- Email: [email protected]
Assessing and Addressing Low Health Literacy Among Surgical Outpatients
Assessing and Addressing Low Health Literacy Among Surgical Outpatients CINDY L. MONACHOS, RN, BS
D
uring a preoperative interview with a 23-year-old female patient, the nurse asked questions that he believed to be “routine.” He listened carefully to the patient’s responses and began to notice that the patient’s body language was more expressive than her verbal responses. The patient avoided direct eye contact, and as she responded to more questions, she continually looked at the floor. The patient’s mumbled and monosyllabic responses gave the nurse a gnawing sensation that something was not quite right. The patient, a vulnerable young woman who was three days postpartum, was about to sign a surgical consent for a laparoscopic tubal ligation that would render her unable to conceive another child. Did she have any comprehension of the legal document she was signing? In an effort to avoid the embarrassment of admitting illiteracy or ignorance, was she just answering “yes” to everything? To preserve her self-respect and dignity, was she blindly trusting the medical system? Was this patient receiving quality care? The nurse realized that he might need to approach this patient with a more customized communication technique. Perhaps it is time that medical professionals ask—and answer—some “routine” questions of their own. How does a patient’s comprehension of his or her medical care fit into a care plan? As health care providers, how are nurses and other medical professionals assessing this crucial aspect of patient care? Are care providers accounting for low health literacy in determining “quality of care”? © AORN, Inc, 2007
HEALTH LITERACY According to the World Health Organization, Health literacy represents 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.1(p10) So in essence, health literacy is the ability to read, understand, and use health information to make appropriate health decisions.2 In a world of perfect health care, patients’ procedures would have been fully explained to them in the physician’s office before they were scheduled for surgery. Friends, relatives, and Internet resources might be consulted, but the patient would already have received and understood the information that is
ABSTRACT PATIENTS WITH LOW HEALTH LITERACY do not have the ability to read, understand, and use health information to make appropriate health decisions. THERE IS A HIGH INCIDENCE of low health literacy in the United States, and health care practitioners in outpatient surgical centers need to be aware of this problem and take steps toward addressing it. TOOLS FOR ASSESSING HEALTH LITERACY are available, and health care practitioners should use these tools to incorporate an assessment of health literacy into their preoperative patient assessments. AORN J 86 (September 2007) 373-383. © AORN, Inc, 2007.
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necessary for his or her care. rials and communication techniques that they Many patients have adequate health literacurrently are using are adequate. cy skills and have the ability, education, and In addition, data from the 2003 National knowledge to find answers to their medical Assessment of Adult Literacy indicated that 30 questions. If they cannot find the answers, million US adults had no more than the simplest they know who to ask to obtain them. But and most concrete literacy skills, 63 million could what about the millions of people who do not perform simple everyday literacy activities, and know how to access health information re95 million could perform moderately challenging sources or who cannot read a consent for literacy activities. Only 28 million US adults could treatment or surgery? What becomes of the perform complex and challenging literacy activipatients who cannot understand their preopties.5 This information suggests that more than erative instructions or how to take their post50% of all adults in the United States may have operative pain medications? One study found difficulties reading critical documents such as surthat 17% of Medicare recipigical consents, preoperative and ents could not understand a postoperative instruction forms, standard Medicaid document prescriptions, health education and 24% could not interpret a forms, insurance forms, or even blood glucose score.3 maps to locate a medical facility. Health literacy is Low health literacy is a very It is important, however, broad term for a multidimennot to confuse illiteracy with more than just the sional problem that stems low health literacy. Health litfrom a lack of education, comeracy is more than just the ability to read written munication breakdowns, eduability to read written matericational materials that are not als; it is the ability to comprematerial; it is the appropriately written, and hend information for managability to comprehend medical jargon that is too diffiing one’s own health. Some cult for patients to understand. experts believe that low health information for How many providers in the literacy, when measured nahealth care field have read a tionally, is statistically worse managing one’s statistical analysis of scientific than illiteracy.2 material and had difficulty Low health literacy is a own health. interpreting what the renational health care problem searcher was trying to say? that affects people regardless Patients with low health literacy of their age, gender, nationalihave equal difficulty underty, income, or social class. standing what health care Patients who are economically providers may believe to be perfectly clear disadvantaged, older adults, or chronically ill health care instructions or documents. are those most at risk for low health literacy.2 Data show that more than 66% of adults in INCIDENCE OF ILLITERACY the United States who are age 60 years or older AND LOW HEALTH LITERACY have inadequate or marginal literacy skills.6 One In 1992, results from the National Adult Litera- study showed that low health literacy levels cy Survey showed that 40 million to 44 million increased with age, with 16% of patients aged 65 Americans age 16 years and older, or approxito 69 years having low health literacy compared mately 23% of all adults in the United States, were to 58% of respondents aged 85 years or older.7 A functionally illiterate. In addition, 53.3 million survey by the Kaiser Family Foundation found Americans, or 28% of US adults, had only marthat 62% of senior citizens aged 65 and older did ginally better reading and computational skills.4 not understand the Medicare Part D prescripThese figures alone should make health care tion drug benefits, and only 13% said they fully providers question whether the health care mateunderstood the changes in the benefit.8
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CULTURAL DIVERSITY
AND
LANGUAGE BARRIERS
Health care providers should be sensitive to changing cultural diversity in the United States when providing health care to patients. Information should be geared to meet the values, traditions, and cultural beliefs of the patients who are receiving the information.2 In addition, it is vital for care providers to assess a patient’s language skills when considering how to communicate health information. One study that examined the health literacy of 3,260 Medicare recipients found that 54% of the Spanish-speaking respondents had marginal or inadequate comprehension levels compared with 34% of English-speaking respondents.3 Another diverse patient population with large numbers of low health literacy patients includes those who do not understand the language, whether it is a foreign spoken language (ie, English) or the “foreign language” of the health care system. These patients may choose to pretend they understand even when they do not. They put their lives in the hands of people they do not know, hoping that the medical professional they have entrusted with their care truly cares about them. In a study by Atchison et al9 regarding the problems associated with African-American and Hispanic patients’ understanding of postoperative surgical instructions, several categories of patient problems resulting from low health literacy were identified, including • improper use of medications, • improper diet, • psychosocial difficulties, and • physical difficulties. The researchers’ conclusion was that the patients’ understanding of their postoperative care was considerably limited.9 Surgeons who work in ambulatory surgery centers (ASCs) receive referrals from many sources, and a patient’s primary care physician may have sent him or her to a surgeon who does not speak the patient’s language. The dialogue that then takes place between the patient and surgeon may not meet the patient’s health care information needs. This scenario underscores how ineffective care provider-patient communication can be.
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A NATIONAL PUBLIC HEALTH CRISIS Understanding basic information and having that information available for use is a fundamental patient right and a building block to make future informed decisions. Gazmararian et al7 reported that 100% of enrollees with low health literacy did not understand the rights and responsibilities section of a Medicaid application compared with 93.7% of enrollees with marginal health literacy and 17.3% of enrollees with adequate health literacy. When information presented is not understood, a multidimensional web of inappropriate choices potentially may be made. These choices affect not only every aspect of the patient’s health regimen, but also national issues in the grander scale of health care. Low health literacy is a problem not only for the people it affects, but for everyone. The results of a 2005 study of 3,000 Medicare patients in a managed care program revealed that patients with low health literacy used an inefficient mix of services, with more reliance on emergency care and less use of appropriate preventive services.10 Creating a vicious cycle, this inefficiency drives up health care costs, leading to increased insurance costs and, ultimately, increased expenses for every consumer. This inefficiency is estimated to cost $73 billion dollars annually in unnecessary hospital stays.11,12 One study found that among Medicaid patients, those with lower than a third-grade reading level had health care costs that were four times greater than the costs for the overall Medicaid population.13 Baker et al14 reported that patients with low health literacy are twice as likely to be hospitalized as patients with adequate literacy skills. Results from another study, which compared health care expenditures for services provided to patients above and below the 20% functional literacy skill level, indicated a 3% to 6% increase in expenditures for services provided to those patients whose functional literacy skill level was in the bottom 20%. The study found that Medicaid, and therefore taxpayers, finances a disproportionately high share of the estimated costs resulting from low functional literacy.13 Thus, improving the nation’s health care knowledge has a great potential to lower the nation’s health care tab.
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PATIENTS
AT
RISK
Often, in fast-paced, over-booked medical offices, patients may spend 15 minutes or less with the physician. Compounding matters, that physician can very often be someone the patient has just met because the patient’s health plan has changed or because another physician recently referred the patient to this new physician. It is the responsibility of health care professionals to assess patients and ensure that they understand their care; patients may misunderstand instructions not only as a result of language barriers, but also because of comprehension barriers. In countless outpatient surgical centers, patients are brought in from many different areas of the country. Surgical centers can have any number of surgeons credentialed to practice medicine through them. For example, if one ASC has 60 surgeons credentialed, that is 60 different physicians’ offices and 60 different sets of office personnel that perioperative staff members are relying on to educate and assess surgical patients before they come to the ASC for surgery. In this world of specialized physicians, procedures, and specialty centers, surgeons often do not meet their patients until the day of surgery. How much can one learn about a patient in 10 minutes before surgery? It is critical that patients with low health literacy be diagnosed before they reach this stage of treatment. Standardized tests, such as preoperative laboratory tests, chest x-rays, and electrocardiograms, are recognized as essential throughout the medical world. Information on the patient’s health literacy level should be just as available to the health care provider as other related health information.
TOOLS
FOR
ASSESSING HEALTH LITERACY
Education will increase patients’ understanding of their health care regimens and increase the quality of care they receive.15 To educate patients, health care providers need to begin by testing patients’ levels of health literacy. Assessment tools and process improvements are needed in every aspect of a patient’s treatment regimen, and some tools have been developed to assist health care providers in assessing literacy levels. Two broad categories of standardized literacy
assessment tools can be used to test patients’ health literacy skills. One group of tests relies on word recognition, and the other, which uses the cloze technique, relies on reading comprehension. The cloze technique measures reading comprehension by removing certain words from a paragraph and having the reader fill in the blanks. Three of the more common tests used in evaluating health literacy are the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS).16 THE REALM. The REALM is a word recognition and pronunciation test comprising 66 medical terms arranged in order of pronunciation difficulty. Starting with simple, one-syllable words (eg, pill, eye) and ending with multisyllable words (eg, antibiotics, potassium), the patient reads down the list, pronouncing aloud as many words as possible. Simultaneously, the examiner scores the number of words that are pronounced correctly, using the standard dictionary pronunciation as the scoring standard.16 One point is awarded for every word pronounced correctly for a total of 66 possible points. The points correspond to four categories of grade-equivalent reading levels. Based on their score, patients are assigned a grade-equivalent reading level that indicates their level of health literacy skills. (Table 1).16
TABLE 1
REALM* Scores and Associated Grade-Equivalent Reading Levels1 Score
Grade-equivalent reading level
0-18 19-44 45-60 61-66
less than or equal to 3rd grade 4th grade to 6th grade 7th grade to 8th grade greater than or equal to 9th grade
* REALM = Rapid Estimate of Adult Literacy in Medicine 1. Wallace L; North American Primary Care Research Group. Patients' health literacy skills: the missing demographic variable in primary care research. Ann Fam Med. 2006;4(1):85-86.
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The REALM test is the most TABLE 2 commonly used health literaTOFHLA* and S-TOFHLA** Scores and cy test available today beAssociated Comprehension Levels1 cause it takes only five minutes for a patient to complete TOFHLA S-TOFHLA the test and have it graded.16 Score Level Score Level THE TOFHLA. The TOFHLA, 0-59 Inadequate 0-16 Inadequate which uses the cloze tech60-74 Marginal 17-22 Marginal nique, is a timed reading 75-100 Adequate 23-36 Adequate comprehension test that is available in both English and * TOFHLA = Test of Functional Health Literacy in Adults Spanish. The standard test ** S-TOFHLA = Short Test of Functional Health Literacy in Adults takes about 22 minutes to ad1. Wallace L; North American Primary Care Research Group. Patients' minister; a short form of the health literacy skills: the missing demographic variable in primary care test also is available that takes research. Ann Fam Med. 2006;4(1):85-86. about seven minutes to administer. The patient is asked to read a passage in which TABLE 3 every fifth to seventh word has been omitted, Newest Vital Sign Scores and and he or she must select a word from four possible choices to fill in the blank. The stanAssociated Literacy Levels1 dard TOFHLA is scored on a scale from zero Score Literacy level to 100, and the short form, or S-TOFHLA, is >4 Adequate literacy scored with 36 possible points. Depending on <4 Limited literacy the number of test points a patient receives, he <2 Greater than 50% chance of or she is rated as having adequate, marginal, or marginal or inadequate literacy inadequate comprehension (Table 2).16 1. Weiss BD, Mays MZ, Martz W, et al. Quick THE NVS. The NVS is a statistically proven, assessment of literacy in primary care: the newest quick screening tool capable of reliably testing vital sign. Ann Fam Med. 2005;3(6):514-522. patients for low health literacy. Patients extract information from an ice cream nutritional label gate today’s health care system.17 and are then required to answer six questions interpreting the information from the label. COMPARISON OF TESTS. One advantage of using Patients are awarded one point for each correct the NVS is that it is available in both Spanish answer, and the number of points indicates the and English; the current REALM is available level of literacy. A score of greater than four only in English. Although TOFHLA also is indicates adequate literacy ability, and a score available in Spanish and English, the NVS can of less than four indicates limited literacy. be administered in three minutes—much more Health professionals need to take necessary quickly than the TOFHLA can be adminisprecautions when dealing with patients who tered. In addition, statistical results extracted score less than two because this score indicates from research show that when the scoring crithat the patient has a greater than 50% chance teria from the NVS and TOFHLA were comof having marginal or inadequate literacy pared, the NVS was a more sensitive indicator skills (Table 3).17 of marginal health literacy than the TOFHLA The quantitative-numerical questions on the and provided a more comprehensive indicator NVS require both reading comprehension and of skill level than the TOFHLA among individthe ability to use mathematical concepts. Reuals who scored higher.17 Future studies are searchers believe that these abilities directly needed, however, to determine how to introcorrelate with the ability to use and underduce and implement use of these tests in pristand text and numbers to successfully navimary and nonprimary care practices.
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Ordering Health Literacy Assessment Tools
T
he Rapid Estimate of Adult Literacy in Medicine (ie, REALM) sample kit, which includes an instruction manual, laminated patient word lists, and scoring sheets, is available for purchase from Terry C. Davis, PhD, LSU Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932, [email protected]. The Test of Functional Health Literacy in Adults (ie, TOFHLA) is available for purchase from http://www .peppercornbooks.com/. The Newest Vital Sign (ie, NVS) is available to health care workers free of charge. Ordering information can be found at http://128.121.233.134/nvs-preorder2.aspx.
The REALM, TOFHLA, and NVS are three different tests that are all reliable indicators of health literacy and are easy to administer. Use of these simple diagnostic tools to assess health literacy will lead to individualized care plans and the use of customized communication techniques geared toward assisting patients in understanding their medical health issues and treatment plans.
PREOPERATIVE ASSESSMENT OF LOW HEALTH LITERACY Although low health literacy can be addressed in an outpatient surgical center, trained personnel in the primary care physician’s office should assess the patient’s health literacy. Such evaluations are simple and quick enough to be performed by office staff members. The results of these tests should be communicated among health care providers as the patient moves through the health care process so that when a physician’s office schedules a patient for surgery, the surgical facility is prepared to address the patient’s health literacy needs, just as it would be prepared to address any other clinical issue. An ASC faces a unique set of challenges because patients have such a short duration of stay. Most of the initial preoperative questioning is completed before the patient comes into the facility. The preoperative assessment begins during the initial health history review and is continued when the patient first enters the facility. This information should include the patient’s health history, current medical concerns, and medications. An improvement to any preoperative assessment process would be the evaluation of the patient’s health literacy. Patients often will
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keep their inadequate literacy skills a secret and devise ways to overcome their difficulty. This behavior can be seen when a health care provider is giving preoperative or postoperative instructions to a surgical patient and the patient says that he or she is too tired or too nervous to read and sign the necessary documents. This behavior also can be seen when a patient asks to bring documents home to complete with a spouse or child or when patients bring a relative or family member with them during the admission process to read the material. Often, patients will read only bulleted points and indicate that they understand the material, when in fact they do not understand it.2 When a patient is belligerent and refuses to complete paperwork, it is necessary for health care providers to look beyond the obvious behavior and question the patient’s level of health literacy. Assessment of the patient’s comprehension and comfort levels in the application and use of medical terminology during the initial preoperative assessment can assist a practitioner in gauging the patient’s level of health literacy. The simple addition of probing, open-ended questions specifically geared toward the patient’s understanding of his or her surgical procedure or of the medications that he or she is currently taking will give the health care professional an indication of the patient’s level of health literacy. This in turn naturally leads a health care professional to a better understanding of a patient’s educational needs. Only then can a care plan be designed to incorporate individualized patient education and guidance, ensuring that the patient comprehends the preoperative instructions and the information about
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his or her surgery, medications, and postoperative home care. This simple act empowers patients to make informed decisions and, ultimately, to give an informed consent. The doctrine of informed consent is based on two guidelines: • every patient has the right to determine what happens to his or her body and • it is the duty of the health care provider performing the procedure to provide a patient with enough information to ensure that the patient’s decision to undergo the procedure is based on knowledge of • the necessity of the procedure, • alternate treatment options, • risks, and • the likelihood of success or failure of the procedure.18 If a patient cannot or does not understand what is being said, let alone the reason why he or she is being given the information, ultimately that patient is being denied his or her basic patient rights.
DEVELOPING EFFECTIVE EDUCATIONAL MATERIALS Most health care literature is written at a 10th-grade level. Most adults, however, read at an eighth-grade level, and 20% of the population reads at or below a fifth-grade level.4 Effective patient education materials should be written at a sixth-grade level or lower with pictures and illustrations. Medical information should be written in clear and concise language.19 Studies show that patient participation in the development of documentation for health care facilities will lead to enhanced patient understanding of written materials. This is because patients at similar literacy levels have similar narrative styles, and patients are more likely to understand something written in a similar narrative style to the one they use.20 Developing understandable health care materials can be achieved by including employees and patients in field reviews. For example, facilities can prepare sample brochures or samples of the documentation to be instituted. These sample materials then can be given to the surgical and nonsurgical employees in the facility with the request that they review the information and offer feedback and sugges-
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tions. Employees generally are from the same demographic area that is being targeted. Subsequently, the draft materials can be offered to a sampling of the patients that best represents the patient population being served, and the patients can be asked to review the information and offer suggestions. Documents that patients are expected to learn from and understand need to be designed for ease of understanding, and the message should be clear. Medical jargon should be eliminated and replaced with common words that are used in daily language. Breaking up medical concepts into bite-size pieces will help patients understand difficult ideas. Active voice and a conversational tone are more familiar and easier for patients to understand.19 Stories, checklists, and fill-inthe-blanks are memory aids that should be included in every teaching arsenal. The layout of documents should help make them easy to read. Tips for making a document more readable include the following: • Text should be in 12 point type. • Text should not be in all capital letters or all italics because this type of text is difficult to read. • Line length should be limited to no more than 5 inches with a lot of white space for the eye to rest on. • Visuals should stand alone and be simple, realistic, familiar, and engaging. • Visuals that show behavior should be realistically portrayed, and written text should be concise.19
STRATEGIES
FOR
CLINICAL PRACTICE
Incorporating basic strategies for improving patient comprehension of medical information into daily clinical practice habits can yield significant results for health care practitioners. Identifying individual habits while speaking with patients during routine encounters is crucial to care providers’ self-improvement. Table 4 lists practice behaviors that can lead to better patient understanding and can be used for health care providers’ self-assessment of effective communication. Above all, perioperative nursing professionals should educate and raise awareness throughout AORN JOURNAL •
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their organization, educating other health care professionals and organization leaders about the necessity of assessing for health literacy. They should suggest and encourage implementing behavior changes, assessment procedures, checklists, and changes in documents and teaching tools and instituting guidelines that are beneficial in assessing and addressing the needs of patients with low health literacy. The American Medical Association Foundation offers a health literacy tool kit with a clinician manual that contains information on resources, communication
TABLE 4
Practice Behaviors That Can Lead to Improved Patient Understanding1,2 Assess the patient population. Redesign patient education materials to target patients’ levels of literacy. Use simple sentences and plain language. Limit points to two or three at a time. Repeat and summarize. Create a shame-free environment, encourage questions, and communicate with patients at eye level. Use teach-back or show-back techniques to assess and ensure patient understanding. Use drawings, diagrams, or models to illustrate what is being communicated. Audiotapes, videotapes, or interactive CD-ROMs are an alternative to written communication. Use the medication reconciliation process. Provide patients with a medication card listing their medications. 1. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. 2. Medication reconciliation guidelines and home medication list. Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/PatientSafety /MedicationSystems/Tools/MedicationReconciliation GuidelinesAndHomeMedicationListLutherMidelfort .htm. Accessed July 27, 2008.
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techniques, and health system barriers.21 This is an invaluable tool for use in educating staff members in medical offices and outpatient surgical centers and as a basis for formulating patient education materials.
ADDRESSING LOW HEALTH LITERACY Low health literacy is a fact of American life and a public health crisis. It is an ethical and financial issue that affects all health care professionals. For moral and ethical reasons, it is important that people are able to understand and follow directions.22 Using resources and ingenuity, today’s health care leaders can use the available tools for assessing low health literacy to develop new programs and educational tools for assessing and addressing the needs of patients with low health literacy. Assessing patients for low health literacy and addressing the needs associated with it in an outpatient surgical center is a continual process that should begin in the primary care provider’s office. This assessment, however, should be the responsibility of all health care professionals who are charged with a patient’s care. Available assessment tools should be used before a patient is scheduled for surgery, and the results of those assessments should be used throughout the entire perioperative experience. Personnel in outpatient surgical centers need to analyze the makeup of their patient populations and develop tools and educational information based on the results of those analyses. Patients also must be encouraged to take an active role in their own health care. The partnership between health care provider and patient regarding information given and received must be continually reviewed. This individualized and direct approach will lead to an overall reduction in health care costs and, ultimately, to higher quality medical care for patients. When patients understand their health care plan, it gives them a sense of empowerment and confidence. This in turn encourages more patient participation leading to increased education and resulting in informed choices in patients’ health care management. These informed decisions affect every consumer and the health care industry as a whole. Addressing the public health crisis of
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low health literacy by improving the delivery of health care and quantifying a patient’s level of understanding increases the quality and continuity of the health care system. Understanding a health care plan is a fundamental and basic patient right. Ultimately, patients’ low health literacy and health care providers’ communication processes must be continually reviewed and improved so that the health care community, with perioperative nurses as teachers, can boast “no patient left behind.”
REFERENCES 1. World Health Organization, Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Health Promotion Glossary. Geneva, Switzerland: World Health Organization; 1998. http://www.who.int/hpr/NPH /docs/hp_glossary_en.pdf. Accessed July 16, 2007. 2. Scudder L. Words and well-being: how literacy affects patient health. J Nurse Pract. 2006;2(1):28-35. 3. Pirisi A. Low health literacy prevents equal access to care. Lancet. 2000;356(9244):1828. 4. Kirsch IS, Jungebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education; 1993. 5. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: National Center for Education Statistics; 2006. http://nces.ed.gov /pubs2006/2006483.pdf. Accessed July 13, 2007. 6. Talking the talk: improving patient-provider communication. Facts of Life: Issue Briefings for Health Reporters. 2003;8(3). http://www.cfah.org /factsoflife/vol8no3.cfm. Accessed July 17, 2007. 7. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6): 545–551. 8. July/August 2005 Health Poll Report Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2005. http://www.kff.org/kaiserpolls/upload /7376.pdf. Accessed July 16, 2007. 9. Atchison KA, Black EE, Leathers R, et al. A qualitative report of patient problems and postoperative instructions. J Oral Maxillofac Surg. 2005;63(4):449-456. 10. Howard DH, Gazmararian J, Parker RM. The
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impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005; 118(4):371–377. 11. Schwartzberg JA. Low health literacy: what do your patients really understand? Nurs Econ. 2002; 20(3):145-147. 12. Fact sheet: low health literacy skills increase annual health care expenditures by $73 billion. National Academy on an Aging Society. http:// www.agingsociety.org/agingsociety/publications /fact/fact_low.html. Accessed July 13, 2007. 13. Impact of low health literacy skills on annual health care expenditures. CHCS fact sheet. Center for Health Care Strategies, Inc. http://www.chcs .org/usr_doc/Health_Literacy_Fact_Sheets.pdf. Accessed July 13, 2007. 14. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791-798. 15. Mantone J. Reading writing and relating: providers—rural and urban—urged to pay more attention to health literacy. Mod Healthc. 2005;35 (32):30-31. 16. Wallace L; North American Primary Care Research Group. Patients’ health literacy skills: the missing demographic variable in primary care research. Ann Fam Med. 2006;4(1):85-86. 17. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514-522. 18. Informed consent. AMA. http://www.ama-assn .org/ama/pub/category/4608.html. Accessed July 27, 2007. 19. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. 20. Kusec S, Oreskovic S, Skegro M, Korolija D, Busic Z, Horzic M. Improving comprehension of informed consent. Patient Educ Couns. 2006;60 (3):294-300. 21. Health literacy. AMA Foundation. October 31, 2006. http://www.ama-assn.org/ama/pub/cate gory/8115.html. Accessed July 16, 2007. 22. Beckley ET. Are you receiving me? Improving patient literacy reduces med mal, safety risks. Mod Physician. 2003;7(6):12.
Cindy L. Monachos, RN, BS, is the director of surgical services, Oak Brook Surgical Center, Oak Brook, IL.
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D
uring a preoperative interview with a 23-year-old female patient, the nurse asked questions that he believed to be “routine.” He listened carefully to the patient’s responses and began to notice that the patient’s body language was more expressive than her verbal responses. The patient avoided direct eye contact, and as she responded to more questions, she continually looked at the floor. The patient’s mumbled and monosyllabic responses gave the nurse a gnawing sensation that something was not quite right. The patient, a vulnerable young woman who was three days postpartum, was about to sign a surgical consent for a laparoscopic tubal ligation that would render her unable to conceive another child. Did she have any comprehension of the legal document she was signing? In an effort to avoid the embarrassment of admitting illiteracy or ignorance, was she just answering “yes” to everything? To preserve her self-respect and dignity, was she blindly trusting the medical system? Was this patient receiving quality care? The nurse realized that he might need to approach this patient with a more customized communication technique. Perhaps it is time that medical professionals ask—and answer—some “routine” questions of their own. How does a patient’s comprehension of his or her medical care fit into a care plan? As health care providers, how are nurses and other medical professionals assessing this crucial aspect of patient care? Are care providers accounting for low health literacy in determining “quality of care”? © AORN, Inc, 2007
HEALTH LITERACY According to the World Health Organization, Health literacy represents 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.1(p10) So in essence, health literacy is the ability to read, understand, and use health information to make appropriate health decisions.2 In a world of perfect health care, patients’ procedures would have been fully explained to them in the physician’s office before they were scheduled for surgery. Friends, relatives, and Internet resources might be consulted, but the patient would already have received and understood the information that is
ABSTRACT PATIENTS WITH LOW HEALTH LITERACY do not have the ability to read, understand, and use health information to make appropriate health decisions. THERE IS A HIGH INCIDENCE of low health literacy in the United States, and health care practitioners in outpatient surgical centers need to be aware of this problem and take steps toward addressing it. TOOLS FOR ASSESSING HEALTH LITERACY are available, and health care practitioners should use these tools to incorporate an assessment of health literacy into their preoperative patient assessments. AORN J 86 (September 2007) 373-383. © AORN, Inc, 2007.
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necessary for his or her care. rials and communication techniques that they Many patients have adequate health literacurrently are using are adequate. cy skills and have the ability, education, and In addition, data from the 2003 National knowledge to find answers to their medical Assessment of Adult Literacy indicated that 30 questions. If they cannot find the answers, million US adults had no more than the simplest they know who to ask to obtain them. But and most concrete literacy skills, 63 million could what about the millions of people who do not perform simple everyday literacy activities, and know how to access health information re95 million could perform moderately challenging sources or who cannot read a consent for literacy activities. Only 28 million US adults could treatment or surgery? What becomes of the perform complex and challenging literacy activipatients who cannot understand their preopties.5 This information suggests that more than erative instructions or how to take their post50% of all adults in the United States may have operative pain medications? One study found difficulties reading critical documents such as surthat 17% of Medicare recipigical consents, preoperative and ents could not understand a postoperative instruction forms, standard Medicaid document prescriptions, health education and 24% could not interpret a forms, insurance forms, or even blood glucose score.3 maps to locate a medical facility. Health literacy is Low health literacy is a very It is important, however, broad term for a multidimennot to confuse illiteracy with more than just the sional problem that stems low health literacy. Health litfrom a lack of education, comeracy is more than just the ability to read written munication breakdowns, eduability to read written matericational materials that are not als; it is the ability to comprematerial; it is the appropriately written, and hend information for managability to comprehend medical jargon that is too diffiing one’s own health. Some cult for patients to understand. experts believe that low health information for How many providers in the literacy, when measured nahealth care field have read a tionally, is statistically worse managing one’s statistical analysis of scientific than illiteracy.2 material and had difficulty Low health literacy is a own health. interpreting what the renational health care problem searcher was trying to say? that affects people regardless Patients with low health literacy of their age, gender, nationalihave equal difficulty underty, income, or social class. standing what health care Patients who are economically providers may believe to be perfectly clear disadvantaged, older adults, or chronically ill health care instructions or documents. are those most at risk for low health literacy.2 Data show that more than 66% of adults in INCIDENCE OF ILLITERACY the United States who are age 60 years or older AND LOW HEALTH LITERACY have inadequate or marginal literacy skills.6 One In 1992, results from the National Adult Litera- study showed that low health literacy levels cy Survey showed that 40 million to 44 million increased with age, with 16% of patients aged 65 Americans age 16 years and older, or approxito 69 years having low health literacy compared mately 23% of all adults in the United States, were to 58% of respondents aged 85 years or older.7 A functionally illiterate. In addition, 53.3 million survey by the Kaiser Family Foundation found Americans, or 28% of US adults, had only marthat 62% of senior citizens aged 65 and older did ginally better reading and computational skills.4 not understand the Medicare Part D prescripThese figures alone should make health care tion drug benefits, and only 13% said they fully providers question whether the health care mateunderstood the changes in the benefit.8
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CULTURAL DIVERSITY
AND
LANGUAGE BARRIERS
Health care providers should be sensitive to changing cultural diversity in the United States when providing health care to patients. Information should be geared to meet the values, traditions, and cultural beliefs of the patients who are receiving the information.2 In addition, it is vital for care providers to assess a patient’s language skills when considering how to communicate health information. One study that examined the health literacy of 3,260 Medicare recipients found that 54% of the Spanish-speaking respondents had marginal or inadequate comprehension levels compared with 34% of English-speaking respondents.3 Another diverse patient population with large numbers of low health literacy patients includes those who do not understand the language, whether it is a foreign spoken language (ie, English) or the “foreign language” of the health care system. These patients may choose to pretend they understand even when they do not. They put their lives in the hands of people they do not know, hoping that the medical professional they have entrusted with their care truly cares about them. In a study by Atchison et al9 regarding the problems associated with African-American and Hispanic patients’ understanding of postoperative surgical instructions, several categories of patient problems resulting from low health literacy were identified, including • improper use of medications, • improper diet, • psychosocial difficulties, and • physical difficulties. The researchers’ conclusion was that the patients’ understanding of their postoperative care was considerably limited.9 Surgeons who work in ambulatory surgery centers (ASCs) receive referrals from many sources, and a patient’s primary care physician may have sent him or her to a surgeon who does not speak the patient’s language. The dialogue that then takes place between the patient and surgeon may not meet the patient’s health care information needs. This scenario underscores how ineffective care provider-patient communication can be.
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A NATIONAL PUBLIC HEALTH CRISIS Understanding basic information and having that information available for use is a fundamental patient right and a building block to make future informed decisions. Gazmararian et al7 reported that 100% of enrollees with low health literacy did not understand the rights and responsibilities section of a Medicaid application compared with 93.7% of enrollees with marginal health literacy and 17.3% of enrollees with adequate health literacy. When information presented is not understood, a multidimensional web of inappropriate choices potentially may be made. These choices affect not only every aspect of the patient’s health regimen, but also national issues in the grander scale of health care. Low health literacy is a problem not only for the people it affects, but for everyone. The results of a 2005 study of 3,000 Medicare patients in a managed care program revealed that patients with low health literacy used an inefficient mix of services, with more reliance on emergency care and less use of appropriate preventive services.10 Creating a vicious cycle, this inefficiency drives up health care costs, leading to increased insurance costs and, ultimately, increased expenses for every consumer. This inefficiency is estimated to cost $73 billion dollars annually in unnecessary hospital stays.11,12 One study found that among Medicaid patients, those with lower than a third-grade reading level had health care costs that were four times greater than the costs for the overall Medicaid population.13 Baker et al14 reported that patients with low health literacy are twice as likely to be hospitalized as patients with adequate literacy skills. Results from another study, which compared health care expenditures for services provided to patients above and below the 20% functional literacy skill level, indicated a 3% to 6% increase in expenditures for services provided to those patients whose functional literacy skill level was in the bottom 20%. The study found that Medicaid, and therefore taxpayers, finances a disproportionately high share of the estimated costs resulting from low functional literacy.13 Thus, improving the nation’s health care knowledge has a great potential to lower the nation’s health care tab.
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PATIENTS
AT
RISK
Often, in fast-paced, over-booked medical offices, patients may spend 15 minutes or less with the physician. Compounding matters, that physician can very often be someone the patient has just met because the patient’s health plan has changed or because another physician recently referred the patient to this new physician. It is the responsibility of health care professionals to assess patients and ensure that they understand their care; patients may misunderstand instructions not only as a result of language barriers, but also because of comprehension barriers. In countless outpatient surgical centers, patients are brought in from many different areas of the country. Surgical centers can have any number of surgeons credentialed to practice medicine through them. For example, if one ASC has 60 surgeons credentialed, that is 60 different physicians’ offices and 60 different sets of office personnel that perioperative staff members are relying on to educate and assess surgical patients before they come to the ASC for surgery. In this world of specialized physicians, procedures, and specialty centers, surgeons often do not meet their patients until the day of surgery. How much can one learn about a patient in 10 minutes before surgery? It is critical that patients with low health literacy be diagnosed before they reach this stage of treatment. Standardized tests, such as preoperative laboratory tests, chest x-rays, and electrocardiograms, are recognized as essential throughout the medical world. Information on the patient’s health literacy level should be just as available to the health care provider as other related health information.
TOOLS
FOR
ASSESSING HEALTH LITERACY
Education will increase patients’ understanding of their health care regimens and increase the quality of care they receive.15 To educate patients, health care providers need to begin by testing patients’ levels of health literacy. Assessment tools and process improvements are needed in every aspect of a patient’s treatment regimen, and some tools have been developed to assist health care providers in assessing literacy levels. Two broad categories of standardized literacy
assessment tools can be used to test patients’ health literacy skills. One group of tests relies on word recognition, and the other, which uses the cloze technique, relies on reading comprehension. The cloze technique measures reading comprehension by removing certain words from a paragraph and having the reader fill in the blanks. Three of the more common tests used in evaluating health literacy are the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS).16 THE REALM. The REALM is a word recognition and pronunciation test comprising 66 medical terms arranged in order of pronunciation difficulty. Starting with simple, one-syllable words (eg, pill, eye) and ending with multisyllable words (eg, antibiotics, potassium), the patient reads down the list, pronouncing aloud as many words as possible. Simultaneously, the examiner scores the number of words that are pronounced correctly, using the standard dictionary pronunciation as the scoring standard.16 One point is awarded for every word pronounced correctly for a total of 66 possible points. The points correspond to four categories of grade-equivalent reading levels. Based on their score, patients are assigned a grade-equivalent reading level that indicates their level of health literacy skills. (Table 1).16
TABLE 1
REALM* Scores and Associated Grade-Equivalent Reading Levels1 Score
Grade-equivalent reading level
0-18 19-44 45-60 61-66
less than or equal to 3rd grade 4th grade to 6th grade 7th grade to 8th grade greater than or equal to 9th grade
* REALM = Rapid Estimate of Adult Literacy in Medicine 1. Wallace L; North American Primary Care Research Group. Patients' health literacy skills: the missing demographic variable in primary care research. Ann Fam Med. 2006;4(1):85-86.
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The REALM test is the most TABLE 2 commonly used health literaTOFHLA* and S-TOFHLA** Scores and cy test available today beAssociated Comprehension Levels1 cause it takes only five minutes for a patient to complete TOFHLA S-TOFHLA the test and have it graded.16 Score Level Score Level THE TOFHLA. The TOFHLA, 0-59 Inadequate 0-16 Inadequate which uses the cloze tech60-74 Marginal 17-22 Marginal nique, is a timed reading 75-100 Adequate 23-36 Adequate comprehension test that is available in both English and * TOFHLA = Test of Functional Health Literacy in Adults Spanish. The standard test ** S-TOFHLA = Short Test of Functional Health Literacy in Adults takes about 22 minutes to ad1. Wallace L; North American Primary Care Research Group. Patients' minister; a short form of the health literacy skills: the missing demographic variable in primary care test also is available that takes research. Ann Fam Med. 2006;4(1):85-86. about seven minutes to administer. The patient is asked to read a passage in which TABLE 3 every fifth to seventh word has been omitted, Newest Vital Sign Scores and and he or she must select a word from four possible choices to fill in the blank. The stanAssociated Literacy Levels1 dard TOFHLA is scored on a scale from zero Score Literacy level to 100, and the short form, or S-TOFHLA, is >4 Adequate literacy scored with 36 possible points. Depending on <4 Limited literacy the number of test points a patient receives, he <2 Greater than 50% chance of or she is rated as having adequate, marginal, or marginal or inadequate literacy inadequate comprehension (Table 2).16 1. Weiss BD, Mays MZ, Martz W, et al. Quick THE NVS. The NVS is a statistically proven, assessment of literacy in primary care: the newest quick screening tool capable of reliably testing vital sign. Ann Fam Med. 2005;3(6):514-522. patients for low health literacy. Patients extract information from an ice cream nutritional label gate today’s health care system.17 and are then required to answer six questions interpreting the information from the label. COMPARISON OF TESTS. One advantage of using Patients are awarded one point for each correct the NVS is that it is available in both Spanish answer, and the number of points indicates the and English; the current REALM is available level of literacy. A score of greater than four only in English. Although TOFHLA also is indicates adequate literacy ability, and a score available in Spanish and English, the NVS can of less than four indicates limited literacy. be administered in three minutes—much more Health professionals need to take necessary quickly than the TOFHLA can be adminisprecautions when dealing with patients who tered. In addition, statistical results extracted score less than two because this score indicates from research show that when the scoring crithat the patient has a greater than 50% chance teria from the NVS and TOFHLA were comof having marginal or inadequate literacy pared, the NVS was a more sensitive indicator skills (Table 3).17 of marginal health literacy than the TOFHLA The quantitative-numerical questions on the and provided a more comprehensive indicator NVS require both reading comprehension and of skill level than the TOFHLA among individthe ability to use mathematical concepts. Reuals who scored higher.17 Future studies are searchers believe that these abilities directly needed, however, to determine how to introcorrelate with the ability to use and underduce and implement use of these tests in pristand text and numbers to successfully navimary and nonprimary care practices.
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Ordering Health Literacy Assessment Tools
T
he Rapid Estimate of Adult Literacy in Medicine (ie, REALM) sample kit, which includes an instruction manual, laminated patient word lists, and scoring sheets, is available for purchase from Terry C. Davis, PhD, LSU Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932, [email protected]. The Test of Functional Health Literacy in Adults (ie, TOFHLA) is available for purchase from http://www .peppercornbooks.com/. The Newest Vital Sign (ie, NVS) is available to health care workers free of charge. Ordering information can be found at http://128.121.233.134/nvs-preorder2.aspx.
The REALM, TOFHLA, and NVS are three different tests that are all reliable indicators of health literacy and are easy to administer. Use of these simple diagnostic tools to assess health literacy will lead to individualized care plans and the use of customized communication techniques geared toward assisting patients in understanding their medical health issues and treatment plans.
PREOPERATIVE ASSESSMENT OF LOW HEALTH LITERACY Although low health literacy can be addressed in an outpatient surgical center, trained personnel in the primary care physician’s office should assess the patient’s health literacy. Such evaluations are simple and quick enough to be performed by office staff members. The results of these tests should be communicated among health care providers as the patient moves through the health care process so that when a physician’s office schedules a patient for surgery, the surgical facility is prepared to address the patient’s health literacy needs, just as it would be prepared to address any other clinical issue. An ASC faces a unique set of challenges because patients have such a short duration of stay. Most of the initial preoperative questioning is completed before the patient comes into the facility. The preoperative assessment begins during the initial health history review and is continued when the patient first enters the facility. This information should include the patient’s health history, current medical concerns, and medications. An improvement to any preoperative assessment process would be the evaluation of the patient’s health literacy. Patients often will
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keep their inadequate literacy skills a secret and devise ways to overcome their difficulty. This behavior can be seen when a health care provider is giving preoperative or postoperative instructions to a surgical patient and the patient says that he or she is too tired or too nervous to read and sign the necessary documents. This behavior also can be seen when a patient asks to bring documents home to complete with a spouse or child or when patients bring a relative or family member with them during the admission process to read the material. Often, patients will read only bulleted points and indicate that they understand the material, when in fact they do not understand it.2 When a patient is belligerent and refuses to complete paperwork, it is necessary for health care providers to look beyond the obvious behavior and question the patient’s level of health literacy. Assessment of the patient’s comprehension and comfort levels in the application and use of medical terminology during the initial preoperative assessment can assist a practitioner in gauging the patient’s level of health literacy. The simple addition of probing, open-ended questions specifically geared toward the patient’s understanding of his or her surgical procedure or of the medications that he or she is currently taking will give the health care professional an indication of the patient’s level of health literacy. This in turn naturally leads a health care professional to a better understanding of a patient’s educational needs. Only then can a care plan be designed to incorporate individualized patient education and guidance, ensuring that the patient comprehends the preoperative instructions and the information about
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his or her surgery, medications, and postoperative home care. This simple act empowers patients to make informed decisions and, ultimately, to give an informed consent. The doctrine of informed consent is based on two guidelines: • every patient has the right to determine what happens to his or her body and • it is the duty of the health care provider performing the procedure to provide a patient with enough information to ensure that the patient’s decision to undergo the procedure is based on knowledge of • the necessity of the procedure, • alternate treatment options, • risks, and • the likelihood of success or failure of the procedure.18 If a patient cannot or does not understand what is being said, let alone the reason why he or she is being given the information, ultimately that patient is being denied his or her basic patient rights.
DEVELOPING EFFECTIVE EDUCATIONAL MATERIALS Most health care literature is written at a 10th-grade level. Most adults, however, read at an eighth-grade level, and 20% of the population reads at or below a fifth-grade level.4 Effective patient education materials should be written at a sixth-grade level or lower with pictures and illustrations. Medical information should be written in clear and concise language.19 Studies show that patient participation in the development of documentation for health care facilities will lead to enhanced patient understanding of written materials. This is because patients at similar literacy levels have similar narrative styles, and patients are more likely to understand something written in a similar narrative style to the one they use.20 Developing understandable health care materials can be achieved by including employees and patients in field reviews. For example, facilities can prepare sample brochures or samples of the documentation to be instituted. These sample materials then can be given to the surgical and nonsurgical employees in the facility with the request that they review the information and offer feedback and sugges-
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tions. Employees generally are from the same demographic area that is being targeted. Subsequently, the draft materials can be offered to a sampling of the patients that best represents the patient population being served, and the patients can be asked to review the information and offer suggestions. Documents that patients are expected to learn from and understand need to be designed for ease of understanding, and the message should be clear. Medical jargon should be eliminated and replaced with common words that are used in daily language. Breaking up medical concepts into bite-size pieces will help patients understand difficult ideas. Active voice and a conversational tone are more familiar and easier for patients to understand.19 Stories, checklists, and fill-inthe-blanks are memory aids that should be included in every teaching arsenal. The layout of documents should help make them easy to read. Tips for making a document more readable include the following: • Text should be in 12 point type. • Text should not be in all capital letters or all italics because this type of text is difficult to read. • Line length should be limited to no more than 5 inches with a lot of white space for the eye to rest on. • Visuals should stand alone and be simple, realistic, familiar, and engaging. • Visuals that show behavior should be realistically portrayed, and written text should be concise.19
STRATEGIES
FOR
CLINICAL PRACTICE
Incorporating basic strategies for improving patient comprehension of medical information into daily clinical practice habits can yield significant results for health care practitioners. Identifying individual habits while speaking with patients during routine encounters is crucial to care providers’ self-improvement. Table 4 lists practice behaviors that can lead to better patient understanding and can be used for health care providers’ self-assessment of effective communication. Above all, perioperative nursing professionals should educate and raise awareness throughout AORN JOURNAL •
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their organization, educating other health care professionals and organization leaders about the necessity of assessing for health literacy. They should suggest and encourage implementing behavior changes, assessment procedures, checklists, and changes in documents and teaching tools and instituting guidelines that are beneficial in assessing and addressing the needs of patients with low health literacy. The American Medical Association Foundation offers a health literacy tool kit with a clinician manual that contains information on resources, communication
TABLE 4
Practice Behaviors That Can Lead to Improved Patient Understanding1,2 Assess the patient population. Redesign patient education materials to target patients’ levels of literacy. Use simple sentences and plain language. Limit points to two or three at a time. Repeat and summarize. Create a shame-free environment, encourage questions, and communicate with patients at eye level. Use teach-back or show-back techniques to assess and ensure patient understanding. Use drawings, diagrams, or models to illustrate what is being communicated. Audiotapes, videotapes, or interactive CD-ROMs are an alternative to written communication. Use the medication reconciliation process. Provide patients with a medication card listing their medications. 1. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. 2. Medication reconciliation guidelines and home medication list. Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/PatientSafety /MedicationSystems/Tools/MedicationReconciliation GuidelinesAndHomeMedicationListLutherMidelfort .htm. Accessed July 27, 2008.
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techniques, and health system barriers.21 This is an invaluable tool for use in educating staff members in medical offices and outpatient surgical centers and as a basis for formulating patient education materials.
ADDRESSING LOW HEALTH LITERACY Low health literacy is a fact of American life and a public health crisis. It is an ethical and financial issue that affects all health care professionals. For moral and ethical reasons, it is important that people are able to understand and follow directions.22 Using resources and ingenuity, today’s health care leaders can use the available tools for assessing low health literacy to develop new programs and educational tools for assessing and addressing the needs of patients with low health literacy. Assessing patients for low health literacy and addressing the needs associated with it in an outpatient surgical center is a continual process that should begin in the primary care provider’s office. This assessment, however, should be the responsibility of all health care professionals who are charged with a patient’s care. Available assessment tools should be used before a patient is scheduled for surgery, and the results of those assessments should be used throughout the entire perioperative experience. Personnel in outpatient surgical centers need to analyze the makeup of their patient populations and develop tools and educational information based on the results of those analyses. Patients also must be encouraged to take an active role in their own health care. The partnership between health care provider and patient regarding information given and received must be continually reviewed. This individualized and direct approach will lead to an overall reduction in health care costs and, ultimately, to higher quality medical care for patients. When patients understand their health care plan, it gives them a sense of empowerment and confidence. This in turn encourages more patient participation leading to increased education and resulting in informed choices in patients’ health care management. These informed decisions affect every consumer and the health care industry as a whole. Addressing the public health crisis of
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low health literacy by improving the delivery of health care and quantifying a patient’s level of understanding increases the quality and continuity of the health care system. Understanding a health care plan is a fundamental and basic patient right. Ultimately, patients’ low health literacy and health care providers’ communication processes must be continually reviewed and improved so that the health care community, with perioperative nurses as teachers, can boast “no patient left behind.”
REFERENCES 1. World Health Organization, Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Health Promotion Glossary. Geneva, Switzerland: World Health Organization; 1998. http://www.who.int/hpr/NPH /docs/hp_glossary_en.pdf. Accessed July 16, 2007. 2. Scudder L. Words and well-being: how literacy affects patient health. J Nurse Pract. 2006;2(1):28-35. 3. Pirisi A. Low health literacy prevents equal access to care. Lancet. 2000;356(9244):1828. 4. Kirsch IS, Jungebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education; 1993. 5. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). Washington, DC: National Center for Education Statistics; 2006. http://nces.ed.gov /pubs2006/2006483.pdf. Accessed July 13, 2007. 6. Talking the talk: improving patient-provider communication. Facts of Life: Issue Briefings for Health Reporters. 2003;8(3). http://www.cfah.org /factsoflife/vol8no3.cfm. Accessed July 17, 2007. 7. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6): 545–551. 8. July/August 2005 Health Poll Report Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2005. http://www.kff.org/kaiserpolls/upload /7376.pdf. Accessed July 16, 2007. 9. Atchison KA, Black EE, Leathers R, et al. A qualitative report of patient problems and postoperative instructions. J Oral Maxillofac Surg. 2005;63(4):449-456. 10. Howard DH, Gazmararian J, Parker RM. The
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impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005; 118(4):371–377. 11. Schwartzberg JA. Low health literacy: what do your patients really understand? Nurs Econ. 2002; 20(3):145-147. 12. Fact sheet: low health literacy skills increase annual health care expenditures by $73 billion. National Academy on an Aging Society. http:// www.agingsociety.org/agingsociety/publications /fact/fact_low.html. Accessed July 13, 2007. 13. Impact of low health literacy skills on annual health care expenditures. CHCS fact sheet. Center for Health Care Strategies, Inc. http://www.chcs .org/usr_doc/Health_Literacy_Fact_Sheets.pdf. Accessed July 13, 2007. 14. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791-798. 15. Mantone J. Reading writing and relating: providers—rural and urban—urged to pay more attention to health literacy. Mod Healthc. 2005;35 (32):30-31. 16. Wallace L; North American Primary Care Research Group. Patients’ health literacy skills: the missing demographic variable in primary care research. Ann Fam Med. 2006;4(1):85-86. 17. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514-522. 18. Informed consent. AMA. http://www.ama-assn .org/ama/pub/category/4608.html. Accessed July 27, 2007. 19. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. 20. Kusec S, Oreskovic S, Skegro M, Korolija D, Busic Z, Horzic M. Improving comprehension of informed consent. Patient Educ Couns. 2006;60 (3):294-300. 21. Health literacy. AMA Foundation. October 31, 2006. http://www.ama-assn.org/ama/pub/cate gory/8115.html. Accessed July 16, 2007. 22. Beckley ET. Are you receiving me? Improving patient literacy reduces med mal, safety risks. Mod Physician. 2003;7(6):12.
Cindy L. Monachos, RN, BS, is the director of surgical services, Oak Brook Surgical Center, Oak Brook, IL.
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