The communication cure for improving health literacy

"Nearly nine out of ten adults may lack the skills needed to manage their health and prevent disease."
Health Literacy Fact Sheet, US Department of Health and Human Services

Health care professionals are respected for the depth and breadth of their clinical knowledge. As essential as this expertise may be, statistics illuminating the hidden epidemic of low health literacy have made the cultivation of a very different skills set—provider-patient communication skills equally important to achieving patient safety and optimizing patient outcomes.

Health Literacy is defined as one's "ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment." For patients with low health literacy, obtaining needed care and complying with treatment instructions can seem impossible. Whether it's interpreting instructions on a prescription bottle, deciphering pages of discharge instructions, completing a health history, or navigating the health care system, low health literacy predisposes patients to poor health outcomes and higher rates of preventable hospital admissions, according to the Department of Health and Human Services.

"Physicians and nurses are patient advocates, and part of that advocacy means helping patients overcome barriers to understanding," says Dr. Weimer, Neurologist, and Chair of the Cooperative of American Physicians Education Committee. Dr. Weimer adds that low health literacy is not merely associated with race, ethnicity, or low income, "It can affect people of all races, ages, people with mental illness, certainly people with diagnoses like dementia—that directly interfere with cognition. Even the stress of hospitalization or a health crisis can affect one's ability to understand and retain information."

As health care professionals, what can you do to improve health literacy?

Never Assume...Assess!

"The single biggest problem in communication is the illusion that it has taken place."
George Bernard Shaw

A patient's health literacy skills may not be evident during the encounter and cannot be detected on the basis of appearance or through casual conversation. Patients with low health literacy are often ashamed of their limitations and try to conceal their confusion from health care providers. Statements such as "I forgot my glasses," or "I'll read this later at home" are ways patients may hide literacy issues. Also, incomplete forms, noncompliance with keeping appointments, or with following the treatment plan should all be investigated, with the utmost sensitivity, for underlying literacy issues. Keep in mind that health literacy is dynamic--even an educated patient can be confused by new and unfamiliar health information.

Use Teach-Back Method, Often

Given what we now know about the hidden epidemic of health literacy, asking a patient, "Do you understand?" and documenting "verbalized understanding" is clearly not enough. Teach-back is a simple and effective way for staff to confirm a patient's understanding by asking the patient to repeat back in his or her own words what was explained to them. To ease the patient's anxiety over getting it wrong and to prevent teach-back from feeling like a test, consider prefacing with, "I want to make sure I was absolutely clear," or, "That was a lot of information to take in, can you repeat back in your own words..." Placing the onus of successful communication on the provider can increase patient comfort and open up a dialogue. Teach-back is appropriate to use any time we provide essential instruction and can reveal barriers to understanding.

Avoiding Information Overload--Teaching what's Essential
In the role of educator, health professionals are challenged with organizing and imparting essential information to reinforce compliance and assist patients in governing their own health. Health literacy experts encourage providers to avoid overwhelming the patient with inessential detail and to keep information brief and "action oriented." Explaining to patients 1) what they need to do 2) why they need to do it and 3) what will happen if they don't—is a great place to start and having them teach-back that information can favorably impact compliance.

Say It Simply - "Please pass the sodium...I mean salt!"
Although your patient recently diagnosed with diabetes will ultimately benefit from understanding the medical terminology associated with their condition (hemoglobin A-1 C, hyperglycemia, etc.) avoiding medical jargon, technical language, and using plain language in oral and written instruction is essential to helping patients overcome initial barriers to understanding. Plain language is language that's understandable the first time it's heard or read. For example, instead of saying to a patient, "Your cardiac condition," saying, "your heart trouble," would be immediately understood by the majority of patients. All patients benefit from plain language.

Uncovering Medication Non-adherence
Medication errors are the most common type of medical error claiming the lives of nearly 400,000 people each year. Additionally, adverse drug events account for nearly 700,000 emergency department visits and as many as 100,000 hospitalizations each year. Many of these errors originate in the outpatient setting where patients, self-administering medication, easily become confused by vague or confusing instructions on prescription labels. "Take two tablets twice daily" is frequently offered as an example of just how confounding and risk-prone these instructions can be for any individual—not just those with low health literacy. Until prescription labeling standards are adopted, providers in the hospital and ambulatory settings can uncover nonadherence and unsafe medication practices by asking patients not only if they're taking their medications, but how they're taking them.

Evaluate & Simplify Written Materials
While the average adult reads at the 8th or 9th grade level, 20% of the population reads at the 5th, making this the appropriate reading level for patient education materials. The AHRQ and CDC websites offer numerous links and resources to help providers assess the quality and readability of written materials. Ample white space, the use of iconography and images, and the chunking and bulleting information are a few suggestions for creating "reader friendly" materials that help improve information retention and recall. Additionally, partnering with patients and asking their opinions on improving the quality of educational materials can yield insights into improvement and foster a patient-centric culture in your practice.

Catherine Miller JD, RN is a Senior Risk Management & Patient Safety Specialist for the Cooperative of American Physicians, Inc. and CAPAssurance program, a Risk Purchasing Group, to bring liability insurance coverage to member hospitals, health care facilities, and large medical groups. For more information about CAPAssurance, please visit

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