Review of health literacy education, training tools and resources for health providers

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2. Communication in health care contexts

Health professionals rely heavily on spoken and written communication. This section is an overview of the health care context and the strategies that health professionals can use to improve the quality of communication with their patients, leading to more effective patient–provider interactions, a better environment for the use of health literacy tools and, ultimately, improved health literacy.

2.1 Patient-centred communication

The patient–provider relationship is highly reciprocal, with both parties having an influence on each other and the medical exchange (Roter 2005). Patient empowerment is an important component of this exchange but little attention has been given to how health professionals can support the empowerment process. The communication strategies that health professionals use can either reinforce a communication-limiting cycle characterised by patient passivity, dependence and reticence, or facilitate more open, patient-centred communication characterised by full engagement and active collaboration in the medical exchange (Roter 2005).

A key aspect of patient-centred communication is tailored communication (Kripalani and Weiss 2006; Weiss 2007; Hironaka and Paasche-Orlow 2008; Sudore and Schillinger 2009). Tailoring communication starts by asking patients what they already know about the topic of discussion and linking new information to this existing knowledge. Connecting new information to existing patient knowledge gives meaning to the new information. It is an important part of the patient–provider exchange (Kripalani and Weiss 2006; Doak et al 1996). The challenge for health professionals is to find a connection that is both familiar and meaningful to the patient but that also expresses the point the health professional wants to get across (Doak et al 2006).

A number of health literacy experts claim that the patient-centred approach to the medical exchange helps uncover possible knowledge gaps and could save time if done correctly (Doak et al 1996; Weiss 2007; Sudore and Schillinger 2009).

Doak et al (1996) also highlight the importance of helping patients to anticipate the next steps in their particular health situation. Providing orientation on what to expect within their particular health context facilitates patient empowerment and makes the experience less traumatic and more manageable, especially for patients with low health literacy or for those from a different cultural background.

2.2 Spoken communication

The quality of spoken interaction between patients and health professionals is crucial to health literacy. Spoken language is our main form of communication, and patients with poor reading skills may better understand a spoken message. Spoken interactions are also context-rich and rely on more than words to communicate information and meaning, with tone, body language and gestures all playing an important part (Zarcadoolas et al 2006). On the other hand, Vandergrift (2006) argues that speech is ephemeral and once the interaction is over there is nothing left except the memory of what was said (which may be incomplete). Further, the listener does not have the option of reviewing the information presented and has little control over the rate of speech.

Zarcadoolas et al (2006, p90) acknowledge the fleeting nature of spoken interactions and for this reason recommend that spoken messages “contain facilitators such as brevity, narrative structure and repetition”. There is a reliance on patients being able to accurately recall, interpret and apply spoken information as they manage their health. However, it can be difficult to remember health information, with Kessels (2003) reporting that 40–80 percent of spoken medical information provided by health professionals is forgotten immediately.

Sudore and Schillinger (2009) assert that spoken communication must be clear and recommend that providers slow down their speech, avoid medical jargon and attempt to prioritise or limit their information to three points or fewer. Using plain language when talking to patients is a strategy recommended by a number of health literacy experts as it creates opportunities for dialogue between the patient and the provider, rather than limiting the encounter to a provider monologue (Rudd et al 2007; Weiss 2007; Sudore and Schillinger 2009).

These same experts agree that overwhelming the patient with too much information is a common provider communication error (Rudd et al 2007; Weiss 2007; Sudore and Schillinger 2009). Given that most patients only remember a few pieces of information from each medical encounter, it is important that professionals limit and structure the amount of information they give their patients. Addressing the patient’s main concern which is often ‘what do I need to do?’ instead of ‘what do I need to know?’ helps tailor the message to the individual patient and keeps the exchange focused on the patient (Sudore and Schillinger 2009). Weiss (2007) emphasises the importance of not withholding important information but rather prioritising the information to the few most important points the patient needs to know during that particular encounter. The rationale behind this approach is that, “advice is remembered better, and patients are more likely to act on it, when advice is given in small pieces and is relevant to the patient’s current needs or situation” (Weiss 2007, p32).

There will always be a tension for health professionals whose contact with a patient may not be ongoing, which may mean that health professionals feel they need to pass on significant amounts of information to patients during a single interaction. In these cases, health professionals still need to take a patient-centred approach and consider how to provide information for the patient at the time of the interaction and how other sources of information can be provided where the patient can obtain further information at a later time.

This will also be a concern where patients have complex or multiple conditions and health professionals need to ensure an ongoing relationship with patients.

2.3 Written communication

Principles of good communication are important in written texts. According to Weiss (2007, p35), “the readability of consent forms and patient education handouts has received more attention than perhaps any other health literacy issue”. Weiss adds that a multitude of studies show that there is often a mismatch between patients’ reading skills and the reading skills needed to comprehend the written information provided (Weiss, 2007).

A common strategy to improve the effectiveness of written patient information is to take a plain language (or plain English) approach. This approach means that information is presented in such a way that the reader can find it quickly and can understand it the first time they read it (Ministry of Health 2012a). There are a number of plain language checklists available (Weiss 2007; DeWalt et al 2010). A detailed plain language checklist relevant to the New Zealand context is included in Rauemi Atawhai: A guide to developing health education resources in New Zealand (Ministry of Health 2012a).

In addition, a New Zealand checklist for plain language alternatives for medical words can be found in the publication Unravelling Medical Jargon (Write Limited 2012).

The Ministry of Health (2012a, p6) states that taking a plain language approach is not in itself sufficient when developing health education resources. It asserts that, “developing people’s health literacy skills means resources also have to include activities that build on existing knowledge by introducing new concepts, vocabulary and information”.

A plain language approach also involves assessing the readability of written information using readability tools such as Fleisch Kincaid and SMOG (Simple Measure of Gobbledygook). Readability tools focus on two aspects of the text – sentence length and number of multisyllabic words. The longer the sentences and the more multisyllabic words used, the higher the readability score, which mean the text is more difficult to read. The plain language approach posits that shortening sentences and replacing multisyllabic words with shorter words will make the text easier to read and understand.

In the United States in particular, readability scores are linked to school grade levels (children’s reading levels) and a view that all health materials should be written at a grade 5 level (10-year-old). However, in the health care context, there are many multisyllabic words that patients and families need to understand, eg, diabetes, insulin and eczema, and it is not possible to simplify these words. Instead these words need to appear in the text and be explained. This will often result in a higher readability score but the text will be easier for a reader to understand because of the explanations provided (Ministry of Health 2012a).

Weiss (2007) states that whatever written materials are used, the effectiveness of the materials will always be augmented if the provider uses additional strategies to build understanding of the materials instead of simply handing them over to the patient to read later. For example, strategies such as highlighting, underlining, circling or numbering key information will make the materials more meaningful to the patient.

In New Zealand, a review of publicly available gout medication resources found that many resources are filled with useful factual information but the presentation of this is often too densely worded, too long or written using health vocabulary that is not always well explained. The review also found that health professionals need to discuss resource content with patients and their families to ensure they understand important messages about gout (Ministry of Health 2012b).

Using design tools to support better understanding of information is especially important when presenting numeric or risk information. Sudore and Schillinger (2009) make six recommendations for improving communication of numeric or risk information. These are:

  1. using multiple formats to present information

  2. using a consistent denominator to help comparisons and avoid confusion

  3. presenting risk in terms of a timeframe that is meaningful to the patient, ie, a 10-year period instead of a lifetime

  4. giving absolute risks instead of relative risks

  5. presenting risk as a frequency instead of a percentage

  6. avoiding using only positive or negative framing and instead use both, eg, “5 in 100 are expected to get the outcome, meaning that 95 out of 100 will not get the outcome” (p4).

In New Zealand, as in other countries, health education resources are often designed with the initial part of the resource providing an explanation about a health condition, with action or instruction messages, such as what to do, provided at the end of the resource. This can mean that patients are overwhelmed by the amount of information provided and stop reading before they reach the part of the resource that tells them what they need to do and why.

Health education resources need to meet two primary objectives: ensuring that resources and messages are understandable to the audience and that resources help the audience develop the health literacy skills they need to understand and manage a particular health issue (Ministry of Health 2012a). A key component of developing a good health education resource is conducting a comprehensive needs analysis. A thorough understanding of the purpose of the resource is crucial, and comes from researching the need for a resource, defining the audience and spending time with the audience to clarify the audience’s needs and preferences prior to developing any draft resources. In practice, the first engagement with an audience often takes place during a focus group where the audience is asked to give feedback on draft resources. This makes it less likely that a resource reflects the priorities, needs and language of the audience.

Conducting a health literacy review is also highlighted as an important part of developing effective health education resources. This is done by identifying the literacy demands of the health issue and the literacy skills of the main audience. If done well, a developer will be able to decide how the resource can bridge the gap between the skills people have and the skills they need (Ministry of Health 2012a).

The challenges of developing the health literacy skills of patients go beyond the principles of plain language and good design. Other factors, such as cognitive load and learning theories, should be taken into account when designing educational interventions targeted to this group.

2.4 Using both spoken and written communication

Sudore and Schillinger (2009) highlight studies which show that providing both written and spoken information increases patient knowledge and satisfaction when compared with spoken information alone. Doak et al (1996), Weiss (2007) and Sudore and Schillinger (2009) also assert that visuals and pictures enhance patient understanding but emphasise that visuals and pictures are not substitutes for written or spoken communication and work best when combined with written or spoken explanations. Katz et al (2006) found that patients’ understanding of medicine labels and patient information sheets was significantly enhanced when written information was combined with pictures, in comparison to text-only information.

2.5 Cultural competence and health literacy

Internationally, Zarcodoolas et al (2006) describe cultural literacy as a component of health literacy and define cultural literacy as the ability to understand and use culture and social identity to interpret and act on information.

Kickbusch et al (2005) state that culture (including the culture of the health system) affects attitudes, perceptions and behaviours at both the patient and provider end, or for those receiving and delivering health services. Culture shapes language, perceptions, beliefs and behaviours, including those related to health and, in particular, health information, messages, treatment, decisions and actions. The Health Literacy Universal Precautions Toolkit (DeWalt et al 2010) lists religion, culture and employment as central components in understanding why patients make the health choices they do. Learning about patients’ ethnic backgrounds, cultural beliefs and religions, and the ability to apply this knowledge to shape the health encounter, shows cultural competence and enhances patient-centred care (DeWalt et al 2010).

Given that cross-cultural interactions in the New Zealand health sector are common, health providers need to be competent in communicating with patients whose cultures are different from their own (Medical Council of New Zealand 2006). Cultural competence is important for patient outcomes as the more a provider understands about a patient and takes into account when explaining treatments, the more relevant, meaningful and acceptable the treatment will be to the patient.

The New Zealand Medical Council outlines a number of standards that health providers need to demonstrate in order to be able to work effectively with patients from different cultures. These standards focus on Māori patients but the principles contained are relevant for other cross-cultural interactions as well. These standards were also designed for general practitioners to apply, but can be applied to other primary health care providers, including pharmacists.

Māori cultural competence standards include the following attitudes, awareness, skills and knowledge:

“A willingness to develop a rapport with Māori patients. The most effective way to understand the communities you serve is by establishing relationships with local Māori, including Māori health professionals in your area.

A preparedness to ask patients about their preferences and a willingness to follow their lead.

An awareness that Māori tradition strongly prefers face-to-face communication and an understanding that Māori place a greater emphasis on the spoken word.

An awareness that body language can be different between Māori and non-Māori. For example, direct eye contact can be seen as a sign of disrespect in Māori culture.

The ability to ask patients about their ethnic background. Asking the question not only demonstrates respect for the patient’s culture and heritage, but also affords an opportunity to discuss the patient’s cultural preferences.

The ability to involve whānau during consultations.

The ability to make sure that patients adequately understand their condition and treatment plan, and not simply rely on printed instructions.”

(Medical Council of New Zealand 2006, p3).

In the New Zealand context, Mauri Ora Associates Limited provides a range of cultural competency courses and training, including an online foundation cultural competency course that includes a module on health literacy.

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