Such patients cannot be reliably identified by questions about their education level, as education does not always predict of literacy—it only measures the number of years an individual attended school. As discussed earlier, our testing included scenarios that assessed both reading and numeracy skills, but in every analysis we performed, the nutrition label with its quantitative-numerical questions was the best predictor of literacy using the TOFHLA as a reference standard.
That the questions from the nutrition label scenario had such high internal consistency suggests answering those questions involved not only a math skill, but also a locate-the-information skill by reading and comprehending and an abstract reasoning skill eg, imagining they have an allergy to peanuts, noting that even vanilla ice cream can have a peanut product in it, and reasoning that peanut oil is probably not good for you if you are allergic to peanuts.
Furthermore, the use of a nutrition label to assess health literacy is intuitively appealing because nutrition labels are familiar items that are important parts of health management for many chronic diseases. They are also used for health promotion in that many healthy people use information on nutrition labels to help achieve health eating habits.
The full TOFHLA, however, is the standardized instrument from which the short version was derived, so its psychometric properties are an appropriate reference standard for the development of new instruments.
Health literacy is a complex construct that encompasses many aspects of how individuals use health information and the health care system.
Our test, like the TOFHLA and the REALM, measures reading and interpretation skills ie, general literacy, reasoning, and the ability to use numbers as applied to material with health content, rather than all aspects of health literacy. The psychometric properties of the Spanish version of the NVS, although adequate to screen patients for limited literacy, were not as good as those of the English version.
This fact may stem from the greater heterogeneity of language and culture among our Spanish-speaking patients, who come from all regions of South America, Central America, and Mexico. Finally, the primary care practices in this study were selected because of their high percentage of Spanish-speaking patients, and among the Spanish-speaking participants the percentage of male patients was relatively small. These practices do not, therefore, have demographics that are fully representative of all primary care practices in the United States.
Testing of the NVS on other patient populations could further validate the accuracy of the instrument. The NVS has advantages over currently available instruments. The NVS also does not have the ceiling effect seen with the TOFHLA and, therefore, particularly in the English version, the NVS provides better discrimination of skill levels among individuals in the upper part of the distribution of literacy skills.
Additional thanks to Maria Chavez, research specialist in the University of Arizona Department of Family and Community Medicine, for her help with data entry. None of these individuals have any other financial interest in the Initiative or in Pfizer, Inc. National Center for Biotechnology Information , U. Journal List Ann Fam Med v.
Ann Fam Med. Barry D. Weiss , MD, 1 Mary Z. Hale , PhD 1. Mary Z. Darren A. Michael P. Frank A. Author information Article notes Copyright and License information Disclaimer. March 24, This article has been corrected. See Ann Fam Med. This article has been cited by other articles in PMC. Keywords: Literacy, health literacy, physician-patient communication, Spanish. Open in a separate window.
Figure 1A. The newest vital sign — English. Figure 1B. Questions and answers score sheet for the newest vital sign — English. Table 1. Prescription for headache medication 3 0. Consent form for angiography 4 0. Self-care instructions for heart failure 5 0. Instructions for tapering prednisone 3 0. Participants Participants were patients from 3 primary care practices in Tucson, Ariz, all of which are affiliated with the University of Arizona College of Medicine.
Participant Recruitment Participants had to be 18 years old or older, speak English or Spanish, have visual acuity sufficient to read the instruments being tested, and have grossly normal cognitive function that was adequate to interact with study personnel. Table 2. Figure 2. Table 3. Literacy and Health Outcomes. Health Communication. In: Healthy People Gottfredson L.
Why g matters: the complexity of everyday life. Reder S. Issues of Dimensionality and Construct Validity. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med. Weiss B. On the demand side, medical care is complex. Health information is often presented in such a way that proficiency in literacy and numeracy is needed to make informed health decisions.
Developing systems of care that do not require advanced health literacy skills could improve the delivery of safe, timely, efficient, effective, equitable, and patient-centered care. Practicing universal precautions — structuring healthcare services to minimize risk for everyone when it is unclear which patients may have difficulty — is the best way to ensure that people have all the information they need to make appropriate health decisions.
Research indicates that clinicians do not accurately identify people with limited health literacy. Healthcare providers have become increasingly aware of the communication and navigation problems their patients experience.
A variety of educational programs and resources to address health literacy have been developed. These approaches, however, have not integrated health literacy strategies into a quality improvement framework to assist practices with the redesign of processes and communication. Such an approach may help to increase adoption of best practices for the care of patients with limited health literacy. In this article, the development process and qualitative observations from implementation testing that occurred as part of the toolkit development are described.
The development process consisted of 3 major tasks: 1 developing individual tools modules explaining how to use or implement a strategy to minimize the effects of low health literacy using existing health literacy resources when possible, 2 testing individual tools in practice and assembling them into a prototype toolkit, and 3 testing implementation of the prototype toolkit in practice.
The HLUP toolkit was designed for use by all staff at a practice, including physicians, nurses, receptionists, and business staff. Approval was granted by the office of Human Research and Ethics at the University of North Carolina to engage practices in the testing of the toolkit. The study team received advice from a diverse expert advisory panel including physicians, nurses, health services researchers, quality improvement experts, and patients.
Panelists identified health literacy resources for possible inclusion in the toolkit, reviewed drafts of individual tools, and reviewed the entire toolkit before it was tested in practices. Six practices participated in the first phase of testing Task 2. Four of these practices, plus 4 additional practices, participated in the testing of the prototype toolkit Task 3. Practices varied in population served, size, practice type, location, and staff composition see Table 1.
All practices engaged members from all parts of the staff including nursing, physicians, practice management, and clerical staff. Representatives from all parts of the staff offered direct feedback on tools and attempted to implement tools appropriate for their position. For example, most practices that tested the teach-back tool used nurses and physicians in the testing. Practices that focused on encouraging questions usually included front desk staff, nursing, and physicians in the process.
The initial step in developing tools for the toolkit was to scan for existing resources. Resources consisted of ideas, strategies, handbooks, training curricula, videos, and other materials that could be used by primary care practices to reduce the health literacy demands on their patients.
These included both resources related to the clinician-patient encounter, as well as those that involved practice-wide redesign. The search team explicitly avoided identifying health education materials related to specific diseases or health topics, as that was beyond the scope of this toolkit. The team conducted the scan by: 1 searching the Internet using the Google search engine and key words such as health literacy, health communication, and health education materials; 2 making general inquiries to health literacy organizations, including the North Carolina Program on Health Literacy www.
More than resources were recorded and catalogued according to media type, author, price only free resources were considered for the toolkit , type of resources, and usefulness for the toolkit on an Excel spreadsheet. Gaps were identified where ideas and strategies existed but there were no suitable materials to support them. For some categories, there were multiple resources that addressed the same health literacy practice.
Furthermore, as anticipated, many of the resources did not include instructions on how to use the resource in clinical practice. Building on existing, freely available resources, a set of 22 prototype tools were constructed. Each tool, 2—4 pages in length, used a concise format designed to enable primary care practices to take quick action. Each tool contained 5 sections: 1 Overview, 2 Purpose, 3 Action—with the nuts and bolts of how to implement the tool, 4 Track Your Progress—with measures for implementation, and 5 Resources.
Each tool linked to resources available on the Internet; resources not available on the Internet were included as appendices to the toolkit. The tools were organized into 4 categories: improving spoken communication, improving written communication, improving self-management and empowerment, and improving supportive systems. We arrived on these categories after reviewing the tools and looking for the general themes. Each of these categories addresses an important facet of caring for people with low health literacy.
First, as is often discussed, improving spoken communication is critical for the patient-practice interactions. In addition to spoken communication, practices frequently communicate with patients using the written word with patient education materials, letters about tests and appointments, or even billing. We felt that some attention to self-management and empowerment, and how a practice can enhance this process for people with low health literacy who face special challenges in managing their conditions , was an important separate element.
The last category, improving supportive systems, addresses the fact that people with low health literacy struggle with several aspects of understanding information outside of the clinical office. Supportive systems, such as referral to literacy programs, other community support, or helping patients obtain their medications, may be important avenues in the care of patients with low health literacy.
Because the final tools were a combination of existing ideas and resources, as well as the product of our attempts at translating them to clinical practice, feedback was sought from clinicians and other staff who would use the tools.
Six practices each were asked to test 4 tools over a 2-week period. This structure allowed us to have rapid evaluation and feedback on the tools and to help the practices develop a strategy for testing new innovations for implementation across their practice. Practice staff then participated in a debriefing call with the study team in which the staff described what they did, how they did it, and what they liked and did not like about the tool.
They also were encouraged to offer any ideas on how the tool could be improved. Table 2 summarizes findings from testing the individual tools. Practices agreed that all tools they tested were important parts of the toolkit, but believed some were similar to each other and could be consolidated. Responding to this feedback, 2 tools related to the physical office environment and 2 tools on linking patients with community resources were combined, reducing the number of tools from 22 to More than one discipline assessing the practice brought more depth regarding strengths and weaknesses.
Completing the assessment often changed the priorities the team had identified prior to the assessment. Many liked how the assessment also listed the tool s to improve each deficiency and the rankings of importance of the tools. The American College of Physicians Foundation video was overwhelmingly well-received as a motivator that really resonated with all staff. Many practices used the PowerPoint presentation and sometimes included it with the video.
They liked its versatility, using slides to create bulletin boards or self-study projects. Many practices were initially drawn to this tool, but when implementing it they often focused on one aspect such as teach-back or Ask Me Three. Practices commented that a video of someone doing teach-back would help providers to better visualize how to incorporate this technique.
Practices noted that it took some time to learn this technique and how to appropriately ask patients to teach-back without appearing to quiz the patient. Most thought that, once learned, it would not take any more time out of their day. Others noted that doing teach-back on patients who were very low literate, had English as a second language, or were receiving a complicated management plan was more difficult and therefore they avoided it.
The teach-back self-evaluation form was found useful by half the practices and noted to be not very helpful by the others. A practice composed of all volunteers stated it was not feasible to provide follow-up due to staff structure and patients who do not have phones.
Another practice interpreted this as community outreach rather than individual patient follow-up. Practices realized they did not know what was on their message machine and appreciated the reminder to take note of it and revise if needed.
All practices that implemented this tool found medication-taking discrepancies and felt this was very worthwhile. The challenge for practices was getting patients to bring in their medications and finding the time to do the review. Financing these efforts seemed to be the biggest challenge. With practices that had limited interpreter services, trying to coordinate them with patient needs was challenging.
Practices felt that being sensitive to cultures and customs was difficult to teach, and the most sensitive providers were ones with firsthand experience in different cultures. Many practices preferred to collect patient information verbally rather than using a form; therefore, they did not see this as useful. This tool was avoided because practices felt there were too many hurdles in introducing new information collection forms.
The scope of this tool was broadened to include strategies for developing and assessing forms and health education materials. Practices indicated that practitioners felt using health education material would add to their day.
The scope of this tool was changed to focus on using health materials rather than developing them see Tool Practices felt this was an easy tool to accomplish, commenting that this tool should be suggested as an easy one to implement. Providers liked the idea of an action plan. They initially saw it as taking more time but felt it would work more smoothly once they practiced it with a few patients.
Practices saw the benefit in this, although they realized that producing graphic medication cards took more time than they could afford. They were able to revise their current electronic medical record system to create medication lists. The 55 questions in the CAHPS questionnaire was viewed as too many, but practices were willing to incorporate some of those questions into their current surveys. Most practices acknowledged the need for a resource manual.
Some had one but it was outdated. Others had a social worker or staff member who performed these types of duties. Practices took the effort to work on their resource manuals but did not seem to adjust their referral sheet to make sure that all patients could understand it.
Practices positively received the idea of linking patients up to literacy resources and, when executed, were surprised that patients received the suggestion well. Practices recognized that some tools were easier to implement than others, and some tools were avoided because staff felt they would take too much time.
These more demanding tools were included in the prototype toolkit nevertheless, as it was thought that the tools could prove valuable to practices that undertook long-term practice redesign, such as creating a telephone follow-up system with case management or redesigning all written materials.
Furthermore, changing healthcare policies eg, the increase in the federal matching rate for interpreter services under the Child Health Insurance Authorization Act and reimbursement for patient-centered medical homes might make implementing these tools more feasible in the near future.
Some staff in practices requested that we add a time frame for how long the implementation would take for each tool. The request was studied, and it was decided that a time of implementation for most of the tools could not reasonably be estimated, so it was not included. A few gaps were identified as the result of the testing of individual tools. One such gap was that practices felt a video would be very helpful to illustrate the teach-back process. No useful teach-back video was found in the scan of resources, so one was created for the toolkit.
Another gap resulted from the fact that many practices did not have experience with quality improvement techniques such as the Model for Improvement 15 and PDSA cycles that were used as a testing and implementation strategy. Visit the National Reporting System website.
Learn more. BEST Plus 2. Reading tasks include reading dates on a calendar, labels on food and clothing, bulletin announcements, and newspaper want ads. Writing tasks include addressing an envelope, writing a rent check, filling out a personal background form, and writing personal notes.
As plans unfold we will continue to keep you informed. Student Performance Levels.
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