Chronic Illness Management and Low Health Literacy

Chronic disease and poor health literacy -- a bad combination.

Chronic disease affects the quality of life of ninety million American adults, and accounts for 7 of 10 deaths in the United States. Self-management of chronic disease is a critical aspect of successful care. However, an inability to understand how to care for oneself or a loved one with a chronic illness can seriously affect even the best intentions and efforts of their physicians.

Researchers in an ongoing study at UC San Francisco have been looking at effective interventions. They note that patients who have limited proficiency in English, or who have a hard time understanding their doctor's instructions and reading health information also experience difficulties finding the care they need. They often receive lower-quality care or tend to underutilize health services (Sudore et al 2006).

This is especially a problem when it comes to the management of chronic illnesses. For example, in a study of asthma patients, Williams and colleagues found that although two-thirds reported graduating from high school, only 60% could read above the sixth-grade level. Reading ability was the single strongest predictor of practical asthma knowledge. Nearly twice as many patients (89% vs. 48%) reading below the third-grade level had poor inhaler technique when compared to patients reading at high-school level (Williams et al 1998).

There are simple ways to improve patient communication.

As health care providers, we want to make sure that our clients with chronic illnesses truly understand how to manage their conditions. How can we make sure they are clear about how to take their new meds and what to watch for? How can we help them navigate the complicated health care system? Here are a few helpful tips for improving your communication with your clients.

• Don't assume. Try to remove the phrase, “Do you understand?” from your vocabulary. When you ask this question, most people will be polite and answer "Yes."
  
  This is especially true for people who may not understand at all what you are saying. People never want to appear to "stupid." Parikh and colleagues describe the lengths to which those with poor literacy skills will cover up their deficiencies. Some never tell even their spouses, let alone a health care provider (1996).
• Use easy-to-read written materials. Make sure the materials you use have been reviewed by a literacy expert to determine their grade reading level and the readability of the design. How words are displayed on a page has a great impact on whether your clients will read the material at all (Doak et al. 1996).
  
  An information sheet dense with small print running all the way across the page, no graphics, and few breaks (such as subheads, paragraph indents, or white space), will likely be thrown away rather than read by most people.
• Use plain language. Talk to your client using “living room language.” Use the everyday words we use to speak to one another. Avoid medical jargon or multiple-syllable words. Keep the number of key messages to a minimum when you talk with your clients.
• Use the teach-back method. After each point, instead of asking, “Do you understand?” say, “I want to make sure I’ve done a good job in communicating with you. Can you tell me, in your own words, how you are going to do what I've asked?” If you notice gaps or misunderstandings, you will know how to correct things.

Want to learn more about chronic illness and low health literacy?

• Want assistance in evaluating or developing health education materials to ensure they meet the needs of your clients? Contact Donna Bell Sanders, MPH, a health educator at California Family Health Council. Her email address is sandersd@cfhc.org.
• The American Medical Association Foundation has two excellent video resources available at their website: “Low Health Literacy: You Can’t Tell by Looking” and “Health Literacy: Help Your Patients Understand.”
• Don't miss the Institute of Healthcare Advancement's Annual Health Literacy Conference to learn more “best practices.” The May 2007 conference will focus specifically on strategies for clinicians to help those patients with literacy challenges better manage their chronic illnesses. For more information about the the Institute, please go to www.iha4health.org.

Adapted from an article by Michael Villaire , MSLM and Gloria Mayer, RN, Ed.D., FAAN both of the Institute for Healthcare Advancement, a non-profit organization that has published a series of “What to Do for Health” self help health books that use simple, everyday language and illustrations designed for everyone, especially people with limited reading skills. For more information, please go to www.iha4health.org.

References

American Medical Association Foundation. 2001. Low health literacy: You can’t tell by looking. 18 min. Videocassette. American Medical Association Foundation.

Doak, C. C., Doak, L.G., Root, J. H. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia, PA: JB Lippincott Company; 1996.

Parikh, N.S., Parker, R.M., Nurss, J.R., Baker, D.W., Williams, M.V. 1996. Shame and health literacy: The unspoken connection. Patient Education and Counseling 27(1): 33-9.

Sudore, R.L., Yaffe, K., Satterfield, S., Harris, T.B., Mehta, K.M., Simonsick, E.M., Newman, A.B., Rosano, C., Rooks, R., Rubin, S.M., Ayonayon, H.N., Schillinger, D. 2006. Limited literacy and mortality in the elderly: The health, aging, and body composition study. Journal of General Internal Medicine, 21(8), 806-12.

Williams, M.V., Baker, D.W., Honig, E.G., Lee, T.M, Nowlan, A. 1998. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114(4), 1008-15.