Low health literacy is widespread among U.S. patients, yet limited research has been done to assess the effects of health literacy practices designed to combat the problem, particularly among safety-net providers in primary care settings. This report presents findings from a 2005 study in which the Association of Clinicians for the Underserved first did an online survey of health care facilities across the country and then followed it up with visits to five selected sites for staff and patient interviews. The study identified five health literacy practices that staff considered especially valuable for their group's patients and potentially applicable to other clinics: a team effort, beginning at the front desk; use of standardized communication tools; use of plain language, face-to-face communication, pictorials, and educational materials; clinicians partner with patients to achieve goals; and organizational commitment to create an environment where health literacy is not assumed.
One might think that "health literacy," defined by the Institute of Medicine as the ability to read, understand, and act on health information, is something we could take for granted in this technologically advanced society. On the contrary, health illiteracyor, more discreetly stated, low health literacyis widespread. Patients with low health literacy are at greater risk of misunderstanding treatment recommendations, having problems in accurately taking prescription medications, and experiencing lower health status and poorer health outcomes.
Although low health literacy can affect all populations, it is a particular problem among those of modest financial means, many of whom are older adults or peoplewith limited education or English proficiency. Patients' inadequate levels of health literacy may therefore be especially challenging to clinicians serving as safety-net providers in primary care settings. Yet limited research has been conducted on the scope of the "health literacy practices" employed by front line providers and on how they are meeting the needs of their patient populations. ("Health literacy practices" refer to all patient-centered care activities and protocols involving assessment of patients' health literacy or actions taken either to improve their low health literacy or minimize its negative consequences.)
Study Goals and Methods
This report aims to help fill the void by identifying health literacy practices that safety-net providers commonly use to improve communication with patients during clinical visits. The report focuses in particular on five promising practices identified during a two-phase descriptive study conducted by the Association of Clinicians for the Underserved (ACU) in 2005. In the first phase, ACU invited primary care clinicians and health care facilities across the country to report, by means of an online survey, the health literacy practices they used with their patients to assist them in understanding their health conditions, treatment options, and treatment plans.
In the second phase, five primary care sites were selected, from the online-survey sample pool of 678 respondents, to participate in more detailed analysis. Selection criteria included diversity of facility type, geographic location, and population served. ACU then visited these five sites to gather additional information. In-depth, face-to-face interviews were held with clinicians and other facility staff, and a sample of adult patients from each of the five sites was interviewed as well.
Promising Health Literacy Practices in Primary Care Settings
The online survey and the site visits revealed five health literacy practices that staff considered especially valuable for their group's patients and potentially applicable to other clinics:
Promising Practice 1: A team effort, beginning at the front desk
Clinicians felt that the entire care team, from reception area to checkout, should be involved. Each team member has an obligation to know if the patient is challenged by health literacy issues and to share this information, formally or informally, with other members. In that way, the care team can work collaboratively to meet the patient's needs. In providing the patient's health care per se, physicians should not act alone but also rely on physician assistants, nurse practitioners, medical assistants, clinical pharmacists, nursing staff, and other members of the care team to restate directions and explanations concerning treatment plans and medication dosing and to provide patient follow-up.
Promising Practice 2: Use of standardized communication tools
Clinicians responding to the online survey, as well as those who participated in the interviews, generally have had little exposure to, and lack knowledge of, formal communication strategies. They report that they usually do not use Teach Back, Ask Me 3, or Motivational Interviewing. Yet, when explaining the strategies they do use, they articulate an adaptation of one or a combination of these formal techniques. Meanwhile, clinicians who expressly use Teach Back, Ask Me 3, or Motivational Interviewing report that these techniques are quite effective at improving communication.
Promising Practice 3: Use of plain language, face-to-face communication, pictorials, and educational materials
Clinicians in the online survey tended to report that certain common-sense approaches were quite effective at improving their communication with patients. These include:
- Use of plain language, free of medical jargon
- Sitting face-to-face with the patient
- Use of simple diagrams or pictograms to illustrate explanations
- Use of educational materials geared to low health literacy individuals.
The clinicians interviewed often spoke about repeating their directions and recommendations, just to be sure they are being heard, and frankly asking patients whether they understand their treatment plan, purpose of any medications, and the dosing of those drugs. Similarly, the care teams and administrators at the facilities visited recognize the value of having forms and educational materials on hand that are culturally and linguistically targeted to each population group they serve and are at the appropriate literacy levels.
Promising Practice 4: Clinicians partner with patients to achieve goals
Clinicians at some health facilities conduct literal goal-setting with their patients and collaborate to achieve those goals. The process necessarily includes patients' agreement to work toward specific goals as well as formal mechanisms for verifying whether patients understand and are pursuing their treatment plans, prescriptions, and dosing.
Promising Practice 5: Organizational commitment to create an environment where health literacy is not assumed
Health literacy practices are most successful at health care facilities that have infused them as part of the operating philosophy, provided in-service training and new-employee orientation, and perhaps even participated in a research study on health literacy.
The Patients' Perspectives
Interviews with patients were conducted during the site visits in order to discern how they felt about communication with their clinicians there. These patients expressed satisfaction with the care site and its clinicians, who seemed to be concerned about them and carefully listened to them. They connect with these providers, build relationships with them, trust their treatment recommendations, and, to the extent possible, seek them out regularly for continuity of care. In addition, patients said that if they are engaged in partnership with their clinicians they feel a high level of confidence in their ability to manage their medical conditions at home.
Barriers to Implementing Health Literacy Practices
Administrators and clinicians alikeboth in the online survey and site visitswere optimistic about ultimately realizing their goals regarding health literacy practices. They also, however, cited some potential barriers, of which the most commonly mentioned were:
- Staff members' belief that low health literacy is not a problem or is considered low-priority when compared with other problems
- Staff members' belief that there is not enough time to implement a health literacy program
- Their concern that the health facility does not have the monetary resources to implement a program.
This report's findings suggest that patients can receive high-quality patient-centered care regardless of any difficulties they may initially have with low health literacy. Toward that end, the report offers 12 recommendations grouped into three distinct categories:
- Prepare clinicians for health literacy practices through their health professional training, both formal and informal
- Improve quality of care in primary care settings
- Advance the research agenda
The report's recommendations are thus directed at clinicians, the health care facilities where they work, their sources of training, and the researchers (as well as the organizations that fund them) who study the outcomes of patient literacy practices.
S. E. Barrett, J. Sheen Puryear, and K. Westpheling, Health Literacy Practices in Primary Care Settings: Examples From the Field, The Commonwealth Fund, January 2008.