2/19/2018 Assessing and Addressing

Assessing and Addressing Health Literacy

Sandy Cornett, PhD, RN Abstract

The ability to communicate effectively with patients who have low health literacy depends on our ability to recognize this problem and to create a patient-centered and shame-free healthcare environment. Because of the shame and embarrassment these patients experience, they often use their well-developed coping skills to mask their limited literacy. Although a number of - and comprehension-assessment tools are available, there is debate whether or not these tools should be used clinically. This article provides guidance in regard to establishing an environment that promotes health literacy, assessing health literacy levels, utilizing strategies to increase health literacy, evaluating the learning that has occurred, and incorporating health literacy concepts into the curriculum.

Citation: Cornett, S., (Sept. 30, 2009) "Assessing and Addressing Health Literacy" OJIN: The Online Journal of Issues in NursingVol. 14, No. 3, Manuscript 2.

DOI: 10.3912/OJIN.Vol14No03Man02

Keywords: assessing health literacy, evaluating learning, health literacy enhancement, healthcare system navigation, guidelines for plain language materials, low health literacy cues, measuring low health literacy, Newest Vital Sign (NVS), oral , plain language, printed communication, photonovela, Rapid Estimate of Adult Literacy in Medicine (REALM), teach back, Test of Functional Health Literacy in Adults (TOFHLA), visuals in low health literacy materials

Although healthcare professionals generally assume that the health explanations and instructions given to patients and families are readily understood, in reality these instructions are frequently misunderstood, sometimes resulting in serious errors. A common reason for misunderstanding health instructions may be the patient’s low health literacy skills. Unfortunately patients with limited health literacy are often considered noncompliant (Baker et al., 1996), when the real problem is a low level of health literacy.

The National Institute for Literacy (NIFL) (1991), views literacy broadly as including more than an individual’s ability to read. The NIFL has defined literacy as “an individual’s ability to read, write, and speak in English, It is important to remember compute, and solve problems, at levels of proficiency necessary to that even people with good function on the job, in the family of the individual, and in society.” literacy skills find that Healthy People 2010 (United States Department of Health and Human understanding healthcare Services, 2000) also adopted a broad definition of literacy, similar to the information is a challenge. NIFL definition of general literacy in defining health literacy 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."

Dalton (2006) has described one low literacy patient as reporting the following experience:

I had some papers, but I didn’t know they were prescriptions and I walked around for a week without my medication. I was ashamed to go back to the doctor, but a woman saw the papers I had and told me they were prescriptions. It’s bad to not know how to read. After getting my medicine I had to come back and ask how to take them because I was urinating too much. They told me I was taking double the medication I was supposed to. I had two bottles and I was taking one from each bottle, but it turned out they were the same medication. But since I don’t know how to read, I didn’t know.

This patient’s experience, unfortunately, is not uncommon. To hear the stories of other patients who have low health literacy as to what it is often like to communicate with health professionals, view the on-line program, Health Literacy and : Help Patients Understand, produced by the American Medical Association Foundation (2007).

The purpose of this article is to explore the most effective ways to assess and address low health literacy so as to develop the ability to clearly and effectively communicate health information to those who struggle with this problem. In this article I will provide guidance in regard to establishing an environment that promotes health http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 1/13 2/19/2018 Assessing and Addressing Health Literacy

literacy, assessing health literacy levels, utilizing strategies to increase health literacy, evaluating the learning that has occurred, and incorporating health literacy concepts into the nursing curriculum.

Establishing an Environment that Promotes Health Literacy

It is important to remember that even people with good literacy skills find that understanding healthcare information is a challenge. They often don’t understand medical vocabulary and the basic concepts in health and Filling out registration medicine, such as how the body works or how to navigate the healthcare forms, health histories, system (Wolf, Gazmararian, & Baker, 2007; Wolf, Gazmarian, & Baker, and consent forms are 2005). Stress and anxiety limit their ability to listen, learn, and remember. particularly difficult for Creating an environment that promotes health literacy requires helping those with low health patients navigate the healthcare system; preparing them to interact literacy skills. productively with their healthcare provider; and providing a respectful and caring environment (Porche, 2009; Weiss, 2007). Each of these necessary activities will be discussed below.

Preparing the Patient to Navigate the Healthcare System

Filling out registration forms, health histories, and consent forms are particularly difficult for those with low health literacy skills. Forms can even be a problem for those with good literacy skills. Hence making simple changes in forms and registration procedures will benefit all patients. Weiss (2007) and Rudd and Anderson (2006) have recommended the following practices to keep the registration and/or admission processes from becoming overwhelming to patients.

Offer all patients help in completing forms. Provide this help in a confidential manner, preferably in an area where they cannot be overheard by others. People are reluctant to discuss personal matters, such as health problems and finances, in front of others. Simplify all forms using clear language, non-medical terms when possible, and easy-to-read formats. Ask only for necessary information at registration or during admission to a facility. Additional information can be provided at a later time.

Referrals for tests, consults with other providers, treatments, or procedures can be a problem for persons with low health literacy. Often the patient is told to read the referral form and call to make an appointment. The patient in this situation has to find out where to go, follow instructions given to prepare for the referral, determine if insurance will pay for the service, and complete a new registration form or additional paperwork. All this can be an overwhelming task for anyone, but especially for those with low health literacy skills. The referral process can be made easier by helping patients in the following ways (Mayer & Villaire, 2007; Weiss, 2007):

Make written instructions clear and simple, using language that is easy to read and understand. Review the instructions with patients and check to be sure they understand the information. If procedures require preparation, ask patients to tell you in their own words what preparation is required. Place directions to the referral site and/or a map on the back of the referral form and review the directions with them. Help patients with insurance issues. Call for an appointment for the patient before they leave the facility

Preparing the Patient to Interact Productively with Healthcare Providers

Helping patients prepare for the appointment is essential if they are to become an active partner in their care. The American Medical Association Foundation (2007) encourages providers to tell the patient what activities to expect when entering the healthcare system, asking patients to:

Report new or different symptoms and anything that doesn’t seem quite right. Bring in a list of all their medications or the actual medication bottles for a review (prescription, herbals, vitamins, minerals, and other over the counter drugs). Provide copies of recent test results or reports they may have from other healthcare providers and personal health records if they have them. Make a list of 2-3 questions they wish to ask. Ask a family member or friend to come with them to help write down information and remember what was said. Clarify what the doctor told them before they leave.

Preparing a Respectful and Supportive Environment

Patients with low literacy skills are often ashamed of this problem and rarely tell anyone (Baker et al., 1996; Parikh, Parker & Nurss, 1996). Even patients with good literacy skills may feel intimidated and avoid asking questions; this behavior may be misinterpreted to mean that they understand the instructions when really they do not understand them.

One way to help patients feel respected and supported is to call them by their title and last name unless they request that you use their first name. Remember that nonverbal behaviors convey important messages. For example, if the receptionist or nurse is trying to check in a patient while on the phone or doing other paper work at the same time, the message received is that the patient’s presence is not important. Patients from other cultures often misinterpret nonverbal gestures, such as the thumbs up or an OK sign made with the thumb and first finger, and consider them to be offensive. Providers are encouraged to pay attention to the patient, use a warm, friendly tone, and smile to let them know that are welcomed. Asking patients if they need any help will go a http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 2/13 2/19/2018 Assessing and Addressing Health Literacy

long way in developing rapport, as will picking up on any verbal or nonverbal clues that might indicate a patient’s extreme anxiety or difficulty understanding what is happening.

Assessing Health Literacy

Knowing whether your patient has low health literacy skills is very important. This knowledge enables you to match your verbal instructions and the level of materials to the health literacy skills of your patient. It may also suggest the benefits of using non-printed teaching materials, such as videotapes, audiotapes, demonstrations, models, pictograms, and other visuals. It is also always important to remember that a patient’s poor communication skills may not indicate a lack of intelligence, but rather a lack of these skills. People with low literacy skills often have the ability to develop these skills; but have not had the opportunity to do so. The following discussion will focus on clinical concerns regarding health literacy, concerns regarding health literacy testing, the Newest Vital Sign, clues that help identify patients with low health literacy, and assessment questions to identify low health literacy skills.

Clinical Concerns Regarding Health Literacy

A patient's literacy level is a concern in healthcare settings because some patients are not aware that they have low literacy skills; they often overestimate ...clinicians routinely their own abilities. In one study of low-literate patients, 75% had never told their overestimate the spouse, 53% never told their children, and one in five never told anyone about ability of patients to their reading problem (Parikh et al., 1996). Kirsch, Jungeblut, Jenkins, and understand medical Kolstad (2005) reported that two-thirds to three-fourths of those reading at the information. lowest reading level, i.e. a below basic level, which is a 5th grade level or below, report that they read “well” or “very well.” Patients who read at the lower levels often arrange their lives in such a way that they read what they can while compensating for their problem with a number of coping strategies. Also of concern is the finding that clinicians routinely overestimate the ability of patients to understand medical information. This occurs even after they spent time with patients who did not understand what they were told (Bass, Wilson, Griffith, & Barnett, 2002; Kelly & Haident, 2007).

Concerns Regarding Testing for Health Literacy

The trend to test patients’ literacy skills began about the time The Joint Commission (TJC) added guidelines to their patient and family education standards to the effect that literacy levels need to be taken into account when teaching. It is important to note that TJC standards do not require testing. The development of specific tests for literacy in healthcare settings may have supported the trend to formally test patient literacy. A reading skills test measures a person’s ability to decode words. Decoding is an essential step in reading that requires transforming letters into words and pronouncing the words correctly. These tests are effective for use in research purposes when a person gives to be tested, but are often not appropriate for use in a general clinical setting. They are not very user friendly in the clinical setting. People with low literacy skills, who already feel stigmatized and fear exposure of their inability to read, may elect to go elsewhere for their medical services if a becomes part of the routine care. Furthermore, unless healthcare providers are trained to communicate effectively with these patients and to select appropriate and easy-to-read materials, knowing a person’s literacy level does not improve care. However, recently there has been some focus on developing screening tools that can be used in the clinical setting. One such tool, the Newest Vital Sign (NVS), is described below. Yet other researchers are continuing work to develop an assessment tool that will provide clinicians with an easy way to get the information they need about their patients’ literacy levels. Table 1 describes tests that measure recognition, pronunciation and/or comprehension.

There is fair evidence to suggest that possible harm outweighs any current benefits of literacy testing (Paasche- Orlow & Wolf, 2007). Patients may be harmed by testing in the form of shame and alienation. Osborne (2005) has shared insights from Archie Willard, an adult learner, who first learned to read when he was 54. Mr. Willard has given us a sense of what testing means to those with low literacy skills by explaining:

As a dyslexic and an adult learner with reading problems, I speak for many other adult learners. We hate having to take written literacy tests. People with other kinds of handicaps are not continually asked to expose their weaknesses to whatever degree they are handicapped. There is no physical pain in taking a written test, but when we have to take a written test there is a lot of frustration inside each of us. We grew up feeling humiliated because we had poor literacy skills and now we are adults. Written tests are seen as another step backward for us and it turns us away.

The Newest Test of Health Literacy: The Newest Vital Sign

The Newest Vital Sign (NVS) is a quick and accurate bilingual (English and Spanish) screening test for general literacy, , and comprehension skills applied to health information, designed to be used in primary care settings. (Osborne et al., 2007; Weiss et al., 2005). This test takes about three minutes to administer and consists of an ice cream container label. Patients read the label while the provider asks six questions about how they would act on the information. A scoring sheet, with the correct answers is used to record the responses. Patients with fewer than four correct answers suggest the possibility of low health literacy. The Newest Vital Sigh package is available at no cost and can be downloaded or ordered at the Pfizer Clear Initiative website (Pfizer, 2008). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 3/13 2/19/2018 Assessing and Addressing Health Literacy

Clues Indicating Low Health Literacy Skills

Most people with low literacy skills are masters at concealing their deficit and are often quite articulate in speaking, so it is difficult to realize that a problem exists. However, observing closely and asking the right questions Most people with low will provide ‘red flags’ that a problem exists with reading and literacy skills are masters at comprehending information. There are a number of characteristics and concealing their deficit and behaviors that patients with low health literacy exhibit: are often quite articulate in speaking, so it is difficult to Patients often make excuses when asked to read or fill out forms. realize that a problem Examples include: “I don’t have my glasses,” “I’m too tired to read ,” and “I’ll read this when I get home.” exists. Poor readers often lift text closer to their eyes, or point to the text with a finger while reading. Many times their eyes wander over the page without finding a central focus. Patients may provide an incomplete medical history or check items as “no” to avoid follow-up questions. Poor readers often miss appointments and/or make errors regarding their medication. Patients with low health literacy become skilled at listening and they often take instructions literally to avoid mistakes. To identify their medications they look at the pills for color, size, and shape, since they can’t read the labels. Patients often show signs of nervousness, confusion, frustration, and even indifference. They may withdraw or avoid situations where complex learning is required. Patients often give incorrect answers when questioned about what they have read.

Watching for these indicators of low health literacy can pay large dividends in terms of improving healthcare for these patients.

Assessment Questions to Identify Low Health Literacy Skills

Asking a patient how far they went in school is not always a good indicator of reading ability. Most people who can’t read have been through the 10th grade, because young people must attend school until they can legally drop out, usually at age 16. Most research shows a two to five year gap between grade level achieved and reading skills (Kutner, Greenberg, Jin, & Paulsen, 2006). Asking the following targeted questions can help identify low health literacy:

Medical terms are complicated and many people find the words difficult to understand. Do you ever get help from others in filling out forms, reading prescription labels, insurance forms, and.or sheets? A lot of people have trouble reading and remembering health information because it is difficult. Is this ever a problem for you? How happy are you with the way you read? How much time do you spend reading each day? What do you like to read? (Newspapers are 10th grade reading level and news magazines are at the12thgrade level). When you have to learn something new or unfamiliar, how do you prefer to learn the information? Do you like to learn by watching TV, listening to the radio, talking with people, trying it yourself, or reading?

Another way to assess for low health literacy is to ask patients to read their prescription bottles and then explain how to take their medication. Chew, Bradley, & Boyko, (2004) found three questions to be an effective screening tool for those with below basic health literacy skills (5th grade level or less), but not as effective for identifying patients with higher levels of health literacy skills.

1. How often do you have somebody help you read hospital materials? 2. How confident are you filling out medical forms by yourself? 3. How often do you have problems learning about your medical condition because of difficulty understanding written information?

Wallace et al. (2006) evaluated the three questions from the Chew et al. (2004) study and concluded that combinations of multiple questions were no more effective in identifying those with low health literacy than one single question. They reported that the question “How confident are you filling out medical forms by yourself?” was the most accurate of the three questions.

A Single Item Literacy Screener (SILS) (Morris, MacLean, Chew, & Littenberg, 2006) was found to have good sensitivity when compared to other validated tools, for identifying patients with low health literacy. This item asked “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from you doctor or pharmacist?” Responses ranged from “1” (never) to “5” (always). The cut-off point of “2” captured all patients potentially in need of assistance.

Utilizing Strategies to Increase Health Literacy

Effective communication strategies will both serve patients with low health literacy and also benefit more literate patients. This section will discuss oral and printed communication as well as a newer type To increase retention, speak of printed material, the photonovela, which is gaining popularity as slowly and limit...advice..., an effective way to communicate with patients having low health focusing the content of the literacy skills. message on a patient’s actions or behaviors that will result in the desired health outcome... http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 4/13 2/19/2018 Assessing and Addressing Health Literacy

Oral Communication

Patients with low health literacy often have problems understanding information given verbally during the patient- provider encounter (Schillinger, Bindman, Wang, Stewart, & Piette, 2004). Research has shown that patients only understand and retain about half of what the provider tells them, and that they do not feel comfortable asking providers to repeat or clarify information (Schillinger et al., 2003). To increase retention, speak slowly and limit the amount of advice given to patients, focusing the content of the message on a patient’s actions or behaviors that will result in the desired health outcome, rather than on detailed facts. It also helps to organize the information logically, focusing on the three to five most important ‘need to know’ points. Logical organization starts with the easiest parts of a message first, then builds on this foundation; it breaks down complex instructions into small units of information to help the patient grasp and understand the information. In this way, patients will feel a sense of success in mastering the information. It is also recommended that instructions be specific, concrete, and vivid, rather than general in nature. People with low health literacy have difficulty with abstract words or general principles and they often don’t know what they need to do if instructions are given in general terms (Doak, Doak, & Root, 1996). For example, if a patient is told to take medicine twice daily, but not the specific times, the patient may not know when to take it, and decide to take two tablets at the same time so as not to forget the second dose of the day.

Using plain language when speaking and means communicating in every day or “living room” language, limiting the length of the message, Using plain language when and organizing information so the receivers get the message quickly and speaking and writing means clearly and in a way that makes sense to them (Weiss, 2007). Healthcare communicating in every day providers should avoid using jargon and medical terminology. If it is or “living room” language... necessary to use a medical term, make every effort to explain the word in plain language. There are a number of medical thesauruses available that can help you find an alternative word for more difficult, complex medical terms (See Table 2).

Reinforcing information is key for retention. Stop after giving each key point to solicit questions and have patients repeat the material back to you. This technique is called ‘chunk and check.’ It makes learning more interesting and helps patients to remember the information better.

Another effective method to improve retention and check for understanding is the ‘teach-back’ technique. To use this method, ask your patients to repeat the information they just heard using their own Stop after giving each key words. One study found that 83.5% of patients retained the point to solicit questions and information when asked to restate it compared to 60.8% of those not have patients repeat the engaged in teach-back (Bertakis, 1977). This form of interactive material back to you. This communication to assess comprehension was associated with better technique is called ‘chunk and glycemic control for patients with diabetes (Schillinger et al., 2003). A check.’ report on Making Safer from the Agency for Health Research and Quality (2001), stated that “Asking patients to recall and restate what they have been told is one of the top eleven patient safety practices based on scientific evidence.”

Printed Communication

Verbal instruction should be reinforced with printed instructional materials that are easy-to-read and visual materials, including models and illustrations. These tools do not replace the personal interaction; they can only help facilitate the interactive process between you and the learner, an essential element of teaching. Guidelines for both written and visual materials will be presented below, along with the principles of Clear Health Communication. User-friendly and easy-to-read materials provide repetition and help rephrase the information for better understanding.

There is a significant gap between patients’ reading and comprehension levels and the reading difficulty of educational materials (Baker et al., 1996; Kutner et al., 2006). Most patient education materials are written above the 8th grade level, with the average level falling between 10th and 12 grades (Estey, Musseau, & Keehn, 1994). Standard informed consent documents often require high school- and college-level reading comprehension (Paasche-Orlow, Taylor, & Brancati, 2003). Many patients, regardless of literacy level, prefer simple, easy-to-read materials written in plain language especially when they are ill (Andrus & Roth, 2002; Mayeaux et al., 1996).

All patients can benefit from seeing pictures, but those most likely to benefit are the patients with low literacy skills. Houts, Doak, Doak,& Loscalzo (2006) believe that providers should: (a) determine how pictures can be used to support key points, (b) ensure that pictures are concrete rather than complex, (c) remove unnecessary details to avoid distractions, and (d) closely link the pictures to simple language print. Pre-testing visual materials with focus groups helps determine if they are easily understood, correctly interpreted, and/or culturally appropriate.

Studies (Campbell, Goldman, Boccia, & Skinner, 2004; Doak et al., 1996; Dowse, n.d.; Houts et al., 2006; Katz, 2006; Osborne, 2006) have shown that the use of pictures in health information improves learner comprehension, especially when information about spatial relationships is presented. In a study on the impact of illustrations on http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 5/13 2/19/2018 Assessing and Addressing Health Literacy

public understanding of cancer screening, the addition of illustrations to written information resulted in a significant (27%) improvement in understanding (Brotherstone, Miles, Robb, Atkin, & Wardle, 2006).

Table 3 lists available guidelines describing how to develop health information materials to ensure that they are user-friendly, easy-to-read, and understandable to a wide audience. One of the most widely used guidelines, Pfizer Principles for Clear Health Communication, includes five elements (Pfizer, 2007):

1. Explain the purpose of the document: Define the purpose and benefits from the patients’ viewpoints. 2. Involve the learner: Focus on the desired patient behaviors and describe useful and realistic actions for the learner to take. 3. Make the material easy to read: Use common words and active voice as if talking to someone; use headings/subheadings to draw attention to the key messages. 4. Make the material LOOK easy to read: Include a lot of white space, use sharp contrast with 12 point font, and cue to direct attention to key points. 5. Select visuals that clarify the material and motivate the learner: Use realistic visuals, graphics appropriate to the learner, and captions that clarify the point of the visual and describe the recommended actions.

The Photonovela

One type of visual that is increasing in popularity for those with low literacy skills is the photonovela. A photonovela is a health education item that is formatted like a comic book, but contains photographs instead of drawings. It includes easy-to-read text to tell a story and stimulate discussion with patients who struggle with low literacy levels. It is a popular form of entertainment literature in Central and South America (Nimmon, 2007).

Often the learners themselves help write and design the photonovela. This creates an empowering experience resulting in a piece of educational material that reflects a particular group of people in the community. Those from the community who are not involved in the production of the photonovela will identify with the message because it closely reflects their beliefs. The Harvard School of (n.d.) has comprehensive information and examples of photonovelas posted on their website .

Steps for designing a photonovela include:

Step 1: Acquire resources:

Large sheets of paper for storyboarding, markers and tape, digital camera, computer, Microsoft publisher software or equivalent, and actors

Step 2: Develop the content by:

Choosing the topic, listing points to be covered, and selecting appropriate visuals and text Drawing on a large piece of paper a grid with a section for each point. Brainstorming ideas for photos and sketching pictures in the grids. Adding text ideas to each grid. Determining the final version of photos and text.

Step 3: Produce the photonovela by:

Selecting actors who match the ethnicity of the audience, having actors sign the necessary release forms. Setting the scene for each photo shoot, considering characters for each shoot, their gestures, expressions, and various clothing items needed. Shooting the photos with a digital camera, downloading the photos, and using software to complete the layout. Inserting the text into the “bubbles” for the dialogue. Completing the final editing. Translating into second language if necessary, using a native speaker for the translation.

Step 4: Pilot test:

Arrange a focus group, interview, or survey with a small group of people who are expected to use the material. During the pilot testing, assess whether the material attracts and holds attention, is accurately perceived, and/or teaches the facts, principles, and interventions presented. Assess also how the material affects the reader’s attitudes and intents to change behaviors, and how the plans for the photonovela might be improved. Evaluating the Learning

In addition to improving retention of information, the ‘teach-back’ method (described above) also demonstrates whether the patient understood the information and provides an opportunity to correct any misunderstandings ...don’t assume that a and reiterate critical information that was not remembered. You can person understands just approach ‘teach-back’ by asking: because they don’t ask questions. ‘Please tell me in your own words what we have discussed.’ ‘What might you tell your family or a friend about your condition?’

Additional evaluation techniques include:

Asking specific and relevant open-ended questions to see if patients can apply the information to their situation, noting, for example, “Some people have problems remembering to take their medicine” and asking “If this happens, what will you do?” http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 6/13 2/19/2018 Assessing and Addressing Health Literacy Presenting a real world problem or scenario that could occur, and asking the person to solve the problem by applying what they have learned, e.g. ask “What would you do if ______happens?” Requesting that patients demonstrate the specific activity and how they could trouble shoot for problems they may encounter doing the skill.

In using the teach-back method, don’t assume that a person understands just because they don’t ask questions. People may feel that asking a question will expose their ignorance, and they don’t want to be embarrassed. Rather ask an open-ended question, for example, “What questions do you have?” If a key point seems to be unclear, rephrase the information, rather than just repeating the information as previously presented.

Incorporating Health Literacy Concepts into the Nursing Curriculum

Given that low health literacy is a major public health problem of the 21st century, it is imperative that our current and next generation of nurses both learn about the burdens that low health literacy places on individuals, on the healthcare system, and on society as a whole, and recognize how nursing can take a leadership role in decreasing low health literacy.

Most current nursing curricula include the patient education process, but do not specifically speak to low health literacy. When students are asked to define health literacy and low health literacy, their answers usually consider only a person’s inability to read, rather than also considering the patient’s comprehension, numeracy, or ability to act on health information. Health literacy concepts can easily be integrated into segments of the curriculum that include communication and patient education (Novitizky, 2009). Objectives, content outlines, and clinical activities to promote an understanding of health literacy are described in Table 4.

Summary

Nurses play a major role in providing leadership that meets the challenge of low health literacy in our society, both at the individual level of care Nurses play a major role in and within our organizations. We need to know how to implement providing leadership that strategies to create a patient-centered, shame-free environment that meets the challenge of low enhances health literacy not only for patients with low literacy, but for all health literacy...both at the patients. Knowing how to assess patients’ ability to read and understand individual level of care and health information is essential if we are to identify the most vulnerable within our organizations. patients who most need help addressing their low health literacy. As of the writing of this article, evidence suggests that this assessment is best done by using appropriate assessment questions and looking for behavioral clues. Visuals are important to increase comprehension and to a treatment plan. A variety of guidelines for preparing clear health communication materials have been presented in this article. Photonovelas, a particular kind of visual that tells a story with photographs and dialogue, and are being developed more frequently for those with low health literacy, have been described.

It is important to begin now to teach future generations of nurses to communicate effectively both orally and in writing with patients who have low health literacy. Teaching students and practicing nurses how to utilize practices that address low health literacy in patients will not only benefit individual patients, but will also help reduce health disparities in the twenty-first century and beyond.

Author

Sandy Cornett, PhD, RN E-mail: [email protected]

Dr. Cornett holds BS and MS degrees in nursing and a PhD in and Instructional Design. She currently serves as Director of the Area Health Education Center (AHEC) Clear Health Communication Program at the Ohio State University College of Medicine, where she has prepared over 6,000 students and practitioners in the health professions in the area of health literacy and consulted with many organizations that need assistance with health literacy issues. She previously served as Program Manager of Consumer Health Education at The Ohio State University Medical Center, Columbus, Ohio, for over 20 years. During this tenure she implemented a patient education system that included 3,000 titles of patient education materials, written below an 8th grade reading level. For more information on health literacy see The Ohio State University’s AHEC Clear Health Communication Program website at http://medicine.osu.edu/orgs/ahec/CHCP.

References

American Medical Association Foundation. (2007). Health literacy and patient safety: Help patients understand. (2nd Edition) (DVD).

Arozullah, A.M., Yarnold, P.R., Bennett, C.L., Soltysik, R.C., Wolf, M.S., & Ferreira et al. (2007). Development and validation of a short-form, Rapid Estimate of Adult Literacy in Medicine. Medical Care, 45, 1026-1033, http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 7/13 2/19/2018 Assessing and Addressing Health Literacy

Baker D., Parker R., Williams M., Pitkin, K., Parikh, N., Coates, W. et al. (1996). The health care experience of patients with low literacy. Archives in Family Medicine, 5(6), 329-334.

Bass, P.F., Wilson, J.F., & Griffith, C.H. (2003). A shortened instrument for literacy screening. Journal of General Internal Medicine, 18, 1036-1038.

Bass, P.F., Wilson, J.F., Griffith, C.H., & Barnett, D.R. (2002). Residents’ ability to identify patients with poor literacy skills. Academic Medicine, 77, 1039-1041.

Bertakis, K.D. (1977). The communication of information from to patient: A method for increasing patient retention and satisfaction. Journal of Family Practice, 5, 217-222.

Brotherstone, H., Miles, A., Robb, K.A., Atkin, W., & Wardle, J. (2006). The impact of illustrations on public understanding of the aim of cancer screening. Patient Education and Counseling, 63, 328-335.

Campbell, F. A., Goldman, B.D., Boccia, M.L., & Skinner, M. (2004). The effect of format modifications and reading comprehension on recall of informed consent information by low-income parents: A comparison of print, video, and computer-based presentations. Patient Education and Counseling, 53, 205-216.

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. Family Medicine, 36(8), 588-594.

Dalton, C. (2006). Quotes from illiterate patients: Examples from Emory University. Retrieved February 26, 2006 from www.healthsystem.virginia.edu/internet/som-hlc/PatientQuotes.cfm

Davis, T.C., Long, S.W., Jackson, R.H., Mayeaux, E.J., George, R.B., Murphy, P.W. et al. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391-395.

Doak, C., Doak, L., & Root J. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: JB Lippincott Co.

Dowse, R. (n.d.). Using visuals to communicate medicine information to patients with low literacy. Adult Learning / Health Literacy in Adult Education, 22-25.

Estey, A., Musseau, A., & Keehn, L. (1994). Patients’ understanding of health Information: A multi-hospital comparison. Patient Education and Counseling, 24, 73-80.

Harvard School of Public Health. (n.d.). Health Literacy Studies - Innovative Materials. Retrieved August 10,2009 from www.hsph.harvard.edu/healthliteracy/innovative.html

Houts, P., Doak, C.C., Doak, L., & Loscalzo, M.J. (2006). The role of pictures in improving health communication: A review of research on attention,comprehension, recall, and adherence. Patient Education and Counseling, 61, 173-190.

Kelly, P. A. & Haidet, P., (2007). Physician overestimation of patient literacy: A potential source of health care disparities. Patient Education and Counseling, 66, 119-122.

Kirsch, I.S., Jungeblut, A., Jenkins L, & Kolstad A. (2005). Executive summary of adult literacy in America: A first look at the results of the National Adult Literacy Survey. Available: http://nces.ed.gov/naal/

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education. Washington, DC: National Center for Education Statistics.

Lee, S.Y., Bender, D. E., Ruiz, R. E., & Cho, Y.I. (2006). Development of an easy-to use Spanish health literacy test. Health Services Research, 41, 1392-1412.

Mayer, G.G., & Villaire, M. (2007). Health literacy in primary care: A clinician’s guide. New York: Springer Publishing Company.

Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The single item literacy screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, 21. Available from http://biomedcentral.com/l47l-2296-7-21

National Institute for Literacy. (1991). Washington D.C. About the National Institute for Literacy. Retrieved August 6, 2009 from www.nifl.gov/about/aboutus.html

Nimmon, L.E. (2007). Within the eyes of the people: Using a photonovel as a consciousness-raising health literacy tool with ESL-speaking immigrant women. Canadian Journal of Public Health, 98(4), 337-340.

Novitizky, J., (2009). Toward a health literacy curriculum. Adults Learning, 20(8), 28-29.

Nurss, J.R., Parker, R.M., Baker, D.W. (2001). TOFHLA: Test of functional health literacy in adults. Snow Camp, N.C., Peppercorn Books & Press, Inc.

Osborne, C. Y., Weiss, B.D., Davis, T. C., Skripkauskas, S., Rodriguez, C., Bass, P. F., et al. (2007). Measuring adult literacy in health care: Performance of the newest vital sign. American Journal of Health Behavior, 31(Suppl 3), S-36-46.

Osborne H. (2004). In other words …healthcare communication from an adult learner’s perspective. Health Literacy Consulting. Retrieved April 19, 2007, from www.healthliteracy.com/ http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 8/13 2/19/2018 Assessing and Addressing Health Literacy

Osborne H. (2005). Health literacy from A to Z: Practical ways to communicate your health message. Boston: Jones & Bartlett Publishers.

Paasche-Orlow M.K, Taylor, H.A., Brancati, F.L. (2003). www.biomedexperts.com/Abstract.bme/12594317/Readability_standards_for_informed- consent_forms_as_compared_with_actual_readability Readability standards for informed-consent forms as compared with actual readability. The New England Journal of Medicine, 348(8), 721-6.

Paasche-Orlow, M. K., & Wolf, M. S., (2007). Evidence does not support clinical screening of literacy. Journal of General Internal Medicine. 23(1): 100-2.

Parikh, N.S., Parker, R.M., Nurss, J.R., (1996). Shame and health literacy: The unspoken connection. Patient Education and Counseling, 27(1), 33-39.

Parker, R.M., Baker, D.W., Williams, M.V., & Nurss, J.R., (1995). The test of functional health literacy in adults: A new instrument for measuring patients’ literacy skills. Journal of General Internal Medicine, 10, 537-541.

Pfizer Clear Health Communication Initiative. (2008). Newest vital sign. Retrieved August 15, 2009 from: www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html

Pfizer Principles of Clear Health Communication. (2007). 2nd Edition. Pfizer Clear Health Communication Program www.pfizerhealthliteracy.com/physicians-providers/chc-principles.html

Porche, R.A., Editor. (2009). Addressing patients’ health Literacy Needs. Oakbrook Terrace, IL: Joint Commission Resources.

Rudd, R., & Anderson, J., (2006). 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 Literacy and Literacy Health and Adult Literacy and Learning Initiative, Harvard School of Public Health. Retrieved August 15, 2009 from: www.ncsall.net/?id=1167

Schillinger, D., Bindman, A., Wang, F., Stewart, A., & Piette, J. (2004). Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Education and Counseling, 52, 315-323.

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., et al. (2003). Closing the loop: Physician Communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163, 83-90.

United States Department of Health and . (2000). Healthy People 2010: Understanding and improving health. 2nd ed. Washington DC: U.S. Government Printing Office. Available at http://health.gov/healthypeople/

Wallace, L. S., Rogers, E. S., Roskos, S. E., Holiday, D. B., & Weiss, B. D. (2006). Screening items to identify patients with limited health literacy skills. Journal of General Internal Medicine, 21, 874-877.

Weiss, B.D. (2007). Health literacy: A manual for clinicians. (2nd edition) Chicago: American Medical Association Foundation.

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., et al. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3 , 514-522.

Wolf, M.S., Gazmararian, J.A., & Baker, D.W., (2007). Health literacy and health risk behaviors among older adults. American Journal of Preventive Medicine, 32, 19-24.

Wolf, M.S., Gazmararian, J.A., & Baker, D.W. (2005). Health literacy and functional health status among older adults. Archives of Internal Medicine, 165, 1946 –1952.

Table 1. Tests to Measure a Person’s Ability to Read and Comprehend Health Materials

Name of Description Strength Weakness Reference Test

REALM – Word Valid with Does not test Davis et al., 1993 Rapid recognition standard tool, for Estimate of and Wide Range comprehension Terry Davis, Ph.D. Adult pronunciation Achievement of the words [email protected] Literacy in of health- Test (WRAT) listed; Medicine related terms; (WRAT-R); available only 66 words listed given in 3 in English; in 3 columns minutes or less does not test from easy to for document hard words or numeracy literacy

REALM-R 8-item version Valid with Does not test Bass, Wilson, & of full REALM WRAT-R; given for Griffith, 2003 (Revised) in less than 2 comprehension minutes of words http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-He… 9/13 2/19/2018 Assessing and Addressing Health Literacy

listed; Terry Davis, Ph.D. available only [email protected] in English; does not test for document or numeracy literacy

REALM – 7-item word Validated with Does not test Arozullah et al. SF recognition 66-item for 2007 test REALM; given comprehension (Short in less than 2 of words Form) minutes listed; available in English only; does not test for document or numeracy literacy

SAHLSA-50 50-item tool Validated tool; Does not test Lee, Bender, Ruiz, – Short based on the given in 3-5 for & Cho, 2006 Assessment 66-item REALM minutes comprehension of Health of words listed Literacy for Spanish- Speaking Adults

TOFHLA – 50-item Tests reading Both sections Parker, Baker, Test of reading comprehension take 22 Williams, & Nurss, Functional comprehension and numeracy minutes to 1995; Health test using skills; give Literacy in modified Cloze Instrument of Nurss, Parker, & Adults technique at choice when Baker, 2001 th th detailed 4 10 , and Peppercorn Books evaluation of 19th grade & Press health literacy reading levels; is needed for 17-item research; numeracy test; Available in English & Spanish and in large print

S-TOFHLA 36-item Validated with Takes 12 Baker, Williams, reading full TOFHA minutes to Parker, (Short comprehension give Gazmararian, & form) at 4th & 10th Nurss, 1999 grade reading levels

Table 2. Medical Thesauruses

Health www.hrsa.gov/servicedelivery/language.htm Resources and Services Administration

Clear Language www.eastendliteracy.on.ca/ClearLanguageAndDesign/thesaurus/ & Design - Canada

National Center http://depts.washington.edu/respcare/public/info/Plain_Language_ for Health Thesaurus_for_Health_Communications.pdf Marketing / CDC- Plain http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-H… 10/13 2/19/2018 Assessing and Addressing Health Literacy

Language Thesaurus for Health Communication

Health ftp://ftp.hrsa.gov/hrsa/hipaaplainlang.pdf Resources & Services Administration – Plain Language Principles and Thesaurus for Making HIPAA Privacy Notices More Readable

Table 3. Guidelines for Development of Materials in Plain Language

The Plain Language http://execsec.od.nih.gov/plainlang/guidelines/index.html Initiative - Executive Secretariat – Canada

Scientific and Technical www.cdc.gov/od/oc/simpput.pdf Information Simply Put

Clear & Simple: www.nci.nih.gov/cancerinformation/clearandsimple Developing Effective Print Materials for Low Literate Readers – National Cancer Institute

Quick Guide to Health www.health.gov/communication/literacy/quickguide/ Literacy- Office of Disease Prevention and – Health Communication Activities

Table 4. Integrating Health Literacy into the Nursing Curriculum

Learning Content Learning/Clinical Activities Objectives

Describe the A. Definition of general DVD of vignettes of persons with health literacy literacy and health low health literacy with problem in the literacy discussion of coping strategies B. 2003 NAAL study US and the they use. Identify barriers to results for general and mismatch health literacy access, diagnosis, treatment, and between public C. Populations at risk self-care. reading levels D. Reasons for low and most literacy health E. Reading levels of most materials. health materials

Assess a A. Characteristics and Administer the NVS and make patient’s ability behaviors of poor observations of patients at a to read, readers clinic; Simulated experience of a B. Observations to make understand, poor reader; Develop a list of C. Questions to ask for and act on assessment of low questions for a listening test. health health literacy – social information. history, medication review D. Screening tools – NVS, SILS

Discuss the A. Studies on the gap Make observations of literacy- between adult literacy http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-H… 11/13 2/19/2018 Assessing and Addressing Health Literacy

impact of low skills and healthcare related demands in various health literacy system demands healthcare settings and discuss on knowledge, B. Risks/costs to strategies for improving the providers and health environment. healthcare systems outcomes, C. Impact on society as a promoting whole behaviors, patient adherence, and healthcare costs

Describe the A. Ensure a patient- Analyze the assessment process guiding centered, shame-free used in a variety of health care principles to environment settings; Use role-play to practice B. Use Plain Language use when using ‘teach back’ method; Use (PL) for patient communicating teaching case studies, video vignettes, or and teaching C. Provide easy-to-read role-play to practice using plain patients and understand language; Compare & contrast information: two health-related consumer appearance/appeal Internet resources; Use PL organization criteria to analyze the reading writing style difficulty of patient education reading levels – Simple Measure of print material; Revise a piece of Gobbledygook difficult education material; (SMOG), FRY Develop a piece (brochure) of Index education material using non-print guidelines; Do a SMOG on a materials piece of education material; Determine methods and materials to use when teaching case study patient with low health literacy.

© 2009 OJIN: The Online Journal of Issues in Nursing Article published September 30, 2009

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