Health literacy

Amongst scholarly journals, authors are commonly encouraged to communicate with their peers in simple language and to avoid jargon, abbreviations and overly complex language. How much more important is communication with recipients of health care, where misunderstandings might result in, at the least, no improvement in health and, at worst, admission to hospital or life-threatening situations.

Health literacy is ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’. ¹ Health literacy requires a complex group of skills that include ‘the ability to interpret documents, read and write prose (print literacy), use quantitative information (numeracy) and speak and listen effectively (oral literacy)’. ²

Health literacy is essential as our health care moves away from a paternalistic model to one increasingly directed towards a partnership between patient and health-care provider. This partnership will be influenced by the level of health literacy of the patient, carer and health-care provider and the degree to which all partners are ‘on the same page’ or at least can find an effective way to communicate both health seeking and health providing behaviours.

Low levels of health literacy (print or oral literacy or numeracy) are associated with higher risk of death, more frequent hospitalizations and higher use of health-care services.^2,3 The most recent American assessment of health literacy highlighted a number of vulnerable groups: (1) older adults (>65% of people aged 65 and older have difficulties using print materials including charts and forms and performing calculations and interpreting numbers); (2) immigrants (lower health literacy associated with speaking a language other than English before commencing school); and (3) people with low income living below the poverty threshold. ⁴

As in other patient populations, levels of health literacy are variable amongst people with chronic obstructive pulmonary disease (COPD). However, it is likely that the proportion of people with low health literacy is relatively high in the population of people with COPD as they are older population with a lower average socioeconomic status, ⁵ both of which are key contributors. Low health literacy might lead to the misunderstanding of instructions, which can impact on adherence to medical interventions. ⁶ This was dramatically illustrated by Davis et al., ⁵ who reported that just over a third of patients with low literacy were able to show how many tablets should be taken when given a written label containing the instruction ‘Take two tablets by mouth twice daily’.

Existing health literacy tests can be time consuming.^7,8 Simply asking patients about their education attainment is not sufficient, as the highest grade of education completed is often higher than the actual level of literacy. ⁹ Whilst there are some health literacy tests that are easy to administer (e.g. Rapid Estimate of Adult Literacy in Medicine (REALM)), patients often feel awkward or embarrassed in providing truthful responses. ¹⁰ Whereas not as accurate as the REALM, several studies have confirmed that asking a single question ‘How confident are you filling out medical forms by yourself?’ may be useful for detecting patients with inadequate health literacy. ¹¹ In the absence of screening, experts encourage health-care professionals to assume that all patients have low health literacy – ‘the lowest common denominator’. ¹² When using this approach, however, it is almost inevitable that patients with higher literacy levels will receive less detailed information regarding their condition, and the perceived insult can in itself provide a barrier to learning.

Sadeghi et al. ¹³ concluded in their article that medical jargon and time constraints are important barriers for proper communication between health-care provider and patient. In spite of addressing communication skills in medical curricula, most medical doctors are far from communication experts, the training is inconsistent and when it comes to daily practice, tight time schedules are more rule than exception. Most of us can only recall small bits of what is said during conversations, instructions and consultations. ¹⁴ What can we therefore expect with regard to active communication with patients, especially when time is limited, patients are older and the content of the conversation is unfamiliar and potentially anxiety provoking? Can we be confident that these patients are able to weigh the pros and cons before e.g. consenting for medical procedures?

Sadeghi et al. ¹³ report that patients themselves note factors such as family support, multimedia resources and other education programmes as encouraging of improved communication between patient and health-care provider. While the doctor may be seen as the ‘font of all knowledge’, it may be better to engage other health-care providers who have received specific skills-based training and have dedicated time (e.g. nurses and nurse practitioners). The use of case managers has been increasing over recent years. These designated case managers often serve as the patient’s companion within the complicated world of health care. They work as a mediator and ‘translator’ for all parties: the patient, physician and other health-care providers. Such a person is better placed to build a trusting relationship with patients, to explore the patients’ literacy levels and to adjust his/her communication to this level. Training in communication skills such as motivational interviewing may help the case manager to assist the patient’s ability to change behaviour and optimize their adaptation to the disease. Possible barriers for changing the lifestyles can be identified, and in partnership with the patient, a strategy can be defined to overcome these barriers.

In order to help deliver key health messages, an increasing variety of tools are available: from the written word to pictorial aids and online programmes. Pictograms are preferable over the written word in patients with low literacy, ⁶ although one should keep in mind that the use of pictograms requires care. Before images can be used with a population, it is preferable to validate and test the images to ensure that both patients and health-care providers perceive the pictograms in a similar way. ⁶ Some detailed information just can not be covered using only pictograms. Use of both written and verbal communication might be the most effective way of increasing patient understanding and therefore compliance. ⁶

Before providing written material, it is preferable to test it for readability. There are a number of ‘ease of reading’ formulas that enable an assessment of the readability. Examples of formulas can be found in the following website: www.readabilityformulas.com/free-readability-formula-tests.php.

One example is the Flesch Reading Ease Readability Formula that provides a score from 0 to 100 with higher scores indicating easier to read texts. Another example is the Simple Measure of Gobbledygook (SMOG index) that estimates an American school grade level (e.g. a score of 7.4 indicates that the text is understood by an average student in 7th grade). Reading formulas is commonly based upon sentence length and the frequency of polysyllabic words within the text and as such does not include familiarity of words or context of information. Hence sentences that are similar in number of characters/words and frequency of polysyllabic words will score the same despite the information being conveyed. Paradoxically, the standard instructions for medication e.g. ‘Take two tablets by mouth twice daily’ score high in terms of ease of reading (Flesch reading ease score = 91; SMOG score = 3), yet in practice is commonly misunderstood. ⁵

Sadeghi et al. ¹³ acknowledged that health literacy has an important role within self-management programmes. The relationship between health literacy and the capacity to learn COPD self-management skills is rarely explored, but it is most likely that patients with low literacy levels are less suitable (maybe even not suitable) for self-management programmes. Action plans are an important component of self-management programmes. Whilst examining the efficiency of COPD action plans, it is apparent that feedback between the health-care provider and the patient regarding use of action plans is of importance to increase the confidence and competence of patients to use action plans correctly. ¹⁵ The latter is illustrated by the lack of effect when just handing out COPD action plans with limited instructions. ¹⁶ Before implementing action plans, as with other comparable tools, it is very important to know more about their usability. Unfortunately, action plans often include flow charts and are therefore more difficult to test with reading formulas such as the SMOG. Rigorous testing of their usability in the target patient population is therefore highly recommended.

Sadeghi et al., ¹³ provided important information regarding barriers to effective communication with people with COPD. The development of effective strategies to overcome these barriers and optimise communication strategies within health-care community needs to be a priority if we are to maximise current and future management plans.