Aaron Rider is a 68 year old Hispanic male, residing in Iowa, who called his physician's office one day with complaints of fever, chills, and persistent cough. He is taken to the office by his wife. After taking a quick history, his primary physician instructs him to go to the hospital for admission. Aaron states, 'I have been as healthy as a horse all my life, except when I took too many blood pressure pills a few months ago. The two bottles stated one pill twice a day for blood pressure, so I took the two white pills with breakfast, then another two one hour later. I followed the directions on the bottle carefully. I counted incorrectly though and took three instead of two in the late morning by mistake. I was never very good at math. I fell because I got dizzy after taking these pills.' Aaron is given a diagnosis of pneumonia by the emergency room physician. He has a past history of hypertension, Alzheimer's disease, and congestive obstructive pulmonary disease. He speaks English well along with Spanish and has a fifth grade education. He was taken out of school at an early age to work in his father's farm. His wife speaks only Spanish. His home medications include: namenda 5 mg po daily, lasix 40mg po bid, potassium chloride 20 mEq po daily, spiriva 1 puff daily, advair 50/250 mg 1 puff daily, and metroprolol 25 mg po bid.
The nurse in the emergency room comes into Aaron's room, and explains to him and his wife, 'Your physician wants you to have a saline lock and an antibiotic called cefuroxime (Zinacef) intravenously every eight hours. He also wants you to be NPO in the morning for a bronchoscopy. Also in order to maintain an accurate urinary output, he wants you to have a foley catheter placed in your urethra. After I insert the foley catheter, I will bring you up to the pulmonary unit.' Aaron begins to worry, what is this foley she is talking about and what is a urethra? What is a bronchoscopy? What is a saline lock? What is NPO? Where are they taking me? His wife is equally distressed, so they both begin to get irritated with the nurse and debate whether it was wise to have come to this hospital at all. The nurse tries to calm them down and provides Aaron and his wife a pamphlet describing the bronchoscopy and a handout from the Internet on foley catheters, but unfortunately they find it difficult to read and are frightened by the pictures. The pamphlet shows a tube that looks like a snake in the picture with labels as fiberoptic endoscope and Aaron gets frightened. He refuses the catheter and the diagnostic test and tells his wife it was a mistake to come here. 'I want to go home right now.'
Health Literacy is 'the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate decisions' (United States Department of Human Resources, 2000). The World Health Organization also defines this new and rapidly evolving concept as, 'the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health' (WHO, 1998). Both of these definitions emphasize the connection of health literacy to illness management and health care decision making. In this case, Aaron needs sufficient information to manage his many chronic illnesses, prevent complications, be compliant with his medication regimen, maneuver in today's health care system, understand his insurance benefits, and maintain his current health status (Rudd, 2010).
Today's health care environment, it's language, and it's customs are foreign and complex to Aaron and many other Iowans. Nine out of ten adults in this country lack the skills to manage their health. Approximately one-half of American adults lack not only health literacy skills, but also numeracy skills as well (Himmelfarb & Hughes, 2011). These persons are most likely to report their health as poor, not seek out health care, and lack health care insurance as well (US Department of Health and Human Resources, 2000; Himmelfarb & Hughes, 2011). This places these persons at risk for multiple health problems.
According to the American Medical Association (AMA) report in 1999, there is a disparity between the literacy skills in the United States (US) and those needed for adequate health care decision making. Aaron is one of many Iowans that cannot read at a fifth grade level. One out of three persons in the United States read below an eighth grade level. A National Adult Literacy Survey revealed that about 13% of Iowa adults function at or below 5th grade level, whereas many patient teaching materials are written at the tenth grade level. Many studies have repeatedly verified that the literacy demands of most health care materials exceed the reading abilities of most U.S. adults (Rudd, 2010).
Most health care professionals picture those with poor health literacy skills as persons of ethnic minorities, immigrants, jobless, and elderly. However although these persons do have problems with health literacy, a national study identifies individuals with low level skills, as also those born in the US. (75%), white (50%), having full or part time jobs (40%), and high school graduates (25%). Most of today's nurses and professionals from other disciplines are not aware that low health literacy is even a problem in our country (Himmelfarb & Hughes, 2011). Getting the message out to all stakeholders that we need to improve health literacy in order to improve our country's health care will be a challenge.
To improve health literacy, health professionals need to recognize who is at risk for low health literacy and intervene with recommended strategies. Some recommended strategies include: teach back (a way to evaluate health messages), brown bag lunches to share information concerning prescription drugs in a relaxed environment (patients bring their medications in a brown bag and discuss them with a knowledgeable health care provider), and use of videos and audio messages (Himmelfarb & Hughes, 2011). Oral messages delivered by the health care provider need to be clear, pertinent to the individual, be in plain language, and not include medical jargon that will baffle our patients (Caudle, et. al., 2010). Written health information presented in pamphlets, web pages, insurance forms, or consent forms needs to be presented plainly and succinctly. If there are any pictures in the document, they need to complement the concepts presented (Rudd, 2010).
Medical language is confusing and many patients do not want to confront medical personnel and ask them to explain themselves. Those with low literacy skills mainly want to hide their shame and feelings of inadequacy. In addition, their culture may have emphasized politeness and discourage confrontation. The terms that are used by health care providers are unfamiliar to many and yet we use acronyms and medical jargon in our explanations to patients daily (Hummelfarb & Hughs, 2011).
Try reading this paragraph: 'On eno doof sedivorp lla eht stneirtun taht a nosrep sdeen. Ti si tnatropmi ot tae a ediw yteirav fo sdoof hcae yad hcus sa: stiurf dna selbategev: elohw sniarg; nael staem, yrtluop tuohtiw niks; dna hsif; yrd saep dna snaeb; dna woltaf yriad stcudorp'. Are you frustrated, uncomfortable, feeling incompetent. However in one study done in a cancer screening clinic found that in the 86 transcripts of conversations between the physician and the patient, there were 350 medical terms used. This was an average of 53.6 words per conversation or visit. Eighty-five percent of these terms were never explained to the patient. Common words used in a prostate screening visit, for example, were biopsy, rectal, anus, prostate, and screening (Duester, Donovan, & McFarrell, 2008). We expect patients to know what we are talking about when diagnostic tests and procedures are ordered. We want them to trust us that we know best about their care. How can they participate in decisions about their health care, when for the most part they do not understand what we are asking them to do.
Nurses also need to take the time to teach. Prior to administration of medications or treatments, we need to explain to the patient what is going on and include them in the decision making process. Many past studies have found that patients are not receiving either written or oral instructions on their medications and many cannot read the labels accurately to include the warning labels (Davis, et. al, 2006). These labels need to be explicit and in Aaron's case need to state: 'take one pill at 8am then another one at 4pm'. We rattle off the discharge or medication instructions from the form and assume the patient understands. Nurses need to ensure that their patients can count the pills accurately, which is part of health literacy skills (numeracy). Medical professionals when communicating health information also need to remember to evaluate their teaching and correct any misconceptions. So in Aaron's case, he needs to state in his own words what each pill is for, count out the correct number of pills, and tell the nurse when he will take them. Nurses need to ensure that the message was accurate and verify that the correct behavior will take place when the patient gets home.
The consequences for not closing this health information gap are grave. An AMA report described these consequences of inadequate health literacy, based on a review of 216 published articles and additional unpublished manuscripts (AMA, 1999). Patients, like Aaron, are at risk for treatment and medication errors resulting in complications, hospital readmissions, and adverse side effects. Those with low literacy skills are twice as likely to be hospitalized, less likely to seek preventative services, less likely to have satisfying health care visits, and more likely to report their health as poor than those with adequate literacy skills. A recent study conducted at the University of California at San Francisco found that patients who have limited proficiency in English or difficulty comprehending physician instructions and health information experience difficulties accessing care, receive a lower quality of care, and underutilize health services (Sedora, et. al., 2006). Inadequate health literacy can also result in spiraling health care costs for both patients and health care facilities (Weiss, 2005; Himmelfarb & Hughes, 2011).
Iowa Nurses Association (INA) is currently focusing on this rapidly growing problem and encouraging employers and all nurses to address this issue (Wood, Kettinger, & Lessick,2007). INA supports the National and State Action Plan of 2010 designed to improve health literacy, and encourage legislators, communities, and health care professionals together to solve this problem (Baur, presentation, 2010). We as nurses need to remove the barriers to health and ensure access to health information for all. We need to educate ourselves about the various evidenced based tools, as teach back, that are available to improve patient understanding and participation in the healthcare environment. We need to educate other disciplines, as pharmacists, about this growing problem. We need to engage in research to identify evidence-based practices that promote optimum health literacy and in curriculum reform so that novice nurses will be informed about this problem as well.
Health literacy is important because without understanding, patients cannot remain healthy and know how to prevent disease and injury. They will not know how to navigate the health care system effectively, as taking their medications properly, where to find proper health care, and how to prevent complications of their illness.
References
American Medical Association. (1999). Health literacy: Report of the Council on Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs. JAMA, 281, 552-557.
Bauer, C. (2010). The National Action Plan to Improve Health Literacy. Presentation presented at Trinity Health Systems in 2010.
Caudle, P., Courtney, K., Guyton, H., Kelley, M., & Kind, C. (2010). Medical Jargon. Retrieved from University of North Carolina at http://www.uncp.edu.
Davis, T., Wolf, M., Bass, P., Thompson, J., Tilson, H., Neuberger, M., & Parker, R. (2006). Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, 145 (12), 888-895.
Duester, L., Christopher, S., Donovan, J., Farrell, M. (2008). A method to quantify residents jargon use during counseling of patients having standardized cancer screenings. Journal of General Internal Medicine, 23 (12), 1947-52.
Himmelfarb, C. & Hughes, S. (2011). Are you assessing the communication 'Vital Sign?' Journal of Cardiovascular Nursing, 26 (3), 177-179.
Hughes, S. & Hayman, L. (2007). Communicating health information to our patients: The tower of babel. Journal of Cardiovascular Nursing, 22 (6), 450-451.
Kirsch, I., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993). Adult literacy in America: A first look at the findings of the national adult literacy survey. Washington, DC: National Center for Education Statistics, U.S. Dept. of Education.
Rudd, R. (2010). Improving American's health literacy. New England Journal of Medicine, 363 (24), 2283-2285.
Sudora, R. L., Yaffe, K., Satterfield, S., Harris, T. B., Mehta, K. M., Simonsick, E. M., et al. (2006). Limited literacy and mortality in the elderly: The health, aging, and body composition study. Journal of General Internal Medicine, 21(8), 806-812.
US Department of Health and Human Services. Healthy People 2010: Understanding and Improving health and objectives for improving health. 2nd ed. Washington, DC: US Government Printing Office; 2000.
Wood, M., Kettinger, C., & Lessick, M. (2007). Knowledge is power. Nursing for Women's Health, 11 (2), 180-188.
World Health Organization (WHO), Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Health Promotion Glossary. Geneva, Switzerland: World Health Organization; 1998.
Weiss, B., Mays, M., Martz, W., Castro, K., DeWalt, D., Pignone, M., et. al. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20, 195-203.
By Chris Kessel, RN, MSN
