Create communication despite health literacy

Health outcomes for low literacy patients improve

Health literacy, according to the Institute of Medicine, is "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" and research has shown that patients are not all created equal.

According to the National Assessment of Adult Literacy issued by the U.S. Department of Education, people with below basic health literacy skills do not recognize a medical appointment on a form or when to have a specific medical test from clearly written, basic information.

So how does a health care institution make sure all patients, no matter their level of health literacy, have the ability to make appropriate decisions? By teaching staff how to educate these patients and providing the tools they need to do a good job.

The starting point is to make sure staff are aware of the problem and the importance of addressing it.

"Staff need to be given an 'awareness' session on health literacy during orientation, or as a mandatory continuing education module," says Sandra Cornett, RN, PhD, director of the AHEC Clear Health Communication Program at The Ohio State University College of Medicine in Columbus.

They need to learn how to assess literacy skills and the strategies to use when communicating with these patients, adds Cornett.

People need to know what health literacy is, that the problem exists, and how it impacts their patient population, says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting in Natick, MA.

Staff need more than facts, the topic must become personally relevant to them, she adds. They need to know that people in health care are not only part of the problem but can also be part of the solution.

"Not only do people need the facts but they need to have that internal sense of why it is important and how they can make a difference," says Osborne.

She gets the point across at workshops by having conversations with the professional staff, sharing stories, and encouraging them to talk amongst themselves and reflect on the issues.

The key is effective communication no matter the level of health literacy. One of the best teaching strategies for people at basic or below basic health literacy is found in "Ask Me 3" (, a program of the Partnership for Clear Health Communication, says Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator at Children's Healthcare of Atlanta.

The first question is, "What is my main problem?" The health care professional should first tell the patient what is wrong with him or her. The second question is, "What do I need to do?" Then the patient would be given specific information such as how to take medication or follow a diet plan. The third question is, "Why is it important for me to do this?" The patient would learn how taking the medication or following the diet plan would benefit him or her.

Ordelt says this method of teaching fits the five basic goals of patient education, which are:

  • Make sure patients understand the needed treatment so they can give informed consent.
  • Teach patients what they need to know to provide self-care at home.
  • Provide the information needed to recognize problems, such as signs of infection.
  • Make sure patients know who to contact when problems occur.
  • Give patients time to speak and have their questions answered.

Focus on teaching strategies

Providing education that answers the Ask Me 3 questions is a good basic teaching strategy. But for patients who have a difficult time understanding verbal instruction or reading information, teachers should keep instruction short and simple, advises Ordelt; discuss the health problem in conversational language and chunk information into small sound bites, she says.

There are a multitude of teaching strategies that will improve the education of low literacy patients. One is the use of plain language in conversation and in print — which is using words people know or explaining clearly terms they need to learn, says Osborne. Ideas can be conveyed by drawing simple pictures or using models that people can see, touch, and manipulate.

Osborne says one of her favorite teaching methods is the use of metaphors or comparing new, unfamiliar medical information to something familiar in a person's life.

"The fall-back plan of education has been talking at people and giving them something to read; yet learning about health and really comprehending what needs to be done is so much more than that," says Osborne.

The assessment is important, which includes asking people how they learn and offering examples of learning styles such as reading, watching television or conversation.

Another important technique for good teaching is to confirm understanding by stopping after key points and asking the patient to explain what was said. Using the teach-back approach, practitioners need to listen for what is not said and correct any misunderstandings, says Osborne.

Cornett says an important element of good teaching is to individualize the information by using examples to which the patient can relate. Also, information given should be relevant to a patient's lifestyle and current situation such as his or her age, gender, occupation, marital status, and culture.

There are even techniques to improve understanding when answering a patient's question. In a paper Cornett wrote, titled Effective use of Teaching Methods, she provides a list of such strategies. For example, practitioners should rephrase the question to make sure they are addressing what the patient wants to know and limit the information to what was asked without adding additional detail.

Addressing the issue of low health literacy with good education techniques is vital as studies have linked low literacy skills to poor health outcomes and a greater use of health care resources, says Cornett. For example, patients with low health literacy skills are more likely to misinterpret prescriptions or to be non-adherent with HIV/AIDS therapy. They have more emergency department visits and are at greater risk of being admitted to the hospital.

The good news is that teaching staff good strategies for education will benefit all patients. Good teaching strategies apply to all patient education, regardless of whether a patient has limited literacy skills, says Cornett.