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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Health Literacy Universal Precautions Toolkit

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Medical care is complicated, and many people struggle with understanding medications, self care, instructions, and followup plans. The way we organize our practice and communicate with patients can help to minimize confusion and lead to better health outcomes. This toolkit is designed to help practices take a systematic approach to reducing the complexity of medical care and ensure that patients can succeed in the health care environment.

Health Literacy

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions about their health.

Seeking medical care, taking medications correctly, and following prescribed treatments requires that people understand how to access and apply health information. Health literacy is the ability to obtain, process, and understand health information to make informed decisions about health care. It involves using literacy as well as other skills (e.g., listening) to perform health-related tasks. According to a national survey, over one-third of the adult population has limited health literacy, meaning that they have basic or below basic health literacy levels. Limited health literacy is associated with medication errors, increased health care costs, and inadequate knowledge and care for chronic health conditions.

The Indian Health Service White Paper on Health Literacy Exit Disclaimer: You Are Leaving www.ihs.gov provides information on health literacy as it relates to American Indians and Alaska Natives.

Universal Precautions?

Universal precautions refers to taking specific actions that minimize risk for everyone when it is unclear which patients may be affected. For example, health care staff take universal precautions when they minimize the risk of spreading bloodborne disease by using gloves and proper disposal techniques. This toolkit offers practices a means to structure their services and their patient interactions to minimize the risk that any one of their patients will not understand the health information they are given, thus allowing patients to make informed decisions about their health care.

Experts recommend assuming that everyone may have difficulty understanding and creating an environment where patients of all literacy levels can thrive. In the case of health literacy universal precautions, primary care practices should ensure that systems are in place to promote better understanding for all patients, not just those you think need extra assistance. Improving patient understanding is beneficial for the patient and health care provider. Research suggests that clear communication practices and removing literacy-related barriers will improve care for all patients regardless of their level of health literacy.

There are numerous methods developed to test the literacy skills of patients however, no gold standard has been identified for assessing health literacy in American Indian or Alaska Native populations. The IHS has performed a preliminary evaluation of three common health literacy tools among more than 500 patients across the country with conflicting results. Further analysis is pending.

Description: Flow diagram showing the relationship of various health literacy components. There are three main categories: access, knowledge, and behavior. Issues related to access are transportation, insurance, schooling, and support systems. These factors can be addressed through tools to improve supportive systems. Issues related to knowledge are medical information, communication, understanding, language, and culture. These factors can be addressed through tools to improve spoken and written communication. Issues related to behavior are self-efficacy, adherence, self-care, and social reinforcement. These factors can be addressed by tools to improve self-management and empowerment. Tools to improve supportive systems can affect tools to improve spoken and written communication, which in turn can improve tools to improve self-management and empowerment. The net affect of using these tools is to improve health outcomes.
FIGURE 2: Factors Necessary to Improve Health Outcomes and Tools to Help
Description: Flow diagram showing the relationship of various health literacy components. There are three main categories: access, knowledge, and behavior. Issues related to access are transportation, insurance, schooling, and support systems. These factors can be addressed through tools to improve supportive systems. Issues related to knowledge are medical information, communication, understanding, language, and culture. These factors can be addressed through tools to improve spoken and written communication. Issues related to behavior are self-efficacy, adherence, self-care, and social reinforcement. These factors can be addressed by tools to improve self-management and empowerment. Tools to improve supportive systems can affect tools to improve spoken and written communication, which in turn can improve tools to improve self-management and empowerment. The net affect of using these tools is to improve health outcomes.

How will promoting health literacy improve health outcomes?

To obtain optimal health outcomes, people need health care access, health knowledge, and behavior change. (See Figure 2.) To help patients and their care givers accomplish these goals, the practice needs a structured approach. We have identified four change areas that are important for promoting health literacy in your practice:
  1. Improve spoken communication.
  2. Improve written communication.
  3. Improve self-management and empowerment.
  4. Improve supportive systems.

Key Change 1: Improve Supportive Systems

All patients need support outside the primary care setting to make healthy choices and adhere to treatment plans. Literacy can affect many aspects of patients' lives, and those with limited literacy are more likely to have additional risk factors for poor health and social and economic well-being. Adults over age 65, some minority groups, low-income individuals, and those with lower educational attainment are more likely to have limited health literacy than others. These individuals may face a host of barriers to achieving optimal health outcomes, many of which cannot be overcome within the walls of a primary care office.

However, primary care practitioners and staff can link patients to community organizations and government agencies. These organizations can assist patients with issues like obtaining insurance coverage, medication assistance, case management, mental health services, basic adult education, and support services for specific health needs (e.g., diabetes education, HIV/AIDS support groups, family planning services). Some patients, especially those with limited literacy, are not going to achieve their health goals unless you go the extra mile to help them access and obtain such services.

Key Change 2: Improve Spoken and Written Communication

Spoken Communication
Studies indicate that patients have difficulty understanding health information that is communicated orally during the patient-clinician interaction. Patients understand and retain about 50 percent of the information discussed by their physicians. This can have an enormous impact on patient safety and adherence. Studies show that those with limited literacy are less likely to:

  • Ask questions during the medical encounter.
  • Seek health information from print resources.
  • Understand medical terminology and jargon.

In addition, increased pressures on primary care physicians limit the time they are able to spend with patients, causing many to move rapidly through multiple points during the encounter. These factors lend to the problem of misunderstanding and poor retention of information. Studies show that patients often leave visits with a very different understanding of what they are supposed to do than their clinicians.

There are multiple places in the patient care process where oral exchanges occur, from scheduling medical visits to communicating health information and treatment options. Each point where verbal communication occurs is an opportunity to improve the clarity and quality of the exchanges between practice staff and patients of all literacy levels and languages.

Written Communication
Health care providers rely heavily on print materials to communicate with patients. Many health-related documents are written at a college level and contain a large amount of text in small print and complex terminology. What are the implications of this for the majority of Americans, who read at the 8th grade level or below? A number of studies have shown that those with limited literacy skills have difficulty understanding written information, including medication dosage instructions and warning labels; discharge instructions; consent forms for treatment and participation in research studies;13 and basic health information about diseases, nutrition, prevention, and health services. The inability to read and comprehend such things can prevent clinicians from obtaining an accurate medical history. It can also impact your patients' ability to understand medical advice, take medication correctly and safely, engage in self-care behaviors, and make informed decisions about their health care. These things contribute to patient outcomes and practice liability.

Key Change 3: Improve Self-Management and Empowerment

An important part of patient-centered medical care is enabling patients to share responsibility for their health and health care. Ultimately, it is the patients who have to adopt a healthy lifestyle and manage their chronic condition. Limited literacy has been associated with poor adherence, self-care behaviors, and understanding of health information. It is therefore not surprising that some studies show that patients with limited literacy skills have poorer control of chronic conditions such as diabetes, HIV, and asthma compared to those with adequate or above average literacy. Studies also show that children of caregivers with low literacy have poorer control of their asthma and diabetes compared to children of caregivers with adequate or above average literacy. In addition, patients with limited literacy are less likely to ask questions or participate in the medical decision making process than those with adequate or above average literacy. Fortunately, there are several health literacy tools that primary care practices can use to help patients manage their chronic conditions and otherwise empower patients to take care of themselves and their families.

There are many tools that can help you to address these key changes for improving the delivery of information to patients. We have provided information on twenty tools as well as links to more information and resources. Below is a listing of these tools. Clicking on the links will either take you to a website or will direct you to more information about the selected tool in this document.

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TOOLS

Tools to promote Health Literacy

Tools to promote key change 1. Improve Supportive Systems

Tools to promote key change 2. Improve Spoken and Written Communication

Tools to promote key change 3. Improve Self-Management and Empowerment

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