Communicating with Patients at Risk for Low Health Literacy

Patients would seek care earlier because they recognize warning signs. They would read and comprehend instructions. They would understand their physician’s advice and ask questions when they do not understand. Effective health communication contributes to all aspects of disease prevention and health promotion. 1 Effective communication between physician and patient is essential for the prevention, diagnosis, and treatment of illness and disease. 4 It assists patients in making complex medical care decisions and to manage their own health concerns better.


Introduction
Health literacy is the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. 1Fundamentally, health literacy is an issue of ethics and equality.
It is essential to reducing health disparities. 2Many skills are necessary for adequate health literacy, including reading, writing, speaking, listening, and being able to advocate for oneself in the health care system. 1,3f the general public was health literate, better health outcomes would be expected. 2atients would seek care earlier because they recognize warning signs.They would read and comprehend instructions.They would understand their physician's advice and ask questions when they do not understand.Effective health communication contributes to all aspects of disease prevention and health promotion. 1Effective communication between physician and patient is essential for the prevention, diagnosis, and treatment of illness and disease. 4t assists patients in making complex medical care decisions and to manage their own health concerns better.

Health Literacy in the Elderly
According to the Institute of Medicine 3 , almost half of all adults in the US have difficulty understanding and acting upon health information.Low health literacy is an increasing problem in the elderly. 5Elderly individuals have more complex disease management and decision-making. 6They are at-risk for cognitive and functional decline.Health literacy decreases with age beyond differences expected in education levels. 7pproximately 25% of communitydwelling older persons have limited health literacy. 67][8] Low health literacy often is accompanied by shame and embarrassment. 9

Health Literacy and Health Outcomes
A US Agency for Healthcare Research and Quality study 10 concluded that low reading skill and poor health were "clearly related".
Individuals with low health literacy used an inefficient mix of health care services. 7Limited health literacy was associated with health disparities and lower healthcare access 6 , poorer physical and mental health 8,11 , non-adherence to preoperative medication instructions 12 , hospital admissions 13 , and higher medical costs 7 .
These characteristics place individuals with limited health literacy at risk for poor clinical outcomes.
More direct teaching by health care professionals is needed to help patients understand their diseases and treatment program. 14Materials with excellent content have limited value until patients and family members understand them. 15Yet, it is difficult to identify patients with inadequate health literacy without formal testing.

Assessing Health Literacy
The Test of Functional Health Literacy in Adults -Short Version (STOFHLA) 14 measures the ability to read real passages using materials from the health care setting.It is a reliable and valid test instrument.The STOFHLA, however, takes seven minutes to complete, too long for most medical encounters.Further, it measures reading skill and not all domains of health literacy.
7] A single question to assess health literacy easily can be asked during most medical encounters.Questions such as, How often do you have someone help you read hospital materials?, How confident are you filling out medical forms by yourself?, and How often do you have problems learning about your medical condition because of difficulty understanding written information?, were effective in detecting inadequate health literacy. 16lthough reading ability is one of the most fundamental components of health literacy, strategies to educate patients cannot depend on written materials alone.Many domains must be evaluated for a complete assessment of health literacy.
The communication gap with vocabulary and language structure probably is greater for patients with low literacy. 9

Doctor-Patient Interactions
Patients report difficulty with communicating with their physicians. 4In a qualitative study of patients being consulted about heart surgery, five important themes resulted. 20The themes were (1) fear of missing information, (2) difficulty understanding information, (3) difficulty recalling information from the physician, (4) not recalling what the patient himself/herself said, and (5) difficulty communicating information to family and friends.

Physicians
can enhance patient understanding with simple modifications to their communication style. 21hese modifications include taking time to assess patient understanding, avoiding medical terminology, using pictures, limiting information provided, repeating instructions, asking patients to demonstrate understanding, and acting respectfully and sensitively.

Health Literacy in Individuals with Hearing Loss
Intuitively, difficulty communicating with a physician would be expected to increase if the patient had a communication disorder.In fact, communication problems with deaf and hard-of-hearing adults may compromise health care quality. 22ndividuals with hearing loss cited risks for medical errors, misdiagnoses, and difficulty obtaining complete and accurate information from physicians.
Patients with hearing loss may not realize the amount of information they miss in the physician's office. 15Use of a hearing aid may not compensate for hearing loss adequately during doctor-patient communications.Further, the exchange of written notes is not sufficient for effective communication. 23Physicians should not assume that they are understood just because a hearing impaired patient nods in acknowledgment or agreement.
The number of Americans with a hearing loss has doubled during the past 30 years. 24hree out of 5 older Americans with hearing loss and 6 out of 7 middle-aged Americans with hearing loss do not use hearing aids.6][27][28][29][30][31][32][33][34][35][36][37] Even a self-reported answer to a single question about hearing loss was shown to be an effective screening tool. 26,28,37

Summary
Poor health outcomes are associated with low health literacy.Low health literacy may be manifested by difficulty reading health information.However, health literacy also is impacted by the doctor-patient interaction.Patients may manifest difficulty understanding verbal health information or expressing health information to the physician.In each instance, the quality of medical care may be compromised.
Given that almost half of adult patients may have difficulty understanding and acting upon health information, health care providers have an obligation to enhance communication with patients, particularly those most at risk.Patients who are elderly, have cognitive or sensory deficits, are communicatively impaired or lack a command of the spoken language, and come from traditionally disadvantaged populations are at higher risk for low health literacy levels.
Simple modifications to the doctorpatient interaction can impact the understanding of health information and encourage the patient to act upon it appropriately.Individual care plans for each patient should be developed.Brief, but effective, assessments of health literacy and hearing loss can be accomplished by a single question addressing the relevant issue.Within the exam room, physicians should take time to assess patient understanding, avoid medical terminology, use pictures, limit information provided, repeat instructions, and ask patients to demonstrate understanding.Physicians must be sensitive to recognize and address these issues.An improvement in the patient's overall health outcomes is the expected result.