the health care provider can safeguard learning of primary
concepts; which take place through patient verbalization or demonstration. (i.e. I want
you to tell me how you will take your medications, so I can be sure I explained it
correctly?) The health care provider does not ask the question such as “Do you
understand?”. The health care provider asks the patient to explain what you just taught
them or to demonstrate the skill you taught them; to use or manage their illness.
HEALTH CARE LITERACY IN THE ADULT 33
Advantages include real time assessment of learning and allows repeated attempts until
learning has been accomplished “teach till goal”. Disadvantages are that teach-back is
time consuming. Does not account for learner’s stress level due to performance anxiety.
(AMA, 2007)
Improving Health Care Literacy
The average reading level in America is at the eighth grade level, and the average written
consent form for a medical procedure is at the high school level. It is a patient’s right to know
what he or she is consenting to have done to their body. The clinician is responsible for ensuring
that the patient understands the procedure. Most bioethicists agree that autonomy is a major
factor in health care decision making. ( Beauchamp and Childress, 1994) An exchange of
information between the provider and patient is essential for value- clarity, which defines
patient’s goals and not the health care providers. (Goodwin C.L.et al., 2014) High health care
literacy is assumed and never tested for. (Volandes A.E. & Passche- Orlow M., 2007) A patient’s
education regarding one’s own health care should not be contingent on the patient asking for
more information. Providers need to ask patient’s to explain the procedure consented for back to
the provider; or teach back the information to the provider. This ensures the information was
received well. It is every health care providers duty to evaluate each patient regarding his health
care literacy.
In Schillinger, (2007) health communication, speed of clinical dialogue, extent of jargon,
using visual representations and the extent of participation are the main determinates of the
effectiveness of the interaction, medical communication is jeopardized as well as patient safety,
when there is discordance in the communication. It is critical that patients, providers, and others
HEALTH CARE LITERACY IN THE ADULT 34
involved in the health care system including finance personnel, learn to speak with clarity and
listen with understanding.
According to the AMA (2007) a checklist for the health care office is as follows;
1- Exhibit a general attitude of helpfulness
2- When scheduling appointments;
-have a person and not a machine, answer the phone
-collect only necessary information
-give directions to the office
-ask patients to bring in all their medications with them and ask them to list any questions
they have
3- Make any signs in the office clear and easy to follow
4- Instruct staff to be polite and welcoming to patients
5- During office check-in
-provide assistance filling out forms
-provide forms in patient’s language
-provide forms at a low literacy level
6- When refering patients for tests, procedures, and consultations
- Review instructions
- Provide directions to referral site
- Provide assistance with insurance forms
7- When providing patients with information
-Review important instructions
-Provide handouts at a low literacy level
HEALTH CARE LITERACY IN THE ADULT 35
-Use non written communication as well, such as oral communication and videos
If we excuse any member of the health care team from these responsibilities; we endanger
patients and their health outcomes. (Volandes and Paasche-Orlow, 2007) It is critical that
providers explain medical information. If providers are only taught to speak clearly and patients
are only taught to listen. The uncommunicated message is the health care providers voice is most
important, a significant amount of health care information is uncommunicated, due to the one
way conversation.
The paternalistic medical model makes the patient obligatorily obedient to the doctor who
makes decisions for them. The patient is passive in the process. This patriarchal model leads to
clinical dependency for the management of their symptoms. (Sadati, Iman, & Lankarani, 2014)
The patient never learns how to manage their own symptoms from chronic disease processes.
Patients and their families have valuable knowledge to share with health care providers about
their health goals, symptoms, and personel and family history. The health care provider must
“obtain, process, and understand” (Volandes and Paasche-Orlow (2007) to identify health needs
and make appropriate care choices. The patient has been socialized by the medical community
that their lack of understanding is their fault. Compliance is most decreased for chronic disease
management when a patient lacks confidence that they can manage their own symptoms.
(Evangelista L.S., et. al., 2010)
Healthcare information was historically distributed to the patient by the doctor at a time when
the patient was the most stressed due to illness and symptom exacerbation. Parsons’s theory of
the “sick role” distinguishes the patient as the recipient of services by a scientifically trained
physician. (Sadati, Iman, & Lankarani, 2014). In the medical model according to Parson, the
HEALTH CARE LITERACY IN THE ADULT 36
doctor controls the conversation. The patient has limited control over the content. This method of
communication does not explore limitations, external or internal stressors of the patient. The
suggestions of the doctor may not be able to be accomplished by the patient due to physical,
social, or financial limitations that the doctor did not explore or allow the patient to
communicate.
When the doctor is in control of the patient’s health care decisions, there is an external locus
of control. Many times health information is given at a time that enables a physician to be most
efficient such as during a medical exam, the exam itself can be very stressful for the patient and
decreases retention. (Helleso, et.al., 2011) Most of the time the doctor is unaware of the
patient’s limited health care literacy because the doctor did not inquire and/or the doctor asked
closed ended questions such as “Do you understand?” (AMA, 2007) Patients with low health
care literacy tend to be obliging and are ashamed of any knowledge deficit blaming themselves
for the lack of understanding. Patients with health care literacy issues are not forth coming with
any limitations.
When control of the health care behavior conversation is external to the patient, and
dominated by the health care provider’s narrative. The doctor does not engage the patient in a
dialogue of what he or she values and what the patient is capable of. This devalues the patient’s
role in their own health outcomes. This manner of health care education makes a patient less
likely to be compliant because they have no control. It also diminishes the patients recall and
they are less likely to remember the medical appointment or advice correctly. Eighty percent of
patients state they forgot what their doctor said as soon as they left the office and 50% of
patients’ do not remember their conversations with doctors correctly. (HRSA, 2014) Only 12%
of the 228 million adults in the US have the skills to manage their own health needs.
HEALTH CARE LITERACY IN THE ADULT 37
The monologue given by the physician regarding another’s health, is a paternalistic method
of communication and reinforces the concept of others having power over their lives and
choices. Leaving the locus of control external to the patient. (Wolinsky,et al. 2009) Locus of
control is the extent to which one believes his or her own actions will bring about rewards or
change in their own environment. (Cicirelli et al., 1980) There is a relationship between internal
locus of control and physical health and well-being. (Strudler et. al. 1976) Internal locus of
control, describes a person who believes, their own actions, affect outcomes in their lives.
External Locus of control, describes a person who believes fate, a higher being and/or external
factors have greater impact on their health then their own actions.
The concept of internal-external locus of control can provide directions for health care
education programs. Evidence of the relationship between locus of control and health- related
behaviors asserts evidence that identifying a patient’s locus of control and providing a health
care intervention model specific to either internal or external locus of control will improve
adherence to health goals. (Strudler et.al. 1976)
Adults retain more knowledge when they are actively involved in the learning process. The
adult learner is motivated to learn when a need is clear and the need to learn a new skill set aligns
with the adult’s goals and values. Social and environmental factors influence a person’s
behavior. In order to motivate a patient to learn about one’s health both their personal
experiences, cultural values and environmental assets and barriers must be assessed.
Motivation to change health care behaviors and improve health care literacy includes accurately
assesing knowledge, allowing adequate family and peer support, accessing medical support
systems. Fatigue, pain, fear, shortness of breath, all must be assesd as factors towards lack of
motivation to participate in activities to improve health care literacy. (Fitzsimmons, 2014) Self-
HEALTH CARE LITERACY IN THE ADULT 38
Care as the right of the patient has continually been acknowledged by nursing, since Florence
Nightingale in Notes on Nursing, published in 1856. Dorthea Orem believed the nurses primary
role was to teach self-care and developed the Self-Care Deficit Theory of Nursing. (Schnell,
2004) Connelly (1993) developed a Model of self-Care in Chronic Illness, defining self-care as
behaviors to promote health, prevent illness, treat, and cope with health problems. The Self-Care
Model developed by Connelly includes the patients psychological status, through self-concept
and social support system. The patient’s self-concept needs to be stable and well to enable self-
care acts which are reinforced through social support which value adherence to therapeutic
behaviors. Without evaluating self-concept and psychological well-being the health care provider
can not accurately assess the patient’s ability to participate in health care literacy improvement
activities.
Empowerment of individuals through knowledge allows people to cope with illness, and
alleviates feelings of hopelessness and despair. (Johnson L.H., Dahlen R., & Roberts, 1997)
According to Johnson L.H., Dahlen R., and Roberts S.L.(1997), ; “Hope is a multidemensional
dynamic life force characterized by confident, however uncertain expectation of achieving a
realistic important future.” Many people suffering from chronic disease and in need of health
care literacy assessment and intervention are suffering from depression. People suffering from
cardiac disease have a prevalence of depression from 17-47%. (Marrides N. & Nemeroff C.,
2013) Depression has been linked to increased mortality, morbidity, decreassed learning and
lower quality of life, therefore it is imperative that it be screened for. Several Depression scales
have been developed such as Beck Depression Inventory, Geriatric Depression Scale, Zung Self-
Rating Depression Scale and Hamilton Rating Scale for Depression all of which can be used to
HEALTH CARE LITERACY IN THE ADULT 39
measure the potential for the co-morbidity of depression, which will guide the health care
provider, if intervention is needed.
Through education in health care literacy; one can reduce apprehension of disease and
illness due to faulty information and replace that information with knowledge that provides
people with the skills to cope with their illness. This learning and increase in health care literacy
empowers a patient and alleviates helplessness a symptom of depression. According to Johnson
L.H., Dahlen R., and Roberts S.L.(1997); “The person without hope is not future orientated, has
perceptions of incompetence, and believes personal behavior cannot achieve personal goals.”
Interventions such as health care literacy assesment and intervention can decrease apprehension
and create coping strategies for managing chronic disease processes.
The healthcare provider can also perform a VARK assessment. The VARK assessment reveals
to the health care professional which way a person learns best; being audio, visual, kinestic or
multimodal. (Sophia Learning, 2015) Up to 60% of people are multimodal learners which means
they have learning preferences that cross over several learning domains. Utilizing the patients
best learning modality can be incorporated into the health care literacy curriculum.
Malcom Knowles, often referred to as the “father of adult education”, found that adult
learning occurs best when it follows certain principles. If trainers follow these guidelines, they
will greatly enhance the learning experience for participants (Knowles, 1990) (Arnold et al.
(1991)
People retain; 20 percent of what they hear; 30 percent of what they see; 50 percent of what they
see and hear; 70 percent of what they see, hear, and say (e.g. discuss, explain to others); and 90
percent of what they see, hear, say, and do.
HEALTH CARE LITERACY IN THE ADULT 40
To increase the odds of retaining new knowledge associated with health care; a patient needs to
both hear, see, say and do something pertaining to the new information acquired during a session
to improve health literacy. The health care provider must assess the health care literacy level the
patient is at prior to the teaching. This enables the health care provider to provide materials and
information at the patient’s health care literacy level. A quick way to assess needs of patients is
to ask them to write down what they expect to get from the health literacy intervention. This
aids the health care provider in clarifying goals. One can also ask patients to list three values they
live their life by, this can clarify values and increase the chances that health care literacy
behaviors are congruent with these values. If health care interventions are congruent with values
the patient is more likely to continue the behavior with the appropriate re-enforcement.
Values drive behaviors to achieve the affect or reward that the person desires. A person who
has an internal-locus of control, can control their actions to achieve the reward obtained from
internal motivation. For example, when the health care provider clarifies a patient’s goal; as
obtaining a healthy weight, and the value of maintaining a healthy lifestyle, the patient will eat
less calories, to obtain the goal of a healthy weight. They will endure the discomfort of eating
less due to their internal locus of control. If a person has an external locus of control, who holds
the goal of obtaining a healthy weight, and maintains the value of maintaining a healthy lifestyle,
the person may not be internally motivated to eat less calories, and endure the distress of calorie
restriction; but will be motivated by a group exercise activity. The external re-enforcement of a
group activity will contribute to the goal of a healthy weight despite consuming the same amount
of calories.
Most health care learning occurs through verbal exchange. Oral communication between
physicians and patients has been shown to impact patient’s knowledge, motivation,
HEALTH CARE LITERACY IN THE ADULT 41
empowerment, choices, and commitment. (Robert D.L., 2004) Oral communication is essential
for proper diagnosis, treatment and management of disease. The average medical appointment is
only 10-16 minutes long; therefore effective oral communication is essential to a successful
outcome for both patient and provider. Health Care literacy is not only reading and math skills
but listening and speaking skills. (Nouri S. & Rudd R., 2015)
In the advent of fragmented health care delivery systems, patient centered communication is
essential, including face-to face, online, and phone conversations. Oral and aural literacy tools
have been developed. Roter and colleagues developed an Oral Literacy Demand Framework that
included (1) technical term use, general language complexity, and (3) structural characteristics of
dialogue, including pacing, density, and interactivity. Patient satisfaction was negatively affected
by the increased use of technical jargon. Non-verbal queue and demeanor were also included in
the assessment. Interventions such as the teach-back method or interactive communication loop
proved to be the best method of ensuring the patient understood the health care teaching.
Another method of assessing aural ability is the Listenability Style Guide; developed by
Rubin which has four construct domains (1) oral based sentence structure, (2)oral-based
vocabulary, (3)features face-to-face conversations, and (4)considerateness toward listeners.
(Nouri S. & Rima R., 2015) Correlations between speaking and listening skills have a significant
relationship between patient outcomes including disease risk, chronic disease management, and
patient self- advocacy. Tools such as the ones above can be included to assess both oral and aural
ability of both the provider and patient, to improve the most often used method of
communicating health information to patients.
HEALTH CARE LITERACY IN THE ADULT 42
During health care discussions providers should pause occasionally to confirm patient understanding
and allow for questions. According to the AMA (2007) the six ways of improving interpersonal
communication with patients include; (1) Slow down; Communication can be improved by speaking
slowly, and by spending just a small amount of additional time with each patient. This will help foster a
patient-centered approach to the clinician-patient interaction. (2) Use Plain, non-medical language;
Explain things to patients like you would explain them to your grandmother. (3) Show or draw pictures,
visual images can improve the patient’s recall of ideas. (4) Limit the amount of information provided and
repeat it. Information is best remembered when it is given in small pieces that are pertinent to the tasks at
hand. Repetition further enhances recall. (5) Use the teach-back technique. Confirm the patient
understood by asking them to repeat back your instructions. (6) Create a shame-free environment:
Encourage questions. Make patients feel comfortable asking questions.
Consider using the Ask-Me-3 program. Enlist the aid of others (patient’s family or friends to promote
understanding.) The Partnership for Clear Health Communication, which is a large consortium of health
care professionals, who encourage patients to ask three basic questions during every medical encounter.
Patients are promoted by posters and brochures in the office that encourage question asking. The
questions recommended by the program included; (1) What is my main problem? (2) What do I need to
do (about the problem)? (3) Why is it important for me to do this? On going continuing education is
needed for teaching regarding complex diseases such as diabetes. Question asking at each appointment
will help the patient expand knowledge base and allow the provider to uncover any difficulties the patient
may be having managing the disease. Improving health literacy as it refers to chronic diseases is a life-
long process. (Long D.R., et.al. 2010) One of the best ways to prove effective teaching is by
demonstrating a decrease in self-care deficits. ( Volandes A.E. & Passche, Orlow M, 2007.)
Teach back is an evidence-based quality indicator according to the National Quality Forum
(NQF). The teach-back approach restates missed information and teaches to goal and at the
patient literacy level. (Traumura, 2013) Teach-back can be utilized in disease conditional and
HEALTH CARE LITERACY IN THE ADULT 43
medication management. Effective coomunication is clear and at the patient’s literacy level and
utilizing the teach –back method improves patient safety. Communication was at the root of
3,000 sentinal events according to the Joint National Committee between (1995-2000).
(Traumura, 2013) Teach-back is an evidence based approach which asks the patient to repeat in
their own words the directions given by the provider in a non-shaming way. A patient would be
able to explain the diagnosis for which they received care for, the treatment they received, and
potential problems to watch for. The health care provider should speak slowly and in short
statements. The volume of information should be two to three key concepts. If the patient has
difficult repeating the information the health care provider should rephrase it until the patient can
repeat the information accurately, which is teaching to goal. The goal being the ability to restate
the health care providers instructions. This method of teach-back promotes adherence.
Objective V. Summary of Health Care Literacy
The U.S. Department of Health and Human Services (2014) defines health care literacy as the
degree to which individuals have “the capacity to obtain, process, and understand basic health
care information and services needed to make appropriate health care decisions”. Ninety million
Americans have low health care literacy costing the United States economy $236 billion dollars
every year. Due to mitigating factors such as decreased medication adherence, poor symptom
recognition and management, and increased utilization of emergency services. (IOM, 2004)
(CHCS, 2014) With the advent of reimbursement based on quality indicators, the health care
provider must demonstrate due diligence in educating patients regarding their disease processes.
Congress has invested heavily in research such as the National Assessment of Adult Literacy to
clarify the scope of the problem. Health care providers must be able to demonstrate their efforts
to improve health literacy to payers by performing and utilizing evidence based strategies.
HEALTH CARE LITERACY IN THE ADULT 44
(AMA, 2007) Utilizing such methods as the Teach-Back Method, supplying materials at low
literacy levels including reading material, using technology based learning, audiovisual
materials, community outreach, action plans and programs such as “Ask Me Three” have all
demonstrated improved outcomes for patients. For this reason all health care personnel must be
able to efficiently provide evidence-based, health care literacy education to practice in the
outcome-based health care environment.
Health Care Literacy Websites
1. Health Literacy HRSA
http://www.hrsa.gov/healthliteracy/
2. Health Literacy-Clear Communication-National Institutes of Health
http://www.nih.gov/clearcommunication/healthliteracy.html
3. Health Literacy-Centers for Disease Control and Prevention
http://www.cdc.gov/healthliteracy/
4. Health Literacy- National Networks of Libraries of Medicine
http://nnlm.gov/outreach/consumer/hlthlit.html
5. Health Literacy Online- Home_health.gov
http://health.gov/healthliteracyonline/
6. AHRQ Health Literacy
http://www.ahrq.gov/health-care-information/topics/topics-health-literacy.html
7. Health Literacy Improvement-Health.gov
http://health.gov/communication/literacy/
HEALTH CARE LITERACY IN THE ADULT 45
8. Health Literacy Studies-Harvard School of Public Health
http://hsph.harvard.edu/healthliteracy/overview/
9. Popular Topics: Health Literacy- Plain Language
http://www.plainlanguage.gov/populartopics/health_literacy/
10. Health Literacy: A Prescription to End the Confussion
https://iom.nationalacademies.org/Reports/2004/Health-Literacy-A-Prescription-to-End-
Confusion.aspx
11. Health Literacy-American Medical Association
http://www.ama-assn.org/go/amafoundation-healthliteracy
12. National Assessment of Adult Literacy (NAAL)
https://nces.ed.gov/naal/health.asp
13. National Center for the Study of Adult Learning and Literacy Environment of Hospitals
and Health Centers: Partners for Action:
http://www.ncsall.net/index.php?id=1163
14. Center for Plain Language-“ Starting a Plain Language Initiative in Your Organization: A
Step-by-Step Approach”
http://www.centerforplainlanguage.org/
15. AHIP’s 2009 Health Literacy Series
http://www.ahip.org/healthliteracy
16. Agency for Health Care Research and Quality, Health Care Innovations Exchange
http://www.innovations.ahrq.gov
17. Partnership for Clear Health Communication-Ask Me 3
http://www.npsf.org/askme3/index.php
HEALTH CARE LITERACY IN THE ADULT 46
18. Hablamos Juntos: Improving Patient-Provider Communication for Latinos
http://www.hablamosjuntos.org/default.asp
19. Group Health Research Institute Program for Readability in Science and Medicine
(PRISM) Readability Toolkit
http://www.grouphealthresearch.org/capabilities/readability/readabilityhome.html
20. PrairieDoc-Home
www.prairiedoc.com
HEALTH CARE LITERACY IN THE ADULT 47
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