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I will give you five reasons!

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2. Improve patient educational outcomes.

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2. Improve patient educational outcomes.

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Overall, patient outcomes may be improved by ensuring a patients understanding of the importance of their collaboration in their health care. Continuing to ensure a patients understanding of health literacy and the nursing staffs techniques education tools, they will be more receptive to different forms of learning/teaching such as "teachback".

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Why Use Teach-back? A Patient Story–Inadvertent Overdose

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By continuing this project, continuous education will be provided to staff to ensure that they are being sensitive to health literacy. Without follow up education, skills may be lost after a short period of time.

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Select to download PDF (413 KB).

Overview

Health materials are effective only when used as part of an overall patient education strategy. Simply handing patients a pamphlet or referring them to a Web site is not enough to promote understanding or behavior change.

Action

Don't assume that your patients read the materials you give them or direct them to.

If the information is critical, make sure you or someone in your office reviews the information with your patient and/or the patient's caregiver.

When reviewing a handout:

Circle or highlight the most important points as you talk about them.

Personalize the material by adding the patient's name, medicines, and/or specific care instructions.

Use teach-back to confirm understanding. Go to Tool 5: Use the Teach-Back Method.

Emphasize the importance of the material by referring to it during followup phone calls, emails, and future office visits. You may need to give the material to the patient more than once.

Practice Experiences
An internal medicine practice developed and trained staff to review a one-page blood pressure educational tool with all patients with hypertension, chronic kidney disease, or diabetes. After using the tool for several weeks, the Health Literacy Team leader reported, "The staff seems to think it was pretty easy to use, easy to explain, and as far as I know, we've had a lot of patients say, 'Wow, thank you. I didn't even know what my BP should be or what a normal BP is.'"

Ensure patients know how to use audiovisual materials or access the Internet.

If you give patients DVDs or refer them to Web sites, make sure that they have the appropriate video equipment, Internet access, and the know-how to view or access these materials. Like written materials, you can't assume that your patients will view audiovisual materials or visit Web sites you recommend. If the content is critical, be sure it gets communicated in person.

Always have a conversation with patients after they view audiovisual materials. Decision aids and tutorials can save time but are a supplement to, not a substitute for, a discussion and checking understanding.

Train patients to use the patient portal and to be discerning consumers of Internet content.

Even patients with excellent health literacy skills may have limited computer skills. To ensure that patients are able to access your patient portal, arrange training sessions to show patients how to get online and retrieve information from the portal. Use the Patient Portal Feedback Form to record how easy it is for patients to use your Patient Portal. Go to Tool 17: Get Patient Feedback for more information about using the form.

If patients are surfing the Internet for medical information on their own, you may want to educate them on how to find accurate health information. You can refer them to this interactive tutorial from the National Library of Medicine.

Practice Experiences
In one family medicine practice, staff wore buttons saying "Ask Me About our Patient Portal." This strategy helped them meet Meaningful Use (MU) objectives that encourage patients to use their patient portal."

Obtain patient feedback on materials.

When following up with patients (Go to Tool 6: Follow Up with Patients), ask whether they found the materials helpful. This can allow you to emphasize the importance of the materials, review any questions patients may have, and obtain input from the patient about the materials provided. Go to Tool 17: Get Patient Feedback for more information about obtaining patient input.

Manage educational materials.

Monitor and organize any materials you distribute regularly to ensure you know the type and amount of materials you have, can easily locate them, and know when you need to update or re-stock them.

Update your list of easy-to-understand materials available through your EHR and patient portal. What is available may change rapidly. Go to Tool 11: Assess, Select, and Create Easy-to-Understand Materials for information about assessing and selecting easy-to-understand materials. If materials are accessed via hyperlinks, check frequently to confirm that the hyperlinks still work.

Create an information order set. Providing clinically relevant information using EHR technology is an objective of the Meaningful Use EHR incentive program, but it's not always easy to find the materials you want when needed. Have someone in your office assess electronically stored materials and identify the best ones, then create "information order sets" for commonly used materials. For example, you might create an order set of materials to give patients newly diagnosed with a chronic condition or who are starting a new treatment. Order sets can also be made available through the patient portal.

Ensure staff know what education materials are available, where they are located (both physically and in the EHR or patient portal), and how to use them effectively. Remind staff on a quarterly basis.

Track Your Progress

Record each time you've run out of materials and each time someone in the office can't find the materials they need. Every quarter, determine whether your system for managing your educational materials is performing better than in the prior quarter.

Periodically check in with staff and ask if they are using the materials and whether alternative materials are needed.

Have checkout staff look at materials that patients have been given. Record the percentage of materials that have been highlighted or personalized.

Some patient portals can report whether patients have viewed information provided through the portal. Find out what percentage of patients are using your portal and what components of the portal are being accessed.

If you field questions from the Health Literacy Patient Survey, calculate what percentage of patients responded "Always" to question #24.

If you use the Patient Portal Feedback Form, check whether patients answered "Yes" to question #7.
Return to Contents

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agency for health care policy and research

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agency for healthcare research and quality

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Use Health Education Material Effectively: Tool #12 | Agency for Healthcare Research & Quality

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Select to download PDF (413 KB). Health materials are effective only when used as part of an overall patient education strategy. Simply handing patients a pamphlet or referring them to a Web site is not enough to promote understanding or behavior change. Don't assume that your patients read the materials you give them or direct them to.

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By continuing to revise patient education and ensure that it is sensitive to health literacy will improve their diabetic management skills. This, in turn, will likely improve their diabetic outcomes. Effectiveness could be assessed through the patient's A1C before updated education, three months after, and then six months after.

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In 2010, it was estimated that there were 285 million adults worldwide with diabetes, with projections that this will increase to nearly 440 million people by 2030 [ 1]. Despite innovative scientific discoveries to advance our understanding of the pathology of diabetes mellitus and to develop novel approaches to therapy, the burden of diabetes continues to escalate and treatment often remains substandard [ 2]. Optimal management of diabetes mellitus requires collaboration between multidisciplinary healthcare providers and patients to encourage effective self-care in many tasks including adherence and manipulation of complex medication schedules, executing detailed dietary recommendations, promoting physical activity and participation in preventative care strategies [ 3].

Although there are many determinants that contribute to the process of care and health outcomes for patients with complex chronic disease, over the past two decades the literature has been growing, illustrating the concept of health literacy as a relevant and influential factor related to diabetes mellitus. In the USA, it has been estimated that more than 90 million people have basic or below-basic literacy skills and more than 110 million have poor mathematical skills [ 4]. A low level of health literacy is common among patients with diabetes mellitus, with estimates ranging from 15 to 40% depending upon the population sampled [ 5- 7]. Diverse patient populations and a variety of contexts of diabetes care have been examined to advance our understanding of the role of health literacy. In this article, we will define health literacy and methods of its assessment, review evidence of its role in the care of patients with diabetes mellitus and discuss strategies to equip providers and healthcare systems to address health literacy in their diabetes management practice.

Health literacy: definition & measurement

Definition

As the concept of health literacy has evolved, there has been heterogeneity in its definition and its interpretation regarding how it relates to health [ 8]. More recently, there has been greater emphasis on the perspective that health literacy represents not only the skills needed by an individual to process health-related information, but also the demands of the health system in terms of the delivery of information or instructions [ 8]. A recent adaptation of the commonly used definition from the Institute of Medicine (Washington DC, USA; 2004) is [ 8]:

"The degree to which individuals can obtain, process, understand and communicate about health-related information needed to make informed health decisions".

As this definition suggests, health literacy is a broad concept including more than individual levels of intelligence, but rather a specific skillset that involves a variety of methods to communicate and interpret health information with unique demands, depending upon the person and their setting.

More specifically, literacy includes skills and demands related to print information (reading and writing), oral communication (speaking and listening), numeracy and attention to cultural relevance [ 9]. Each of these domains contributes to the practical care of patients with diabetes mellitus. Numeracy or the use of numbers in daily life [ 10] is closely associated to an individual's skills of literacy such as reading, but requires distinct expertise. Despite adequate literacy skills, people frequently have poor quantitative skills [ 10]. Finally, with the rising prevalence and severity of diabetes mellitus and escalating racial disparities [ 11], the incorporation of tailored cultural strategies into diabetes management by health providers is important to promote the equity of the demands of the health system together with the individual's ability to effectively use diabetes-care information.

Measurement

As with the definition, a variety of tools to measure health literacy and numeracy have been developed. The most widely used are the Rapid Estimate of Adult Literacy in Medicine (REALM) [ 12] - a word-recognition survey - and the Test of Functional Health Literacy Assessment (TOFHLA) and its shortened version [ 13, 14]. Both of these surveys are commonly used in research; the REALM can be rapidly completed, although it requires interviewer administration, and the TOFHLA requires approximately twice the time at 12-15 min. However, there remain concerns about the ability of each of these instruments to characterize people with higher levels of health literacy skills [ 5]. Alternatively, there are simple questions proposed to screen for low health literacy that have demonstrated good correlations with the traditional measures of health literacy [ 15]. For the question, 'How confident are you at filling out medical forms by yourself?', persons responding 'not at all confident' or 'a little confident' have five-times higher odds of having low health literacy compared with those who respond with more confidence to this question [ 16]. A detailed comparison of the properties of these and other health literacy measures is available elsewhere [ 17].

Numeracy may be assessed either as a component of a health literacy evaluation (TOFHLA) or separately with several different methods [ 18]. In chronic disease care, such as diabetes, applied quantitative skills may be more closely aligned with the self-care demands for patients. The Diabetes Numeracy Test (DNT) is a valid and reliable assessment of diabetes-specific numeracy that evaluates a variety of quantitative skills using a word-problem-based format within the context of common diabetes tasks such as interpreting results from glucose self-monitoring, evaluating a nutrition food label and calculating medication requirements () [ 19]. A limitation of this instrument for uses other than research is that the administration time is usually more than 15 min. The development of numeracy screening questions, such as those for health literacy, may have a more practical use in clinical care.

Evaluation of health literacy or numeracy, either as a screen or in more detail, in clinical practice remains a source of debate. It has been suggested that we should practice 'universal precautions' and adhere to clear communication strategies that all patients can use effectively [ 20]. In addition, it is important to recognize that poor literacy skills are often associated with strong feelings of shame and embarrassment for patients [ 21, 22]. Considering this concern, more recent advocacy has been to evaluate patient's learning and literacy skills [ 16] and, through organizational strategies, to equip providers to provide necessary psychological and emotional supports for patients, remembering that reducing the demands of our 'system' is at the core of improving health literacy [ 23]. We will further discuss some of these strategies specific to diabetes care.

Health literacy: evidence of impact on diabetes mellitus

There are several pathways via which health literacy influences important health outcomes, including the acquisition of new disease-specific knowledge, improving self-efficacy and adherence with self-care behaviors. The conceptual model by Baker () illustrates these hypothesized relationships by highlighting patient characteristics that are associated with literacy skill, the complexity of both written and spoken health information and other factors such as cultural norms that are relevant to successful self-care [ 24]. Although the depth of the literature is limited, each of these pathways has been examined in patients with diabetes, including important outcomes such as glycemic control.

Knowledge, self-efficacy & self-care behaviors

It is essential that patients with diabetes have an understanding of the signs and symptoms of hypoglycemia, hyperglycemia and how to properly self-administer medications to control diabetes. Low health literacy has been consistently associated with worse diabetes knowledge in a variety of settings including ambulatory and hospitalized older patients in the USA and Japan [ 6, 25- 27]. For example, despite the majority of participants reporting having attended a diabetes education class, only 50% of patients with inadequate literacy skills recognized the common symptoms of hypoglycemia such as feeling shaky, sweaty or hungry and, moreover, only 38% correctly reported the need to eat if experiencing the symptoms [ 27]. Low diabetes numeracy has also been strongly associated with low levels of diabetes knowledge compared with higher numeracy skills (52 vs 86%; p < 0.001) [ 5]. Efforts to improve diabetes knowledge increasingly involve computer-based technology. A survey of patients with diabetes and low literacy showed that 83% reported a willingness to learn, and a basic knowledge of, computer skills to become further educated about diabetes care [ 28]. However, patients with low literacy may not improve their knowledge as recipients of multimedia and technology-based programs as much as those with adequate literacy; therefore, other supportive strategies may need to be included [ 29].

Self-efficacy of diabetes self-care has been significantly associated with self-care behaviors and glycemic control [ 30]. Using a variety of instruments, several previous studies have examined health literacy, diabetes self-efficacy and glycemic control, with only one study demonstrating an association between health literacy and diabetes self-efficacy [ 25, 31, 32]. By contrast, while we also observed that health literacy and numeracy were associated with diabetes self-care and self-efficacy, it was numeracy that remained more strongly related when examined together [ 33]. Self-care in diabetes relies heavily on quantitative tasks for interpreting glucose measures, adjusting medications and executing dietary recommendations. Therefore, it may have been anticipated that individuals who are facile with mathematics applied to diabetes are also more likely to have greater confidence in performing self-care tasks. Interventions to encourage self-care, including specific approaches to improve self-efficacy, may have additional influence on patients with low health literacy levels.

Although health literacy has been associated with many health behaviors, there has been little evidence to date from patients with diabetes. Examinations of health literacy and diabetes numeracy have failed to demonstrate significant associations with adherence to diet, exercise, blood glucose monitoring or foot care under usual care circumstances [ 5, 33, 34]. In one small study of 77 participants (22% with limited health literacy), after participation in a diabetes educational program, the limited health literacy participants self-reported more frequent self-care including diet, glucose monitoring and foot care compared with those with adequate literacy, suggesting the potential benefit of educational counseling, especially for low health literacy patients [ 35]. While literacy has been identified as a factor in adherence to medications in other chronic illnesses such as heart failure [ 36], possibly related to difficulties with identifying medication, reading prescription labels and warnings [ 37- 39], there is limited research examining this relationship in patients with diabetes. Given that medication management is fundamental to diabetes care, further research is needed to determine the magnitude of impact that health literacy skill may have on this important self-care behavior.

Glycemic control: hemoglobin A1C & hypoglycemia

The results describing the relationship between health literacy and glycemic control have been mixed. In 2002, Schillinger et al. reported that inadequate health literacy was associated with nearly twofold increased odds of poor glycemic control compared with adequate health literacy (adjusted odds ratio: 2.03; 95% CI: 1.11-3.73; p = 0.02) [ 7]. However, reports have failed to show a significant association between health literacy and glycated hemoglobin [ 5, 27, 40, 41]. This is not surprising as glycemic control is most likely to be influenced by a large number of heterogeneous social and biologic determinants. In a recent examination of pathways by which health literacy influences diabetes control, social support was identified as a mechanism by which health literacy was indirectly related to glycemic control [ 26].

As discussed earlier, numeracy skills may be more closely related to the applied tasks required for successful diabetes self-care to secure and maintain optimal diabetes control. In nearly 400 patients from four primary-care or diabetes specialty clinics, we found that diabetes-related numeracy, as measured by the DNT, was modestly significantly associated with hemoglobin A1C (A1C) [ 5]. Low levels of numeracy skills may identify patients at high risk for poor diabetes outcomes and may also be an important consideration in the development of educational interventions. Furthermore, we examined the role of numeracy in explaining the commonly observed racial disparities in glycemic control [ 42]. African-American race was associated with higher levels of A1C (r = 0.12; p < 0.01) and also diabetes-related numeracy (r = −0.46; p < 0.001). When adjusted models were applied that included diabetes-related numeracy as a mediator in the path between race and A1C, the relationship between African-American race and A1C was reduced to a nonsignificant association (r = 0.10). While the role of socioeconomic status and education cannot be dismissed, numeracy - a distinct component of health literacy - may indeed have an important role in understanding diabetes care and outcomes.

Equally important in diabetes control is the risk of serious hypoglycemic events. Since low health literacy has been associated with poor knowledge of hypoglycemic symptoms and treatments, it was hypothesized that these patients may also be at higher risk of hypoglycemic events. In a community-based sample of over 14,000 patients with diabetes, 11% reported a serious hypoglycemic event within the past year and limited health literacy skills were associated with a 30% increased odds of experiencing an event (odds ratio: 1.3; 95% CI: 1.1-1.6; p < 0.001) [ 43]. Again, low health literacy characterizes a vulnerable patient population that is at high risk of poor diabetes outcomes.

Strategies to address health literacy in diabetes care

Recognizing that low health literacy is common and associated with many facets of diabetes care - including important outcomes - strategies to address health literacy have been developed, tested and promoted. The foundation of these strategies rests with the principles of clear health communication, including assessment of understanding, use of plain language, emphasizing few key points and using effective printed materials [ 44]. There are many methods that may be tailored to specific practice settings and we review in brief a selection of these here.

Tools to enhance patient-provider communication

Although there are many resources available in brochure, fact sheet and web-based formats to deliver information to patients with diabetes, the complexity of the content, including the reading level of the text, often surpasses the skill of patients and presents a barrier for information delivery to those with low health literacy [ 45, 46]. Recently, several diabetes materials have been developed specifically to address low health literacy and to be used interactively between patients and providers to promote patient understanding, empowerment and improved self-efficacy with self-care behaviors.

The Diabetes Literacy and Numeracy Education Toolkit (DLNET) [ 101] is a comprehensive 24-module resource to facilitate communication between patients and providers to promote effective diabetes learning and self-care [ 47]. Module topics include blood glucose monitoring, medication administration and dietary instructions (). The toolkit format adheres to clear communication principles with a low-grade reading level, using color coding, pictures and step-by-step instructions. In two randomized controlled trials, the DLNET was tested as part of an enhanced diabetes-care program compared with standard educational materials. In 198 patients, the use of the DLNET reduced their hemoglobin A1C by more than those in the control group (median difference: −0.70 [95% CI: −1.10 to −0.20]; p = 0.005), but this difference was not sustained after the intervention was concluded [ 48].

Considering low health literacy, the American College of Physicians Foundation (ACPF) developed the 'Living with Diabetes Guide' as a resource for patient education and also to promote goal setting and shared decision making in diabetes care [ 49, 50]. Similar to the DLNET, the guide includes materials related to blood glucose self-monitoring, medication and dietary adherence and exercise. Initial studies have demonstrated that interactive use of the guide with provider counseling resulted in more than 90% of patients successfully executing an identified behavioral goal [ 49]. There were no differences observed in health literacy status, suggesting that the guide has utility for diabetes patients of all skill levels.

While the individual patient encounter remains the cornerstone of care, there is a growing interest in communicating with patients by email or web-based technology portals. This mechanism is proposed to be an efficient means to deliver information and may address health literacy with customized content, use of audio or video, and assessments of patient's understanding. However, for vulnerable patients, including those with low health literacy, there may be a furthering of disparities related to access or utilization of these methods. Sarkar et al. evaluated the use of a patient portal that has been in use over the past 10 years in a large population of patients with diabetes and found that those with low health literacy were 70% less likely to use the resource at all, 40% less likely to use it even if they had created an account and were 30-60% less likely to use the individual functions of the portal once they entered the site compared with those without low health literacy levels [ 51]. A recent review suggests further areas of research, including care utilizing cell phones or other mobile device technology as a mechanism to enhance care delivery for patients of limited literacy [ 52]. As new health information technology systems are created to promote information sharing, ensuring equity of access and ease of use must be a priority.

Assessment & modifying health systems

Healthcare systems including hospitals, ambulatory-care organizations, insurance providers and community health centers are increasingly considering addressing health literacy as a means to improve processes of care for patients. Several tools have now been developed and validated to provide organizations with a way of evaluating their clinical practices with a focus on enhancing patient-centered communication. While none of these resources are specific to patients with diabetes, the strategies are universal and can be applied to complex chronic disease care.

In April 2010, the Agency for Healthcare Research and Quality (MD, USA) released the 'Health Literacy Universal Precautions Toolkit' [ 102]. This toolkit is available online and informs organizations regarding how to construct a team to address health literacy, methods to improve both spoken and written communication, specific guides to create action plans, empower patients and foster a supportive environment to engage patients. Included in this resource are examples of forms, letters, scripts for telephone services, focus group guides, posters to gain buy-in from both patients and providers and much more. Organizations might consider adopting this as a comprehensive entity or may use sections tailored to their environment's specific needs. Other simplified lists of prompt questions for use by health plans to address health literacy covering written materials, web navigation, provider call lines and disease management programs have also been described [ 53].

Organizational assessment tools, specifically to evaluate the practice and quality of patient-centered communication, have also been recently validated by the Ethical Force program [ 54]. A unique aspect of this assessment is the inclusion of the opinions of not only patients but also providers, nonclinical personnel and administrative personnel who comprise the organization. Nearly 6000 patients were enrolled from across 13 heterogeneous health-care settings including urban and rural hospitals and federally qualified health centers. Patients with low health literacy, compared with those with adequate literacy, consistently had lower odds (28-79%) of reporting that their organizations 'always' delivered patient-centered communication on seven different domains [ 55]. It is the responsibility of the organizations and the participants within those organizations to reduce the system's demands to improve health literacy and provide useable information to all patients. Additional research in each of these important areas is needed to establish efficacious and feasible strategies that can then be widely disseminated and implemented. Achieving this goal may then build effective engaging relationships with patients to promote informed decision making, increase successful self-care and optimize health outcomes, especially for patients with diabetes.

Conclusion & future perspective

In patients with diabetes, low health literacy is common, associated with a lack of diabetes knowledge, self-efficacy and self-care behaviors. Low health literacy and poor numeracy skills are also associated with poor glycemic control, and addressing literacy in multidisciplinary diabetes educational and management programs improves important health outcomes. However, much remains unknown regarding the relative impact of different strategies to improve health literacy including those for patients, providers and health organizations. As the field continues to evolve, more precise instruments to characterize health literacy will be developed and more directed interventions will be rigorously evaluated and implemented in practical clinical settings. Given the growing international support to improve the interaction between vulnerable patients and health systems, health literacy will likely be an important contributor to optimizing the delivery of diabetes care.

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Health literacy in diabetes care: explanation, evidence and equipment

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In 2010, it was estimated that there were 285 million adults worldwide with diabetes, with projections that this will increase to nearly 440 million people by 2030 [ 1]. Despite innovative scientific discoveries to advance our understanding of the pathology of diabetes mellitus and to develop novel approaches to therapy, the burden of diabetes continues to escalate and treatment often remains substandard [ 2].

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5. Adhere to a nurses call to action to provide the most quality patient care to patients struggling with low health literacy levels.

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5. Adhere to a nurses call to action to provide the most quality patient care to patients struggling with low health literacy levels.

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Nurses should understand the importance of educating those with a low health literacy level as their literacy level typically correlates with their overall health status. Patients with a disease so fragile, such as diabetes, have a variety of concerns which must be understood (diabetic foot care, wound healing, follow up eye care, etc.). It is the duty of a nurse to ensure a patient's understanding.

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LIMITED HEALTH LITERACY and lack of basic math skills (numeracy) are more pervasive problems than many nurses suspect. Combine these limitations with a largely self-managed chronic disease such as diabetes and the possible complications-such as severe hypoglycemia-can be catastrophic. In diabetes, use of high-risk drugs such as sulfonylureas and insulin require additional patient understanding to prevent admissions for hypoglycemia and overuse of hospital resources.

Patients with a limited ability to read and write shouldn't be considered unintelligent. Many patients with low literacy skills can learn complex self-management protocols, provided they receive clear instructions. This article provides a literature review about health literacy related to diabetes self-management and gives nurses evidence-based tools they can use to help patients overcome health literacy or numeracy issues.

Understanding health literacy and numeracy

The CDC defines health literacy as the degree to which someone has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. These skills are a prerequisite to make sense of health information and services or to provide health information and services to others.

Health numeracy describes the skills and ability to understand and use numbers required to successfully execute many health-related tasks, including:

calculating medication dosing intervals and correction scales for insulin.

interpreting medication instructions and food labels.

determining insulin-to-carbohydrate ratios.

deciphering charts (such as for growth and body mass index).

weighing the risks and benefits needed to make informed decisions related to healthcare, such as appropriate A1C target ranges based on comorbidities and age.

Understanding the impact

Health literacy is one of the strongest predictors of health status-stronger than income, employment status, education level, and racial or ethnic group. Assessing and managing low health literacy is important for nurses who hope to help patients with diabetes stay safe, informed, and well controlled.

The scope of the problem is described by the National Center for Education Statistics. Overall, it estimates that only 12% of adults have proficient levels of health literacy, defined as the skills needed to perform more complex and challenging literacy activities. The CDC identifies 18.8 million people in the United States as having diabetes. If 88% of them have health literacy deficiencies, then 16 million Americans will have problems managing their diabetes, especially if they take insulin.

Looking at the literature

Al Sayah et al. conducted a systematic review of 24 studies about the relationship of health literacy or numeracy and at least one health outcome in people with diabetes. The results indicate that low health literacy is consistently associated with poorer diabetes knowledge.

Other retrospective or smaller studies have shown some concerning trends, however. Kaiser Permanente's Diabetes Study of Northern California (DISTANCE) examined the impact of health literacy on a cross section of patients with diabetes (N = 14,357). They asked patients to self-report their level of health literacy and any significant episodes of severe hypoglycemia, such as losing consciousness or needing assistance to manage the reaction. Overall, they noted that problems learning, needing help reading, and lack of confidence with forms were independently associated with significant hypoglycemia. Of the 14,357 patients, 11% or 1,579 individuals had experienced signs and symptoms of severe hypoglycemia. Within this group experiencing severe hypoglycemia, 59% were taking insulin, 23% were taking mixed oral medications, 13% were taking secretagogues, and 5% were taking metformin alone. They also reported that 8% or 129 of 1,579 had to go to the ED or were admitted to the hospital because of their signs and symptoms. For these reasons, hypoglycemia seems to be implicated as a potentially serious and costly consequence of limited health literacy in this population.

The impact of health literacy on our nation's veterans is also substantial. A study of 502 veterans in Miami, Fla., evaluated the impact of inadequate health literacy. They found that 29% of their population had low health literacy, 26% had marginal literacy, and 45% had adequate literacy. For those veterans with inadequate health literacy, they perceived their health as poor or fair (63%) compared with those with adequate health literacy (37%). This perceived lack of health and limited health literacy poses barriers to clinical outcomes that nurses need to understand when interacting with veterans, especially those with a complicated, largely self-managed chronic disease such as diabetes.

Problems with health numeracy can have a large impact on diet management and nutrition as well as on A1C control. A study by Bowen et al. found that patients with diabetes (N = 150) with numeracy problems consumed more calories from carbohydrates than from protein or fats. They also noted that those with low numeracy skills were more likely to estimate portion size incorrectly, misinterpret food labels, and receive worse diabetes self-care.

The Bournemouth Diabetes and Endocrine Centre in the United Kingdom found that people (N = 112) with higher health numeracy skills (53%) achieved lower A1C levels than their counterparts.

Osborn and colleagues examined the relationship of self-efficacy to health literacy and numeracy and diabetes control. Their cross-sectional primary care study of 383 participants found that health literacy and numeracy are each associated with greater diabetes self-efficacy, and greater diabetes self-efficacy is associated with lower A1C levels.

Some studies found that patients with low health literacy have more hospital readmissions and use the ED more often. Rubin et al. noted poor health literacy (lack of knowledge about diabetes and discharge instructions) was one of five major reasons for early readmission of patients with diabetes in their qualitative study. They indicated that most patients lacked awareness that the A1C reflects the average range of blood sugar over 3 months, and most didn't know their most recent A1C value.

Berkman and colleagues reviewed six studies and found that all but one study showed a statistically significant association of increased hospitalization and use of inpatient services with lower health literacy levels. Moreover, their review of studies showed an association of greater ED use with low health literacy.

Health literacy also impacts appointment no-show rates. Holtzman and colleagues conducted a study at a university dental clinic in Los Angeles (N = 200) and found that the strongest predictor for failing to show for appointments was seeking health information through fewer rather than more sources. The second most common reason, however, was lack of health literacy.

Patients with lower health literacy are more likely to make errors when taking their medications. Mixon et al. reported that among patients taking cardiac medications, female participants with higher health literacy and higher subjective numeracy had lower odds of misunderstanding their medications' indications, doses, or frequency. Furthermore, Berkman et al. examined participants' ability to interpret prescription medication and nutrition labels and found a positive correlation with health literacy level.

Health literacy assessments can also impact patient satisfaction. Komenaka et al. conducted a study (N = 2,026) that found routine health literacy assessment is feasible in a surgical practice and doesn't cause any perceived decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed.

In summary, lack of health literacy may lead to multiple strains on the healthcare system as well as for patients, including medication errors, missed appointments, adverse medical outcomes, and lower patient satisfaction. For patients with diabetes, a chronic disease requiring daily self-management, it's imperative to assess for limited literacy and numeracy skills and adjust interventions appropriately.

Performing an assessment

Understandably, many patients aren't willing to admit they have literacy problems. Assessing this clinical barrier can be complex. First and foremost, remember that years in school or education level may not accurately reflect literacy skills. Wallace notes that while "variables such as years of education are associated with health literacy, they are not perfectly correlated and do not provide enough information to guide care." Some patients with limited health literacy have completed high school or college, are well spoken, may look over written materials and say they understand, hold white collar or even healthcare jobs, and function well when not under stress.

The National Assessment of Adult Literacy discussed additional reasons for limited literacy skills. These can include learning disabilities, cognitive decline in older adults, and the "use it or lose it" theory of neuroplasticity that suggests that reading abilities are typically three to five reading levels below the last year of school completed.

Cornett provides some of these red flags to keep in mind when meeting a patient for the first time. These warning signs could indicate problems with health literacy or numeracy.

Patients often make excuses when asked to read or fill out forms; for example, "I don't have my glasses," "I'm too tired to read," or "I'll read this when I get home."

Poor readers often lift text closer to their eyes or point to the text with a finger while reading. Their eyes may wander over the page without finding a central focus.

Patients may provide an incomplete medical history or check all items as "no" to avoid follow-up questions. Poor readers often miss appointments and make medication errors.

Patients with low health literacy become skilled at listening, and they often take instructions literally to avoid making mistakes. For example, they may be instructed in clinic to take nutritional insulin three times a day, but then they skip a meal and still take the insulin. In this case, they may not be able to read the prescription label that says to take this insulin with meals. To identify their medications, they look at the pills for color, size, and shape because they can't read the labels. Patients may appear nervous, confused, frustrated, or even indifferent. They may withdraw or avoid situations where complex learning is required. Patients often give incorrect answers when questioned about what they've read.

Powers et al. provide a review of the 10 most common health literacy assessment tools. They identify the Rapid Estimate of Adult Literacy in Medicine (3 minutes), the Test of Functional Health Literacy in Adults (7 to 12 minutes), and possibly the Medical Term Recognition Test (2 minutes) as the most accurate tools for identifying patients with limited health literacy. Cooper-Bailey et al. also provide reviews for several diabetes-specific assessment tools such as the Diabetes Numeracy Test-15, DNT-Adolescent and DNT-14 Adolescent, Diabetes-specific Health Literacy Index, Literacy Assessment for Diabetes, and Spoken Knowledge in Low Literacy in Diabetes scale.

One succinct method proposed to determine health literacy is asking the following three simple questions:

How confident are you when filling out medical forms by yourself?

How often do you have someone help you read hospital materials?

How often do you have problems learning about your medical condition because of difficulty understanding written information?

However, Johnson et al. didn't find single-item questions (as above) used to screen for written health literacy to be effective screening tools for health numeracy. They did find that a low education level is a specific predictor of low health numeracy. Therefore, despite the available literacy tools, it's probably best for the busy clinician to use a Health Literacy Universal Precautions approach when dealing with all patients and their families. (See Additional health literacy resources.)

This means clinicians should assume all patients have some measure of limited health literacy and numeracy. Using this approach will ensure that clinicians will be communicating information in a way that can be understood by the half or more of the population with low literacy skills.

Various communication methods to overcome low literacy and numeracy barriers are presented here to help optimize diabetes education and the nurse's impact on care.

Nursing interventions

When communicating with any patients and families, and especially those suspected of limited health literacy and numeracy, an important first rule is to limit or "chunk" needed information into small pieces. This way, teaching can be done slowly and the patient can be evaluated for understanding. The Agency for Healthcare Research and Quality (AHRQ) suggests breaking healthcare information into three main parts, from the patient's perspective:

Explain what's wrong (briefly).

Why is it important to me?

Keep patient communication simple and focus on action steps rather than on complicated explanations and pathophysiology. Make sure information is culturally sensitive by asking if there's anything you should know about their culture, beliefs, or religious practices that would help you take better care of them. Then make a note of it. Use active voice; for example:

Take this insulin daily.

Carry glucose tablets for low blood sugar.

Simple communication strategies, which are also important, should focus on the "need to do" rather than on "nice to know." Always begin by asking patients at each visit what's important to them or what brings them in for a visit. Explore what they want to know to make informed decisions and to execute day-to-day management of their disease. When focusing on specific "need to do" activities, a return demonstration is a must to ensure comprehension and accuracy. Some additional strategies include the following.

Use plain language (avoid medical jargon).

Prioritize learning goals.

Focus on action, not information.

Use concrete and specific phrases.

Provide multiple communication forms: printed, verbal, and visual, which include hands-on learning with a real syringe and needle or video information.

Confirm that the patient understands the teaching.

Encourage questions.

Be sure to use words that patients are familiar with such as "blood sugar" instead of "glucose." Focus instructions on actions you expect them to do at home related to their blood sugar. Explaining the pathophysiology of diabetes will just confuse a patient with low literacy skills. Concrete instructions are best. For instance, say, "Check your blood sugar three times a day before meals, treat low blood sugar of 70 or lower with 4 glucose tablets, and recheck your blood sugar in 15 minutes." Always provide directions in large print, preferably using one- or two-syllable words.

After information has been communicated, make sure to confirm patient comprehension. The teach-back method encourages patients to use their own words to describe what they've learned. (See Teach-back tips for patients with low literacy.) AHRQ states three benefits to using the teach-back method:

It improves patient understanding and adherence.

It decreases call backs and cancelled appointments.

It improves patient satisfaction and outcomes.

Comprehension of patient teaching needs to be confirmed in patients managing diabetes. Examples include how to appropriately treat hypoglycemia. A good way to enlist patient feedback might be to ask something like this: "To make sure I explained how to treat a low blood sugar the right way, can you tell me in your own words how you'd describe this to a family member?"

Provide clear instructions to notify the healthcare provider in instances of hypoglycemia or hyperglycemia and review these guidelines at each visit to ensure patient safety.

Remember that the basic health literacy rules apply to printed instructions as well. Multiple programs are available online to assess the reading grade level of printed materials and determine appropriate formats. A simple practical rule for the busy nurse is to use plain language and keep all words to one or two syllables when speaking or providing printed instructions. Educational material should be clear and uncluttered. Sentences should be short, with headings and subheadings to break up the text.

The National Diabetes Education Program reminds clinicians to assess for a sufficient amount of white space; otherwise, an education sheet can look overwhelming to a patient with low literacy. Also, including color photos whenever possible always makes the material more appealing.

Some examples of creative solutions and resources for patients with low literacy include using pill cards with pictures, diagrams created for patients, and free online instructional videos, such as those provided by manufacturers of glucometers and insulin pens. (See Example of a simple pill card.) Try to include family members or other community support help and resources. For patients with limited numeracy skills, use a picture showing a plate with a healthy meal instead of teaching carbohydrate counting. (See Using Choose My Plate.) Incorporating a teach-back demonstration of correct insulin administration technique is a must.

White, Wolff, Cavanaugh, and Rothman have created an extensive Diabetes Literacy and Numeracy Education Toolkit. This toolkit can be requested from its authors. AHRQ also has an extensive online toolkit noted in the resource section of this article. Use this and online literacy and numeracy education toolkits.

Making a point

In summary, nurses need to understand the impact of health literacy and numeracy deficits on the day-to-day self-management of chronic diseases such as diabetes. Using the simple assessment and universal precautions intervention strategies outlined here can improve the quality of life for patients with diabetes who also have health literacy and numeracy barriers. Ultimately, diabetes care can be enhanced with decreased episodes of hypoglycemia and hospital readmissions by helping patients achieve their diabetes self-management goals and health outcomes.

Teach-back tips for patients with low literacy

Use a caring tone of voice and attitude.

Display comfortable body language and make eye contact.

Use plain language.

Ask patients to explain back, using their own words.

Use nonshaming questions. For instance, instead of asking patients if they can read, ask them if they have any trouble with written directions on their medications.

Use open-ended questions. Avoid questions that can be answered with a simple yes or no.

Emphasize that the responsibility to explain clearly is on you, the provider.

If patients can't teach-back correctly, explain again and reassess.

Use reader-friendly print materials to support learning.

Document use of, and the patient response to, teach-back.

Source: Always Use Teach-back! 10 elements of competence for using teach-back effectively. 2016. www.teachbacktraining.org. Developed by Health Literacy Iowa.

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Improving health literacy in patients with diabetes : Nursing2018

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LIMITED HEALTH LITERACY and lack of basic math skills (numeracy) are more pervasive problems than many nurses suspect. Combine these limitations with a largely self-managed chronic disease such as diabetes and the possible complications-such as severe hypoglycemia-can be catastrophic.

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1. Maintain adherence to the ACMH mission & vision statements.

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1. Maintain adherence to the ACMH mission & vision statements.

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ACMH is dedicated to providing quality patient care. A huge piece of a patients health status stems from their understanding of how to effectively care for themselves.

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Staff Eudcation

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Health Literacy Basics for Health Professionals