Giving patients the tools is first step, ensuring they understand is the next

Focus on teaching materials and techniques that improve comprehension

Warning: Health literacy can have a greater impact on your hospital’s bottom line by affecting more than the patient education department. Patient educators say that patients who do not understand or can’t read instructions for prescriptions, informed consent forms, educational materials, and appointment slips have more hospital visits and longer hospital stays than those with higher health literacy skills.

"If patient education managers don’t pay attention to health literacy, they won’t have good health outcomes. The ultimate goal of doing patient education is to have healthier people," says Audrey Riffenburgh, MA, president of Riffenburgh & Associates, an Albuquerque, NM-based business specializing in health literacy and plain-language communication.

Health literacy is a difficult issue because people who read poorly have different levels of reading skills. If two low literacy patients are handed the same pamphlet, their level of understanding would differ because they both understand words differently from the material. "One of the frustrating things about people who do not read well is that they do not all read poorly in the same way," explains Deborah Yoho, CEO of the Greater Columbia (SC) Literacy Council. Even good readers have difficulty understanding materials at such times when they are in pain, under stress, or unfamiliar with a medical condition.

While it is important to note a patient’s ability to read and understand complex information, many other factors influence comprehension. The patient’s motivation, interest, and investment in the situation impact health literacy, as well as their culture, primary language, age, and disabilities, says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting in Natick, MA.

Don’t rely solely on written material

To address the issue of health literacy, Patient Education Management interviewed several experts in the field. Following is a list of components that should be included in a patient education program to ensure all patients understand, regardless of their health literacy level.

A variety of teaching materials.

People do not all learn in the same way. Some learn best by reading the information, while others are visual or audio learners. Therefore, a variety of teaching materials should be kept on hand, including visual charts, posters, models, videos, and audiocassette tapes. "For basic diabetes education, a health educator might sit down and tape the instructions on how to take medication so patients have a cassette tape they can listen to in the car or with other family members," says Riffenburgh.

To determine how patients learn best, ask them, she says. If they don’t know, suggest they think of a time when they learned something new. Ask them if they watched someone else do it, if they listened to a lecture, read about it, or just tried it on their own, she suggests.

A good assessment of the patient group.

Know who uses your clinics and hospital, advises Linda McIntosh, EdM, RN, CS, coordinator of patient education at Cambridge (MA) Health Alliance. Her health care facility serves a large number of people who speak Haitian Creole, which only recently evolved into a written language. Therefore, those who are educated read French, while the others may not read at all or have limited literacy. Because people don’t read, the families who have immigrated to the United States exchange information with their friends and relatives in Haiti using audiotapes. Therefore, the health care facility picked audiotapes as a teaching tool, as well as print materials with pictures and one-word descriptions.

To determine how best to teach Haitian patients with diabetes, McIntosh formed a focus group and found that the Haitians liked to sit around and talk gathering information from each other. As a result, support groups for Haitians with diabetes were organized.

Computers can help by making collecting demographic information easy. To determine such factors as age, ethnic background, and whether English is the patient’s first language, ask them those questions when they come to the clinic and track the information on a computer, says Yoho.

Good teaching techniques

• A program to educate health care providers.

Health care workers who understand the issues of health literacy and how to overcome barriers to learning will do a better job of teaching patients. Therefore, those who educate patients must be taught how to effectively teach people who might have difficulty understanding the information. They also must learn to create a safe, nonjudgmental environment for learning, says Riffenburgh. (For teaching tips, see article on p. 112. To learn how to educate staff about health literacy issues, see Guest Column on p. 115.)

• Policies for proper evaluation of learning.

Good patient education techniques include the assessment of the patient before teaching to uncover learning barriers, as well as an assessment of their understanding following the teaching. To determine if a patient comprehends the teaching, Riffenburgh suggests the following techniques:

— Ask patients to tell you how they will explain what they’ve learned to their family. Help them rehearse in their own words.

— Have them demonstrate what they learned; for example, changing a dressing or measuring a dose of medication for their child.

— Encourage patients to identify one action they will take in the next week. Have them describe the action in detail so you know whether they have understood the instructions.

In a busy clinic, it is almost impossible to determine if a patient can read. Therefore, time would be better spent determining comprehension by asking the patient questions about their treatment or having them demonstrate a skill, says Kristina Anderson, literacy coordinator at Harborview Medical Center in Seattle. "We need to determine patient understanding rather than do a literacy assessment, and we need to make sure there is a variety of tools available to teach," she says.

• Easy-to-read written materials.

Whenever possible, have easy-to-read materials on a topic that provide the basic information and additional print materials written at a higher level with more information. In this way, patients can be given a choice, says Riffenburgh. Also, if you suspect the patient has difficulty reading, review the material with him or her. "Provide people with review markers when working with print materials. Circle, underline, highlight, or put arrows to the points you want the patient to remember and go back to review," she explains.

Print materials always should be used to reinforce teaching, and not used in place of verbal instruction. "Sometimes, when health educators are busy, they just hand patients material; the interactive piece is what makes it valuable. It isn’t so much whether patients know the information off the top of their head, but if they can find the information. Show them how to use the material," advises McIntosh.

(Editor’s note: Need help with health literacy issues? Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting offers TeleClasses, which are interactive training sessions conducted over the phone. For a list of classes, visit her Web site at www.healthliteracy. com. Audrey Riffenburgh, MA, President, Riffenburgh & Associates, offers workshops on evaluating written materials with computer software readability formulas. She can conduct them via conference calls with up to five people. Information on health literacy can also be obtained by visiting the Health Literacy Toolbox 2000 at

For more information about health literacy, contact:

Kristina Anderson, Literacy Coordinator, Harborview Medical Center, 325 9th Ave., Box 359710, Seattle, WA 98104. Telephone: (206) 731-6621. E-mail:

Linda McIntosh, EdM, RN, CS, Coordinator of Patient Education, Cambridge Health Alliance, 1493 Cambridge St., Cambridge, MA 02139. Telephone: (617) 591-4526. E-mail:

Helen Osborne, MEd, OTR/L, President, Health Literacy Consulting. Telephone: (508) 653-1199. Fax: (508) 650-9492. E-mail: Web site:

Audrey Riffenburgh, MA, President, Riffenburgh & Associates, 1606 Central Ave. S.E., Suite 201, Albuquer-que, NM 87106. Telephone: (505) 242-5808. Fax: (505) 246-9164. E-mail:

Deborah Yoho, EDS, CEO, Greater Columbia Literacy Council, 921 Woodrow St., Columbia, SC 29205. Telephone: (803) 765-2555. E-mail: