The following Friday session was “I Don’t Understand What You Told Me: Working with Low Health Literacy” given by Renee Cordrey. This topic in and of itself doesn’t have much to do with neurologic physical therapy, but it does have something to do with assessing and treating the whole patient; therefore, will have a hand in our physical therapy outcomes.
First, let’s define health literacy: “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It is very different from general literacy. Education is no guarantee of health literacy. Approximately 12% of the general population has “proficient” health literacy. The other 88% who do not have satisfactory health literacy are over 65, male, non-white, rural folk with less education, a lower income and quite possibility poor vision. These people have trouble with filling out forms, may complain about the number of forms and grip them tightly when reading or may have someone else fill it out for them; knowing how to answer health history questions; following directions for self-care and disease management upon discharge; not understand their risks nor how to manage risks; understanding lab values and blood sugar levels; determining medication dosage and describe their pills in terms of how they look, ex. “I take 2 of the white round ones and 1 red one in the morning….”; not understand nutrition or healthy eating; making decisions like choosing a health plan; recognizing billing errors; planning out preventative care; giving consent for care; and worst of all, they hide their difficulties out of shame and so do NOT ask questions. At 88% of the population, health care workers are also in this bunch, so don’t assume that because someone works in health care that they do not have difficulty with health literacy. I won’t lie; I have trouble picking out my insurance plan. I feel like I understand the generalizations a little more each year with the choice presentations, but the details change each year, so it’s a battle to really understand.
As we can see in the list of difficulties above, these people are often going to show their signs at our front desk first, so it is IMPERRITIVE that we train our front desk staff to spot them. As I mentioned in the previous value post, we can train our front desk staff or perhaps a tech to do simple paper and pencil assessments, which the health literacy assessments most certainly are! The ones recommended by Renee were: The Short Assessment for Health Literacy in English and Spanish (cual es muy important a mis pacientes) and the Rapid Estimate of Adult Literacy in Medicine– Short Form. Other things you can do on the front end for these folks includes: training ALL staff to spot them in orientation and an inservice for current staff; when pursuing partnerships, grants, contracts and budget, consider purposefully mentioning the low health literacy population and make them a part of your company’s written goals. It would also be a good idea to review your forms, website and educational materials. The reading level shouldn’t be above 4th grade. Use Microsoft Word (Tools –> Readability) to determine this. Limit the number of 3 syllable words you use. Use a serif font in 14+ size, active voice and short sentences. Also, do not be afraid of white space as it gives a mental break when reading. Or consider using bulleted lists. Walls of text are a no-no. Put the most important thing you want the patient to know first on the page. Use pictures to provide visual explanations of the text. Consider referencing the online Plain Language Medical Dictionary to help you write things in simple words that Joe Schmoe Public will understand. Medline Plus is a good quality, easy-to-understand resource for patient education. On your website, consider linking to good quality patient education websites as we know they’re looking. Might as well direct them to something quality and easy-to-read. On your forms, the lawyers require us to put certain paragraphs and phrases on our paperwork unfortunately, which no one understands and I don’t even bother reading honestly. For these items include a “Translated” section in bold, so they can skip all the “legalase” and just read what’s important to know. Also consider health literacy in your signage both inside and outside your facility and use pictures as much as possible.
When working with people who have low health literacy, consider what you’re saying to them. Try to limit the amount of verbal jargon you use. Speak slowly. NEVER attempt to do patient education when you’re in a time crunch. You’re wasting everyone’s time then, because it won’t stick. Ask them and watch for non-verbal signs of understanding of the education you provide. I call it being “glazed over.” You can see in their eyes when you lose or overwhelm them as they are no longer looking at you, but through you. Then can they do what you are asking them to do? Can they follow a home exercise program? Do they understand what and why you’re asking them to do the home exercise program? Encourage patients to have a second set of ears with them on educational sessions, so that what they don’t hear or understand, maybe the other person got it.
After your educational session, check for understanding. Throw out the old, “Do you understand?” and instead ask open ended questions about the specifics of your session. “What part of this will be the most difficult for you?” “How will you change your exercise habits?” “What questions do you have for me?” Consider having a teach back session. I find this VERY important, especially with physical skills. Any time I teach a physical skill, like assisting with a transfer, I’ll demonstrate once and then have the person receiving the education demonstrate the skill back and provide a critique. This takes loads of time, but is very important. I’ll do this with the HEP as well; I’ll go through it verbally and have the patient perform the whole thing to make sure they are translating the words and pictures from the page to appropriate body motion. Limit the number of topics in a session and only to need to know info. They can read up details later if they want in written materials. Keep it specific to what they are supposed to DO. Also avoid scare tactics, like “If you don’t do your HEP every day, you’ll never get better.” They’re scared and overwhelmed enough as it is.
I’ve tried to implement a few of the strategies listed above on my website and will be further considering my treatment plans in the clinic in light of health literacy. What’s your plan? What are you going to do in light of this knowledge?