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Improving health literacy is an uphill task, for it to be effective there has to be a synergy between stakeholders in the health and education sectors like health educators, researchers, health and medical professionals, government and the community at large.Institute of Medicine published Health Literacy: A Prescription to End Confusion (2004), which advocated for increased education through a health literacy curriculum for health and allied fields like medicine, nursing, pharmacy, public health etc. The prescription also recommended continuing education and clinical practice to improve health literacy for health professionals and staff.
Identify the Signs of Low Literacy
According to Center for Health Care Strategies fact sheet two (2013), low literacy assessments for patients can be informal or formal
Informal patient assessment includes seven skills
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- Frequently miss appointments;
- Failure to complete registration forms;
- Inability to name medications or explain their purpose or dosing;
- Identifying pills by looking at them, not reading label;
- Inability to give coherent, sequential medical history;
- Showing lack of follow-through on tests or referrals; and/or
- Repeatedly use statements such as ‘I forgot my reading glasses,’ ‘I’ll read through this when I get home,’ or ‘I’m too tired to read,” when asked to discuss written material.
Formal patient assessment and
- REALM/D (Rapid Assessment of Adult Literacy in Medicine/Dentistry): which measures patients’ ability to read common/simple medical words.
- SAHLSA (Short Assessment of Health Literacy for Spanish-speaking Adults): for adults who speak Spanish as a primary language.
- TOFHLA (Test of Functional Health Literacy in Adults): which measures reading and numeracy using common medical contexts and materials. There is a shortened seven-minute version.
Use Plain Language
Using jargon is awesome as long as it is not with patients who are in the consulting room, thinking about their medical conditions. Use plain English when talking with patients, this enables the patients to discuss their medical issues from their own perspective during consultation.
Plain language was been defined by Dr Robertson Eagleson as “ a clear, straightforward expression, using only as many words as are necessary. It is language that avoids obscurity, inflated vocabulary and convoluted construction. It is not baby talk, nor is it a simplified version of … language.’
It was defined by Richard Wydick as “Language that is clear, concise and correct.”
Plain language emphasizes on writing a text that is clear, concise, efficient and free flowing for the reader. The center for plain language has said that “ a document, web site, or other information is in plain if the target audience can read it, understand it, act on it and even teach it.”
Medical professionals need to be able to explain things and issues to the patients as precisely and as clearly as possible, break it down to the simplest form. Show empathy and compassion for their situation, it make them very relaxed and comfortable enough to open up.
For better comprehension, patient written materials should be made in such a way that it would be friendly to them. This means using plain or simple words, short but precise sentences (preferably in bullets) and lots of space.
Teach Back or Show me
Physicians can use the teach back and show me method to confirm that the information given is well understood by getting patients to “teach back” what has been discussed. This goes beyond asking them if they understand what was being discussed, it is more like a check of how the physician explained the things than how the patients understood them.
The show and tell method is very useful for certain situations like showing people where and how to carry out certain actions like applying medications, taking injections.
Use “Chunks and Checks” Method
When medical professionals speak with clients, they usually convey a lot of information and explain more than one concept. This makes it extremely difficult for the patients to both understand and retain these information. It is advisable to break down the information that they need to convey into smaller and more manageable bits (chunks) rather than giving it all out at once. Between each “chunk” they use methods like teach back to evaluate if the patients understood what they explained before moving on to the next information.
This method allows the patients to ask questions about what they did not understand as the discussion progresses, rather than wait till the end, as it may affect their understanding.
Use Pictures
Medical professionals can use pictures to help patients understand their treatment plan. Sometimes, spoken and written words are misunderstood or misread (especially when communicating complex ideas or terminologies to patients). In this case, pictures and visuals would be a very effective tool in improving their understanding. Pictures are used to compliment text and support oral explanations. For example, when explaining something like applying topical medication or giving insulin injections, pictures would assist patients to fully understand instructions.
Encourage Patients to Ask Questions
In as much as it is the duty of health professionals to ensure that they provide information that is reliable, understandable and accurate, it can be very useful to encourage patients to ask questions. As part of this process, patients need to feel that it is totally “OK” to ask questions, that their questions will be listened to. This is because there may be specific questions the patient wishes to ask about like impact of their sickness on their ability to work, it is important that they feel comfortable enough to ask these questions and being active partners in any decisions being made about their health.
One of the most common methods of asking questions is the “Ask me three method,” this method encourages patients to ask three questions which will provide them with the information that they need to know about their situation:
- What is my main problem?
- What should I do?
- Why is it important for me to do this?
Use professional interpreter for patients whose can not speak English
Like we discussed earlier, some patients (especially foreigners) can not understand even plain English. They can not be denied access to good health services. Make sure to have an interpreter to explain both to you and the patients what is being discussed. Make sure the interpreter is a medical professional or medical interpreter who understands and can explain the medical terminologies. This will make the non-English speaking patients very comfortable and relaxed.
Locate and use appropriate patient education materials (when needed), to boost oral communication, and review these materials with patients to ensure they fully understand them.
Try as much as possible to use combination of oral and written communication to discuss health issues with patients. The written materials serve to validate what you already told them, the fact that another person has already said or written about it makes it very believable. Make sure these materials are written at the appropriate reading level and make sure to explain in fine details every aspect of the materials to ensure sound comprehension.
Evoke patients’ prior knowledge of their health issues in a non provocative or shaming manner
Ask patients to tell you about what they already know pertaining their health issue for example hypertension or diabetes. Allow them explain it to you in their own words, this gives them a sense of ownership of the situation.
Be An Active Listener
Active listening is a communication skill developed by psychologist Carl Rogers, it has to do with giving unparalleled attention to the speaker (Kathryn Robertson, 2005). Knight.S (1985) defined attention as “placing all of your attention and awareness at the disposal of another person, listening with interest and appreciating without interruption.”
Active listening is not at all easy, as it requires concentration and attention to all the minute details the speaker is conveying. It requires the listener to rid themselves of all distractions and personal concerns in order to engage in the communication exchange.
We do not only listen with our ears, we listen with our eyes, heart, mind and imagination. We listen not only to the words of the other person, but also the messages buried in the words.
In the words of McWhinney (1989, p. ), “The greatest single problem in clinical interviewing is the failure to let the patients tell their story”.
Clinicians must learn to not just pay attention to the words of their patients, but to their tone of voice, eye contact and body language while they speak. According to Elyse Barbell Rudolph, active listening not only helps to identify gaps in comprehension, it can also identify cognitive or performance problems. Listening actively seem like much work for clinicians because most medical programs emphasize on “talking,” and not “listening”
- Rudolph identified additional ways in which active listening can be used in medicine
- Do not be satisfied when the patient’s explanation is “good.” Instead, listen for what the patient did not say, what was missing can show gaps in comprehension.
- Respond to your patients’ explanations. According to Rudolph, “clinicians owe patients at least one more sentence rather than simply ending with Okay, thank you.”
- Repeat/ teach patients again when you notice a deviation from what you already said earlier.
- Routinely offer help with forms and paperwork
Medical professionals should try as much as possible to offer support to patients (especially those with low proficiency level) who have to fill forms and paperwork. Medical establishments should critically review their forms and paperwork to ensure they do not cause undue anxiety and stress for the patients. Offering routine support can reduce pressures on patients who may be struggling with the forms.
Conclusion
There is an urgent need to widen the scope of health literacy in clinical practice. Health literacy should be seen as a shared responsibility between patients, health care professionals, systems and organizations. There has to be a consensus on how to spot people with low literacy levels, which includes setting a benchmark for exhibiting low literacy levels. Globally accepted approaches do not exist and as a result, health professionals often rely on their own assessment of behavioral cues like poor adherence to medications and prescription, to identify patients with low literacy level (Van der Heide, Poureslami, Mitic, Shum, Rootman, & Fitzgerald, 2018).
There should also be a consensus on how to determine the level of performance of health care professionals, organizations in terms of providing understandable and usable information. The fight for health literacy among health care professionals can not be complete without the input of the patients, their views are imperative for effective health literacy in the clinical setting. Currently, patients are not voicing out their concerns or their voices are not being heard in the health literacy conversation.
Universities training health care professionals should include health literacy curses in their curriculum. Currently, there are very few official curricula that address health literacy.
In all, the best approach to health literacy is to establish an equilibrium between patients skills and the performance of health care systems, professionals and organizations. According to Rudd and Anderson (2006), one can not effectively decide the issue of literacy without considering both sides of the divide such as reader and the book, listener and speaker.
