When Patients Don’t Understand: Ways to Combat Health Literacy Problems

About 80 million Americans have limited or low health literacy, says the US Department of Health and Human Services' Office of Disease Prevention and Health Promotion. They have trouble understanding and using available medical information related to their illness or therapeutic regimen. Older patients have the highest rates of low health literacy, so this problem has important implications for cancer patients. Nurses are well positioned to help patients overcome this barrier to wellness, thereby improving patient safety, lowering costs of care, and supporting better long-term health outcomes.

In June, an Institute of Medicine Roundtable on Health Literacy released "Ten Attributes of Health Literate Health Care Organizations," a discussion paper on how healthcare providers can improve health literacy. Cindy Brach, MPP, senior health policy researcher at the Agency for Healthcare Research and Quality, is the lead author.

Discussion papers are not the same as reviewed reports from the IOM (and do not necessarily represent official IOM views), but the authors emphasize that "Ten Attributes" provides "concrete, practical actions healthcare organizations can immediately take to close the gap between individuals' health literacy skills and the demands of complex healthcare systems." I've paraphrased the 10 attributes and highlighted specific recommendations:

• Have leaders integrate health literacy into the organization's mission, structure, and operations. Assign organizational health literacy improvement to a health literacy officer, high-level task force, or the chief medical officer. Cultivate "health literacy champions" throughout the organization. Designate funds and human resources for training staff and develop appropriate communications materials. Establish goals, incentives, and accountability for health literacy improvement at every level of the organization.
• Integrate health literacy into planning, evaluation measures, patient safety, and processes for quality improvement. Use tools (e.g., from AHRQ, other groups) to formally assess and monitor health literacy. Patients should be able to understand and easily complete health-related surveys. Track and report communication failures. Perform root-cause analyses to address systematic sources of error.
• Use programs that prepare staff to be health literate and monitor their progress. Online literacy training courses, from AHRQ, AMA, CDC, ODPHP, and other groups are recommended, as are health literacy training sessions within or outside the organization. Identify "expert educators" in an organization who can serve as health literacy mentors. Collaborate with patients who can be effective health literacy speakers/trainers.
• Include the patient population served in designing, implementing, and evaluating health information and services. Include members of the populations served in the organization's governing bodies and health literacy advisory groups (with adult educators, health literacy experts), and in developing patient materials.
• Meet the needs of populations with a range of health literacy skills, but avoid stigmatization. Use technology (e.g., audiovisual material) to address limited health literacy. Written information should reinforce spoken communication. Streamline information collection (only essential information collected, only once). Provide special assistance with insurance and personal patient matters.
• Employ health literacy strategies in interpersonal communications and confirm patients' understanding at all points of contact. Verify patient comprehension and literacy skills, using techniques like "teach back," "show me," "teach to goal," or "chunk and check." Focus on actionable information. Limit each conversation to two or three key messages. Use written materials only to highlight key spoken instructions, with graphics/3D models to support teaching.
• Provide easy access to health information and services, and patient navigation. Have patient-friendly design features (e.g., signs, arrows) that incorporate easily understood language and symbols. Include languages commonly spoken by the patient population. Integrate/co-locate services (e.g., medical, psychosocial) in the same facility. Have staff (e.g., navigators) help patients learn about/connect to programs (e.g., wellness, case management) within and outside the organization. Pre-test electronic health applications (information kiosks, patient portals) on individuals with limited health literacy.
• Design and disseminate content (print, audiovisual, social media resources) that's easy for patients to understand and act on. Do not substitute educational materials for in-person education. Materials should be high quality and suitable for those with limited health literacy (photo-novellas, cartoon illustrations, audiovisual/multimedia presentations). Brach and coauthors provide great tips for optimizing oral, written, and online communication, from resources including NCI, HHS, and CMS. People in the target audience with low health literacy should be involved in designing/testing educational materials before they are disseminated through electronic media.
• Address health literacy in communications about medicines, in care transitions, and in other high-risk situations. Identify high-risk situations or topics requiring extra attention and resources (informed consent, pill boxes/charts and dosing devices, labeling on medication containers, patient discharge and follow-up materials, end-of-life care), and have plans to ensure safe communication.
• Communicate clearly what is covered in patients' healthcare plans and what an individual patient will have to pay for services.

How do you feel about programs, resources, and tools used by your institution to address health literacy issues? Is your institution health literate?