It is imperative that...providers recognize when patients are struggling to understand health-related instructions, identify patients’ usual means of compensating for health literacy limitations, and intervene appropriately... Today’s healthcare environment is rapidly changing and becoming increasingly complex. For patients who must navigate this complex system, make informed healthcare decisions, and care for acute or chronic health conditions at home, the complexity of healthcare terminology, devices, and instructions can be overwhelming. If, in addition to this complexity, patients have limited health literacy, managing their healthcare becomes even more difficult. Although low health literacy levels have been associated with poorer patient health outcomes, many healthcare professionals are unaware of which of their patients have health literacy limitations; and often they do not know how to intervene appropriately with these patients (Rogers, Wallace, & Weiss, 2006; Singleton, 2009). It is imperative that we as healthcare providers recognize when patients are struggling to understand health-related instructions, identify patients’ usual means of compensating for health literacy limitations, and intervene appropriately to assure patients’ understanding of their health conditions and required self-care behaviors. It is also essential that we incorporate health literacy-related content into the nursing education curriculum, so that new nurses will be skilled in communicating with patients having low health literacy levels.

In this article we will discuss the significance of inadequate health literacy and ways to identify and intervene with patients who have limited health literacy. We will describe how we incorporated health literacy content into a nursing curriculum and then assessed the impact of this education session on the students’ ability to master the content and apply it in the clinical setting. We will also present findings regarding the incidence of health literacy limitations among a sample of medical-surgical patients and report their preferred behaviors to compensate for their lack of understanding of health-related information.

Significance of the Health Literacy Problem

Low health literacy is not uncommon among elderly adults. The Institute of Medicine (IOM) (2004b) defines health literacy as the ability to obtain, understand, and act on healthcare information and instructions. This includes activities such as taking prescribed medications appropriately, providing informed consent for medical procedures and tests, following instructions for self-care of a health condition, reading food labels in order to follow a prescribed diet, and navigating the complex healthcare system (Cutilli, 2005; Hess & Whelan, 2009; Lorenzen, Melby, & Earles, 2008).

Low health literacy is not uncommon among elderly adults. It is estimated that at least 36% of adults in the United States (US) have limited health literacy (Kutner, Jin, & Jin, 2006). This percentage climbs to 59% for the U.S. elderly. It is also higher in minority (particularly Black and Hispanic) and immigrant populations (Kutner et al., 2006; Rudd, 2007; Singleton, 2009). United State citizens covered by Medicare and Medicaid insurance, and those without insurance also have lower health literacy levels (Kutner et al., 2006). Even patients who are well educated and highly literate, but who have limited healthcare experience, may struggle with the complexity of healthcare terminology and procedures (Cornett, 2009; IOM, 2004a).

Patients with lower health literacy levels experience higher rates of hospitalization and emergency room use. Limited health literacy has been identified as having a significant impact on patient health. Patients with lower health literacy levels experience higher rates of hospitalization and emergency room use. They have overall poorer physical function, less knowledge about managing their chronic health conditions, and less participation in the healthcare decision-making process. They also use fewer preventive care services (Baker et al., 2002; Baker et al., 2007; Dewalt, Berkman, Sheridan, Lohr, & Pignone, 2004; DeWalt, Boone, & Pignone, 2007; Katz, Jacobson, Veledar, & Kripalani, 2007). Low health literacy in the US is costly, both in terms of poorer health and the financial burden on the healthcare system. It is estimated that yearly healthcare costs resulting from low health literacy levels range from 106 to 238 billion dollars (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007).

Identifying and Intervening with Patients Who Have Limited Health Literacy

Although healthcare providers often think that they are able to identify patients with limited health literacy levels, studies indicate that they fail to identify up to half of the patients who struggle to understand health information (Rogers, Wallace, & Weiss, 2006; Singleton, 2009). Some observable cues to health literacy limitations include: “forgotten” glasses that prevent patients from reading printed instructions or forms, missed appointments due to navigation problems or lack of understanding of directions, difficulty completing health forms, inability to list and describe the purpose of prescribed medications, limited questioning of the healthcare provider, and apparent lack of follow through on self-care instructions (Fernandez & Schillinger, 2009; Katz et al., 2007).

There are a number of health literacy tests that healthcare providers can use to assess a patient’s health literacy level. These tests include the Rapid Estimation of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (TNVS) (Baker et al., 2007; Cutilli, 2005; Lehna & McNeil, 2008; Peterson, Dwyer, Mulvaney, Dietrich, & Rothman, 2007; Reeves, 2008; Rogers et al., 2006). However, all these tests take several minutes to administer and score, limiting their usefulness in a busy clinical setting. In addition, patients may feel that health providers think they are “stupid” because they are unable to answer the questions correctly. They may be ashamed of their limitations, or may even refuse to complete the tests (Cutilli, 2005; Paasche-Orlow & Wolf, 2008).

There is...[an] another approach to identifying patients with health literacy limitations--one that is more efficient to administer and may elicit fewer negative feelings among patients. There is, however, another approach to identifying patients with health literacy limitations--one that is more efficient to administer and may elicit fewer negative feelings among patients. Chew has developed three specific screening questions that have been shown to identify patients with low levels of health literacy (Chew, Bradley, & Boyko, 2004). These questions, using a five-point Likert scale, ask patients: “How confident are you in filling out medical forms by yourself?” (response options range from Not at all Confident to Very Confident); “How often do you have someone help you read hospital materials” (responses range from Always to Never); and “How often do you have problems learning about your medical condition because of difficulty understanding written information” (options range from Always to Never). Chew (Chew et al., 2004; Chew et al., 2008) and Wallace (Wallace et al., 2007; Wallace, Rogers, Roskos, Holiday, & Weiss, 2006) have compared the results of these three questions with the TOFHLA and REALM tests, finding strong correlations between test scores. In a semi-structured interview with clinic patients from an urban, underserved family medicine residency clinic, participants indicated that Chew and colleague’s questions were generally acceptable, particularly if asked in the privacy of the examination room (Farrell, Chandran, & Gramling, 2008). All respondents felt that health literacy screening was worthwhile.

Although Chew’s three questions are effective in identifying patients having low health literacy, they, like the other tests, miss determining what patients do when they don’t fully understand important health information or instructions, i.e., how they compensate for their lack of understanding. In some cases, patient compensatory behaviors (described below) may contribute to the failure to understand important health information. Without this assessment data, it is difficult for health professionals to either support patients in using compensatory behaviors that will promote understanding or suggest behaviors that would better help patients understand vital health information.

Incorporating Health Literacy Content into Nursing Education Programs

Many nurses and other healthcare professionals have not been adequately trained in identifying and interacting with patients having lower health literacy levels (DeSilets & Dickerson, 2009; Speros, 2009; Vernon et al., 2007). Patient teaching is a core nursing responsibility. However, if patients do not understand what nurses have taught them, effective communication has not taken place (Parker & Gazmararian, 2003). Mandates from the Institute of Medicine, Healthy People 2010, and The Joint Commission (TJC) support teaching nurses about health literacy (IOM, 2004b; TJC, 2005; U.S. Department of Health and Human Services, Healthy People 2010, 2000). However, nursing education programs often fail to specifically address health literacy issues when covering patient education content (Cornett, 2009), and currently, there is no standard for the depth of health literacy content to be included in undergraduate nursing education. A review of the literature revealed a gap in demonstration of the effectiveness of health literacy education in changing student knowledge and application of health literacy principles in practice.

The purpose of the study described below was to determine the impact of a health literacy education session on student knowledge of health literacy concepts and ability to apply this knowledge in the clinical setting. A secondary purpose of the study was to identify both the prevalence of limited health literacy among hospitalized patients and also the behaviors patients use to compensate for their lack of understanding health information.

Assessing the Impact of a Brief Education Session on Health Literacy

A brief education session about health literacy was planned for sophomore (beginning level) nursing students at a large Mid-Atlantic university. The sophomore class consisted of 112 students (101 females and 11 males), all enrolled in the generic BSN program. The vast majority of students were “traditional” undergraduates—entering college directly after high school, and only a few had previous healthcare experience in a nursing assistant-type role.

Because no formal content related to health literacy had been presented previously, a pre-test was given to assess student knowledge just before presentation of the content. Students were informed that the pre and post-test were for the purpose of determining the effectiveness of the instruction session, and that the tests would not be included in their course grade. The education session consisted of 20 minutes of content covering the significance of the problem of low health literacy, identifying via behavioral cues those patients who may have health literacy issues, Chew’s three screening questions, and essential interventions in interacting with and teaching patients who may have health literacy issues. A case study involving a patient with limited health literacy was then presented and discussed. At the conclusion of the education session, students completed a post-test containing the same questions as the pre-test.

In the corresponding beginning-level clinical course, content related to health literacy assessment was added to the assessment section of the care planning document that students were asked to complete while caring for a hospitalized patient. This added content included Chew’s three screening questions and questions asking patients what they do when they have difficulty understanding either written or verbal health information/instructions. Students were asked to identify interventions they would take based on the collected health literacy assessment data.

Informal review of the student pre- and post-test data, as well as patient assessment data, indicated that further analysis would be beneficial, and that reporting of the results may be valuable. At that point an application was made to the West Virginia University Institutional Review Board (IRB) for a retrospective study of the data. After IRB approval and de-identification of student names on pre- and post-tests, the data were coded and analyzed.

Analysis and Results

One hundred three students completed the pre and post-test knowledge assessment. Paired t-test comparisons indicated a significant increase in student knowledge about health literacy after the brief educational session (see Table 1). Mean test scores increased from 6.5 to 8.4 on the 10 item inventory.

Table 1. Comparison of Pre-Test and Post-Test Health Literacy Scores

Data from 94 patients hospitalized on one of the medical-surgical units at the university hospital were obtained through care plan review. Students had collected health literacy assessment data, which was a component of the patient assessment database, through interviewing a patient who was assigned to them during the clinical rotation. The health literacy patient assessment sheet was removed from the remainder of the assessment database--no identifying patient information remained in the data sheet containing the health literacy assessment questions. Data were coded and entered into SPSS version 17 for analysis. There were no more than three missing data points in any of the analyses, and cases with missing data were excluded on a test by test basis.

Mean patient age was 54 years and median education level was that of a high school graduate. Race/ethnicity data was not available from the care plan source, but no students identified language as a barrier for any patients. Three of the 94 patients were identified as having potential minor, short-term-memory problems.

Patient responses to the question about patient confidence in filling out medical forms indicated that 43% were somewhat confident, a little confident, or not at all confident, meeting Chew’s criteria for health literacy risk. Similarly, 38% of patients reported sometimes, often or always needing help reading hospital materials, and 38% reported sometimes, often, or always having problems learning about their health condition due to trouble understanding written material, meeting Chew’s criteria for limited health literacy levels (See Table 2).

Table 2. Frequency of Categorical Responses to Chew’s Screening Questions

Note: Responses to the right of the bold column line indicate a limitation in health literacy.

After collapsing age into two categories--under 60 years (n = 51), and 60 years and older (n = 41)--we compared patient responses to the health literacy questions by age, using the Mann-Whitney statistic. No age determination was available for two of the 94 patients. Results indicated that older patients were significantly less confident in filling out medical forms (Z = -3.9, p = .000), and reported more often needing help in reading hospital materials (Z = -3.1, p = .002) (See Table 3).

Table 3. Comparison of Age and Health Literacy Responses

Comparisons of patient education level with responses to the health literacy questions via Kruskal-Wallis analysis indicated significantly different responses according to education level. In general, as reported education levels increased, the confidence in filling out medical forms increased χ² (df 6) = 28.1, p = .000, and patients reported less often needing help reading hospital materials; χ² (df 6) =19.0, p = .004—see Table 4. In addition, as education levels increased, patients reported less often having problems learning about their health condition because of trouble understanding written information; χ² (df = 6) = 24.2, p = .000. However, as evident in the mean rank data presented in Table 4, there were two instances in which the mean ranks decreased somewhat as education level increased—an unexpected finding. Mean ranks for all three literacy questions were slightly lower for patients reporting middle school education as opposed to elementary education. However, only one patient in the study sample reported an elementary school education—thus the findings may not be noteworthy. In addition, mean ranks for patients reporting college graduation were slightly lower than for those reporting some college for all three of the health literacy questions.

Table 4. Comparison of Education Level and Health Literacy Responses

Patients more frequently identified directing their questions to an RN as opposed to their physician. Patient narrative responses to the questions asking what they did when they had trouble understanding either written or verbal health information were categorized according to theme and tallied. In reviewing the data it was noted that patients typically responded with only one answer or behavior, and sometimes provided general answers to the questions, such as “ask questions or ask someone.” Students had not been given instructions to prompt patients for specific behavioral responses or additional behaviors, if only one answer was given.

Patient responses to the question asking what they did if they were having trouble understanding written information are listed in Table 5. The most frequent patient response was to ask a family member, followed by an RN or MD. Patients more frequently identified directing their questions to an RN as opposed to their physician. Five patients reported not usually having any trouble understanding written health information. Although only a few patients identified responses of trying to understand the material themselves, or trusting the MD and signing a form, these responses are quite concerning in terms of potential contributions to an adverse patient outcome.

Table 5. Identified Compensatory Behaviors for Lack of Understanding of Written Information (N = 94)

The most common specific patient response to lack of understanding of...health information was to ask a family member... [they, however] may have no better understanding...
than the patient... Patient responses to the item asking what they do if they don’t understand verbal instructions were, most commonly, to ask questions, although patients often didn’t identify to whom they would direct the questions. When patients did specifically state whom they would ask questions of, family members were identified more frequently than the RN or physician (See Table 6). Six of 94 patients identified that they would just “let it go” or do nothing—a response that could contribute to continued lack of understanding and adverse patient health outcomes. Three patients indicated not having any difficulty understanding verbal health information.

Table 6. Identified Compensatory Behaviors for Lack of Understanding of Verbal Instructions (N = 94)

...health literacy... should be threaded throughout the entire nursing curriculum... even a short education intervention can impact student knowledge...Our final step in data review and analysis was to look at student responses to the health literacy assessment data that they had collected. Students identified appropriate interventions in response to identified patient health literacy limitations, including “making sure the patient understands the health information,” “using teach-back to assess patient understanding,” “explaining the information in simple terms,” “using alternative teaching forms and videos,” “assuring that patient family members are present during teaching,” “presenting information in small pieces,” and “using simple terms and explanations.” The interventions students identified in response to the assessment data reflected appropriate application of health literacy principles.

Discussion and Implications

Nursing graduates must be astute in identifying patients who lack understanding of health information and who may be using detrimental behaviors to compensate for a lack of understanding. This section will discuss why these study findings should raise concern among nurses and all healthcare professionals regarding the adequacy of patient comprehension of the health-related teaching they are given. Study limitations will be addressed. Future directions will be identified.

Discussion

In this exploratory study, the significant increase in nursing student knowledge scores after presentation of health literacy education content in the classroom setting indicates that even a short education intervention can impact student knowledge of critical health literacy issues. However, whether students continue to retain and use the knowledge gained in this brief education session is not known. Just as with other critical nursing education content, health literacy is a topic that should be threaded throughout the entire nursing curriculum and stressed in each clinical rotation. New nursing graduates need to be able to: (a) identify patients at risk for not being able to understand and act on health information, (b) communicate health information and instructions in a way that promotes patient understanding, and (c) check for patient understanding (DeSilets & Dickerson, 2009; Speros, 2009).

Another...concern was that some patients would “try again” to understand...and not ask questions, just let the issue “go”...[t]he likelihood for adverse health outcomes could be significantly increased by patient compensatory behaviors. The incidence of low health literacy among this convenience sample of hospitalized medical-surgical patients is consistent with national norms (Kutner et al., 2006) and findings of other researchers (Katz et al., 2007). The finding that older patients and those reporting lower education levels are at higher risk for low health literacy is also consistent with the literature (Kutner et al., 2006; Rudd, 2007; Speros, 2009).

Patient compensatory behaviors for lack of understanding of health information have not been reported in the literature as frequently, but some behaviors identified in this study are quite concerning. The most common specific patient response to lack of understanding of both written and verbally conveyed health information was to ask a family member. The concern with this response is that family members may have no better understanding of the health information than the patient, and may cause the patient to become even more confused about what he/she was told. Thus, the patient would continue to lack an understanding of vital information. Another issue of concern was that some patients would “try again” to understand printed material or instructions independently and not ask questions, just let the issue “go” (meaning do nothing about their lack of understanding), or trust the physician and sign any requested forms regardless of understanding.  These compensatory behaviors might result in adverse outcomes, including patients consenting to procedures that they have no understanding of, going home from a clinic without filling a needed prescription, taking medications incorrectly, or not performing necessary self-care activities. The likelihood for adverse health outcomes could be significantly increased by these patient compensatory behaviors.

Study Limitations

This study was a retrospective data analysis—a quasi-experimental design. Use of a control group in implementation of the student education intervention would have strengthened the design. In addition, the patient population represented a convenience sample of patients, specifically those patients that the students selected for completion of the formal assessment and care planning clinical assignment. Although the proportion of patients with lower health literacy levels was comparable to those reported by other authors, these findings cannot be widely generalized. In addition, when patients responded in broad terms to student questions asking what they did when they didn’t understand health information or instructions, students had not been instructed to request that the patient identify specifically of whom he/she would ask the questions. Regarding patients responding in general terms that they would ask questions about the information they didn’t understand, it was not possible to determine whether their behaviors would most likely lead to clarification of information, or potentially result in continued lack of understanding. It would be beneficial in future patient assessments to ask specifically whom patients would consult to clarify the health information they were given.

Implications

Incorporation of simple and effective health literacy questions into all patient assessment databases would help to identify patients for whom health literacy is an issue. Results of this study have significant implications for nursing practice and nursing education, as well as for guiding future research. Given the significance of low health literacy in the US, all nursing education programs should be incorporating health literacy content throughout their undergraduate and graduate curricula. Nursing graduates must be astute in identifying patients who lack understanding of health information and who may be using detrimental behaviors to compensate for a lack of understanding. They must also be able to adapt patient education interventions to assure patient understanding of vital health information. Practicing nurses must be competent in these same areas. Perhaps completion of a continuing education program about health literacy should be required for re-licensure of RN’s. Outcome measures for such an education program would need to be identified and monitored, including both measurement of patient understanding of health information presented by nurses who had completed health literacy education, and also patient health outcomes.

Incorporation of simple and effective health literacy questions into all patient assessment databases would help to identify patients for whom health literacy is an issue. Development and implementation of appropriate interventions to assure patient understanding may significantly reduce negative health outcomes. Research is needed to identify the most effective interventions to assure patient understanding of important health information, and to document the impact of these interventions on patient treatment adherence and health outcomes. Nurses, who are the front-line providers of patient education and information, are encouraged to take the lead in demonstrating the value of health literacy assessment and the need for appropriate education interventions to improve patient health outcomes.

Author

Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC
Email:ksandjecklin@hsc.wvu.edu

Dr. Sand-Jecklin is an Associate Professor of nursing at West Virginia University (WVU). Her scholarly interests include teaching/learning strategies, health literacy, and holistic/complementary nursing care. She has conducted research studies in the areas of health literacy and nursing education. Dr. Sand-Jecklin has received the WVU Outstanding Teacher Award for her work in the field of education.

Billie Murray, MSN, FNP-BC
Email: bmurray@hsc.wvu.edu

Ms. Murray is a Lecturer and Clinical Instructor in nursing at West Virginia University. Her research interests include health literacy and patient self-medication management. She has received the WVU School of Nursing Innovative Teaching Award for utilizing simulation as an education strategy.

Barbara Summers, MSN, RN
Email: bsummers@hsc.wvu.edu

Ms. Summers is a Lecturer and Clinical Instructor at West Virginia University School of Nursing. She teaches an introductory freshman nursing course and a sophomore clinical course. Barbara has 36 years of clinical experience in adult critical care. Her scholarly interests include team-based learning and simulation.

Joanne Watson MSN, RN
Email: jewatson@hsc.wvu.edu

Ms. Watson is a Senior Lecturer and Clinical Instructor at West Virginia University School of Nursing. She coordinates the sophomore-level theory and clinical courses. Ms. Watson has 20 years of experience in Critical Care/Emergency Nursing; she has taught nursing for 16 years. Her scholarly interests include clinical education and evidence-based practice.