Science Communication: Health Literacy

6 Minute Read

Authors: Ye Zhu, MD, PhD and Julpohng Vilai, MD

Purpose

To increase awareness of and identify high risk for limited health literacy; and to develop clinical skills for communicating with patients and families with different levels of health literacy.

Learning Objectives

1.       Describe the concept and significance of health literacy;

2.       Identify patient and family needs according to their health literacy level; and

3.       Integrate effective communication strategies for patients and families with different levels of health literacy.

During my clinical training, I frequently encounter situations where patient outcomes are hindered by suboptimal treatment adherence. There are many reasons why patients fail to take medications or receive treatment as directed. One of these reasons is health literacy. In practice, the gap between our medical advice and how patients receive it has been surprisingly large. Most of the time, patients and their families seem willing to follow medical guidance; however, due to miscommunication or limitations in comprehension, the treatment regimen is carried out incorrectly.

As a pediatrician, this problem may be further complicated by the health literacy of the primary caregiver—their ability to comprehend their child’s medical condition and provide medical care can affect the child’s treatment outcome. For example, I have frequently seen pediatric patients with asthma, who were supposed to be given a daily steroid controller, but who were incorrectly given daily albuterol. Overuse of albuterol can lead to medication dependence and increased asthma symptoms and exacerbation. Similarly, it is common to see patients with type 1 diabetes that don’t understand their insulin regimen and subsequently, are admitted for diabetic ketoacidosis. These cases incentivized me to start my journey of exploring health literacy to better understand how to help patients and their families manage their care. Also, I hope this article will help initiate conversations on health literacy, improve awareness, and call more attention to its clinical importance.

What is health literacy?

Health literacy is an ability to use general literacy skills, including reading, writing, numeracy, listening and speaking, in obtaining, understanding, appraising, and synthesizing the knowledge of health, healthcare and health system; communicating and applying health-related information in various formats; and the ability to maintain health through self-management and working in partnerships with health providers.(1) In other words, it is how individuals recognize, understand, achieve, utilize, and evaluate their health care resources with the help of health providers.(2) Health literacy is critical to ensure a healthy society and promote health equity. For example, high health literacy is associated with healthy behaviors and has been shown to be protective against contracting infectious diseases.(3) Additionally, higher health literacy is also associated with better weight control and obesity prevention.(4) These are just a few of the multitude of benefits of high health literacy.

Health literacy barriers

Despite the importance, health literacy is limited in the adult population throughout the world. A European study of eight countries reported that almost half of individuals had insufficient or problematic health literacy that limited their ability to carry out their health care treatment.(5) In Canada, 2 out of 3 adults and 9 out of 10 elderly people lacked adequate capacity to identify, obtain, understand, and achieve the health information and health resources they needed for their medical care and were not able to make appropriate decisions.(6) In the United States, health literacy follows a similar trend and substantial disparities exist among certain racial and ethnic groups; for example, evidence suggests that 41% of Hispanics and 24% of non-Hispanic African Americans have below basic health literacy compared to 9% of non-Hispanic whites.(7)

With pediatrics, Yin et al reported that more than half (68.4%) of parents enter the name and birth dates of their children incorrectly on a health insurance form, and 65.9% of them had difficulties calculating the cost of insurance per year using a table listing the insurance policy based on income and household size. Additionally, about half of the parents did not understand a body mass index (BMI) table, and 36.3% of parents had difficulty determining when to administer medications according to drug labels.(8) 

Assessment of health literacy

Unfortunately, clinicians do not have a standard assessment of patients’ understanding of their disease and whether their care plans are followed appropriately. Although formal assessment methods exist, their use in busy clinical environments may be inefficient and impractical.  These formal methods to measure health literacy include the Newest Vital Sign, Rapid Estimate of Adult Learning in Medicine, and Test of Functional Health Literacy in Adults; however, these methods involve multiple-item questionnaires. The Single Item Literacy Screener, by contrast, is a one-item screening questionnaire: “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Scores are: 1-never, 2-rarely, 3-sometimes, 4-often, and 5-always. Scores 2 and above indicate the possibility of difficulty in reading health related information.(9) Due to the simplicity and brevity, the Single Item Literacy Screener is a great instrument to implement in the clinical setting to assess the health literacy of your patients.

Improving health literacy

To help identify and improve limited health literacy, the U.S. Department of Health and Human Services issued The National Action Plan to Improve Health Literacy in 7 goal areas:(10)

1. Health information developed and disseminated is accurate, accessible, and actionable

2. Clinical practice promotes communication, informed decision making and care access

3. Incorporate health and medical sciences education from early childhood through the university level education

4. Utilize community-based services for adult education, and linguistically and culturally appropriate health information and instructions

5. Engage partnership and collaboration, such as government agencies and non-profit organizations, to develop guidance and change policies

6. Develop research and evaluation methods

7. Dissemination of evidence-based practice, by professional associations, journal articles, etc.

In practice, improving provider-patient communication during visits is critical to health literacy. A study found that the majority of patients or their primary caregivers learned health information and care plans through a face-to-face discussion with providers.(11) With children, the chosen communication method directly impacts the health literacy of the primary caregiver regarding management and outcomes of children’s health issues.(12) To that end, written material is effective in improving health literacy and enhances adherence to medical treatment and healthy behaviors.(13)  Furthermore, tailoring medical information to the abilities of patients or primary caregivers (e.g., linguistically and culturally) improves their health literacy and ultimately, improves children’s health outcomes.(14) The general consensus is that written material should be prepared in a way that a patient and/or primary caregiver with low health literacy could understand.(15) Last but not least, health literacy usually requires health care providers’ support and guidance as it is very difficult for patients or primary caregivers to acquire accurate medical knowledge from public channels.

What can clinician educators do?

Clinician educators play an important role in teaching and modeling clear communication. Here are 6 helpful tips that can be demonstrated, imparted, and practiced with learners to improve health literacy:

• Assess a patient’s baseline understanding before providing extensive information. (“Could you tell me what you already know about asthma?”)

• Avoid medical jargon and vague terms. Explain things clearly using plain language. (Say “trouble breathing” instead of “respiratory distress”.)

• Emphasize only 1 to 3 key points. Repeat these throughout the visit.

• Encourage patients to ask questions and use an open-ended approach. (Ask “What questions do you have?” instead of “Do you have any questions?”).

• Use teach-back methodology to confirm patient understanding. Ask the patient or primary caregiver to demonstrate a procedure, skill, or behavior (e.g., how to use a metered dose inhaler). This helps you determine whether you explained a concept clearly enough.

• Give written instructions and provide useful educational materials. This lets the patient or primary caregiver know exactly what should be done after the visit, gives more time to absorb the information, and can be shared with caregivers and family members.

Consider using direct observation as a strategy to ensure a learner can effectively give information and explore available resources such as the health literacy universal precautions toolkit (https://www.ahrq.gov/health-literacy/improve/precautions/index.html) developed by the Agency for Healthcare Research and Quality (AHRQ) to help providers communicate with, empower, and support patients.

Conclusions

Health literacy is a patient’s ability to obtain and use basic health information and resources. It may facilitate or hinder a person’s ability to manage their health care and treatment plan, and the effects on health outcomes can be significant and varies from person to person. We encourage clinician educators to help learners gain more awareness and skills in identifying patient/parent’s health literacy level, helping them understand their treatment plan, engaging them in clinical decision making, and empowering them toward better managing their care.

References

1. Liu C, Wang D, Liu C, et al. What is the meaning of health literacy? A systematic review and qualitative synthesis. Family medicine and community health. 2020;8(2)

2. Vamos S, Okan O, Sentell T, Rootman I. Making a case for “Education for health literacy”: An international perspective. International journal of environmental research and public health. 2020;17(4):1436.

3. Castro-Sánchez E, Chang PW, Vila-Candel R, Escobedo AA, Holmes AH. Health literacy and infectious diseases: why does it matter? International Journal of Infectious Diseases. 2016;43:103-110.

4. Fong B, Shum PY. Promotion of weight control in Hong Kong. 2016.

5. Sørensen K, Pelikan JM, Röthlin F, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). The European journal of public health. 2015;25(6):1053-1058.

6. Murray T, Hagey J, Willms D, Shillington R, Desjardins R. Health literacy in Canada: a healthy understanding. 2008.

7. Lopez C,  Kim B, Sacks K. Health Literacy in the United States: Enhancing Assessments and Reducing Disparities (2022). Available at SSRN: http://dx.doi.org/10.2139/ssrn.4182046.

8. Yin HS, Johnson M, Mendelsohn AL, Abrams MA, Sanders LM, Dreyer BP. The health literacy of parents in the United States: a nationally representative study. Pediatrics. 2009;124(Supplement_3):S289-S298.

9. Morris NS, MacLean CD, Chew LD, Littenberg B. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC family practice. 2006;7:1-7.

10. Baur C. The national action plan to improve health literacy. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 2010;

11. Skeens K, Logsdon MC, Stikes R, et al. Health literacy and preferences for sources of child health information of mothers with infants in the neonatal intensive care unit. Advances in Neonatal Care. 2016;16(4):308-314.

12. Aharon AA, Nehama H, Rishpon S, Baron-Epel O. Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children. Patient education and counseling. 2017;100(4):768-775.

13. DeWalt DA, Hink A. Health literacy and child health outcomes: a systematic review of the literature. Pediatrics. 2009;124(Supplement_3):S265-S274.

14. Scharpen AL, Stille CJ. From strangers in a foreign land to active, engaged citizens. Pediatrics. 2018;141(2).

15. Parker R. Measuring health literacy: What? So what? Now what. National Academies Press Washington, DC; 2009:91-98.