Health Literacy
2009; Lippincott Williams & Wilkins; Volume: 119; Issue: 7 Linguagem: Inglês
10.1161/circulationaha.108.818468
ISSN1524-4539
AutoresDaniel J. Oates, Michael K. Paasche‐Orlow,
Tópico(s)Healthcare Systems and Technology
ResumoHomeCirculationVol. 119, No. 7Health Literacy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBHealth LiteracyCommunication Strategies to Improve Patient Comprehension of Cardiovascular Health Daniel J. Oates and Michael K. Paasche-Orlow Daniel J. OatesDaniel J. Oates 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. and Michael K. Paasche-OrlowMichael K. Paasche-Orlow 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. Originally published24 Feb 2009https://doi.org/10.1161/CIRCULATIONAHA.108.818468Circulation. 2009;119:1049–1051Case 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.The ProblemAccording 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.8The ImpactPatients 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.14Numerous 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.15Barriers 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.15Strategies for Clear CommunicationNumerous 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. Table. Clear Communication StrategiesGuiding PrinciplesSpecific StepsVNA indicates Visiting Nurse Association.Clinical skills1. Avoid jargon.2. Use simple sentence structure and plain language.3. Speak slowly.4. Use analogies, if appropriate (eg, "Getting a pacemaker is like replacing the electrical wiring in your house").5. Limit the amount of information discussed: Focus on 2 or 3 key points per visit and repeat them. Use others (office staff, VNA, home physical therapist, etc) to help reinforce key points.Be specific1. Use clear, action-oriented directives.2. Stress action steps the patient should take.3. Stress concrete, specific steps that the patient can take.4. Minimize information about anatomy and physiology.5. Focus instead on answering the patient's question, "What do I need to do?"Use multiple forms of communication1. Use more than 1 communication modality to give the most important information.2. Pictures can help convey complex information or explain procedures.3. Videos or interactive computer programs may also be useful.4. Get feedback from patients to make certain such patient education materials work with your patients.Help patients ask questions1. Create an environment conducive to patients asking questions. Instead of asking, "Do you have any questions?" you can ask, "What questions do you have for me?"2. Empower your patients to always leave medical encounters knowing the answer to the question, "What do I need to do?"Confirm comprehension1. Conduct "teach back." Part A: "Tell me what you'll tell your family about what we talked about." Part B: Focus feedback on aspects not understood. Part C: Reevaluate comprehension ("close the loop") and provide additional feedback until mastery has been exhibited.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.Universal PrecautionsThe 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.19ConclusionsIntegration 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.20Sources of FundingDr Oates is supported in part by a Geriatric Academic Career Award from the Health Resources and Services Administration (HRSA), No. 1 K01 HP00020-01.DisclosuresNone.FootnotesCorrespondence to Daniel J. Oates, MD, MSc, Geriatrics, Robinson 2, Boston Medical Center, 72 E Concord St, Boston, MA 02118. E-mail [email protected] References 1 Ratazan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratazan SC, Parker RM, compilers. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM publication No. CBM 2000-1. Bethesda, Md: National Institutes of Health, US Department of Health and Human Services; 2000.Google Scholar2 Institute of Medicine, Committee on Identifying Priority Areas for Quality Improvement. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academies Press; 2003.Google Scholar3 "What Did the Doctor say?" Improving Health Literacy to Protect Patient Safety. Available at: http://www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-4121-8874-99C7B4888301/0/improving_health_literacy. pdf. Accessed August 28, 2008.Google Scholar4 Health literacy: report of the Council on Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 1999; 281: 552–557.CrossrefMedlineGoogle Scholar5 ACP Foundation. Promoting Health Literacy. Available at: http://foundation.acponline. org. Accessed August 28, 2008.Google Scholar6 Kunter M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NECS 2006-483). Washington, DC: US Department of Education, National Center for Education Statistics; 2006.Google Scholar7 Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielson-Bohlman LT, Rudd, RR. The prevalence of limited health literacy. J Gen Intern Med. 2005; 20: 175–184.CrossrefMedlineGoogle Scholar8 Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999; 281: 545–551.CrossrefMedlineGoogle Scholar9 Schillnger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB. Association of health literacy with diabetes outcomes. JAMA. 2002; 288: 475–482.CrossrefMedlineGoogle Scholar10 Bennett CL, Ferreira NR, Davis TC, Kaplan J, Weinberger M, Kuzel T, Seday MA, Sartor O. Relationship between literacy, race and stage of presentation among low income patients with prostate cancer. J Clin Oncol. 1998; 16: 3101–3104.CrossrefMedlineGoogle Scholar11 Scott TL, Gazmararian JA, Williams MV, Baker DW. 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Patient Educ Couns. 1996; 27: 33–39.CrossrefMedlineGoogle Scholar16 Horowitz CR, Monteith S, McLaughlin M, Sisk JE, Chatterjee S. Low health literacy is common and unhealthy: do we recognize it in our own patients? J Gen Intern Med. 2004; 19 (suppl 1): 176.Google Scholar17 Hironaka LK, Paasche-Orlow MK. The implications of health literacy on patient-provider communication. Arch Dis Child. 2008; 93: 428–432.CrossrefMedlineGoogle Scholar18 Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998; 1: 2–4.MedlineGoogle Scholar19 Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman AB. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003; 163: 83–90.CrossrefMedlineGoogle Scholar20 Paasche-Orlow MK, Schillinger D, Green SM, Wagner EH. How health care delivery systems can begin to address the challenge of limited health literacy. 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