Incorporating the Patient into Education: Are you Planning to ‘Win it’ or Are you ‘in it to Win it’?

“Shared decision-making”

“Patient-centered care”

“Patient perspectives”

“Patient voice”

These phrases have buzzed around the continuing professional development (CPD) community for years, especially when it comes to discussions on best practices in developing educational strategies that affect health outcomes. But are we doing enough to embrace and develop education that is truly effective, accessible, and meaningful to patients? 

The short answer: We could do more.

Health Literacy

What We Know

The US Department of Health and Human Services defines health literacy as “the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Health literacy has become an especially hot topic owing to changes in the US healthcare system and calls to action for the better engagement of patients in their care plans. It is not enough for patients to be able to understand the health information that they read and hear; patients need to use that information to make informed care decisions, to manage their care, and to navigate the healthcare system.

In 2006, the National Assessment of Adult Literacy (NAAL) published data on a nationwide literacy survey. The survey categorized the health literacy of 19,714 adult participants into four performance levels: Below Basic, Basic, Intermediate, and Proficient. Even when excluding data from patients who were non-English speakers and from patients with mental or cognitive disabilities, the survey found that 22% of participants had “basic” health literacy and 14% of participants had “below basic” health literacy, as defined by the NAAL. For example, these participants were unable to accurately determine the time to take a medication based on information found on a pill bottle. Only 12% of all survey participants were “proficient” in health literacy, according to the NAAL.

Low health literacy is associated with poor overall health, poor management of chronic diseases, an increased risk for hospitalizations, higher rates of emergency-department use, and an increased risk for mortality. Patients with low literacy are less likely to engage in shared decision-making, and healthcare professionals (HCPs) may wrongfully attribute signs commonly associated with low health literacy (Table 2) as patients’ lack of motivation in improving health or engaging in self-care.

Still, HCPs only occasionally assess whether patients understand the instructions given to them. Experts suggest a variety of factors may impede assessment, including: language barriers; the overabundance of health literacy measurement tools; screening tools that aren’t universal or suitable for certain departments; and HCPs’ overconfidence in addressing health literacy issues.,,,,,, Even when asked whether they understand instructions, patients are often reluctant and embarrassed to admit confusion. 

What We Can Do

Create a level of awareness/cognitive dissonance among our HCP learners that health literacy is impeding their patients’ health outcomes. Provide education and training on health literacy and evidence-based counseling methods that assess and improve patient recall, memory, and comprehension. Health-literacy–assessment tools that can be conducted at point-of-care in less than a few minutes include the Rapid Estimate of Adult Literacy in Medicine (REALM),  Single Item Literacy Screener, and Newest Vital Sign (NVS). The Teach-Back method and the Ask Me 3® method are simple, quick counseling strategies that address comprehension concerns without judgement or embarrassment. (Information on the Teach-Back Method can be found here. Information on the Ask Me 3® method can be found here.) These tools can be easily incorporated into CE/CME activities, particularly with case studies and patient simulations. Additionally, we should work with faculty to develop content that promotes “plain language” discussions with patients; this is a proven communication style that strips away medical jargon and terminology and uses everyday examples to aid in patient comprehension.,, 

Reading Levels and Comprehension Levels

What We Know

Regardless of health literacy levels, patients recall only about half (49%) of the decisions and recommendations made during a healthcare visit. Enduring patient-targeted materials are used frequently to improve patient recall and to reinforce care instructions. However, studies show that, regardless of the disease state, health topic, or delivery format, these materials are consistently written at reading and comprehension levels that far exceed patients’ capabilities.

Many assume that reading levels and comprehension levels are the same as the person’s last completed school year, but this is often incorrect. Although the majority of US adults have obtained at least a high school diploma, the reading level of the average US adult is between 7th and 8th grade. 

The National Institutes of Health recommend that materials intended for patients be written between a 7th and 8th grade reading level, while the American Medical Association recommend that these materials be written at a 6th grade reading level and the Joint Commission recommends that these materials be written at or below a 5th grade reading level. Yet, general healthcare materials that patents need to read — e.g., informed consent forms, prescription labels — is written at a 10th grade or higher reading level, and most patient-education materials significantly exceed a 6th grade reading level.,,,,,,,

Reading levels don’t equate to comprehension levels. One study assessed the phrase "Take two tablets by mouth twice daily". Of those with a reading level at or below 6th grade, 71% were able to read and explain the phrase, but only 35% could demonstrate how many pills were to be taken per day. A person’s comprehension level is often 1 to 2 grade levels lower than that person’s reading level. Comprehension levels drop even lower in times of anxiety or stress — experiences that are not uncommon during medical visits.

What We Can Do

Test the accessibility of our patient education. Although they are not without limitations, programs such as Microsoft Outlook and Microsoft Word allow users to run the Flesch Reading Ease test and Flesch-Kincaid Grade Level test on documents to test readability; the latter pinpoints the US grade level of readability for the text. Other readability tests and readability formulas can be found online, often with free “calculators” for ease of testing. A good place to start is ReadabilityFormulas.com. (For full disclosure, the reading level of this article is “college – graduate college”.)

Scientific writers and patient-education writers can different skill sets. Do not assume that your scientific writer or faculty can simply put on a different hat and write content for patients. The writer of any educational content intended for patients needs to be experienced at writing at a 4th to 6th grade reading level, have knowledge of the issues that the patients are facing, know how much information is enough, understand when to include pictographs, and be familiar with personalized decision aids. Don’t look to reinvent the wheel. If your organization does not have the resources or specific skill sets necessary to develop effective, accessible patient-target materials, look for partners who do. 

Conclusion

As a community, we need to look at the educational needs and barriers of patients — including health literacy, reading, and comprehension challenges — with the same vigor and resolve as we do for the needs and practice gaps with our HCP learners. It’s time to hold ourselves accountable for the patient-targeted materials that we produce and reflect on whether these materials are accessible and meaningful to all patients … or are just more noise in a sea of ineffective health information. Activating and advancing our own competencies to provide content and resources aligned with patient health literacy and understanding is certain to improve health outcomes.

References

Note: Since the functionality of cross-referencing in Word is not fool-proof, I did not cross-reference. References are completed using the “EndNote” function in Word, thus there are duplicate entries.