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Assessing Health Literacy in Clinical Practice


Assessing Health Literacy

The ability to communicate effectively with patients who have limited health literacy offers the potential to improve their understanding about their medical problems and what they need to do about them, and thus enhance their health status. Evidence is emerging that use of specific communication techniques with individuals who have low health literacy can result in better health outcomes -- such as improved diabetic control when clinicians use the "teach-back" technique to verify that patients understand what they need to do. [59] Table 2 shows other recommended techniques for enhancing communication with patients who have limited literacy skills. [60]

Table 2. Techniques Recommended for Improving Communication With Patients Who Have Limited Health Literacy

Communication Method Comment
Talk more slowly Communication is enhanced when patients have more time to absorb what is being said.
Use nonmedical language Unless patients have personal experience with a particular medical illness, they have no reason to be familiar with medical terms that pertain to that illness. Explain things to patients in simple terms, like you might explain them to your grandmother.
Limit information Research shows that patients recall only a fraction of what clinicians tell them -- often because clinicians give them too much information. Recall is enhanced if information is limited to 2 or 3 key points and these points are repeated.
Use "teach-back" Ask patients to repeat what you told them about what they need to do, to verify that they understand correctly.
Encourage questions Individuals with low literacy tend to lack self-empowerment and often will not spontaneously ask questions. You need to encourage them to do so.
Adapted from: Weiss BD. Health Literacy and Patient Safety: Help Patients Understand: A Manual for Clinicians. 2nd ed. Chicago, Ill: American Medical Association Foundation and American Medical Association; 2007.

The problem is, however, that few clinicians recognize the prevalence of limited health literacy among their patients. In fact, several studies have shown that clinicians markedly underestimate the prevalence of limited health literacy among patients they see, and that even after spending time in an exam room with patients, they are unable to correctly identify those with limited health literacy or who did not understand what they were told. [61-64]

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Republished with permission of Terry C. Davis, PhD

The question thus emerges as to whether and how to identify patients who have limited health literacy. The sociodemographic risk factors discussed earlier, with perhaps the exception of failure to complete high school, are neither sensitive nor specific enough to use them to "label" particular patients as having limited health literacy. However, patients sometimes say things or exhibit behaviors that serve as clues that they have limited health literacy. There are a number of techniques that can be used to estimate the rate of limited health literacy in a practice or even assess the health literacy skills of individual patients. This section of the article will discuss those exam room clues and health literacy assessment techniques.

Examination Room Clues to Limited Health Literacy

Communication experts have pointed out that patients with limited health literacy sometimes provide clues to their literacy skills. These clues fall into 3 categories: (a) responses to receiving written information; (b) responses to questions about medication regimens; and (c) specific behaviors.

Responses to written information. Individuals with limited literacy often develop socially acceptable ways to avoid having to read in the presence of others. For example, when presented with written forms or handouts, individuals with limited literacy will sometimes say things like: "I forgot my glasses so I will read this when I get home" or "Let me bring this home so I can discuss it with my children." Others will attempt to read and complete written forms but will complete them incorrectly or with strange or inappropriate responses.

Responses to questions about medications. Patients who have limited health literacy may be unable to provide the names of their medications or explain what their medications are for. They are also often unable to explain the timing of how their medications should be taken.

Behaviors. Because they lack understanding of what they need to do, patients with limited health literacy may miss follow-up appointments or fail to follow through with tests and referrals. They also may fail to adhere to recommended medication regimens. [65,66]

When a patient presents any of these examination room clues, the clues should serve as "red flags" that the patient likely has limited literacy skills. Unfortunately, while these clues are useful when present, the vast majority of patients with limited literacy will not exhibit them -- so these clues are insufficiently sensitive to permit identification of patients with limited literacy skills.