COMMENTARY

Low : and Interventions

Darren A. DeWalt, MD, MPH

ealth literacy entered the mainstream medical literature the problems associated with not well can help us identify in 1995 with an article published in the Journal of the key principles for addressing health literacy. H 1 American Medical Association . Since that time, we have The most up-to-date portrait of reading ability in the witnessed the emergence of a field of research and advocacy United States was the 2003 National Assessment of Adult that attempts to improve health so that all Literacy (NAAL). 2 The NAAL found that 43% of adults read people can understand and act on health information. In this at basic or below basic levels. Based on analysis by economists commentary, I will review the epidemiology of low health and educators, people who read at these levels are not adequately literacy, our understanding of the relationship between literacy skilled to compete in the current economy or to effectively and health outcomes, and emerging interventions to mitigate negotiate much of the system. 3 This current state of the effects of low health literacy. As this field rapidly gains new affairs is astounding and should call close attention to how we insights, we are beginning to learn how to address the problem. provide health care. If close to half of the population we serve is unable to accurately participate in Epidemiology of Low health care, we need to fundamentally Health Literacy “If close to half restructure how we operate. As we pursue patient-centered care, we must Health literacy, as defined by of the population consider the information processing Healthy People 2010 and described skills of those we serve and adjust our in the issue brief in this issue of the we serve is unable actions to match the skill level. North Carolina Medical Journal , is a construct which has been elusive to Health Literacy and Health measure as a single variable. Most of to accurately Outcomes the research to date has focused on the ability to read basic health participate in The importance of health literacy is information. However, all of us can underscored by its relationship to health identify a friend or colleague who health care, we need outcomes. The research to date has has excellent reading skills, but who focused on the relationship between has low health literacy. This person to fundamentally reading ability and health outcomes, has trouble understanding and acting largely because reading ability is easier on health information. As such, restructure how we to measure than the broader concept describing the epidemiology of health of health literacy. Regardless, if poor literacy requires an explanation of operate.” reading ability translates to poor what has been traditionally measured health outcomes—after controlling in these studies. To date, researchers have measured reading ability for variables like insurance, income, race, ethnicity, and disease as a proxy for health literacy. Measuring reading ability emphasizes severity—then we are more confident that inability to understand the role of understanding written health information and would health information is an important factor for health outcomes. likely classify our colleague with excellent reading skills as having In 2004, the Agency for Healthcare Research and Quality “high health literacy.” So, although measuring reading ability (AHRQ) released a report on the relationship between literacy does not give us the full picture of health literacy, understanding and health outcomes. 4,5 This report found that, across several

Darren A. DeWalt, MD, MPH , is an assistant professor of medicine in the Division of General Internal Medicine at the University of North Carolina School of Medicine. He can be reached at dewaltd (at) med.unc.edu or Campus Box 7110, Chapel Hill, NC 27599-7110.

NC Med J September/October 2007, Volume 68, Number 5 327 areas of health and health care, low literacy was associated with that further study in this area could be promising. a worse prognosis than higher literacy even after controlling for What about the children? Unfortunately, approximately confounding variables. one-third of our nation’s children do not graduate from high Since the publication of the systematic review, several new school, a statistic that has not changed in 30 years. 19 As such, I articles have added to the evidence by evaluating new populations anticipate that the problem of low health literacy will remain and new outcomes. Two studies have documented that people with us in the foreseeable future. Expanding curricula in health with lower literacy die at a faster rate than people with higher literacy for primary and secondary education may help to literacy. 6,7 Patients with low literacy are more likely to familiarize students with the health care environment, but misunderstand prescription medication instructions and improving graduation rates may be more important for the warning labels. 8-10 Young children with asthma who have overall health of the population. parents with low literacy have more days of school missed and more hospitalizations. 11 The body of literature associating low 2. Improve Written and Multimedia Communication literacy with worse health outcomes becomes more robust each Most of the research and advocacy related to health literacy year. Some studies are beginning to explore potential mediating has focused on written and multimedia communication. variables such as self-efficacy, 12,13 medication knowledge, 10,14,15 Numerous studies have shown that the of health and patient- communication. 16 As we begin to information almost always exceeds the reading ability of its understand the mediators between literacy and health outcomes, intended audience. If we (health care professionals) were a our intervention design will become more informed and effective. agency, we would be fired. Creating better written messages and using other forms of media (audio or Interventions to Mitigate the Effects of Low video) have been tested in clinical research and can improve Health Literacy knowledge. 5 Written messages targeting specific illnesses can increase the rate of physician-patient dialogue on a topic and Interventions to mitigate low health literacy usually fall into increase the receipt of clinical preventive services. 20,21 Creating one of 4 categories: health messages that are understandable by most of the intended audience is an imperative for any systematic approach toward (1) Improve health literacy skills in the population addressing low health literacy. Experts have developed guides (2) Improve written and multimedia communication for creating health messages, 22 and more and more examples are (3) Improve patient-provider communication in health care published in the medical literature. 23-25 visits Beyond improving specific patient education materials, we (4) Alter systems of care need to consider broad-based campaigns to activate people to ask questions and seek clarity. Such campaigns have been created No doubt, such a framework is an oversimplification, but it including the Justus-Warren Heart Disease and Stroke Task lays out what we need to think about when addressing health Force message “Start with Your Heart” 26 and the AHRQ funded literacy at the state level. I will briefly review each category and message “Questions Are the Answer: Get More Involved With the current state of knowledge for each. Your Health Care.” 27 Although we do not know how much effect these messages have had, they normalize the behavior of 1. Improve Health Literacy Skills in the Population seeking clarity in the health care setting. Such social marketing Although the most attractive solution, this may be the most approaches may lead to more efficacious health care encounters. elusive. Improving the reading ability of an adult takes hours of personalized instruction and self-motivation. With one year of 3. Improve Oral Communication in Health Care Visits intense adult basic education, a person’s reading level increases researchers have known for years about one or two grade levels. Such improvements, if targeting that patients remember about 50% of what they are told in a germane topics, may improve function in the health care visit with a physician. 28 Even that which is remembered is often environment, but educating 90 million adults with such remembered incorrectly. 29 This is especially of concern when specificity and intensity is not feasible. No studies have been most health communication takes place orally in the health care published that demonstrate improved health literacy over time. setting. Therefore, strategies that improve oral communication As such, we do not know if specific health-related information may lead to better health outcomes, particularly for those with processing can be improved faster than general reading ability. low health literacy. We have a small amount of evidence that literacy training People who have strong reading and information processing programs can improve depression outcomes, regardless of the skills can get by in the current environment because they can improvement in literacy. Two studies have enrolled people in seek more information after they leave the health care setting adult literacy courses, and both showed an improvement in by looking on the Internet or in books. Unfortunately, a large depression symptoms when compared to a control group. 17,18 part of society cannot access information so easily and must The mechanism of the effect may be related to self-confidence rely on good information transfer in the clinic or hospital. and life skills improvement for people who have been struggling Although an important area of research, we do not have much to get by. Regardless of the mechanism, the outcome suggests empirical evidence on what strategies work best.

328 NC Med J September/October 2007, Volume 68, Number 5 The most promising strategy to facilitate understanding in One system in North Carolina created a diabetes disease the office setting is the teach-back method. Using this method, management program within the practice that included clinical the clinician explains a concept or behavior to a person, then pharmacist practitioners, diabetes educators, and care assistants asks the person to explain it back in his or her own words. This to help educate and respond to the needs of the patients with can give the clinician the opportunity to clarify any areas the diabetes. 34 This program focused mostly on the patient’s person did not adequately understand. This method is the only desired behavior goals and used the teach-back method when way a clinician can be certain that the patient or family under - communicating. However, the program also helped patients stands the content. An added bonus to this method is that the navigate the by teaching them how to get rides to patient recall will be better because of having to communicate the clinic and how to register for pharmacy benefits when the it to the clinician. forms were too complicated. Although patients of all literacy One published study has evaluated the use of the teach-back levels benefited from the program, those with low literacy method by audiotaping visits between patients with diabetes received much greater benefit from the program. 35 In essence, and their . 30 The study found that the teach-back this program reduced disparities in outcomes for patients with method was used with only 20% of the patients. However, low literacy. those patients had 9 times the odds of having their blood sugar The same practice developed a heart failure self-management below the average (a lower blood sugar is good in this context). training program targeted toward patients with low literacy Although an observational study, it suggests this approach may skills. 25 This program offered training for the patient with several have benefit. It was also noted that those visits which included follow-up phone calls to reinforce the education. Although this the teach-back method were not longer. In addition to this program did not offer specialized medical care or ancillary help study, the teach-back method and its variants are tried and true like the diabetes program, it did reduce hospitalizations among pedagogic methods advocated by educators as far back as all patients. 36 Patients with low literacy benefited as much or Socrates. 31 more than those with higher literacy, but the study was not large Another strategy for improving oral communication is to enough to explore whether the disparities in fact narrowed. limit the number of topics communicated at one time. In the A large public hospital in California tested 2 forms of diabetes context of a health care encounter, the clinician often mentions support versus usual care. 37 One of the intervention arms used several different ideas, prescribes medications, and suggests automated telephone disease management (ATDM) to call specific self-care behaviors. Frequently, there is no summation of patients and gather information on how the patient was doing. the main points, and the clinician is not aware of the elaborate If any concerns were elicited, the patient received a call from a content he or she has just imparted. People have a variety of nurse educator. The other intervention arm used group visits to capacities for remembering things, so the clinician must tailor provide self-management support. The study found that patients the amount of information to a given patient. I advocate that in the ATDM had improved functional status, self-management, clinicians try to limit the number of points they expect the and compared to patients in the group visits arm patient to remember to 3. Anything beyond that requires and in the control arm. supplementary methods to help the patient remember and System changes to provide more comprehensive care appear reinforce the information. promising for patients with low literacy. A system that does not require advanced literacy skills will likely improve care for 4. Alter Systems of Care patients regardless of literacy level. Hence, health literacy meets Lastly, we must consider the role of our care systems in quality improvement. As we proceed with redesigning our care making health care less effective for patients with low health systems, we should consider the role of the patient and how we literacy. Most current care systems rely on complex organizations can reduce the navigation burden, eliminate clinical inertia, that make lots of errors including problems in scheduling, and provide tailored and effective self-management support to prescriptions, administering medications, and receipt of reach optimal health outcomes. self-management support. In these systems, patients with higher health literacy can often get by, but not easily. A patient Conclusions with low health literacy is left extremely vulnerable and likely receives substandard care. At the time of the 2004 AHRQ Understanding and addressing low health literacy will systematic review, no studies directly demonstrated whether require further basic research but also implementation science system changes could mitigate the effects of low health literacy. and quality improvement. Basic research in the field is expanding Making health care systems responsive to the needs of people rapidly and we will continue to identify best practices. with low health literacy is not easy. In many quality improvement Implementation has lagged behind because, until recently, we programs, the provision of self-management support is the did not have evidence-based methods to improve outcomes. hardest improvement to implement with fidelity and efficacy. 32 The emergence in the past 3 years of evidence-based approaches Fortunately, models are beginning to emerge, 33 and some practices should lead to the next phase of implementation science to help have shown improved health outcomes for patients with low us provide health literacy sensitive care to patients in our clinics, health literacy. hospitals, and venues. NCMJ

NC Med J September/October 2007, Volume 68, Number 5 329 REFERENCES

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