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What is Health Literacy?

An excerpt from “Health Literacy” Sandra A. Smith & Jose Caldero’n   

What is Health Literacy?
Health literacy is a ‘type’ of functional literacy.  Like computer literacy, it develops with need, opportunity and experience. While much attention has been given to “patients who can’t read”, the difficulties of working with them, and the extra costs they incur, such patients are the exception. Very few Americans cannot read at all. Still, nearly everyone has low functional health literacy; that is, they have below basic to proficient literacy skills, but lack background knowledge, medical vocabulary, and experience in the healthcare system. For example, few people have need or opportunity to learn and talk about diabetes until they experience it. Upon initial diagnosis, their health literacy - or more specifically in this example - their “diabetes literacy” begins to develop. Similarly, until a person has need of medical services and opportunity to utilize the healthcare system, they will lack the background knowledge and vocabulary to navigate the system efficiently. With experience, their health literacy, or specifically in this example, their “healthcare literacy” improves – they progress toward higher levels of functioning in the context of that system. In this manner of thinking, everyone has low functional health literacy; screening is not necessary; and universal precautions are in order.  

What promotes health literacy?
To date most work to improve health literacy has focused on healthcare providers enhancing information delivery. The source of most healthcare communication problems is a mismatch between providers’ and patients’ logic, language and experience.9 Due to special training and vocabulary, physicians and other healthcare professionals think and talk about health, illness and treatment like no one else. While physicians may interact daily with institutions and technology, for many patients, major illness or injury marks their first encounter with an institution of any kind. Even with native-born patients proficient in English, culture and language can be barriers to efficient effective care. Federal and state law, Medicare and Medicaid regulations, and accreditation standards place responsibility for patient understanding squarely with the physician. Kleinman developed a set of interview questions to elicit a patient’s experience of a condition and treatment. 10 Practitioners can use these questions to close gaps between a patient’s logic, language and experience and their own. Another promising practice is a “teach back” method in which the provider asks the patient to “show me what you are going to do.” Over 300 studies make clear that most written health information exceeds patients’ literacy skills. Numerous guidelines have been published to increase the readability of health education materials, including the FONBAYS method developed by the authors of this chapter for simplifying the readability of text and survey questions.   However, improved information delivery alone is not likely to mitigate the relationship between low literacy and poor outcomes. Investigating whether and how literacy skills and functional health literacy affect self-efficacy, self-care, trust and satisfaction may lead to effective strategies. Theoretically, social support from family, friends or social services providers may buffer the negative impacts of low literacy and low health literacy by enabling a person to understand information, enter and navigate the health system and adhere to treatment regimens.11 Collaboration between healthcare organizations and literacy enhancing community services, such as adult basic education and English language learning classes, may also prove beneficial.  

Taking the view that everyone has low health literacy, practitioners can apply promising practices as universal precautions: 

  • Become aware of the culture of Medicine and your institution.
  • Become aware of your patient's culture.
  • Use the patient's language.  Say "walk" instead of "ambulate."
  • Be aware of the pictures your words create in the patient's mind.  Be especially aware of common words used as medical terms, for example (stool, screen, cap).
  • Ask the patient to 'teach back' to confirm s/he understands the same way you do.
  • Focus on behavior. Talk about the patient needs to do now, not facts about the condition.
  • Limit discussion to the 'critical minimum' information the patient needs now to cope and recover.
  • Adults learn by retention. Say the most important thing three times.
  • Select or prepare written information that is easy to read and understand.
  • Reading aloud takes learning deeper faster.  Ask patients to read aloud the most important part of treatment instructions.
  • Refer patients with less than high school education who do not read for fun to literacy enhancing services.
  • Encourage formal education.
  • Encourage reading for fun, especially reading aloud (including reading to children).

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