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Definition of "Health Literacy"
The term health literacy refers to the ability to read, understand, and act on health information.3,4 In the recently released report titled Health Literacy: A Prescription to End Confusion, the Institute of Medicine1 emphasizes that this type of literacy refers to more than just reading skills; it also encompasses listening, speaking, writing, as well as arithmetic and conceptual skills. It includes the capacity to obtain, process, and comprehend basic information and services necessary for making appropriate decisions regarding one’s health. Low or limited health literacy refers to an inability to adequately understand and act upon basic health information.5
Importance of Health Literacy
The problem of inadequate health literacy has national as well as local dimensions.6 As a national healthcare problem, low health literacy costs the healthcare system an estimated $58 billion each year1,7 and represents a stronger predictor of a person’s health status than their age, income level, educational level, employment status, race, or ethnicity.8 Its epidemiology reveals widespread distribution, affecting both young and old, poor and wealthy, the little and highly educated, the apparently healthy and the desperately ill.8,9 Despite its variable etiology, one consistent clinical manifestation of this problem highlighted in the Agency for Healthcare Research and Quality report is the growing body of evidence that supports the conclusion that low health literacy is associated with poor health outcomes. Some examples of those outcomes include the following:
Extension of these outcomes to acute and critically ill patients is, unfortunately, easy to accomplish. When patients don’t understand how or when to take each of their medications, when they only partially recall how to adjust therapies that need to be titrated, when they fail to recognize adverse complications or untoward drug effects, neglect to arrange transportation for a clinic appointment, or record their pulse incorrectly, problems with literacy for health matters can easily represent or develop into life-threatening health problems.
Health literacy would be a challenging problem if critical care nurses had unlimited amounts of time, staff, and instructional resources to devote to patient education and discharge planning programs, if patients remained hospitalized until they were well, and if all health needs could be met by healthcare professionals. In a work environment characterized by minimal, fleeting, or no time to provide essential health information, where patients may be transferred or discharged with virtually no notice, and where patients and families can be abruptly handed responsibility for increasing amounts of their own healthcare, the issue of health literacy both exacerbates and escalates many weaknesses already existing in the healthcare system. This is no time to assume that information and skills that our patients require to recover, regain, and maintain their health have been effectively communicated merely because they have been "taught." Teaching and learning are neither synonymous nor automatic. We can facilitate each of these processes, however, to better ensure that our patients can both understand and appropriately act on information vital to their health.
Supporting Health Literacy
Critical care nurses can play an integral and collaborative role in promoting health literacy for our patients. Some of the strategies suggested by the many national organizations addressing this problem include the following8:
Recognize patients at higher risk for low health literacy
Patients especially vulnerable to low health literacy include those unable to read; those unable to understand or speak English; elderly or disabled patients with diminished sensory, motor, and/or cognitive function; the poor, immigrants, and patients with multiple, chronic health problems.
Recognize patients whose ability to comprehend and retain information may be transiently or intermittently impaired
Even patients with normal health literacy may experience distraction, stress, anxiety, pain, or numerous other intrusions on their ability to process and recall health information.
Keep in mind that many people with limited health literacy have well established behavioral patterns they use to hide or cover this inadequacy
Patients or family members may be ashamed, fearful, or intimidated to admit that they do not understand instructions or information given to them. Even poised, articulate and otherwise functional adults may hide this revelation from their spouses, children, or friends.
Create an environment that makes patients, families, and significant others comfortable asking questions
Slow down during interactions with patients and family members who may hesitate to pose questions or request clarifications because the clinician’s demeanor is rushed. Sit down at the patient’s eye level to converse. Provide privacy to facilitate open exchanges of highly personal information.
Encourage patients (and families and significant others) to ask healthcare providers questions
The Partnership for Clear Health Communication’s first patient education endeavor was creation of a simple tool called Ask Me 3,14 which was designed to enhance patient and healthcare provider communication. The program teaches patients the importance of asking and understanding the answers to the following 3 questions:
Reduce use of medical jargon when communicating with patients
Use plain and easily understood language. Verify that communications are mutually understood.
Provide health information that is easy to understand, retain, and use
Some of the suggested approaches to making information more readily understood include the following8:
Trust but verify
An essential component of all patient education and discharge planning is confirmation that the patient (and families and significant others, as appropriate) understands what has been communicated, can recall important points or retrieve that information readily, and can correctly perform any techniques or skills he or she will be called upon to use. Although we would like to trust that learning has indeed occurred, the literacy issue reminds us that former President Reagan’s maxim to "Trust but verify" is the more prudent course to follow. Requiring patients to explain what was related in their own words, to locate various pieces of critical information, and to return demonstrate procedures are some approaches to secure this validation.
Design patient education and discharge planning materials so that all patients can understand and use them. Always pilot test materials with the target users before implementing
A 2002 Roper study titled "Health Literacy & Prescription Drug Experience: The Front Line Perspective from Patients, Physicians, and Pharmacists" and reported by the Partnership for Clear Health Communications8 revealed that 50% of adults read below the eighth grade reading level; 20% read below the fifth grade level; and 40% of seniors read below a fifth grade level. These findings suggest that patient education and discharge planning instructional materials be designed at or below the fifth grade reading level. Guidance in designing materials for patients with low literacy can be secured from most of the resources suggested.
Suggest and arrange for family members and significant others to accompany patients at education or discharge planning sessions
Many patients find it both supportive and helpful to have another adult with them to hear, see, and experience their interactions with healthcare staff. Because of the often threatening nature of healthcare situations, even persons with no health literacy problems will often find this useful for recall and clarification of information.
Use available resources to learn more about this issue
A wealth of resources related to the topic of health literacy is available on the Internet. Some good places to start searching for the numerous organizations working collaboratively on one or more aspects of this problem are mentioned below. All these groups provide numerous links to other sites that can inform healthcare professionals on this topic.
Critical care nurses may not be able to eradicate the problem of health literacy, but we can surely contribute to mitigating some of its potentially harmful effects.
References
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