Authors: Anna S. Miller, BA
Rima E. Rudd, Sc.D.
Health literacy studies have garnered attention among health practitioners, researchers, and policymakers. Findings from the first survey of adult literacy skills in industrialized nations conducted in the1990s worried those in the education and economic sectors1,2 and spurred health researchers to examine implications for health. By 2004, a substantial body of literature indicated that people with limited literacy skills face more health problems than do those with stronger skills. They are less likely to engage in preventive care or to successfully manage a chronic disease. They are more likely to face increased hospitalizations and indicate worse health status3,4. Studies also demonstrated a profound mismatch between the lay public's literacy skills and the demands and assumptions of health materials, resulting in a proliferation of information that cannot be easily used.
Initially, health literacy inquiries were focused on the skills of the public and health outcomes. Health literacy was defined as "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health."5 This definition afforded limited opportunity for intervention within the health sector and left the responsibility for improvement with those in education. A deeper understanding of the interactive nature of literacy helped expand options for action with a focus on the quality of health information, the communication skills of health professionals, and the characteristics of health institutions. This concept of health literacy as an interaction supports action to make health information and health services more accessible and healthful action more feasible. We draw from health literacy studies and literature to highlight some recommended actions.
Complaints about navigating the U.S. health care system are ubiquitous. People get lost in paperwork and in the hallways. Accessible information technology can help embed health literacy practices into institutional activities to support providers and patients. The identification and mitigation of barriers, an application of 'universal precautions' related to health information, and systems redesign can improve access to information and care. Assessment tools and suggestions for institutional change that focus on a 'health literate organization' are readily available6,7.
Critical health education takes place when patients talk with their providers or when community members engage with public health workers. Professionals are using teach-back to take responsibility for the communication, to increase peoples' knowledge and self-efficacy, and to lower readmission rates8-10. Professional schools are encouraging students to state 'let's check to see if I was clear and included all the key information'. Similarly, asking 'have I explained this clearly?' rather than 'do you understand?' shifts responsibility to the speaker. Studies indicate that people with low literacy skills are uncomfortable asking questions or advocating for themselves and professionals are encouraged to solicit inquiries by noting, 'Many people have questions about this. What are your questions?' In addition, many medical and nursing schools are now incorporating a 'second language' approach in their training. Students are encouraged to use common language and define technical words-including regular, normal, risk-and to provide examples when feasible.
Health education efforts are supported by written material, such as pamphlets and follow up directions. Findings from thousands of assessment studies indicate that most health materials are too difficult for patients to understand or use. However, while we all rely on educational materials, few among us are responsible for developing them.
To improve the situation, institutions may insert literacy-related provisions in their contracts with vendors responsible for the materials - such as proof of pilot testing with members of the intended audience and reports of assessment scores. Many tools and checklists are freely available online for assessment processes. At the most basic, 'readability assessments' offer an indication of reading level. The SMOG, for example, focuses on word and sentence length to offer a measure of difficulty. Other tools offer a more nuanced assessment by focusing on key issues such as purpose, vocabulary, and organization. The CDC's Clear Communication Index includes attention to organization, accuracy, cues for action, and math demands. The AHRQ's PEMAT focuses on 'understandability' and action-ability'. The PMOSE/IKIRCH assesses displays such as lists, graphs, and charts. Other tools, including HealthLiteracyOnline.gov, provide guidelines for simplifying the user experience and offer checklists for review.
Each of these tools is useful for assessments as well as for the development of new materials. Staff members should become familiar with these tools so that they can make decisions about material worth purchasing and distributing. So too should researchers and practitioners so that newly developed materials incorporate findings and innovative suggestions from the field.
Decision Making & Consent
Attention continues to be paid to the legal jargon and mandated language in consent documents and many institutions offer plain language 'translations'. In addition, patients faced with a consent process or medical decision also grapple with numbers, fractions, percentages, ratios, or sophisticated concepts such as risk. Health professionals can help patients by doing calculations for them whenever possible11 and by using a uniform approach to numbers. Writers and speakers should use the same denominators when they use fractions and not switch between fractions and percentages or between percentages and ratios. Well-designed displays, such as those using pictograms, can offer clarity and help patients compare and contrast options. Institutions must support their professional staff by providing rigorously designed and evaluated materials to be used with patients and families facing options and making decisions.
Health literacy inquiries and implementation studies continue to grow thanks to the contributions of health professionals in a wide variety of fields. When providers and researchers pay attention to the mismatch that can occur between individuals' literacy skills and system demands, they can support healthful action. Health professionals can critically examine their talk and the materials they distribute with attention to vocabulary and numbers. At the same time, health professionals must be supported in their efforts to increase access to information and care. This can only be done through changes in health institutions. All people, regardless of skill level, benefit from having clear directions and explanations. Best practice involves the promotion of 'accessible' information and accessible services.
- OECD. Adult Literacy. 2018; http://www.oecd.org/education/innovation-education/adultliteracy.htm. Accessed October 30, 2018.
- OECD. Skills Matter: Further Results from the Survey of Adult Skills. Paris: OECD Publishing; 2016.
- Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine. 2011;155(2):97-107.
- Nielsen-Bohlman L, Panzer AM, Kindig DA, Committee on Health Literacy, Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.
- Nutbeam D. Health Promotion Glossary. Health Promotion International. 1998;13(4):349-364.
- Institute of Medicine. How can health care organizations become more health literate? Workshop Summary. Washington, D.C.: National Academies Press; 2012.
- Rudd RE, Anderson JE. The Health Literacy Environment of Hospitals and Health Centers. Partners for Action: Making Your Healthcare Facility Literacy- Friendly. National Center for the Study of Adult Learning and Literacy (NCSALL); 2006.
- Almkuist KD. Using Teach-Back Method to Prevent 30-Day Readmissions in Patients with Heart Failure: A Systematic Review. MEDSURG Nursing. 2017;26(5):309- 351.
- Griffey RT, Shin N, Jones S, et al. The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: A randomized, controlled study. Journal of communication in healthcare. 2015;8(1):10-21.
- Nouri SS, Rudd RE. Health literacy in the “oral exchange”: An important element of patient-provider communication. Patient Education and Counseling. 2015;98(5):565-571.
- Apter AJ, Paasche-Orlow MK, Remillard JT, et al. Numeracy and Communication with Patients: They Are Counting on Us. Journal of General Internal Medicine. 2008;23(12):2117-2124.
- Ancker JS, Senathirajah Y, Kukafka R, Starren JB. Design Features of Graphs in Health Risk Communication: A Systematic Review. Journal of the American Medical Informatics Association. 2006;13(6):608-618.