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).


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”.


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


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,


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.


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.


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.


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)


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


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


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


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)


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)


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.


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,


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


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


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


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.


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.


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


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


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)


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.


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)


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


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


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


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)


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


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.


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


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


-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


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.


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-


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


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.


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,


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.


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


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.


(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/


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


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


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