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Health care illiteracy: Your chance to make a difference

Bill Kohlhepp, MHA, PA-C; Julie A. Theriault, PA-C

Bill Kohlhepp is a past president of the AAPA and Associate Director, Quinnipiac University PA Program, Hamden, Conn. Julie Theriault is President of the AAPA and a family practice PA with the Sutter Medical Group, Elk Grove, Calif.

Yolanda has been a patient in our clinic for about 20 years now. In addition to other chronic problems, Yolanda has diabetes and hypertension. When I* started to care for Yolanda, I was frustrated. All of her numbers were off. Her glycohemoglobin was 10.2%, and her BP was always high. They taught us in PA school to write out instructions in easy-to-read English for patients having difficulties. I did, and she still was out of control. I had all of her instructions translated into Spanish, her native language, but nothing changed. One day, something dawned on me, and I asked Yolanda if she could read. She meekly told me that she couldn’t read at all. She had been too embarrassed to tell me. It totally changed my approach to her care. I saw her a few weeks ago, and her diabetes and hypertension are almost under control. I needed to improve my own health literacy to help Yolanda with hers, so she could take her medicine correctly and improve her health-related habits.

*Julie Theriault

The Host City Prevention Campaign

In this issue of JAAPA, Zachary Hartsell brings our attention to health literacy—a topic that should be of major concern to all clinicians (see “Health care illiteracy: Implications for providers,”). He provides a clear definition for health literacy, offers ways to recognize low health literacy in patients, and provides a guide to low-cost interventions. Hartsell also mentions that health literacy is the theme of the AAPA’s 2004-2005 Host City Prevention Campaign.

Each year, the Host City Prevention Campaign focuses on an issue chosen by the PA Foundation, the AAPA, the Association of PA Programs, and the Student Academy of AAPA (SAAAPA). Throughout the year, SAAAPA student societies and AAPA constituent organizations have been raising money to support programs that address health literacy issues in local communities. One third of the money raised will go to ManaTEEN in Manatee County, Florida. ManaTEEN is the nation’s largest locally-based, youth-led volunteer program in the nation. It will use the grant to establish a health literacy program to teach students about obesity, teen pregnancy, HIV and other sexually transmitted diseases, and drug and alcohol abuse. In addition to their fundraising efforts, SAAAPA has partnered with ManaTEEN on a nationwide children’s book drive. PA students and PAs will donate the books and bring them to Orlando, Florida, where bins to collect them will be placed in various spots at the AAPA’s 33rd Annual Physician Assistant Conference. After the conference, the books will be distributed to children whose lives were affected by last year’s hurricanes.

During regional meetings and at sites near PA programs, Student Academy and AAPA leaders are giving presentations on health literacy. In addition, while at regional meetings or in their own communities, students and PA graduates are going to local schools to read to elementary school students and provide them with copies of the books that are read to them.

A central theme

Health literacy is central to the PA profession’s approach to issues faced by our patients. It touches on many of our areas of current focus—health care quality, patient safety, patient adherence, patient advocacy, cultural diversity, and Healthy People 2010, to name a few. It also provides an opportunity for the Academy to work in partnership with the American Medical Association (AMA), the American Academy of Family Physicians, and other health care organizations.

Hartsell’s article establishes a clear link between low health literacy and lower quality patient care. He notes, “Patients with low health literacy have more hospitalizations, fewer primary care physician visits, and poor adherence to physician recommendations.” Hartsell goes on to postulate that failure to address low health literacy may increase malpractice risks for clinicians and the potential for loss of accreditation for health care organizations.

The article raises another issue—that of patient safety—that has garnered attention from the AAPA in recent years. As patient advocates, PAs have embraced patient safety efforts recommended by the Institute of Medicine (IOM). Last year, the Institute focused on the clear link between health literacy and patient safety. Within their report entitled Health Literacy: A Prescription to End Confusion, the IOM established several “Wishes for Society.” One “wish” is that people become more able to “obtain, interpret, and use health information,” and another is that health care providers and institutions “take responsibility for providing clear communication.”¹ Through its Quality Care Committee, the AAPA is looking at how the two issues of health care quality and patient safety merge. Certainly, health literacy is an example of that coming together.

The link between patient adherence to treatment recommendations and health literacy is evident in Hartsell’s reference to the difficulties that some patients face with following directions. These are caused by problems with reading and with processing health care information. In April 2004, the AAPA and the PA Foundation brought together a blue-ribbon panel of experts to launch a campaign to address patient adherence.* Panel members identified literacy issues as affecting adherence, and they echoed some of the points also made by the IOM regarding the important role sufficient health literacy will play in the self-management of chronic diseases.

*For articles that were developed out of the April 2004 patient adherence conference, see the November 2004 issue of JAAPA.

Coalition building

Health literacy provides another opportunity for the PA profession to support the efforts of the Surgeon General and Healthy People 2010, which is the Department of Health and Human Services’ “road map” for the nation’s health. Surgeon General Richard Carmona has described low health literacy as “a threat to the health and well-being of Americans and to the health and well-being of the American medical system.” He has called on health professionals to “bring the dialogue about health literacy into greater focus among health professionals and society as a whole.”²

Hartsell compliments the AMA for taking the lead with its “Help Your Patients Understand” campaign. The AAPA and practicing PAs can support the efforts of the AMA’s campaign by purchasing educational materials from the AMA Foundation. The campaign looks to improve communication by identifying behaviors to be utilized by health professionals once they have identified one or more of the “red flags” that suggest a low literacy patient. First, the AMA offers a number of strategies, including such basic approaches as “exhibiting a general attitude of helpfulness” and “routinely reviewing important instructions and providing easy to read handouts.” Then, the AMA lists steps to improve interpersonal communication, including “using plain, nonmedical language; using the teach-back or show-me technique to confirm understanding; and creating a shame-free environment.”³

Another opportunity for PAs to act in coalition with other health care professional organizations is the AAPA’s efforts with the Partnership for Clear Health Communication.⁴ In an effort to increase awareness of low health literacy and to develop solutions to address this issue and its impact on health outcomes, a number of national organizations have come together to form the Partnership. Looking to provide patients with tools to assure clear communication and to allow them to better understand and act on health information, the Partnership launched an initiative entitled “Ask Me 3.” Educational materials encourage patients to ask their providers three simple yet essential questions:

1.   What is my main problem?
2.   What do I need to do?
3.   Why is it important for me to do this?

In addition, the Partnership provides strategies for health care professionals to utilize in responding when patients ask these questions and others. Generally, the techniques parallel those suggested by the AMA. Most importantly, they suggest “creating a safe environment where patients feel comfortable talking openly with you,” and they recommend “using visual models to illustrate a procedure or condition.”⁴

What you can do

We encourage PAs to read Hartsell’s article to learn more about low health literacy and to incorporate his suggestions for interventions into their practices. To become a better patient advocate, investigate the resources listed in the article to increase your understanding of the issue. Look to adopt methods that will permit you to identify patients with low health literacy and to embrace strategies to enhance communications with patients who have low health literacy. Most importantly, work to create a comfort level with your patients that will encourage them to admit to you when they can’t read your directions or understand your recommendations. To solve the problem of low health literacy, you first have to know it is there.   

REFERENCES

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