Health Literacy

Studies show low health literacy is linked to poor health outcomes and is especially a concern for older adults.

What is Health Literacy?

You can find many definitions of health literacy, but this one from the National Library of Medicine is widely accepted:

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.

Health literacy depends not only on the skills of the patient. Health literacy also depends on the ability of health care professionals to communicate effectively, in a manner which can be understood by the patient.

What are the consequences of low health literacy?

Low health literacy is clearly linked to poor health outcomes. According to a fact sheet from the United States Department of Health and Human Services, people who have limited health literacy skills:

• are less likely to use preventive care
• are less able to manage chronic conditions
• are more likely to visit the emergency department
• are more likely to be hospitalized
• are more likely to report their health as poor

Who is at risk for low health literacy?

In the United States, a 2006 report from the Department of Education, based on the 2003 National Assessment of Adult Literacy, estimates that only about 12% of the adult population are proficient in health literacy. The healthcare environment is becoming more complex at the same time the health care consumer is expected to assume more responsibility for his or her own care. Probably everybody will encounter some health literacy issues at some point. Still, we know that some segments of the population – including older adults – are more likely to experience poor health literacy.

Why are older adults at more risk than other people?

Older adults scored the lowest of any age group on the health literacy portion of the 2003 National Assessment of Adult Literacy. Only 3% of older adults scored high enough to be considered proficient, while nearly 30% scored at the lowest level: "below basic."

Older adults are also far more likely to have multiple, chronic health conditions. The combination of their more complex healthcare needs and their lower health literacy skills is a dangerous combination.

Further Reading – Major Health Literacy Resources

• Clinical-Community Linkages. Agency for Healthcare Research and Quality, Rockville, MD.
• Health Literacy: A Prescription to End Confusion. 2004. Institute of Medicine, National Academies Press, Washington, DC.
• Health Literacy Universal Precautions Toolkit. June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
• National Action Plan to Improve Health Literacy. 2010. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Washington, DC.
• Patient Education Materials Assessment Tool (PEMAT) and Users' Guide. 2013. Agency for Healthcare Research and Quality, Rockville, MD.
• Teaching Patients with Low Literacy Skills. 2nd ed. 1996. Doak, Doak, & Root. Lippincott Williams & Wilkins, Philadelphia, PA.

What Does the research say?

Berkman ND, Sheridan SL, Donohue KE, et al. Agency for Healthcare Research and Quality. Health literacy interventions and outcomes: an updated systematic review. 2011 March Evidence Reports/Technology Assessments no.199.

Sudore RL, Schillenger D. Interventions to improve care for patients with limited health literacy. Journal of Clinical Outcomes Management. 2009 Jan 116(1):20-29.

Today's healthcare environment places many demands on patients. We are expected to take an active role in decisions about our treatment and goals even as rapid technological advances complicate nearly every decision. Health literate patients must be comfortable talking to doctors and other providers in order to get the information needed to make good decisions.

Effective Communication

How can we help older adults gain the skills they need to effectively communicate with their healthcare providers?

The resources of the National Institute on Aging are a great place to start. Here you'll find:

• Everything you need to host your own 45 minute presentation on Talking with Your Doctor, including a PowerPoint presentation, a script for the presenter, and handouts for the participants. You don't need any special training – there's even a list of tips for preparing for the presentation.
• The section What do I need to tell the doctor? to help older adults plan for their next doctor's appointment. You can also find information on choosing a doctor.
• Finally, you may be interested in Talking with Your Older Patient, which offers practical advice for doctors and other providers who work with older adults.

The Agency for Healthcare Research and Quality (AHRQ) is another place to look:

• Taking Care of Myself: a Guide for When I Leave the Hospital can be printed out and used to keep track of everything a patient needs to know as they leave the hospital: medications, upcoming appoints, contact information, and instructions on diet, exercise, and questions to ask the doctor. You can also order bulk quantities of the booklet for a small fee.
• The Question Builder is an online tool that helps a patient prepare for a doctor's visit by guiding the user through a set of questions that should be answered at the visit. The result is a customized list of questions to take along.

Additional Resources

• These videos from AHRQ show both patients and doctors talking about the importance of asking questions. Several of the videos feature older adults.
• The Ask Me 3 program from the National Patient Safety Foundation. Do you know the three questions?
• Be a Prepared Patient, from the Center for Advancing Health, includes a section on getting the most out of your appointment, as well as advice on medication management and health insurance issues.
• The Patient's Toolkit for Diagnosis, found on patient-experience.org helps patients keep track of symptoms, tests, questions to ask, and medications.

Did you know that studies show that nearly 30 percent of hospital admissions among older adults are medication-related? Many older adults take multiple medications and have complicated dosing schedules.

Helping the older adults you serve to manage their medications may be one of the most valuable things you can do.

Here are some tools to get you started:

• Be a Prepared Patient, from the Center for Advancing Health, includes a section on understanding your prescriptions, as well as advice on communicating with your doctor, and health insurance issues.
• Medication Safety for Women from the Food and Drug Administration offers basic information, and links to booklets and brochures about medication safety, including a medication record.
• Making a Medication List Makes You Smart, created by the American Society of Health-System Pharmacists, offers a printable form for you to create a medication list. This site also provides links to other medication list making resource.
• My Medication Record (PDF), also from the FDA, is an extensive, four page medication record that you can print out.
• Taking Care of Myself: a Guide for When I Leave the Hospital, a booklet from the Agency for Healthcare Research and Quality (AHRQ), can be printed out and used to keep track of everything a patient needs to know as they leave the hospital: medications, upcoming appoints, contact information, and instructions on diet, exercise, and when to call the doctor.

Sources

Marek KD, Antle L. Medication Management of the Community Dwelling Adult. In: Hughes RG, editor. Patient Safety and Quality: an Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US) 2008 Apr. Chapter 18.

Do you know how to find trustworthy sources of health information? Are you able to show older adults and their caregivers where to find the information they need?

Helping Older Adults Find Health Information

Many of us turn to the Internet for health information, but an expert panel convened by the Centers for Disease Control reported that many older adults do not use the Internet. They may be unfamiliar with the computer, or they may have cognitive or vision issues which make using the computer difficult.

While you may be able to teach some willing older adults to find health information for themselves, it may be even more valuable for you to learn how to find the best information for them.

Health Information Resources

• MedlinePlus from the US National Institutes of Health (NIH), includes an extensive collection of health information materials. Look for the special "Easy to Read" section.
• A to Z Health Topics Index from the National Institute on Aging (NIA), provides links to downloadable "AgePage" pamphlets and other NIA resources on a variety of health related topics.
• Need to Know by Niche, a series of booklets on popular topics, designed by NICHE – Nurses Improving Care for Health System Elders

Video Resources

Many older adults have difficulty with printed materials you may find that video resources work well with this population.

• MedlinePlus includes a variety of videos and tutorials.

Evaluating Health Information Resources

If you are selecting health information materials to share with older adults, you will need to evaluate them not only for accuracy and reliability, but also for health literacy. Here's where to learn about evaluating health information resources for older adults:

• How to Write Easy-to-Read Health Materials – While these guidelines from Medlineplus.gov were created for authors, they give a helpful overview of what to look for when selecting health information.
• Making it Work: Selecting Health Information Brochures for Adults, by Helen Osborne of Health Literacy Consulting, offers tips for evaluating printed materials.
• Patient Education Materials Assessment Tool (PEMAT) – You may want to familiarize yourself with this tool from the Agency for Healthcare Research & Quality (AHRQ). The PEMAT is a systematic tool to aid in assessing written and audio-visual tools.

We may need to think about another kind of literacy: health insurance literacy.

According one definition, developed by a group led by the Consumer's Union, and published in their report Measuring Health Insurance Literacy: a Call to Action, health insurance literacy is "the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family's) financial and health circumstances, and use the plan once enrolled."

Health Insurance and Medicare Resources

Many people, including many older adults, need help finding their way through the Medicare and health insurance mazes. Here are some resources you can use to help find the right path.

• Benefits Checkup – this website from the National Council on Aging is not specifically about health insurance, but it's a great place to find programs to help those in need pay for medicine, health care, and food.
• From Coverage to Care – a great series of booklets and videos to help introduce people to how health insurance works. You can print the booklets out yourself. The booklets and videos are all available in both English and Spanish.
• Health Insurance Glossary – from healthcare.gov, explains dozens of commonly used insurance terms.
• HealthCare.gov – this collection of informational articles can answer many questions about the health care marketplace.
• Medicare.gov – the official Medicare site should be the first stop for current and prospective Medicare customers.
• MedlinePlus – the MedlinePlus health insurance page is a clearinghouse for a wide-ranging variety of health insurance resources. You can find brochures, videos and tutorials, as well as many links to carefully selected websites.
• My Medicare Matters – from the National Council on Aging, is a great resource for learning about Medicare. It is particularly useful for those new to Medicare.

Teach-back is an evidence-based method of ensuring that the listener understands your health-related message.

The Method

Many studies have shown that most spoken medical information is quickly forgotten, or incorrectly remembered. A 2003 article by Roy Kessels, Patients' Memory for Medical Information, describes how recall and understanding decrease with age. Stress and anxiety further limit a person's ability to remember spoken information. According to Kessels, only about 14 percent of spoken medical instructions are remembered correctly.

Teach-back is an evidence-based method of ensuring that the listener understands your health-related message. By asking your listener to explain the information back to you, you can assess and confirm their understanding of the material you've presented.

• To see some examples of teach-back in action, watch these videos from the North Carolina Program on Health Literacy.
• Always Use Teach-back, a website created by the Iowa based UnityPoint Health, and Health Literacy Iowa, includes a teach-back toolkit, an interactive learning module, and an extensive list of resources.

Is there a way to measure how well we are communicating? Can we track how well we are doing?

The CAHPS Item Set for Addressing Health Literacy may help start with the appendix beginning on page 4 of their website. The survey asks 31 questions. A shorter version, with only 5 questions, may tell you what you need to know. Ask your patients to rate how well you communicate health information to them.

• Are your instructions about how to take medications easy to understand?
• Do you use teach-back?
• Do you give your patients a chance to talk about their questions and concerns?

Teaching Health Professionals About Health Literacy

Are you interested in learning more about health literacy? Perhaps you want to teach other health professionals. Or maybe you would like to earn some continuing education credits. Here's how:

Start here:

• Health Literacy – Find Training (CDC) is a great guide to health literacy, plain language, and cultural competence training. Resources from the CDC are highlighted, but a resources from a variety of sources are included.

Here are a few more websites:

• Cultural Competency and Health Literacy: a Guide for Teaching Health Professionals and Students, the "Maryland Primer," provides resources and a framework for teaching about health literacy.
• Ohio State University Health Literacy Distance Education offers CE credit for nurses and others. There are 12 modules available, including one specifically on working with older adults. There is a registration fee, plus an additional fee for each module. Modules offer from 1.0 to 1.5 contact hours.

Graphs and charts:

• Icon Array is a great tool from the University of Michigan for creating charts to help explain risk.
• Visualizing Health is another fascinating tool, also from the University of Michigan, Visualizing Health helps you create your own graphic displays of health data.