This section is an overview of evidence-based health literacy education and training tools and resources for health professionals. Due to the lack of examples of health literacy initiatives from New Zealand, this section draws on tools and resources mostly developed and used in the United States. These tools are drawn from a toolkit and a collection of health literacy interventions, as well as references in professional development materials (DeWalt et al 2010; Sheridan et al 2011; Berkman et al 2011; Kripalani and Jacobson 2007; Shoemaker et al 2011).
Several systematic reviews of health literacy interventions have been undertaken in the United States (Sheridan et al 2011; Berkman et al 2011). Sheridan et al (2011, p49) identified that there were “several discrete design features that improved participant comprehension in one or a few studies (e.g. presenting essential information by itself or first, presenting information so that the higher number is better, presenting numerical information in tables rather than text, adding icon arrays to numerical information, adding video to verbal narrative)”.
In addition, the authors identified “the design features that facilitate intervention success. For instance, common features of interventions that changed distal outcomes (e.g., disease biomarkers and hospitalizations) included their high intensity, theory basis, pilot testing, emphasis on skill building, and delivery by a health professional, for example, a pharmacist or a diabetes educator” (Sheridan et al 2011, p50).
Berkman et al 2011 (p5) identified that, “effective interventions to mitigate the effects of low health literacy may work by increasing knowledge and self-efficacy or by changing behaviour”.
3.1 Finding out what patients already know
Patients come to each health encounter with existing knowledge which needs to be taken into account during the encounter. This knowledge is represented or organised in long-term memory as sets of information or schema (Anderson 2004). When patients receive new information (whether verbally, through reading or a combination of both) they relate this new information to what they already know or have experienced. This is how new knowledge is created. There are two types of sets or schema – content and textual (Singhal 1998). Content schemas are about knowledge of the world including personal, day-to-day knowledge as well as specialised knowledge. Textual schemas are about how texts (both spoken and written) are organised in terms of structure, vocabulary and tone. Both schemas are important. Patients’ schemas are activated when they receive new information. However, if that information does not relate to their existing content or textual schemas, then the information will not be added to existing schema and could be rejected. For example, if a health professional starts talking about the need to take medicines and the patient already believes (knows) they can manage their condition through lifestyle factors, the patient will need to be provided with information about risks and benefits of medicines if the patient is to modify their schema and add the new information. In a similar way, if patients are used to receiving information in a particular format, and that format is changed to another less familiar format, their textual schema may not help them get information from the new format.
Health professionals need to find out their patient’s schema at the beginning of each health encounter so a health professional can find a way of adding new information to existing schema. This is as straightforward as asking, “What do you know about ...?”
In the same way, health professionals also need to match their language to the patient’s language and then extend the patient’s language with the introduction of essential technical vocabulary and explanations.
Finding out what patients already know is part of the universal precautions approach because it assumes that all adults have some prior knowledge or experience to build on. It also gives health professionals useful information about where to start the health dialogue.
3.2 Checking understanding or teach-back
Doak et al (1996) state that a health professional’s ability to get meaningful feedback from patients is crucial to effective communication. The use of open-ended questions and the teach-back method to confirm patient understanding empowers patients to be more actively involved in the encounter which will give the health professional better information about how the patient is currently managing their condition. Teach-back is also known as ‘teach-to-goal’ or ‘closing the loop’ (Sudore and Schillinger 2009; Weiss 2007; DeWalt et al 2010).
Checking and confirming patient understanding is one of the most important aspects of good communication. However, many providers fail to do this (Sudore and Schillinger 2009). Many providers make the mistake of simply asking, ‘Do you have any questions?’ or ‘Does that make sense?’ as a way of seeking confirmation. Asking closed questions such as these has been shown to be an ineffective way to gauge patient understanding, as patients are most likely to answer in the positive, even when they don’t understand (Weiss 2007). Instead, asking, ‘What questions do you have?’ facilitates patient empowerment by conveying to them that it is normal to have questions. As a result, the patient is more involved in the medical encounter (Sudore and Schillinger 2009).
Following any discussion generated by patient questions, checking patient understanding can be achieved using the teach-back method. Sudore and Schillinger (2009, p3) define the teach-back method as a “technique in which the clinician asks the patient to restate or demonstrate the knowledge or technique just taught”. When done well, the teach-back method is an effective tool in confirming that the provider has given a clear explanation in a way that is understandable to the patient (DeWalt et al 2010). Schillinger et al (2003) recommend that providers de-stigmatise the encounter by placing the onus of clear communication on themselves. Health professionals can take responsibility for the encounter by framing their enquiry appropriately. For example, “I’ve just said a lot of things. To make sure I’ve covered everything and explained things clearly, can you describe for me what you need to do?”
Weiss (2007) states that if patients cannot explain or demonstrate what they should do, health professionals must assume that they did not provide the patient with adequate explanation. In these cases, new efforts are required to ensure patient understanding. Studies have established that, when used effectively, the teach-back method does not result in longer medical encounters, but does improve patient understanding and outcomes (Schillinger et al 2003; Weiss 2007).
Teach-back is the most widely referred to health literacy intervention. However, it needs to be introduced slowly and those using it need to practise to become confident with this technique (DeWalt et al 2010).
Reviewing medicine is an opportunity for health professionals to discuss the medicines a patient is taking and helps health professionals identify and answer patient questions, confirm what medicine a patient is taking, identify and/or avoid medicine errors and assist a patient to take their medicine correctly (DeWalt et al 2010).
Medicine reviews, also known as brown bag reviews, are a patient-centred practice that encourages patients to routinely bring in all their medicines and supplements to every medical appointment. Bringing in the actual medicines, rather than asking patients to provide a list of medicines, places a lower health literacy demand on the patient who may have poor writing skills or be unsure about what to include on a list. A medicine review provides an opportunity to review how the patient interprets medicine labels and instructions and to check understanding about side effects and interactions.
The importance of asking questions has already been referred to in relation to checking, understanding and teach-back. Health professionals are trained to use closed diagnostic questions (requiring ‘yes’ or ‘no’ answers or very specific short answers) and shifting to using open-ended questions diverges from that training. As with teach-back, health professionals need time to practise using open-ended questions, such as, “Most people have lots of questions, what questions do you have?” instead of, “Do you have any questions?” or “Do you understand?”
Patients are more likely to understand, remember and act on health information if it is presented in a logical sequence, such as problem, action, rationale. However, in the same way as plain language, information is not sufficient on its own to build health literacy. Information needs to be accompanied by appropriate support in order for patients to understand and use that information (The Health Foundation 2011).
3.6 Helping patients anticipate the next steps
Explaining to a patient the next steps they will be taking in relation to a health issue enables that person to better navigate the system, answer questions, anticipate what might be asked of them and understand how long it could take to get test results and the importance of follow-up appointments or procedures (Doak et al 1996). Anticipating the next steps draws on adult learning principles that an adult is intrinsically motivated to learn independently where the learning is directly related to that adult’s day-to-day life.
3.7 Using written materials effectively
Written materials have already been discussed in Section 2 of this review. If written materials are going to be used to reinforce new information then health professionals need to link the written material to the spoken information given by highlighting, marking or otherwise indicating the relevant information.
Reinforcing new or important information relates to the issue of working memory and cognitive load (Kessels 2003; Ngoh 2009; Baker et al 2011). Patients may need to be reminded of critical information on a number of occasions before it is part of their working memory. The need for reinforcement can be identified by checking understanding (using teach-back), as well as asking patients what they know about their condition or treatment. Reinforcement should also be used if, as a result of checking for understanding (using teach-back), it becomes apparent that the patient does not recall all the information given. In this situation, the piece of information that is missing should be reinforced by the health professional.
Reinforcement can be used to refer to a critical step or piece of information, as well as acknowledge that patients have developed new knowledge and behaviours.
3.9 Action plans
An action plan outlines the steps that a patient needs to take to achieve their health goal. It is created by the patient and provider. In helping patients integrate these steps into their daily lives, action plans allow patients to be actively involved in their own care and have been shown to be effective in bringing about desired behaviour change (DeWalt et al 2010). Patient motivation is a crucial component of an effective action plan. The patient must be motivated to change their behaviour and the central goal must be determined by the patient. If the goal is not important to the patient then the desired behaviour change will be difficult to achieve. Goals need to be small, specific and realistic for the patient, and the timeframe for re-evaluation should be short. Follow-up by the health professional is important to show a genuine interest in helping the patient achieve their goal (DeWalt et al 2010).
Research shows that 20–50 percent of patients do not take prescription medicine as directed (Kripalani et al 2007; Ngoh 2009; Viswanathan et al 2012). Patients with limited health literacy are less likely to know how to take their medicines and more likely to experience difficulty in following complex medicine regimens. Improving patient understanding around medicines and how to take them can reduce the number of medicine errors and increase a patient’s ability to care for their illness. This is especially true in the case of chronic illness (Kripalani et al 2007; DeWalt et al 2010; Viswanathan et al 2012). Ngoh (2009) states that poor medication adherence is not simply a patient problem; health professionals including pharmacists are also involved. Although no single intervention has been shown to improve the medication adherence of all patients, research shows that several factors are key to improving patient medication adherence, including clear and effective communication from health professionals (including pharmacists) and the presence and nurturing of trust in the relationship between health professionals (including pharmacists) and patients (Ngoh, 2009).
Kripalani et al (2007) claim that self-efficacy is an important consideration when seeking to enhance patients’ medicine understanding and adherence, and can be built through the simplification of certain behavioural steps while providing an opportunity to rehearse these steps. Their research suggests that an illustrated medicine card (pill card) created at the point of care (where the health professional is either prescribing or dispensing the medicine) is considered valuable by patients, especially by those with marginal literacy skills. Pill cards use pictures and short, simple phrases to show each medicine, its purpose, the correct dose and when to take it (DeWalt et al 2010). Pill cards are not appropriate for medicines that are to be taken ‘as needed’, as they do not require daily adherence (Jacobson et al 2008). The feasibility of pill cards as a tool to enhance patients’ medicine understanding and adherence is reinforced by Blake et al (2010), who found that use of an illustrated medicine schedule was beneficial in a pharmacy setting. The study also highlighted the importance of providers being well trained in clear communication and adequate resources being available to ensure the successful implementation of the intervention. In the New Zealand context, some district health boards provide patients, on discharge, with ‘yellow’ cards listing their medicines and directions for taking the medicines. Some community pharmacists use these cards as well.
The ‘yellow’ card is likely to be an unfamiliar text for patients, and the descriptions of the purpose of each medicine and directions for taking the medicine are often complex. Examples of this complexity include phrases such as, “take regularly if pain persists”, “maintain adequate fluid intake”, “do not use for prolonged periods” and “abdominal discomfort may occur” (K Brackley, New Zealand Hospital Pharmacists’ Association, personal communication, 28 August 2012). These ‘yellow’ cards differ from pill cards in that there are no actual images of the pills, or any use of icons, in relation to when the pills are to be taken
This review has provided an overview of evidence-based health literacy education, training tools and resources for health professionals available in New Zealand and overseas. As already mentioned health literacy is a relatively new concept in New Zealand and there is limited understanding in the health sector of how to improve health literacy levels (New Zealand Guidelines Group 2011). The infancy of health literacy in New Zealand is reflected in that the majority of initiatives outlined in this review originate from the United States, the major exceptions being the cultural competency training tool developed by Mauri Ora Associates Limited, and Rauemi Atawhai: A guide to developing health education resources in New Zealand (Ministry of Health 2012a).
Since the New Zealand Guidelines Group report was published in 2011, a number of other publications from the United States (e.g. Brach et al 2012; Koh et al 2012) have emphasised the systemic aspects of health literacy with the role of the health workforce being only one of a number of aspects that need to be addressed for the building of health literacy skills.
The health professional plays an important role in reducing the health literacy demands of health care encounters. Reid and White (2012) have identified a number of strategies and tools that can be used in this regard:
“Health literacy demands can be reduced by:
making it easier for patients to navigate health services, systems and processes
encouraging health conversations and helping people to identify and ask questions
finding out what people know as the starting point of any health conversation
tailoring the conversation to take into account what they already know
making the amount of information or instructions passed on manageable for the patient and their whānau
checking that you have been clear when talking to a patient by asking them to ‘teach-back’
encouraging whānau involvement in health conversations
going through written information with patients and whānau rather than handing it out to be read later
making medicine and treatment information clearer
following up and monitoring prescribed medicines and instructions
re-designing health education resources, letters and forms so they are clear to the audience.” (pp2–3)
Health professionals will need time to learn about and then practise using the strategies and tools outlined in this review. Health professionals will also need to learn not only how to rephrase what they say, but also to adjust tone and body language for the strategies and tools to be effective.