Professional Review
Health Literacy: Implications and Strategies Melissa Culp, MEd, R.T.(R)(MR)
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iteracy is a comprehensive process in which people read, view images, listen, discuss, and write to understand information. It is a holistic approach to reading and writing that helps an audience to comprehend and apply information beyond a superficial level.1 Literacy is important for understanding educational curricula, law, government, and consumerism, but health literacy for patients is of utmost concern. According to the Committee on Health Literacy, health literacy is, “[t]he degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” 2 A report from the Agency for Healthcare Research and Quality (AHRQ) regarding health literacy and patient outcomes linked lower health literacy to higher risk of mortality for seniors, reduced medication compliance, and poorer overall health status among seniors.3 In addition: moderate evidence about health care service use showed that lower health literacy was associated with increased hospitalization (5 studies), greater emergency care use (9 studies), lower use of mammography (4 studies), and lower receipt of influenza vaccines (4 studies).3 The AHRQ documented additional studies that did not demonstrate strong correlations between health literacy and outcomes because they were too broad, poorly designed, biased, or for other reasons. 106
However, the AHRQ’s findings suggest that a patient’s understanding of health language and text can affect his or her outcome. Because literacy affects patient outcomes, a focus on health literacy and comprehension is important. According to Scott et al, “[i]f low literacy patients have lower rates of compliance with suggested tests, then interventions may need to specifically address issues of health literacy.” 4 For patients to have sufficient information to make good choices, health professionals must have strategies in place to improve patient comprehension.5 When facing an initial diagnosis or planned procedure, the public often turns to the Internet for background and instant information. In most areas of medicine, patient-geared Web sites written by professional organizations provide accurate, clear information about tests and diseases. There are several ways to support patients in the radiology environment and in health care in general. Documented strategies for radiology departments include writing patient literature at appropriate reading levels, adopting an attitude of giving informed choices, and tailoring communication to the health literacy level of the patient. To help with patient comprehension, the American Medical Association and the National Institutes of Health recommend that patient materials be written no higher than a seventh-grade reading level. When David Hansberry from Rutgers conducted 3 studies reviewing radiology-specific patient Web sites, RADIOLOGIC TECHNOLOGY, September/October 2015, Volume 87, Number 1
Professional Review Culp
he found them to be written at higher than recommended levels—with different sites ranging in readability from 9th to 12th grade levels. 6-8 He suggests that rewriting online patient resources might increase awareness of radiology’s role in diagnosis and could help patients comprehend medical information. Once patients come to the radiology department, there are additional ways to consider health literacy as a factor in improving patient care and experience. Providers who adopt an attitude of informed choice rather than informed consent can increase overall patient understanding and satisfaction. Informed consent is consent given by a patient for a medical procedure after understanding the relevant risks, benefits, and facts. Patients often see the typical informed consent documentation and discussion as legalistic, protecting the physician, difficult to comprehend, and giving only limited understanding.9 Conversely, informed choice puts more emphasis on patient comprehension by using appropriate vocabulary and language, avoiding paternalism, being flexible in the presentation of information to meet the patient’s needs, and using visual decision aids. Although an informed choice approach improves patient literacy and complements the goals of patient care, it requires a shift in the attitudes of providers. An additional strategy for improving patient literacy in radiology or other health environments is to increase self-awareness among health professionals about the level at which they are communicating. Smith et al found that radiation therapists reported using basic language when working with populations they perceived as having low health literacy; however, with direction and support the therapists were able to tailor their language and communication even more specifically to match the health literacy level of individual patients.10 Therapists were encouraged to use minimal medical terminology, incorporate visual aids, use analogies, and reiterate information. Smith postulates that this structured approach to health literacy could minimize adverse outcomes in the radiation therapy environment. Additional interventions that improved patient health literacy included presenting critical information by itself on paper and then in an immediate follow-up discussion so that the patient is not distracted by other RADIOLOGIC TECHNOLOGY, September/October 2015, Volume 87, Number 1
data and details.3 This approach allows for clearer understanding because main ideas are separated from less important information, which is useful for readers with low literacy.1 Another option is to show video along with narration when possible, which is an example of a multimodal environment.1,3 Different forms of media used together appropriately can increase and support literacy. Another important strategy for improving patient health literacy is through student education. When students receive formal education about their future profession, instruction about communicating with patients is essential. The American Society of Radiologic Technologists curricula have objectives to support instruction in this topic and recommend educating students about professional communication, age-appropriate language, cultural diversity, socioeconomic backgrounds, and lifestyle choices.11 To promote health literacy among different patient populations, students must understand and empathize with varying groups of people. An educational and fun way to emphasize health literacy levels for students is to have them act out scenarios in which some participants play patients and some play technologists. This type of activity—along with written reflection about health literacy—supplements text and classroom instruction. In addition, registered technologists and faculty evaluate students during their clinical rotations to determine whether they communicate adequately with patients. Today’s students are tomorrow’s health care professionals; incorporating education about patient health literacy is essential. In summary, the literature supports that health literacy affects patient outcomes. Several documented strategies exist to improve literacy and comprehension, including writing patient literature at appropriate reading levels, adopting an attitude of giving informed choices, and tailoring communication to the health literacy level of the patient. Furthermore, instructors in the medical imaging field must teach students the importance of patient health literacy and clear communication. As these students enter the workforce, they will carry with them the information and skills to work with all types of patients. Health literacy for patients empowers them to understand medical situations, giving them autonomy over decision making and likely improving outcomes. 107
Professional Review Health Literacy: Implications and Strategies
Melissa Culp, MEd, R.T.(R)(MR), is clinical assistant professor in the division of radiologic science for the University of North Carolina at Chapel Hill. Her teaching foci are radiographic positioning, pathology, and health care delivery. She has an interest in sustainable global health radiology initiatives. Culp can be reached at
[email protected].
References
10. Smith SK, Zhu Y, Dhillon HM, et al. Supporting patients with low health literacy: what role do radiation therapists play? Support Care Cancer. 2013;21(11):3051-3061. doi:10.1007 /s00520-013-1875-7. 11. American Society of Radiologic Technologists. Radiography curriculum. http://www.asrt.org/educators/asrt-curricula /radiography. Published 2012. Accessed July 30, 2014.
What strategies do you use to increase health literacy in patients? Share your ideas at www.asrt.org/myasrt.
1. Vacca RT, Vacca JL, Mraz ME. Content Area Reading: Literacy and Learning Across the Curriculum. 11th ed. Upper Saddle River, NJ: Pearson; 2013. 2. Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. http://www.nap.edu/catalog/10883.html. Published 2004. Accessed January 13, 2015. 3. Agency for Healthcare Research and Quality. Health literacy interventions and outcomes: an updated systemic review. http://archive.ahrq.gov/research/findings/evidence-based -reports/litupsum.html. Published March 2011. Accessed January 13, 2015. 4. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40(5):395-404. 5. Institute of Medicine Roundtable on Health Literacy. Innovations in Health Literacy Research: Workshop Summary. http://www.nap.edu/catalog.php?record_id=13016. Published 2011. Accessed January 13, 2015. 6. Hansberry DR, John A, John E, Agarwal N, Gonzales SF, Baker SR. A critical review of the readability of online patient education resources from RadiologyInfo.Org. AJR Am J Roentgenol. 2014;202(3):566-575. doi:10.2214/AJR.13.11223. 7. Hansberry DR, Kraus C, Agarwal N, Baker SR, Gonzales SF. Health literacy in vascular and interventional radiology: a comparative analysis of online patient education resources. Cardiovasc Intervent Radiol. 2014;37(4):1034-1040. doi:10.1007/s00270-013-0752-6. 8. Hansberry DR, Ramchand T, Patel S, et al. Are we failing to communicate? Internet-based patient education materials and radiation safety. Eur J Radiol. 2014;83(9):1698-1702. doi:10.1016/j.ejrad.2014.04.013. 9. Goske MJ, Bulas D. Improving health literacy: informed decision-making rather than informed consent for CT scans in children. Pediatr Radiol. 2009;39(9):901-903. doi:10.1007 /s00247-009-1322-6.
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