Addressing low health literacy for better outcomes

CHICAGO—Teaching self-management skills is an important part of patient care across the continuum, according to David Baker, MD’s presentation, “Literacy, Numeracy, and Improving Care in the Chronically Ill," at the 2014 Healthcare Leadership Forum. Baker, chief of the Division of Medicine General Internal Medicine and Geriatrics at Northwestern University's Feinberg School of Medicine, pointed out that for communications to make a difference in patient outcomes, they need to be at a level patients understand.

“Effectively communicating in healthcare,” he explained, “means that people come away with an understanding of what’s wrong with them. As physicians, it’s our job as they leave our care, to enable them to make decisions for themselves, and to explain self-management tasks so that we can reduce the risk of possible future events.”

According to Baker, one of the most difficult things to accomplish is motivating behavior change in patients. There are several challenges to successful communication in healthcare, the most basic of which is that the average person really knows very little about their body in terms of vocabulary and a framework for communications.

Baker referenced a national literacy study that showed just how many Americans have limited reading ability. The 2003 National Assessment of Adult Literacy (NAAL) revealed that 93 million American adults, representing 43 percent of the adult population in the U.S., have basic or below basic literacy as compared to intermediate or proficient levels. Approximately 30 percent are functionally illiterate.

The concept of health literacy differs from literacy itself. According to NAAL, health literacy requires basic reading skills, but also the ability to understand oral communication, use numbers and math skills, understand how to navigate the health system on a basic level, as well as the ability to communicate with healthcare providers and their staff. 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 decisions. These skills are imperative for patients to be able to do the following:

• Communicate health problems to their providers and understand health information
• Read prescription bottles and understand treatment regimens
• Read and understand warning labels to recognize potentially life-threatening complications from medications
• Implement self-care strategies and manage their health at home
• Read and understand health insurance forms, informed consent, and public assistance applications

Baker developed a test of functional health literacy in adults, where patients are given basic tasks and measured on their ability to complete them. As part of the test, patients are given appointment cards, prescription medication bottles, directions and other various instructions and asked to act upon the information. His data prove that lower literacy patients have much more trouble understanding and completing even basic tasks such as knowing when they’re scheduled for their next appointment. He points out several examples to illustrate communication breakdowns with patients. One such example was a prescription medication bottle with printed instructions that read: Take medication on an empty stomach—either one hour before or two hours after a meal. The patients were asked what time they should take the medication if they were planning to eat lunch at noon. Thirty-nine percent of patients were unable to answer the question at all, and more than 60 percent of patients failed to answer correctly. What may seem like a simple label may be very complicated to patients with low literacy and numeracy.

In another example, he cited a diabetic study that was completed to determine whether patients understood their blood sugar levels. They received a paper that read: Normal blood sugar range is between 60 and 150. Your blood sugar today is 160. Is your blood sugar normal today? Baker reports that 37 percent of people answered incorrectly. Most incorrect answers were “I don’t know."

Baker points out that numeracy, which refers to quantitative skills, though critically important in terms of health literacy, was not the culprit in this situation. When probed further, patients asked, “Why is there sugar in my blood?” Upon reporting this Baker emphasizes that patient communications need to be written at a level that patients will understand.

In another case example, Baker measured the number of people who left the Emergency room with a concrete understanding of their diagnosis, which forms the foundation upon which their subsequent health decisions are based in the time immediately following the visit. According to Baker, 80 percent of English speakers understood their diagnosis. Only about 40 percent of non-English speakers knew their diagnosis.

“We need to be able to communicate better,” said Baker. “Even 80 percent is a poor result for the general population.”

Baker’s research shows that patients with low literacy had a 50 percent higher hospitalization rate, but they’re also more likely to die, a connection that was made by following the patients over eight years and obtaining death records.

“The average person in the U.S. really struggles to understand,” said Baker. “Low literacy levels are further compounded by low numeracy levels. People have a very poor understanding of risk. Part of this is numeracy; many people can’t understand percentages, and consequently, are unable to understand probabilities and interpret risk.

When patient communication is poorly developed, resulting in a lack of understanding, patients have little chance of correctly modifying behaviors to lessen their risk. Baker cites some typical types of patient information, both online and in print, demonstrating that the average patient would have a lot of difficulty understanding it at all.

“The concept of scaffolding, where patients need to understand A before they can learn B, is helpful in communications, but healthcare communications tend to focus on D, E and F,” said Baker, “with the assumption that A, B and C have already been understood.” Patient visuals, Baker suggested, also are created by doctors and nurses, and more geared for health professionals rather than patients.

Helpful healthcare communications, said Baker, incorporate stepwise learning, assessment of mastery and repetition, however, most communication about health and medical issues is still confined to the short, hurried time during the medical encounter.

Baker recommended we make radical improvements in our health communication and educational tools, including the following:

• Make sure health educators know how to develop plain language materials.
• Focus on essential information that patients need for self-management and decision making.
• Give patients education information prior to a visit.
• Use teach back and teach-to-goal approaches to check comprehension and correct errors.
• Use repetition with face-to-face communication or using media to reinforce understanding.