The Triple Threat to Healthcare Communication

In a report by the Joint Commission in 2007, the “triple threat” to health communication was identified as a leading cause in poor health outcomes in Americans. Cultural barriers to understanding western medicine, limited English proficiency, and low health literacy make up the “triple threat.” Low health literacy, though often associated with culture and language barriers, is also found in patients who are proficient in English and who share the mainstream American culture. This latter group may be especially at risk of having their low health literacy go unrecognized.

Providers routinely overestimate the ability of individual patients to participate in healthcare conversations and follow instructions. A provider’s ability to identify low health literacy begins with being aware of assumptions we may find ourselves making about people’s literacy. Consider the following:

• A patient from “mainstream” American culture may have good verbal skills but may not be able to read.
• A patient who speaks non-standard English (i.e. regional dialects or ethnic speech variations) may have very high overall literacy
• A patient who appears highly educated and reasonably knowledgeable about healthcare can still have trouble understanding the medical jargon in patient instructions, lab results, consent forms, etc.
• Someone born outside the U.S. may pronounce English poorly but still understand English well and even be able to read English well.
• Limited English ability often indicates low health literacy, but literacy in a mother tongue is the most important indicator of exposure to formal education and western medical concepts.

 Behavioral Cues to Health Literacy Limitations?

• Making excuses – “forgotten” glasses, “too tired – I will read it later.”
• Bringing someone along who does most of the talking/fills out forms
• Holding text close, following lines with index finger
• Watching others (mimicking behaviors)
• Difficulty completing health forms
• Inability to list/describe purpose of prescribed medications
• Limited questioning of the healthcare provider

 Talking About Health Literacy with Patients/Families

Attempts by providers and health systems to educate patients with limited health literacy are often unsuccessful. Most health education information for patients – both oral instructions and written information – is far too complex for the average person to understand. The average American reads at the 8th-9th grade reading level, but the majority of healthcare information is written above the 10th grade level. Similarly, people struggle with understanding numbers. When numbers are embedded in text – as is often the case with healthcare information – studies show people’s comprehension of written material drops dramatically.

But perhaps the most pressing problem in healthcare communication is that patients with limited health literacy are less likely to ask questions of providers. In part, there can be cultural hindrances at play. People from some cultures are taught that it is not OK to ask questions of authority figures. People who aren’t proficient in English may feel ashamed of their language barrier. They may even refuse the help of interpreters. However, the lack of active participation in conversations with providers isn’t limited to cross-cultural patients. It is extremely common among people with low health literacy regardless of cultural background.

 Helpful Things Clinicians Can Say:

• I really really like it when my patients ask me questions. Sometimes, I even worry when my patients DON’T ask any questions.
• All questions are good questions.
• Talking about medicine is difficult. Medical words are difficult. If it is OK with you, it helps ME to use an interpreter. (Start picking up the phone).
• A lot of people have trouble reading and remembering health information because it is difficult. Is this ever a problem for you?
• When you have to learn something new, how do you prefer to learn? Do you like to learn by watching TV, listening to radio, talking with people, reading?

 Medication Errors

A vast percentage of patients, especially those with limited health literacy, do not understand medication instructions and often take medications incorrectly. The problem is greatest in elderly patients (the age group that NAAL data indicate has the highest reported rate of limited health literacy. [1]) Clinicians should anticipate there will be long lines at pharmacies, over-busy pharmacists, and patients who are not inclined to ask questions when they pick up their prescriptions. Providers must take the time to instruct patients on exactly how to take the medications they prescribe.

Three Health Literacy Screening Tools:

The question sometimes arises about screening patients for health literacy. The three best-know tools designed for this purpose are described below. However, the health literacy screening tools currently available are problematic for a number of reasons, the most obvious being that even the shortest assessment is “one more thing” to get done during an office visit. Arguably, administering and debriefing these instruments takes precious time away from conversation between patient and provider.

1. The most widely used tool is the NVS (Newest Vital Sign).

• The instrument is available in English and Spanish,
• Patients typically complete the NVS assessment in about 3 minutes. [2]
• The “examiner” asks the patient 6 questions about the content on a nutrition label.
• More than 98% of patients agree to undergo the assessment during a routine office visit. [3]
• The NVS can be obtained online at no cost from the Partnership for Clear Health Communication.

2. The REALM

• The instrument is a word-recognition test, in which patients are presented with a list of 66 medical words beginning with easy words (eg, fat, flu, pill) and progressing to more difficult words (eg, osteoporosis, impetigo, potassium).
• Patients are asked to read through the list and pronounce each word out loud. The examiner scores the patient on the number of words pronounced correctly.
• No attempt is made to determine if patients actually understand the meaning of the words.
• There are many questions about the validity of the REALM for patients in general, and for nonnative speakers of English in particular. [4]

3. Test of Functional Health Literacy in Adults

• The TOFHLA is a more complex health literacy assessment instrument often used in research.
• The TOFHLA is available in English and Spanish.
•  Its full-length form requires 20 or more minutes for administration. A shortened version can be completed in about 12 minutes.
• The full TOFHLA has 2 parts. The first part uses 17 multiple-choice questions that test a patient’s ability to interpret documents and numbers (numeracy). The second part assesses reading comprehension.

References

1.  Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 NAAL (NCES 2006-483). Washiongton DC: Naitonal Center for Education Statistics, US Department of Education; 2006

2   Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the  Newest Vital Sign. Ann Fam Med. 2005;3:514-522

3. Ryan JG, Leguen F, Weiss BD, et al. Will patients agree to have their literacy skills assessed in clinical practice? Health Educ Res. 2007 : Sep 22 {Epub ahead or print}.

4.  Catherine Elder, Melissa Barber, Margaret Staples, Richard H. Osborne, Rosemary Clerehen, & Rachelle Buchbinder (2012) Assessing Health Literacy: A New Domain for Collaboration Between Language Testers and Health Professionals, Language Assessment Quarterly, 9:3, 205-224, DOI