Health Lit Clinicians

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Manual or clinicians

Second edition

Barry D. Weiss, MD

Removing barriers to better, safer care

A continuing medical education opportunity

Sponsored in part by AstraZeneca

Health literacy and patient safety:

Help patients understand


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2007 American Medical Association Foundation and American Medical Association.

All rights reserved. The contents o this publication may not be reproduced in any orm without writtenpermission rom the American Medical Association Foundation.

Release date: May 2007Expiration date: May 2009


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Health literacy and patient safety:

Help patients understand

Manual or clinicians

Second edition

Author:

Barry D. Weiss, MD

University o Arizona College o Medicine, Tucson

With contributions rom:

Joanne G. Schwartzberg, MD, American Medical Association, Chicago

Terry C. Davis, PhD, Louisiana State University, Shreveport

Ruth M. Parker, MD, Emory University College o Medicine, Atlanta

Patricia E. Sokol, RN, JD, American Medical Association, Chicago

Mark V. Williams, MD, Emory University College o Medicine, Atlanta

Removing barriers to better, safer care


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The Health Literacy Educational Toolkit, 2nd edition has been

re-approved for CME credit through May 2012. Please read the

following page for new instructions effective May 2009.


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Health literacy educational toolkit, 2nd ed

Important Continuing Medical Education Information for Physicians

Effective May 2009

PLEASE NOTE THE NEW INSTRUCTIONS FOR CLAIMING CREDIT EFFECTIVE MAY 2009:

Physicians may earnAMA PRA Category 1 CreditTM for this activity Health literacy educationaltoolkit, 2nd ed. by viewing the accompanying instructional video, reading this manual for clinicians,studying the case discussions, and completing the enclosed evaluation and post-test. The estimatedtime to complete the activity is 2.5 hours. Physicians must then complete the CME questionnaire(including both the evaluation and the post-test) provided at the back of thi s manual andsubmit it v ia mail or fax to:

American Medical Association FoundationAttn: Health Literacy515 N. State St.

Chicago, IL 60654Fax: (312) 464-4142

Al l submiss ions must be s igned and dated.

A certificate documenting your participation in the CME activity will be forwarded to you uponsuccessful achievement of a score of at least 70%.

Original release date: May 2007Date of most recent activity review: April 2009Activi ty exp iration date: May 2012

Disclosures for Content ReviewersClaudette Dalton, MD, Rockingham Memorial Hospital, Harrisonburg, Va. Nothing to discloseDaniel Oates, MD, M.Sc., Boston University School of Medicine, Boston, Mass. Nothing to disclose

Accred itation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical education for physicians.

Designation Statement

The American Medical Association designates this enduring material for a maximum of 2.5AMA PRACategory 1 Credits. Physicians should claim only the credit commensurate with the extent of theirparticipation in the activity.


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An AMA continuing medical education program

Accreditation statement

The American Medical Association is accredited by the Accreditation Council or Continuing MedicalEducation to provide continuing medical education or physicians.

Designation statementThe American Medical Association designates this educational activity or a maximum o 2.5 AMA PRACategory 1 Credits. Physicians should only claim credit commensurate with the extent o their participationin the activity.

Non-physicians may receive a certicate o participation or completing this activity.

Learning objectives

The enclosed materials will enable physicians to: Dene the scope o the health literacy problem.

Recognize health system barriers aced by patients with low literacy. Implement improved methods o verbal and written communication. Incorporate practical strategies to create a shame-ree environment.

Instructions or obtaining CME credit

Ater viewing the accompanying instructional video, reading this manual or clinicians, and completing thecase discussions, record your answers to the continuing medical education (CME) questionnaire on the CMEanswer sheet provided at the back.


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Disclosure policy

To ensure the highest quality o CME programming, and to comply with the Accreditation Council orContinuing Medical Education Standards or Commercial Support, the American Medical Association(AMA) requires that all aculty and planning committee members disclose relevant nancial relationships with

any commercial or proprietary entity producing health care goods or services relevant to the content beingplanned or presented. The ollowing disclosures are provided:

AuthorDr. Weiss: Research grants and consulting ees, Pzer Inc.

ContributorsDr. Schwartzberg: Nothing to discloseDr. Davis: Nothing to discloseDr. Parker: Nothing to discloseMs. Sokol: Nothing to disclose

Dr. Williams: Nothing to disclose

CME Planning CommitteeLouella L. Hung, MPH: Nothing to discloseAmerican Medical Association Foundation, ChicagoJoanne G. Schwartzberg, MD: Nothing to discloseAmerican Medical Association, ChicagoBarry D. Weiss, MD: Research grants and consulting ees, Pzer Inc.University o Arizona College o Medicine, Tucson


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Introduction 6

Health literacy 8

National Assessment o Adult Literacy ..............................................................................................................8

Procient skills ...........................................................................................................................................10

Intermediate skills ......................................................................................................................................10

Basic skills ..................................................................................................................................................10

Below basic skills........................................................................................................................................10

Population groups at risk or limited health literacy ..........................................................................................10

Day-to-day problems associated with limited health literacy ............................................................................12

Implications o limited health literacy ...............................................................................................................13Literacy and health knowledge ..................................................................................................................13

Literacy and health outcomes ....................................................................................................................13

Literacy and health care costs....................................................................................................................14

Literacy and the law ..................................................................................................................................15

You cant tell by looking 16

How can I tell i an individual patient has limited health literacy skills?

Red fags .....................................................................................................................................................17

The social history .......................................................................................................................................19

Medication review .....................................................................................................................................19

Measuring health literacy ...................................................................................................................................20

Strategies to enhance your patients health literacy 22

Making your practice patient-riendly ...............................................................................................................22

Attitude o helpulness ..............................................................................................................................25

Scheduling appointments ..........................................................................................................................25

Oce check-in procedures ........................................................................................................................25

Reerrals and ancillary tests .......................................................................................................................27

Table o contents

Health literacy and patient safety: Help patients understand


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Improving interpersonal communication with patients 28

Communication and malpractice lawsuits .........................................................................................................28

Communication and medical outcomes ............................................................................................................29

Steps to improving communication with patients .............................................................................................29

Slow down ..................................................................................................................................................30

Use plain, nonmedical language ................................................................................................................30

Show or draw pictures to enhance patients understanding and recall .....................................................32

Limit the amount o inormation given at each visitand repeat it ........................................................32

Use the teach-back technique ................................................................................................................33

Create a shame-ree environment: Encourage questions ..........................................................................34

- Ask-Me-3 .....................................................................................................................................34

Creating and using patient-riendly written materials 35

Written consent orms and patient education handouts ...................................................................................35

Principles or creating patient-riendly written materials .........................................................................35

- Depth and detail o the message..................................................................................................37

- Complexity o text.......................................................................................................................38

- Format ..........................................................................................................................................39

- User testing ..................................................................................................................................39

Nonwritten patient education materials ............................................................................................................40Graphic illustrations (pictures, pictographs, models) ...............................................................................40

Audiotapes and compact discs ...................................................................................................................40

Videotapes ..................................................................................................................................................41

Computer-assisted education .....................................................................................................................41

Final comments 43

Case discussions 45

Useul resources 48

CME questionnaire 49

CME answer sheet 51

Reerences 53

American Medical Association Foundation and American Medical Association


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Introduction


Communication is essential or the

eective delivery o health care, and

is one o the most powerul tools in

a clinicians arsenal. Unortunately,

there is oten a mismatch between a

clinicians level o communication and

a patients level o comprehension. In

act, evidence shows that patients oten

misinterpret or do not understand much

o the inormation given to them byclinicians. This lack o understanding

can lead to medication errors, missed

appointments, adverse medical

outcomes, and even malpractice

lawsuits.

There are many reasons why patients do not

understand what clinicians tell them, but key among

them is inadequate health literacyi.e., a limited

ability to obtain, process, and understand basic health

inormation and services needed to make appropriate

health decisions and ollow instructions or

treatment. Clinicians can most readily improve what

patients know about their health care by conrming

that patients understand what they need to know and

by adopting a more patient-riendly communication

style that encourages questions.

The need or todays patients to be health literate

is greater than ever, because medical care has grownincreasingly complex. We treat our patients with an

ever-increasing array o medications, and we ask them

to undertake more and more complicated sel-care

regimens. For example, patients with congestive heart

ailure were prescribed digoxin and diuretics in the

past, while todays patients take loop diuretics, beta

blockers, angiotensin converting enzyme inhibitors,

spironolactone, and digoxin. They may also receive

a biventricular pacemaker that needs monitoring,

and they oten take medications or hypertensionand hyperlipidemia. In the past, these patients were

simply instructed to decrease their physical activity,

but now they weigh themselves daily, report weight

gain to their clinicians, eat low-sodium and oten

low-at diets, and participate in structured exercise

regimens. Similarly, therapy or patients with asthma

was once limited to theophylline pills, but today

these patients must learn to use inhalers with spacers


11/62American Medical Association Foundation and American Medical Association

and understand the dierence between controller

medications and rescue medications. They must

also test their peak fow rate, take tapering doses o

prednisone, and identiy and eliminate allergens rom

their homes. Patients with diabetes may have the

most dicult task o all, as they need to understand

actors aecting blood glucose control so they can

modiy insulin regimens on a meal-to-meal basis in

response to nger-stick glucose measurements.

Unortunately, current data indicate that more

than a third o American adultssome 89 million

peoplelack sucient health literacy to eectively

undertake and execute needed medical treatmentsand preventive health care. Inadequate health

literacy aects all segments o the population, but

it is more common in certain demographic groups,

such as the elderly, the poor, members o minority

groups, and people who did not speak English during

early childhood. The economic consequences o

limited literacy or the US health care system are

considerable, estimated to cost between $50 billion

and $73 billion per year.

Since publication o the rst edition o this manual,

a great deal o new inormation has become available

about the eects o literacy on health care and

health outcomes. Much o this inormation has been

described in research papers and in a report on health

literacy rom the Institute o Medicine.

In the pages that ollow, this manual reviews the

problem o health literacy, its consequences or

the health care system, and the likelihood that a

clinicians practice includes patients with limited

literacy. The manual then provides practical tips

or clinicians to use in making their oce practices

more user riendly to patients with limited literacy,and gives suggestions or improving interpersonal

communication between clinicians and patients.

Finally, the manual concludes with several case

discussions based on vignettes in the accompanying

instructional video.


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Health literacy


Health literacy, as dened in a report by

the Institute o Medicine, is the ability

to obtain, process, and understand

basic health inormation and services

needed to make appropriate health

decisions and ollow instructions or

treatment.1 Many actors can contribute

to an individuals health literacy, the

most obvious being the persons general

literacythe ability to read, write, andunderstand written text and numbers.

Other actors include the individuals

amount o experience in the health

care system, the complexity o the

inormation being presented, cultural

actors that may infuence decision-

making, and how the material iscommunicated.

National Assessment o Adult Literacy

Every 10 years, the US Department o Education

conducts a national survey to document the stateo literacy o the American public. The most recent

survey, the National Assessment o Adult Literacy

(NAAL) conducted in 2003, provides the most

comprehensive view o the general literacy and

health literacy skills o American adults. The NAAL

tested a stratied representative national random

sample o some 19,000 adults who were interviewed

in their place o residence. Each participant

was asked to provide personal and background

inormation and to complete a comprehensive seto tasks to measure his or her ability to read and

understand text, interpret documents, and use and

interpret numbers (Table 1).

While the main purpose o the NAAL was to

measure the general literacy skills o American adults

specic items were devoted to specically assessing

health literacy. These items ocused on the ability o

individuals to understand and use text, documents,

and numbers pertinent to commonly encounteredhealth care situations. These situations included

care o illness, dealing with preventive care, and

navigating the health care system.

The NAAL results were reported by dividing the

health literacy skills o subjects into our levels2:

procient, intermediate, basic, and below

basic (Figure 1). Most doctoral-level clinicians all

into the small percentage o the population that has

procient skills, while 36% o American adults78

million peoplehave only basic or below basic

skills. Add to this gure the approximately 5% o

individuals that could not be tested in the NAAL

because they lacked sucient skills to participate in

the survey, and the total number o Americans with

limited health literacy totals more than 89 million!


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Table 1. Examples o health literacy tasks on the National Assessment o Adult Literacy

Level Sample tasks

Profcient Calculate an employees share o health insurance costs or a year, using a table that shows

how the employees monthly cost varies.

Find the inormation required to dene a medical term by searching through a complex

document.

Evaluate inormation to determine which legal document is applicable to a specic health

care situation.

Intermediate Determine a health weight range or a person o specied height, based on a graph that

relates height and weight to body mass index. Find the age range during which children should receive a particular vaccine using a chart

that shows all the childhood vaccines and the ages children should receive them.

Determine what time a person can take a prescription medication, based on inormation

on the prescription drug label that relates the timing o medication to eating.

Identiy three substances that may interact with an over-the-counter drug to cause side

eects, using inormation on the over-the-counter drug label.

Basic Give two reasons why a person with no symptoms o a specic disease should be tested or

the disease, based on inormation in a clearly written pamphlet.

Explain why it is dicult or people to know i they have a specic chronic medical

condition, based on inormation in a two-page article about the medical condition.

Below basic Identiy how oten a person should have a specied medical test, based on inormation in

a clearly written pamphlet.

Identiy what is permissible to drink beore a medical test, based on a set o short

instructions.

Circle the date o a medical appointment on a hospital appointment slip.

Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy o Americas Adults: Results rom the 2003 National Assessment o Adult Literacy. USDepartment o Education. National Center or Education Statistics (NCES) Publication No. 2006-483; September 2006.

American Medical Association Foundation and American Medical Association


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Procient skills

At the procient level, individuals have ullydeveloped health literacy skills and can read

and understand virtually all text and numerical

inormation they might encounter in health care

settings. These individuals, however, account or only

about 13% o the American adult population.

Intermediate skills

The next highest skill level is termed intermediate.

Individuals with intermediate health literacy skills

constitute about 53% o the population. They candeal with most o the text and numerical inormation

they encounter in health care settings, although

they would have diculty dealing with dense or

complicated text and documents. Examples o

intermediate skills include checking a reerence

source to determine which oods contain a particular

vitamin or calculating body mass index rom

inormation provided on a graph.

Basic skillsPeople with basic health literacy skills, who make up

22% o the population, can perorm the basic tasks

o reading and understanding a short pamphlet that

explains the importance o a screening test. They

would not be able to reliably perorm intermediate-

level tasks. Most would have diculty understanding

typical patient education handouts or lling in health

insurance applications.

Below basic skills

About 14% o the American adult population hashealth literacy skills below even the basic level. These

individuals are typically unable to perorm the basic

tasks needed to achieve ull unction in todays society,

including interactions with the health care system.

They can only perorm rudimentary literacy tasks like

identiying the date o a medical appointment rom a

hospital appointment slip given to them. They would

typically have diculty with basic-level tasks.

Population groups at risk orlimited health literacy

Persons with basic and below basic health literacy

skills are ound in all segments o society. In act,

most are white, native-born Americans. Nonetheless,

limited health literacy is much more common in

certain segments o the population.

Table 2 shows the percentage o certain high-risk

population groups in which many individuals scored

in the basic or below basic levels on the NAAL.These groups include the elderly, persons with limited

education, members o ethnic minorities, and people

who spoke a language other than English in their

childhood home. Unemployed persons, those with

limited income, and individuals insured by Medicaid

are also more likely to have limited health literacy.

Visual diculties and learning disabilities such as

dyslexia account or health literacy decits in only a

very small percentage o NAAL subjects.

Figure 1.

0 0 0 20 0 20 0 0 0 100

14 22 53 12Graph illustrates the percentage o participants inthe National Assessment o Adult Literacy (NAAL)with health literacy scores in each o the our literacyprociency categories.

Source: Kutner M, Greenberg E, Jin Y, Paulsen C.The Health Literacy o Americas Adults: Resultsrom the 2003 National Assessment o Adult LiteracyUS Department o Education. National Center orEducation Statistics (NCES) Publication No. 2006-483; September 2006.

Below basic Basic Intermediate Profcient


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I your patient population includes many individuals

in any o the groups mentioned above, it is likely that

your practice includes persons with limited health

literacy skills. It is important, however, to keep in

mind that persons with limited health literacy do

not t into easy stereotypes. Indeed, one study o

afuent individuals living in a geriatric retirement

community ound that 30% scored poorly on a test

o unctional literacy in health care situations.3 And

a cover article in Fortune magazine told the stories o

several billionaire executives who had limited general

literacy skills.4 As with nearly all poor readers, they

had developed coping mechanisms that worked in

their business and social lives, but might not work

well in an urgent health care situation.

Group Belowbasic

Basic Total

% % %

Age (years)

19-24 10 21 31

25-39 10 18 28

40-49 11 21 32

50-64 13 21 24

65 and older 29 30 59

Highest education level completedLess than or some high school 49 27 76

High school graduation (no college study) 15 29 44

High school equivalency diploma 14 30 44

Racial/ethnic group

White 9 19 24

Asian/Pacic Islander 13 18 31

Black 24 34 58

Hispanic (all groups) 41 25 66

Health insurance statusEmployer provided 7 17 24

Privately purchased 13 24 37

Medicare 27 30 57

Medicaid 30 30 60

No insurance 28 25 53

Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy o Americas Adults: Results rom the 2003 National Assessment o Adult Literacy. USDepartment o Education. National Center or Education Statistics (NCES) Publication No. 2006-483; September 2006.

Table 2. Percentage o adult population groups with health literacy skillsat NAAL below basic and basic levels

American Medical Association Foundation and American Medical Association 11


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Day-to-day problems associated withlimited health literacy

Numerous studies in health care settings demonstratethat persons with limited health literacy skills oten

have a poor understanding o basic medical vocabulary

and health care concepts. For example, one study o

patients with limited health literacy ound that many

did not really understand the meanings o words that

clinicians regularly use in discussions with patients

words like bowel, colon, screening test, or blood

in the stool (Table 3).5 In another study, one out o

our women who said they knew what a mammogram

was turned out not to know.6

Table 3. Common medical words that patients withlimited literacy may not understand

Blood in the stool

Bowel

Colon

Growth

Lesion

Polyp

Rectum

Screening

Tumor

Source: Davis TC, Dolan NC, Ferreira MR, Tomori C, Green KW, Sipler AM,Bennett CL. The role o inadequate health literacy skills in colorectal cancerscreening. Cancer Invest. 2001;19:193-200.

Lack o understanding is not just limited to medical

terms. Several studies, conducted in both primary

care and specialty practices in dierent parts o the

United States, show that persons with limited health

literacy skills also do not understand, or are not awareo, concepts basic to common diseases. For example,

ewer than hal o low literacy patients with diabetes

knew the symptoms o hypoglycemia,7 and the

majority o low literacy patients with asthma could

not demonstrate proper use o an asthma inhaler.8

Table 4 shows some other problems experienced

by persons with limited health literacy when they

interact with the health care system.9,10,11,12

Table 4. Some other health systemproblems experienced by persons with

limited literacy skills

26%did not understand when their

next appointment was scheduled

42%did not understand instructions

to take medication on an empty

stomach

(Up to)

78%

misinterpret warnings on

prescription labels

86%could not understand rights

and responsibilities section o a

Medicaid application

Sources: (a) Williams MV, Parker RM, Baker DW, et al. Inadequate unctionalhealth literacy among patients at two public hospitals.JAMA. 1995; 274:1677-1682; (b) Baker DW, Parker RM, Williams MV, et al. The health care experienceo patients with low literacy.Arch Family Med. 1996; 5:329-334; (c) Fact Sheet:Health literacy and understanding medical inormation. Lawrenceville, NJ: Center orHealth Care Strategies; 2002; (d) Wol MS, Davis TC, Tilson HH, Bass PF III,

Parker RM. Misunderstanding o prescription drug warning labels among patientswith low literacy.Am J Health Syst Pharm. 2006; 63:1048-1055.

It is important to emphasize that limited

understanding o health concepts and health

inormation is not solely a problem o persons with

low literacy skills. Highly literate, well-educated

individuals also report diculty understanding

inormation provided to them by cliniciansusually

because clinicians use vocabulary and discuss

physiological concepts unamiliar to those whodo not have a medical education. Even patients

with average reading levels are oten unable

to understand consent orms used or research

studies on cancer drugs and may not comprehend

medication instructions, such as those or what to

do about missed oral contraceptive pills.13,14 And, in

a well-known anecdote, a prominent obstetrician

reported that he was unable to ully understand the

12 Health literacy and patient safety: Help patients understand


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explanation he received rom an orthopedist about

his upcoming orthopedic surgery.

Implications o limited health literacy

The limited ability to read and understand health-

related inormation oten translates into poor health

outcomes. Most clinicians are surprised to learn that

literacy is one o the strongest predictors o health

status. In act, all o the studies that investigated the

issue report that literacy is a stronger predictor o an

individuals health status than income, employment

status, education level, and racial or ethnic group.15,16,17

Be aware that education level is a poor surrogate

or general literacy skills and or health literacy.

Education level only measures the number o years

an individual attended schoolnot how much the

individual learned in school. Thus, asking patients

how many years o school they completed does

not adequately predict their literacy skills. Indeed,

ully 39% o NAAL participants with a high school

education had only basic reading skills, and 13% had

skills below the basic level.

2

Literacy and health knowledge

Patients with limited health literacy have less

awareness o preventive health measures and less

knowledge o their medical conditions and sel-care

instructions than their more literate counterparts.

This knowledge decit has been documented or a

variety o health conditions, ranging rom childhood

ever to asthma to hypertension. Persons with

limited health literacy skills also exhibit less healthybehaviors (Table 5).18,19

Literacy and health outcomes

Persons with limited health literacy skills have poorer

health status than the rest o the population.15,16,17,20

Indeed, several studies in diverse settings have

shown that, even ater controlling or a variety o

sociodemographic variables, limited understanding

o health concepts (i.e., poor health literacy) is

associated with worse health outcomes. This may

be due to the aorementioned decits in health

knowledge, as well as medication errors, poor

understanding o medical instructions, and lack o

sel-empowerment.

Table 5. Some health knowledge defcits and riskybehaviors o persons with limited literacy skills

Health knowledge decits

Patients with asthma less likely to know how to

use an inhaler Patient with diabetes less likely to know symptoms

o hypoglycemia

Patients with hypertension less likely to know that

weight loss and exercise lower blood pressure

Mothers less likely to know how to read a

thermometer

Less likely to understand direct-to-consumer

television advertising

Less healthy behaviors

More smoking, including during pregnancy

More exposure to violence

Less breasteeding

Less access to routine childrens health care

Sources: (a) Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, GlassJ. Knowledge and attitude on screening mammography among low-literate,low-income women. Cancer. 1996;78:1912-1920; (b) Williams MV, Baker DW,Parker RM, Nurss JR. Relationship o unctional health literacy to patients

knowledge o their chronic disease: a study o patients with hypertension ordiabetes.Arch Intern Med. 1998;158:166-172; (c) Davis TC, Byrd RS, ArnoldCL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescentsin a summer sports program. J Adolesc Health. 1999; 24:403-411; (d) ArnoldCL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status,reading level, and knowledge o tobacco eects among low-income pregnantwomen. Prev Med. 2001; 32:313-320; (e) Kaphingst KA, Rudd RE, DejongW, Daltroy LH. Comprehension o inormation in three direct-to-consumertelevision prescription drug advertisements among adults with limited literacy.

J Health Commun. 2005;10:609-619; () Yu SM, Huang ZJ, Schwalberg RH,Nyman RM. Parental English prociency and childrens health services access.Am J Public Health. 2006;96:1449-1455.



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The relationship between limited health literacy

and poorer health occurs in all socioeconomic groups

and in many disease states. For example, Medicaremanaged care enrollees (mostly older individuals)

are 29% more likely to be hospitalized i they have

limited health literacy skills (Figure 2).21 Medicaid

enrollees (mostly individuals with limited income)

with diabetes are less likely to have good glycemic

control i they have limited health literacy (Figure

3).22 Indeed, although not all research has come to

a similar conclusion, evidence suggests that literacy

may be the mediating actor in determining which

patients have good diabetes control.

23,24

Figure 2. Percentage o Medicaremanaged-care enrollees requiringhospitalization over a 3-year period

18%

14%Percent

20 ____________________________________

15 ____________________________________

10 ____________________________________

5 ____________________________________

0 ____________________________________

Low-literacy Adequate literacy

Source: Baker DW, Gazmararian JA, Williams MV, et al. Functional healthliteracy and the risk o hospital admission among Medicare managed careenrollees.Am J Public Health. 2002;92:1278-1283.

Figure 3. Patients with tight diabetes control

35 ____________________________________30 ____________________________________

25 ____________________________________

20 ____________________________________

15 ____________________________________

10 ____________________________________

5 ____________________________________

0 ____________________________________

Percent

Low-literacy Adequate literacy

Tight diabetes control defned as a glycated

hemoglobin level 7.2%

20%

33%

Data rom: Schillinger D, Grumbach K, Piette J, et al. Association o healthliteracy with diabetes outcomes.JAMA. 2002;288:475-482.

Literacy and health care costs

The adverse health outcomes o low health literacy

translate into increased costs or the health care

system. In one small study, the average annual healthcare costs or all Medicaid enrollees in one state was

$2,891 per enrollee, but the annual cost or enrollees

with limited literacy skills averaged $10,688 (Figure

4).25 Another study, this one o 3,260 Medicare

enrollees in sites around the country, ound higher

costs or emergency room and inpatient care or

people with limited health literacy.26


18%

14%


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Figure 4. Annual health-care costs oMedicaid enrollees

$12,000 ________________________________

$10,000 ________________________________

$8,000 ________________________________

$6,000 ________________________________

$4,000 ________________________________

$2,000 ________________________________

$0 ________________________________

All enrollees Enrollees with limited

literacy

$2,891

$10,688

Data rom: Weiss BD, Palmer R. Relationship between health care costs andvery low literacy skills in a medically needy and indigent Medicaid population.

J Am Board Family Pract. 2004;17:44-47

The combination o medication errors, excess

hospitalizations, longer hospital stays, more use o

emergency departments, and a generally higher

level o illnessall attributable to limited health

literacyis estimated to result in excess costs or the

US health care system o between $50 billion and$73 billion per year.27 According to the Center or

Health Care Strategies, this is equal to the amount

Medicare pays or physician services, dental services,

home health care, drugs, and nursing home care

combined.28

Literacy and the law

The Joint Commission and the National Committee

or Quality Assurance have both adopted guidelines

speciying the need or patient education inormationand consent documents to be written in a way that

patients can understand.29,30 Accordingly, ailure to

provide understandable inormation to patients may

be a negative actor in the accreditation status o

a health care organization. The Joint Commission

recently published a white paper on health

literacy.31

Our legal system recognizes the patient-physician

relationship as a duciary relationship, which is the

highest standard o duty implied by law. In the case

o inormed consent, courts consistently state that

because o the duciary relationship between patients

and physicians, physicians have a duty to ully

disclose, in good aith and in general terms, the risks

and benets o medical interventions and procedures.

With consistency, courts have described inormed

consent as a process o educating patients so they

understand their diagnosis and treatment. A Virginia

court stated that consent is not a piece o paper

but rather a process o physicians helping patientsunderstand their condition or the purpose o making

inormed decisions.32 The South Carolina Supreme

Court declared that a patient must have a true

understanding o procedures and their seriousness.33

Moreover, in Ohio, a court said that the physicians

duty to patients includes ully disclosing inormation

and, as ully as possible, ascertaining that patients

understand the inormation on the documents they

are signing.34

For patients with limited health literacy skills,

clinicians thus need to deliver this inormation in a

clear, plain language ormat. In act, clinicians can

best serve their patient population by providing all

patients with easy-to-understand inormation.



20/62

You cant tell by looking


Given that 89 to 90 million adults in

the United States have limited health

literacy, you probably see patients every

day who have trouble reading and

understanding health inormation. In

addition, even persons with adequate

skills may have trouble understanding

and applying health care inormation,

especially when it is explained in

technical, unamiliar terms. Patientsmay be verbally articulate and appear

well-educated and knowledgeable,

yet ail to grasp disease concepts or

understand how to carry out medication

regimens properly.

Patients with limited health literacy can be dicult

to identiy. The population groups listed in Table

6 are known to be at higher risk or limited health

literacy, but keep in mind that many patients within

these groups actually have well-developed skills.

Conversely, many patients with limited health

literacy do not all into any o the population groups

listed in Table 6.

The important message is that you cant tell by looking

whether someone has sucient skills to adequately

understand health concepts and carry out health

care instructions. Because you cant tell just by

looking, clinicians and medical practices can bestdeliver eective medical care by providing easy-to-

understand inormation to all patients. Later in this

manual, we will show you how you can do this.

Table 6. Key risk actors or limited literacy

Elderly

Low income

Unemployed Did not nish high school

Minority ethnic group

(Hispanic, Arican American)

Recent immigrant to United States

who does not speak English

Born in United States but English

is second language


21/62American Medical Association Foundation and American Medical Association 1

How can I tell i an individual patient has limitedhealth literacy skills?

Red fags

While you cant tell by looking, some o your

patients may drop clues, or red fags, indicating

they have limited health literacy. I your patients

have ever lled out their registration orms or health

questionnaires incompletely or incorrectly, or taken

their medications the wrong way, they may have

done so because o limited literacy skills or because

they were not amiliar with the medical terms and

concepts in these orms. Other clues to limited

literacy are listed in Table 7.

Table 7. Behaviors and responses that may indicate limited literacy

Behaviors

Patient registration orms that are incomplete or inaccurately completed

Frequently missed appointments

Noncompliance with medication regimens

Lack o ollow-through with laboratory tests, imaging tests, or reerrals to consultants

Patients say they are taking their medication, but laboratory tests or physiological parameters do not

change in the expected ashion

Responses to receiving written inormation

I orgot my glasses. Ill read this when I get home. I orgot my glasses. Can you read this to me?

Let me bring this home so I can discuss it with my children.

Responses to questions about medication regimens

Unable to name medications

Unable to explain what medications are or

Unable to explain timing o medication administration



It is important to understand, however, that the

absence o such clues does not indicate that a patient

has adequate health literacy. Most individuals with

limited health literacy are undetected by the health

care system. In act, patients with limited general

literacy skills go to great lengths to hide this rom

others, some even going so ar as to bring decoy

reading materials with them to the clinicians oce

or handing articles about medications or treatments

to their clinician. The majority o patients with

limited literacy skills have never told anyone in the

health care system, and most have never even told

amily members (Figure 5).35 Similarly, patients with

well-developed literacy skills who ail to understandhealth inormation may also avoid asking questions

or ear o appearing stupid or annoying to the

clinician.

In other words, you cant tell by looking and you cant

expect your patients to tell you.

Figure 5. Non-disclosure olimited literacy

Percent

90 ____________________________________

80 ____________________________________

70 ____________________________________

60 ____________________________________

50 ____________________________________

40 ____________________________________

30 ____________________________________

20 ____________________________________

10 ____________________________________0 ____________________________________

Co- Health Spouses Friends Childrenworkers care

providers

Histogram bars indicate the percentage o persons

with limited literacy skills who had never told co-

workers, health-care providers, spouses, riends,

or their children about their limited literacy.

85%

75%68%

62%

52%

Data rom: Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shameand health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33-39,



The social history

Some physicians have ound it helpul to add a

question about literacy skills to the social history.Ater asking about occupation and education, they

add How happy are you with the way you read? or

What is the best way or you to learn new things?

Use o these and similar questions gives the patient

an opportunity to open up and discuss the issue

i desired.

Recent research in this area has ocused on patients

responses to any one o several specic questions

as indicators o limited health literacy skills.36,37,38

The two questions or which the most validation

data are available are How oten do you need to

have someone help you when you read instructions,

pamphlets, or other written material rom your doctor

or pharmacy? and How condent are you lling

out medical orms by yoursel? (Table 8). These

questions have been studied in several settings and

have sensitivities or detecting limited literacy skills

ranging rom 54% to 83%.

The discussion that ollows can lead the patient

and clinician to agree on the importance o

understanding health inormation, and on the need

to nd alternate ways or patients to learn what they

need to know to care or themselves. It is essential

that such discussions, and indeed any questions about

reading skills, be conducted in a private, sae, and

supportive environment, and that all questions are

asked in a neutral, nonjudgmental ashion.

Medication review

Another suggested method or identiying patients

who have limited health literacy skills is the brown-bag medication review. At the time an appointment

is made, ask the patient to bring in all medications

(prescription and over-the-counter medications,

nutritional and herbal supplements, etc). When the

patient comes to the oce, the clinician or medical

assistant can conduct the medication review by

asking the patient to name each medication and

explain what it is or and how it is taken.


24/62

As patients respond to these questions, note whether

they identiy medications by reading the label or by

opening the bottle and looking at or pouring the

pills into their hands. Identiying the medication

by looking at the pills may be a clue to limited

literacy skills. When responding to questions about

how to take the medication, the patient may have

memorized instructions such as take one pill three

times per day. However, when probing urther with

questions such as When was the last time you took

one o these pills? and When was the time beore

that? the patients conusion may become apparent.

Measuring health literacy

A number o instruments have been developed to

assess the health literacy skills o patients (Table

8). For the most part, these tools have been used

or research. Some clinicians, however, have used

these instruments in their own clinical settings

to measure the literacy skills o a sample o their

practices patients. Doing so permits the entire sta

to develop a better sense o the literacy level o

their overall patient population, thereby helpingensure that patient education materials and other

communication modalities are targeted appropriately

to patients level o understanding.

While many clinicians and most patient advocacy

groups have expressed concern that patients are

ashamed and will not want to have their literacy

skills assessed when they come to see a physician,

a recent study suggests otherwise. The study, which

involved nearly 600 patients, randomized 10 private

and 10 public practices in Florida into practices that

did and did not assess literacy skills o their patients.

In the practices that conducted literacy assessments,

the assessment was perormed by the practices

nursing sta at the time nurses obtained patients

vital signs. Fully 99% o patients in the practices

that assessed literacy were willing to undergo the

assessment, and doing so did not decrease patientsatisaction. In act, patient satisaction was slightly

higher in the practices that perormed literacy

assessments, perhaps because the literacy assessment

provided an opportunity or more interaction and

communication between patients and practice sta.43




Table 8. Some methods or assessing literacy skills

Methods Description Validated in Length

English Spanish (minutes)

Single question screens3,3, 3

How oten do you need to have someone help you when you read

instructions, pamphlets, or other written material rom your doctor or

pharmacy? (positive answers are sometimes, oten, or always)

Yes No 1

How condent are you lling out medical orms by yoursel? (positive

answers are somewhat, a little bit, or not at all)

Yes No 1

Assessment instruments

Newest Vital Sign39

(www.NewestVitalSign.org)

Screening instrument or use in

clinical settings. Patients review

a nutrition label and answer 6

questions about the label.

Yes Yes 3

Rapid Estimate o Adult Literacy

in Medicine40Used in both clinical and research

settings. Word recognition

list. Patients read list o 66

words and are scored on correct

pronunciation.

Yes No 2

Short Assessment o Health

Literacy or Spanish-speaking

Adults41

Patient is presented with 50

words, each with a correct and

incorrect meaning, and patient

must select correct meaning.

No Yes 5

Short Test o Functional Health

Literacy in Adults42Used mostly in research. Patients

questioned about 4 numerical

items and 2 prose passages about

medical issues rom which specic

words have been deleted, andpatient must select appropriate

words rom a list o multiple-

choice options.

Yes Yes 8


26/62

Strategies to enhance yourpatients health literacy


While there is little that clinicians can

do to boost the general literacy skills

o their patients, there are strategies

you can use to enhance patients

understanding o medical inormation.

In act, by making your practice more

patient-riendly, communicating in

easy-to-understand language, creating

and using patient-riendly written

materials, and veriying patientsunderstanding o inormation you

provide, you can deliver more eective

care to all o your patients.

Making your practice patient-riendly

Imagine that you are one o the nearly 36% o adults

in the United States who had basic or below basicgeneral and health literacy skills on the NAAL.

You cant read and ully understand an article in a

newspaper. You cant ll in a government application

or Social Security, Medicare, or Medicaid benets.

You cant ollow a bus schedule or a map. You dont

really understand what a cancer screening test is,

or the meaning o words like rectum, tumor,

prostate gland, or mammogram. Perhaps English

is your second language.

Imagine also that you, the patient, are coming to visit

your practice or the rst time today. What will you

nd there? What paperwork will the sta ask you to

produce or complete? What rules and procedures will

they ask you to ollow? What kinds o paperwork will

you receive i you are reerred or ancillary tests or

consultations with other clinicians, and how will you

nd your way to those tests and consultations? Will

you receive handouts and consent orms? I so, will

you be able to understand them (Figure 6)? What doyou know about your medical insurance coverage

assuming, o course, you are not one o the more than

40 million Americans without medical insurance?

This section o the manual provides suggestions and

tips or making your practice more patient-riendly

(summarized in Table 9). While the paragraphs above

use the example o a patient with limited general

literacy skills, implementing the recommendations

in this section will benet all the patients in your

practice.


27/62

Figure 6.

Your naicisyhp has dednemmocer thatyou have a ypocsonoloc. Ypocsonolocis a test or noloc recnac. It sevlovnignitresni a elbixel gniweiv epocsinto your mutcer. You must drink alaiceps diuqil the thgin eroeb thenoitanimaxe to naelc out your noloc.

The text above, which provides basic inormation

about colonoscopy, provides a sense o what it might

be like or a person with limited literacy skills to read

a handout similar to those you may give to patients

in your oce. The words are spelled backwardscan

you read it?

Individuals with limited literacy skills preerinormation with short words and short sentences,

and that contains only essential inormation. Long or

unamiliar words, written backwards in the example

above, are oten dicult to decipher. Dicult words

slow down reading speed and as a result, decrease

understanding. Similar concerns apply to oral

communicationsimple, plain language is the best

way to communicate.




Table 9. Checklist or patient-riendly ofce procedures

Exhibit a general attitude o helpulness.

When scheduling appointments

Have a person, not a machine, answer the phone.

Only collect necessary inormation.

Give directions to the oce.

Help patients prepare or the visit. Ask them to bring in all their medications

and a list o any questions they might have.

Use clear and easy-to-ollow signage.

Ask sta to welcome patients with a general attitude o helpulness.

During oce check-in procedures

Provide assistance with completing orms.

Only collect essential inormation.

Provide orms in patients language.

Provide orms in an easy-to-read ormat.

When reerring patients or tests, procedures, consultations

Review the instructions.

Provide directions to the site o reerral. Provide assistance with insurance issues.

When providing patients with inormation

Routinely review important instructions.

Provide handouts in an easy-to-read ormat.

Use nonwritten modalities.



Attitude o helpulness

A general attitude o helpulness rom you and other

members o your sta can go a long way towardshelping your patients eel comortable in your

practice. This attitude starts rom the top; through

example, clinician leaders and oce managers

can encourage all employees to help patients eel

comortable asking questions about oce procedures

and their medical care. While everyone is involved,

one o the most important individuals is the person

the patient encounters rstthe receptionist.

To advertise the attitude o helpulness to patients,

it may be useul to have all members o the ocestaincluding the clinicians and clerical sta

wear a button that states, Ask me. I Can Help

(Figure 7).

Figure 7.

Scheduling appointments

When patients call the oce to make an

appointment, a person should answer the phonenot a machine asking the patient to select numerical

options. Ideally, the person answering the phone

should be able to converse with the patient in the

patients preerred language.

Inormation collected on the phone should include

only what is needed to process the appointment

and expedite oce fow. It should omit nonessential

inormation or inormation that duplicates what

others will ask later.

Ask i the patient needs directions to the oce. For

rst-time patients, oer to send (or ax or e-mail)

directions to the oce.

Finally, help patients prepare or the visit by asking

them to bring in all their medications and to make a

list o the questions they wish to ask. Let them know

that they are welcome to have someone accompany

them to the visit and be a part o the discussion.

Oce check-in procedures

Oce check-in proceduresparticularly the

completion o registration orms and health

questionnairesoten present an obstacle or

patients with limited general and health literacy. The

next time you receive a patient registration orm that

is incomplete or completed incorrectly, consider that

the patient may have had diculty reading it.

Ask me.I can help.



Solutions to this problem are simple and benecial

to all patients who have diculty completing

registration orms (e.g., persons with limited literacy,

as well as persons with vision decits, tremors).

They are summarized in Table 10.

Table 10. Tips or assisting patients withregistration orms

Routinely oer all patients assistance in

completing orms.

Only collect inormation that is essential.

Collect inormation and/or provide assistance inthe patients preerred language.

Be sure orms are designed in

reader-riendly ormat.

First, and perhaps most importantly, oce sta

should routinely oer all patients the opportunity

to have someone assist them with the completion

o registration orms. This can be done by stating,

Some o these orms can be dicult to ll out. Iyou need help with them, please dont hesitate to

ask me or help. Assistance should be provided in a

condential manner. Patients should be brought to a

cubicle or empty examination room so they will not

have to discuss their health problems, nancial status,

or other personal matters aloud in the waiting area.

Second, registration orms should be simple and

request only necessary inormation. For example,

i a nurse or physician will later ask a patient about

medication allergies, there may be no added value

in having the patient provide this inormation on

the registration orm. Similarly, i oce sta asks or

and photocopies an insurance card, there may be

no reason to have the patient complete insurance

inormation on a registration orm. Asking patients

or unnecessary inormation serves no good purpose

and intimidates those who nd it dicult to provide

this inormation.

Third, inormation should be collected in a patientspreerred language whenever possible. Forms should

be provided in the patients preerred language, or

someone who speaks the patients preerred language

should be available to provide assistance.

In addition to the three aorementioned

recommendations, make certain that the physical

appearance and ormat o the registration orm

complies with the principles o easy-to-read patient

materials. These principles are presented in the nextsection o this manual.



Reerrals and ancillary tests

When patients are sent or blood tests and

imaging studies, or reerred to other clinicians orconsultations, treatments, or procedures, they are

oten handed a piece o paper and told to make an

appointment. For many patients, and especially

those with limited literacy skills, making that

appointment can be dicult. Again, imagine you are

the patient with limited health literacy skills. You, as

the patient, must read the reerral instructions, then

call and make an appointment in another practice

that may have its own registration system and orms

to complete. You also need to determine i insurancecoverage will pay or this service (an advanced health

literacy task mastered only by those with procient

skills), and complete additional paperwork or the

insurance company. Then you will need to ollow pre-

appointment instructions, which could include bowel

preparation or a colonoscopy or proper adjustment o

medications beore a procedure. Finally, you will need

to get to the site o the consultation or procedure and

be present at the correct time.

Most clinicians have dealt with tasks like these and

know they can be rustrating. For a patient who has

below basic NAAL health literacy skills, these tasks

may be overwhelming.

The solutions to this problem are straightorward.

Any written instructions should be clear and simple

and, as discussed in the next section, they should be

written in easy-to-understand language and ormat.

Oce sta should review instructions with patients

and check that patients understand. It is a good idea

to read written inormation out loud, rather than

assume that your patients can read and understand

the inormation on their own.

Business oce sta should be available to assist

patients with issues related to insurance coverage.

Complicated procedures (e.g., bowel preparation)

should be reviewed in detail, as should directions tothe reerral site. It can be useul to have a simple map

on the back o reerral orms, appointment notices,

and test requisition slips, so that the directions can be

highlighted and reviewed with the patient.


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Improving interpersonalcommunication with patients


Clinician-patient communication is

an important actor in health literacy.

Good communication is crucial or a

successul clinician-patient relationship

and eective exchange o inormation.

Breakdowns in communication can

lead to conusion or patients, poor

health outcomes, and even malpractice

lawsuits against clinicians.

Communication and malpractice lawsuits

Poor communication between patients and

clinicians is a major actor leading to malpracticelawsuits. In act, attorneys estimate that a clinicians

communication style and attitude are major actors

in nearly 75% o malpractice suits.44 The most

requently identied communication errors are

inadequate explanations o diagnosis or treatment,

and communicating in such a way that patients

eel that their concerns have been ignored

(Table 11).45,46,47,48

Table 11. Clinician-patient communicationproblems involved in malpractice lawsuits

Inadequate explanation o diagnoses

Inadequate explanation o treatment

Patient eels ignored

Clinician ails to understand perspective o patient

or relatives

Clinician discounts or devalues views o patients

or relatives

Patient eels rushed

Sources: (a) Vincent C, Young M, Phillips A. Why do people sue doctors? astudy o patients and relatives taking legal action. Lancet. 1994; 343:1609-1613; (b) Hickson GB, Clayton EW, Githena PB, Sloan FA. Factors thatprompted amilies to le medical malpractice claims ollowing perinatalinjuries.JAMA. 1992; 267:1359-1363; (c) Hickson GB, Clayton EW, EntmanSS, et al. Obstetricians prior malpractice experience and patients satisactionwith care.JAMA. 1994; 272:1583-1587.



Communication and medical outcomes

Studies have shown that eective communication

with patients has a benecial eect on medicaloutcomes. These benets include lower rates o

anxiety, pain, and psychological distress, and higher

rates o compliance and symptom resolution.49

In particular, it has long been known that patients

adherence to therapy is heavily infuenced by

communication style. Specically, clear and concise

instructions delivered to patients by clinicians the

patients trust are associated with improved rates o

adherence.50

Steps to improving communication with patients

General consensus exists among health literacy

and communication experts that there are six basic

methods or improving communication with patients

(Table 12).51,52 Although initially recommended

based on expert opinion, research results are

providing evidence that these methods work.

Table 12. Six steps to improving interpersonalcommunication with patients

1. Slow down.

Communication can be improved by speaking

slowly, and by spending just a small amount o

additional time with each patient. This will

help oster a patient-centered approach to the

clinician-patient interaction.

2. Use plain, nonmedical language.

Explain things to patients like you would explain

them to your grandmother.

3. Show or draw pictures.Visual images can improve the patients

recall o ideas.

4. Limit the amount o inormation provided

and repeat it.

Inormation is best remembered when it is given

in small pieces that are pertinent to the tasks at

hand. Repetition urther enhances recall.

5. Use the teach-back technique.

Conrm that patients understand by asking them

to repeat back your instructions.

6. Create a shame-ree environment: Encourage

questions.

Make patients eel comortable asking questions.

Consider using the Ask-Me-3 program. Enlist

the aid o others (patients amily or riends) to

promote understanding.



Slow down

Communication is improvedand the risk o

malpractice claims decreasedwhen clinicians spendmore time with patients. Only a short amount o time

is needed to make a dierence. Data rom multiple

US states indicate that primary care physicians who

have been the target o malpractice liability claims

spend an average o 15 minutes per patient on

routine visits, while physicians who have never had

a malpractice claim against them spend an average

o 18 minutes. This is a dierence o a mere three

minutes.53

In addition to spending more time, clinicians can

optimize the use o this time by creating a patient-

centered visit. In a patient-centered visit, the

clinician ocuses on addressing the patients concerns.

Behaviors such as sitting rather than standing,

listening rather than speaking, and speaking slowly

can urther create an impression that you are ocused

on the patient, and patients may respond to these

behaviors by perceiving that you have spent more

time with them than you actually have. These and

other useul behaviors are listed in Table 13.

Table 13. Behaviors that improve communication

Use orienting statements: First I will ask you

some questions, and then I will listen to your

heart.

Ask patients i they have any concerns that have

not been addressed.

Ask patients to explain their understanding otheir medical problems or treatments.

Encourage patients to ask questions.

Sit rather than stand.

Listen rather than speak.

Clinicians oten express concern that a patient-

centered approach results in a substantial increase

in the duration o oce visits. Research shows

otherwise. In one important study, patients who

were allowed to talk without interruption or as

long as they liked spoke or an average o only one

minute and 40 seconds.54 In another study, patients

were permitted to voice their initial concerns at the

beginning o an oce visit, again or as long as they

wished without interruption. The mean spontaneous

talking time was only 92 seconds, with a median

value o 59 seconds.55

While patient-centered visits do not takesubstantially longer than traditional visits, they create

an atmosphere in which patients eel that their needs

have been met. This aids in the development o an

eective patient-clinician alliance, with potential

benets such as increased patient compliance and

decreased risk o malpractice suits.

Use plain, nonmedical language

You should always seek to use plain, nonmedical

language when speaking to patients. Words that

clinicians use in their day-to-day conversations

with colleagues may be unamiliar to the majority o

nonmedically trained persons.

A good approach is to explain things to patients

in language that you might use when talking to

your grandmother. This is sometimes called living

room language, the language o the amily, or

conversational language. Table 14 gives some

examples o plain language alternatives to medicalwords. Conversational language creates opportunities

or dialogue between the clinician and patient, rather

than limiting communication to a monologue by

the physician.



Table 14. Plain language alternatives to medical terms patients may not understand

Medical term Translation into plain language

Analgesic Pain killer

Anti-infammatory Lessens swelling and irritation

Benign Not cancer

Carcinoma Cancer

Cardiac problem Heart problem

Cellulitis Skin inection

Contraception Birth control

Enlarge Get biggerHeart ailure Heart isnt pumping well

Hypertension High blood pressure

Inertility Cant get pregnant

Lateral Outside

Lipids Fats in the blood

Menopause Stopping periods, change o lie

Menses Period

Monitor Keep track o, keep an eye on

Oral By mouth

Osteoporosis Sot, breakable bones

Reerral Send you to another doctor

Terminal Going to die

Toxic Poisonous


36/62

Show or draw pictures to enhance patients

understanding and recall

The saying that a picture is worth a thousandwords is particularly true when communicating

with patients who may have trouble understanding

medical concepts delivered in words.It has long been

known that visual images are remembered better

than letters and words.56 That is why we oten recall

a persons ace but not their name, or the picture on

a books cover, but not the name or author o the

book.57

Research shows that pictures enhance patientsunderstanding o what they need to do.58,59 Pictures

are not substitutes, however, or written or verbal

communication, as understanding is best when

pictures are combined with written or verbal

explanations.

Furthermore, the most eective pictures are simple

ones. For example, i you are trying to explain that

an aortic valve needs to be replaced, the illustration

should display a heart, an aorta, and an aortic

valve. Additional details, such as coronary arteries

and other heart valves, and perhaps all the cardiac

chambers, should not be included i they are not

relevant to the patients specic health problem.

Inclusion o irrelevant details distracts the patient

and diminishes the eectiveness o the picture as a

teaching tool.

Limit the amount o inormation given at each

visitand repeat it

Another key to eective communication is to limitthe amount o inormation provided to patients at

each visit. This does not mean you should withhold

important inormation. Rather, it means that you

should ocus your communication on the one or the

ew most important things a patient needs to know

at the time o the visit. The principle behind this

approach is that advice is remembered better, and

patients are more likely to act on it, when the advice

is given in small pieces and is relevant to the patients

current needs or situation.

For example, at a patients rst visit ollowing a

diagnosis o type 2 diabetes, the most important

message oten is that the sugar level in your blood

is high, and you must start taking medicine to lower

the sugar level. Inormation about physiology o

glucose control, while ultimately important or the

patients ability to sel-regulate diabetes control, is

not important at the rst visit and should not be

discussed at that time. Inormation about potential

complications o diabetes might be mentioned, but is

not the main ocus o the visit. The ocus o the rst

visit is the initiation o treatment.

Ater discussing the key inormation with a patient,

this inormation should be reviewed and repeated,

because repetition is the key to learning and memory.

Ideally, the inormation will be reviewed and

repeated by multiple members o the health care

teamperhaps by a physician, nurse, pharmacist,

dietician, and others.



37/62

Repetition can be achieved even ater the patients

visit through handouts to reinorce the inormation

provided in person. Consider reading handouts

to patients to emphasize the importance o the

inormation. I the handout is too long to read out

loud, it may be too complex and consideration should

be given to developing and using simpler handouts.

Preparation o patient-riendly handouts will be

discussed in the next section o this manual.

Some experts suggest calling patients several days

ater delivering important inormation to urther

reinorce learning.60 While not routinely necessary,

such phone calls can be helpul or reinorcingparticularly important inormation. When making

this call, try to avoid making it seem that you are

calling only to repeat the instructions or to check

up on the patient. Rather, make it clear that you

want to help by stating, I just wanted to be sure

that everything I told you was clear, and to

nd out how are you doing with the treatments I

recommended.

Use the teach-back technique

The teach-back technique is an eective method

or ensuring that patients understand what you have

told them (Table 15). It involves asking patients to

explain or demonstrate what they have been told. For

example, you can say, I want you to explain to me

how you will take your medication, so I can be sure I

have explained everything correctly, or Please show

me how you will use the asthma inhaler, so I can be

sure I have given you clear instructions, or When

you get home your spouse will ask you what thedoctor saidwhat will you tell your spouse?

Table 15. The teach-back technique

Do not ask a patient, Do you understand?

Instead, ask patients to explain or demonstratehow they will undertake a recommended

treatment or intervention.

I the patient does not explain correctly, assume

that you have not provided adequate teaching. Re-

teach the inormation using alternate approaches.

In using the teach-back technique, clinicians take

responsibility or adequate teaching. I patients

cannot explain or demonstrate what they shoulddo, clinicians must assume that they did not

provide patients with an adequate explanation or

understandable instructions. The result should be

new eorts to ensure that patients learn what they

need to know. And, o course, it is important not

to appear rushed, annoyed, or bored during these

eortsyour aect must agree with your words.

Research indicates that the teach-back technique

is eective, not just or improving patients

understanding, but also or improving outcomes.

For example, patients with diabetes whose physicians

assess patients comprehension and recall with the

teach-back technique have signicantly better

diabetes control than patients whose physicians do

not use the technique.61

The teach-back technique should replace the more

common practice o simply asking a patient, Do you

understand what I have told you? Experience shows

that patients oten answer yes to such questions,even when they understand nothing.



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Create a shame-ree environment:

Encourage questions

To oster eective communication with patients, itis essential to create a shame-ree environment in

which patients eel comortable asking questions

about what they do not understand. Without such an

environment, many patients, even those with well-

developed literacy skills, may eign understanding

material to avoid seeming stupid or annoying to

the clinician.

One simple strategy to encourage questions is to

let patients know that many people have dicultyreading and understanding the medical inormation

I give them, so please eel comortable asking

questions i theres something you dont understand.

Make certain to ollow up on this by answering any

questions your patient may have.

Another strategy is to ask patients during the visit

i they would like a amily member or riend to be

with them during discussions about diagnoses and

options or treatment. Research shows that patients

with limited health literacy oten seek the assistance

o amily or riends ater visits with clinicians in

interpreting what their clinicians told them.62 By

oering this opportunity in a routine, nonjudgmental

way, patients will eel comortable bringing others

into the examination room.

Ask-Me-3

The Ask-Me-3 program is a more ormal, but

potentially eective approach to encouragingquestions.63 Sponsored by the Partnership or Clear

Health Communication, a large consortium o

proessional organizations that includes the AMA

Foundation, Ask-Me-3 encourages patients to ask,

and physicians to answer, three basic questions during

every medical encounter. The questions are shown in

Table 16.

The Ask-Me-3 questions serve as an activation tool

that encourages patients to ask questions. Patientsare made aware o the program through posters and

brochures displayed in the oce. Evidence shows

that even long ater Ask-Me-3 is implemented in a

practice, many patients continue to ask the questions

and nd them a useul ramework or engaging in

conversation with their clinician.64

Table 16. The Ask-Me-3 questions

What is my main problem? What do I need to do (about the problem)?

Why is it important or me to do this?



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Written consent orms andpatient education handouts

The readability o consent orms and patienteducation handouts has received more attention than

perhaps any other health literacy issue. Countless

studies in a variety o health care settings have

shown that there is a mismatch between patients

reading skills and the reading skills needed to

comprehend the consent orms and handouts they

are given.65,66,67,68,69,70 More recent studies reveal that

patient education materials on the Internet are also

too dicult or the average reader.71,72,73 Indeed, most

written materials intended or patients are writtenat a diculty level that exceeds the reading skills o

average Americans.

Medical practices should ensure that the reading

diculty level o their patient materials matches

the reading skills o the patients. Clinicians can

use a variety o approaches to reach this goal. One

approach is to develop practice-specic written

materials; the principles or doing this are discussed

below and shown in Table 17. Alternatively,clinicians can purchase materials that have already

been developed on the basis o these principles;

such reader-riendly written materials may be ound

through the list o useul resources at the end o

this manual.

Whatever written materials are used, their

eectiveness may be increased i the clinician or

sta reads them aloud and highlights, underlines,

circles, or numbers key points or the patient to

remember. Drawing supplemental pictures and

writing out steps and directions or individual

patients can also be helpul.

Principles or creating patient-riendly

written materials

Written materials that are easy or patients toread and understand are benecial to all patients.

Indeed, evidence indicates that all patientsnot just

those with limited literacy skillspreer easy-to-

read materials to more complex or comprehensive

materials.

The basic principles (Table 17) or creating patient-

riendly written materials involve attention to

(a) the depth and detail o the content, (b) the

complexity o the text itsel, (c) the ormat inwhich the material is prepared, and (d) user testing.

The practical application o these principles is

reviewed in the ollowing paragraphs. Readers who

desire more detailed inormation on creating easy-

to-read written materials or patients can consult

standard textbooks74,75,76 on creating eective

patient education inormation, or attend seminars or

workshops oered by experts in the eld (see Useul

resources at the end o this manual).

Creating and using patient-riendlywritten materials



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Table 17. Formatting checklist or easy-to-read written materials

General content

Limit content to one or two key objectives. Dont provide too much inormation or try to

cover everything at once.

Limit content to what patients really need to know. Avoid inormation overload.

Use only words that are well known to individuals without medical training.

Make certain content is appropriate or age and culture o the target audience.

Text construction

Write at or below the 6th-grade level. Use one- or two-syllable words.

Use short paragraphs.

Use active voice.

Avoid all but the most simple tables and graphs. Clear explanations (legends) should be placed

adjacent to the table or graph, and also in the text.

Fonts and typestyle

Use large ont (minimum 12 point) with seris. (Seri text has the little horizontal lines that you see in this

text at the bottoms o letters like , x, n, and others. This text, on the other hand, is non-seri.) Dont use more than two or three ont styles on a page. Consistency in appearance is important.

Use upper- and lower-case text. ALL UPPER-CASE TEXT IS HARD TO READ.

Layout

Ensure a good amount o empty space on the page. Dont clutter the page with text or pictures.

Use headings and subheadings to separate blo

Health Lit Clinicians

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