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Focus on Health Literacy and it's Relationship
to Quality
Health Literacy - "It might as well be Greek!"
There are many times when our patients must have this feeling
about the information and directions given them in our efforts to care
for them. The feature article beginning on page 2 of this issue, (reprinted
from our “sister” publication in Iowa) gives us a good background
to begin addressing the issue of health literacy in our organizations.
One of the components of addressing this issue is looking
at the readability of our printed materials. The recommendation is to
keep printed materials for patient information and education at no more
than a 6th grade reading level.
There are a number of easy to use tools that will help you to assess your
printed materials. An Internet search of “readability testing”
will lead you to these.
1. The Gunning Fog Index: This is one of the most popular
and easy to use. You take a sample of the document, determine the average
number of words per sentence, the percentage of hard words, and then use
a simple mathematical formula to calculate the “grade” level.
2. Flesch Reading Ease: This calculates the average number
of words/sentence and syllables/word, and then uses a formula to calculate
a score. The higher the score, the easier it is to read. The aim is a
score of approximately 60 to 70.
3. Flesch-Kincaid Grade Level. This is similar to the Flesch
Reading Ease except that the formula is altered to give a grade level
that is approximate to the number of years of schooling it would take
to read the document.
4. The SMOG Readability Formula: This tool takes a sample
of 30 sentences from the document. Ten come from the beginning, 10 from
the middle, and 10 from the end. It counts all the words with 3 or more
syllables and using a formula or conversion table, gives an approximate
grade level for the material.
The University of Missouri Communications Publication CM201
outlines ten principles of clear writing, clear statement. It can be found
at the following address: http://muextension.missouri.edu/xplor/comm/cm0201.htm.
Health Literacy – A Risk Management
Approach
What is Health Literacy?
Health literacy is a costly health care problem that often goes unrecognized
by both patients and providers because most health care providers believe
they do a good job of communicating with their patients. While this may
be true, nearly half of the United States population may be at risk for
excess hospitalizations and poor health outcomes because they are unable
to read and/or understand the health information provided to them.1
Health literacy problems are increasing because of increased reliance
on the written word for patient instruction, and the increased complexity
of our health care system. Although health care organizations and providers
are becoming more aware of the health literacy problem, there are additional
steps that should be taken in order to successfully manage and solve the
problem.
General literacy is “an individual’s
ability to read, write and speak in English and compute and solve problems
at levels of proficiency necessary to function on the job and in society,
to achieve one’s goals, and develop one’s knowledge and potential.”2
Health literacy has been defined by Healthy People
2010 as “the degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed to
make appropriate health decisions.”3
The AMA Council of Scientific Affairs more specifically defines functional
health literacy as “the ability to read and comprehend prescription
bottles, appointment slips, and other essential health related materials
required to successfully function as a patient.”4
Who Has Health Literacy Problems?
Health literacy affects people from all backgrounds and especially those
with chronic health problems.5 Numerous
factors affect a person’s ability to read and/or understand health
care information. These factors include the person’s general literacy,
education level, age, self-efficacy, cultural background, experience with
the health care system, complexity of the information, and how the information
is communicated.
Even a well educated, articulate adult may have difficulty
understanding the details of their upcoming surgery or the purpose of
their medication. However, the population most at risk for health literacy
problems are those who have a hard time reading in general. In 1992, the
National Adult Literacy Survey found that 40 to 44 million Americans (approximately
1/4 of the US population) demonstrated skills on the lowest literacy proficiency
scales, which means they are functionally illiterate.6
The survey also found another 50 million Americans have marginal skills,
which means they were able to demonstrate skills on Level 2 on each of
the literacy scales.7 Low general literacy
is especially prevalent among the elderly. Sixty-six percent of adults
in the United States age sixty and over have inadequate or marginal literacy
skills and 44% of the adults aged sixty-five and older were classified
as functionally illiterate.8
What Are The Effects Of Poor Health
Literacy?
Health literacy affects numerous areas of an individual’s health,
including their personal; health knowledge, health status, and use of
health services.9 Poor health literacy can
led to poorer health, which can in turn lead to more frequent hospitalizations
and higher health care costs for the patient. Patients with low literacy
skills have a 50% increased risk of hospitalization.10
A study of Medicaid patients found those reading below a third-grade level
had an average annual health care costs four times those of the overall
Medicaid population.11 Not only does health
literacy lead to higher health care costs for the patient but it creates
serious financial consequences for health care providers. In 2003, it
is estimated that low functional health literacy resulted in $73 billion
in additional health care costs.12
What Can Health Care Organizations
Do To Focus On The Health Literacy Problem?
Staff education is key to assisting with the health literacy problem.
In order to improve the quality of care we provide to patients and families,
we as health care organizations and providers need to understand the prevalence
and consequences of inadequate health literacy. We can learn and support
effective communication skills, create shame-free, patient-friendly organizations
and clinic environments, create and use patient-friendly written materials,
and ensure ongoing education and awareness about health literacy among
all staff.
A patient’s understanding of health care information
can be improved with a few modifications. Many patients either do not
recognize their inadequate literacy or are ashamed and hide it. The following
is a list of ways in which health care providers and organizations can
help.
1. Educated staff with the variety of resources available
for use such as the AMA Health literacy Program – Help Your Patients
Understand.
2. Adopt the “Ask Me 3” Program – Make
sure patients ask and understand the answers to these three simple
questions: 14
• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?
3. Optimize communication with patients.15
• Talk more slowly.
• Simplify verbal instructions – use plain, non-medical language
and avoid jargon.
• Use graphic illustrations such as pictures and models.
• Prioritize the most important points.
• Encourage patients to ask questions. Use teach-back and show-me
methods.
• Recognize signs of lack of understanding and make appropriate
interventions.
4. Create and use patient-friendly materials and forms.16
• Keep forms simple by asking only for information that you need
and use.
• Use everyday words and avoid medical jargon whenever possible.
• Use a font and type style that are easy to read. Use dark print
on light paper.
• Include pictures/graphics when appropriate.
• Use text construction at or below sixth grade level.
• Consider alternatives to written materials such as videos, audiotapes,
pictures, and models.
5. “Attitude of Friendliness” atmosphere –
create a shame-free enviroment.17
• Make patients feel comfortable asking questions.
• Have an environment that is respectful, caring, and safe.
• Take patient’s concerns seriously.
• Discuss how you can best help the patient care for themselves.
• Ask patients how they want information communicated to them.
• Observe patients filling out forms and offer assistance if they
appear to be having difficulties.
• Recognize first impressions for the patient makes a big difference.
• Use interpretation/translation services.
Health literacy concerns touch every socioeconomic level,
every ethnic group, and every community. Inadequate health literacy skills
are however, disproportionate among some of our most vulnerable population
such as the poor, the elderly, minorities, and those suffering from chronic
diseases.
As health care professionals, we should be committed to
helping a patient understand his/her own health, and improving health
literacy as everyone’s responsibility.
Disclaimer: This article is provided for information
on the subject of risk management and does not contain legal advice.
Article written by Emily Reiners, IHS Law Clerk, Second
Year Law Student, Drake University Law School and Traci Copple, IHS Law
Clerk, Third Year Law Student, Drake University Law School.
Editor: Barb Earles, RN, MS, CPHQ, CPHRM – Director
of Risk Management, Iowa Health System – 2004. © Iowa Health
System.
References
1. American Medical Association Foundation & American Medical Association,
Health Literacy: Help Your Patients Understand.
2. National Literacy Act of 1991
3 Healthy People 2010. U.S. Department of Health and Human Services, Office
of Disease Prevention and Health Promotion.
4. Selden C, et al., Health Literacy, January 1990 through 1999. NLM Pub.
No. CBM 2000-1. 2000, National Institutes of Health, National Library
of Medicine.
5. Center for Health Care Strategies, Inc. http://www.chcs.org/resource/hl.html
6. http://www.nifl.gov/nifl/facts/NALS.html
7. http://www.nifl.gov/nifl/facts/NALS.html
8. Pfizer Clear Health Communication Initiative, 2003-2004.
9. Health Literacy, JAMA, February 10, 1999, vol. 281, No. 6.
10. Your Patients Can’t Follow Instructions and They Don’t
Understand, American Medical News, June 16, 2003.
11. Pfizer Clear Health Communication Initiative, 2003-2004.
12. Your Patients Can’t Follow Instructions and They Don’t
Understand, American Medical News, June 16, 2003.
13. American Medical Association Foundation & American Medical Association,
Health Literacy: Help Your Patients Understand.
14. Ask Me 3: http:www.askme3.org/
15. American Medical Association Foundation & American Medical Association,
Health Literacy: Help Your Patients Understand.
16. Osborne, Helen. In Other Words…Make It Easy… Writing Healthcare
Forms that Patients Can Understand and Complete. On Call, March 2003.
Vital Messages…Helping Patients Take Their Medications Safely and
Correctly. On Call, Feb. 2003.
17. American Medical Association Foundation & American Medical Association,
Health Literacy: Help Your Patients Understand.
This article is used with the permission from Iowa Association
for Health Care Quality – Communique’ and
Iowa Health System. Copyright 2004 – HIS. All rights reserved.
It is important that all members of MHQP know you are invited
to attend Board Meetings. If you have questions, feel free to contact
the Board Members.
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Quality Line and Between
the Lines are designed to provide members information on vital
issues in Minnesota healthcare, trends, CQI methodologies, legislation
and news about our organization. Published quarterly in Spring, Summer,
Fall, Winter. |
Editor:
Patricia Beilke
Beilke.Patricia@mayo.edu
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