doi: 10.1161/CIRCULATIONAHA.108.818468
(Circulation. 2009;119:1049-1051.)
© 2009 American Heart Association, Inc.
Clinician Update |
Health Literacy
Communication Strategies to Improve Patient Comprehension of Cardiovascular Health
From the Section of Geriatrics (D.J.O.) and Section of General Internal Medicine (M.K.P.-O.), Department of Medicine, Boston University School of Medicine, Boston, Mass.
Correspondence to Daniel J. Oates, MD, MSc, Geriatrics, Robinson 2, Boston Medical Center, 72 E Concord St, Boston, MA 02118. E-mail daniel.oates{at}bmc.org
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Introduction |
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Case presentation: A 67-year-old retired school bus driver presents to your office for an initial visit after having had an acute myocardial infarction, which is complicated by new-onset congestive heart failure. She comes to your office alone, with a bag of 5 pill bottles, and asks, "Do I really need all these pills?"
To care for themselves and participate in their health care, patients must be able to understand and act on information and instructions given to them by their healthcare providers. This concept is known as health literacy, which is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and health services needed to make appropriate health decisions."1 Basic literacy skills, such as proficiency in reading, writing, listening, interpreting images, and interacting with documents, as well as facility with numeric concepts and basic computation, are central to the concept of health literacy and greatly affect a patient’s level of health literacy.
The Institute of Medicine, American Medical Association, American College of Physicians, and the Joint Commission have targeted health literacy as a cross-cutting priority area for quality improvement to transform US health care.2–5 Patients with the largest disease burdens are often those with the least ability to understand and use health information. This is due in part to a lack of focus on patient education and poor communication skills by clinicians. In this article, we discuss the prevalence of limited health literacy, its impact on health outcomes and healthcare utilization, and strategies that providers may use to enhance their communication skills.
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The Problem |
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According to the 2003 National Assessment of Adult Literacy, a 30 000-household US Department of Education survey, 36% of US adults possess basic or below-basic health literacy skills.6 For people with basic health literacy, most documents such as patient education brochures, informed consent forms, notices of privacy protection, patient bills of rights, and even pill bottles are far too complex. The prevalence of limited health literacy is higher for those with low educational attainment, the elderly, racial and ethnic minorities, and people with chronic disease.7 Indeed, more than 50% of those 80 to 84 years old and more than 70% of patients 85 years old and older have marginal or limited health literacy.8
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The Impact |
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Patients with limited health literacy have worse diabetic control9; often present with more advanced diseases, such as prostate cancer10; use fewer preventative services11; and are up to twice as likely to be hospitalized.12 Additionally, older adults with limited health literacy have a hazard ratio for mortality over a 5-year period of 1.52 compared with those with normal health literacy.13 Many factors account for this worse health status, including an increasingly complex healthcare system, difficulties accessing healthcare, limitations in patient-provider communication, and the failure of providers to promote self-management and recognize patient barriers to communication and comprehension.14
Numerous barriers to healthcare access exist for those with limited health literacy. Insurance companies and government programs often introduce hurdles for those seeking care in the form of application procedures and paperwork, which deter those with literacy problems from seeking care, often owing to embarrassment or perceived shame from their limited literacy.15
Barriers can be present within the patient-provider relationship itself that make adequate communication and comprehension difficult. Providers often assume that their patients are functionally literate and communicate with them assuming they are able to read and comprehend information, although this often is not the case.16 Clinicians can often be rushed and therefore make patients feel rushed and embarrassed to ask questions. The office visit can be a daunting interaction, especially for those with limited health literacy. Patients often prefer to be quiet than to admit that they do not understand their doctor’s instructions. They fear that their limited literacy skills will be revealed.15
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Strategies for Clear Communication |
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Numerous strategies are available that clinicians can implement that will help their patients overcome limited health literacy (Table).17 Some of these communication techniques appear easy to implement; however, these strategies often require practice and the participation and training of an interdisciplinary team, as well as feedback from patients.
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The goal is to help patients become informed and activated.18 This cannot be achieved without a welcoming environment in which patients are comfortable asking questions. Shame is a prominent emotion that patients with limited literacy associate with medical encounters. Everything from registration to referrals should be made clear and simple. If you are not hearing questions, patients do not feel welcome to ask. Who are the people in your healthcare setting with the responsibility to elicit and answer patients’ questions? Do they help patients feel comfortable asking questions? There are many ways to distribute this responsibility of eliciting and answering questions, but if the tasks are not clearly defined, achievement of the objective is unlikely.
Avoiding the use of medical jargon during the encounter is another important way to improve patient comprehension. Medical providers often use terms that are straightforward to them, yet may not be so to patients. Commonly heard jargon such as the words "echo," "stress test," and "EKG" may confuse patients and make them fearful unless these words are explained. Use of jargon can be a subconscious technique providers use to assert their role as a health professional and exhibit the mastery they have of their topic area. Unfortunately, it does not promote patient understanding. To make matters worse, even simple words can function as jargon. For example, medical providers tend to use the term "diet" to refer to all the food a person consumes. Patients, however, tend to use the word "diet" to refer to an effort to lose weight. It can be hard to identify and drop the jargon; feedback from non-health professionals can be useful. Taking time to explain in plain terms the action steps you want patients to take will help improve patient understanding, and it can be an effective way for providers to show that it is important to them that their patients understand.
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Universal Precautions |
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The ultimate way to ensure that communication with your patient has been successful is to check. In doing this, physicians often ask, "So, do you understand?" (while getting up and walking for the door, training the patient to respond "yes"). This is not a helpful check for comprehension. A more effective technique is to conduct a "teach back," in which you ask the patient to explain to you or teach back the critical action items from the encounter. You may ask, "We talked about several things today. I want to be sure that it is clear what you are going to do, so please tell me, what is the plan?" or "When you go home, what will you tell your partner about what you need to do every day?" Such questions are helpful in determining the extent of understanding and also what parts of the action plan the patient may not have understood fully. Clinicians can then provide immediate feedback and educational efforts to correct items the patient did not comprehend. This may need to take a different form than simply repeating the idea. The success of this teaching then needs to be evaluated with another round of teach back to determine whether the information has been imparted successfully.19
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Conclusions |
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TopIntroductionThe ProblemThe ImpactStrategies for Clear...Universal PrecautionsConclusionsReferences |
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Integration of the clear communication techniques outlined here may take practice and training for a wide range of clinical staff; however, the high prevalence and significant clinical impact of limited health literacy warrant the expenditure of time and resources. Implementation of the communication techniques presented will help create a prepared and proactive clinical team that will be able to empower patients with limited health literacy to become informed.20
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Acknowledgments |
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Sources of Funding
Dr Oates is supported in part by a Geriatric Academic Career Award from the Health Resources and Services Administration (HRSA), No. 1 K01 HP00020-01.
Disclosures
None.
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References |
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