Health Literacy in a Primary Care Setting

BACKGROUND: Low health literacy is prevalent in the United States. As a result, the Agency for Healthcare Research and Quality (AHRQ) developed universal health literacy precautions to improve patient understanding of health information. Using universal precautions and specific tools, such as teach-back, has been shown to decrease morbidity and improve patient outcomes. PURPOSE: The purpose of this quality improvement project is to assess provider knowledge of health literacy in a primary care setting. A secondary purpose is to assess the use of patient education material for patients with diabetes, hypertension, and hyperlipidemia that meet universal precautions. METHODS: This study was a single-center, cross-sectional quality improvement study on the use and understanding of health literacy. This project was a one group preand postintervention design to evaluate the perceptions and knowledge of providers regarding health literacy before and after an in-service. The focus of the in-service was on universal health literacy precautions and the teach-back method. The sample consisted of 22 primary care providers for the pre-survey and 18 primary care providers for the post-survey. RESULTS: The percentage of providers that reported doing well at providing patients with a list of their medications and clear instructions on how to take them increased from 27.3% to 72.2%. While not statistically significant, there was an increase from 36.4% to 66.7% of providers who follow up with patients to determine if action goals were met. Providers identified diabetes education materials to be used routinely in clinic. CONCLUSION: Provider understanding and use of the AHRQ’s universal health precautions is essential to improving patient outcomes and satisfaction. The teach-back method is a simple and easy tool for providers to use during patient interactions that can improve patient knowledge and HEALTH LITERACY IN PRIMARY CARE 2 adherence to treatment regimens. To improve overall patient health, patient experience, and quality of life, providers must ensure universal health literacy precautions are delivered to all patients. HEALTH LITERACY IN PRIMARY CARE 3 Health Literacy in a Primary Care Setting Introduction The understanding of health information is crucial in patient self-management of health promotion and disease prevention. Health literacy is considered an essential element to healthcare practice (Office of Disease Prevention and Health Promotion [ODPHP], 2010). In 2010, the United States Department of Health and Human Services’ (HHS) Office of Disease Prevention and Health Promotion developed a national action plan to improve health literacy. The action plan focused on two guiding principles: all people have the right to health information that helps them make informed decisions, and health services should be delivered in ways that are easy to understand and that improve health, longevity, and quality of life (HHS, 2010). This final project report seeks to assess provider knowledge of health literacy in a primary care setting, provide education regarding health literacy, and reassess provider knowledge. Background Health Literacy Health literacy is an essential component of the overall patient experience in all healthcare settings. The need for patients to understand their individual health education is essential in disease prevention as well as acute and chronic disease management. The definition of individual health literacy is “the skills, knowledge, motivation and capacity of a person to access, understand, appraise, and apply information to make effective decisions about health and health care and take appropriate action” (Johnson, 2016, p. 21). Healthcare providers must be cognizant of patient health literacy levels and assure that education provided meets standards that are conducive to patient understanding. This is demonstrated by research that has been collected for over two decades that indicates health information isn’t presented in a way that is usable by HEALTH LITERACY IN PRIMARY CARE 4 most Americans (U.S. Department of Health and Human Services, 2010). Nearly 9 out of 10 adults have difficulty using everyday health information that is routinely available in healthcare facilities, retail outlets, media, and communities (U.S. Department of Health and Human Services, 2010, p. 2.3). These findings emphasize how important it is to provide appropriate health literate information that is conducive to patient comprehension. The healthcare field as a whole has continually overestimated the level of health literacy for the majority of the patient population (Johnson, 2016, p. 21). Based on national data, more than one-third of the population has a low health literacy (Hersh, Salzman, & Snyderman, 2015, p. 118). Low health literacy is defined as basic or below basic health literacy skills or a third grade reading level (Kutner, Greenberg, Jin, & Paulsen, 2006, p. v). According to a national health literacy survey conducted in 2003 by the American Institutes for Research, only about 12% of Americans are proficient in successfully navigating the health system and acting on health information (Kutner, Greenberg, Jin, & Paulsen, 2006, p. v). Low health literacy effects many different populations within the United States. Those with the most risk for low health literacy and resulting worse health outcomes include those with lower socioeconomic status or education, the elderly, low English proficiency and/or non-native English speaking, and those who are receiving publicly-financed health coverage or other socio-economic assistance (Center for Health Care Strategies, 2013, p.5). It is important for the provider not to assume a person’s level of education as being related to their level of health literacy. Even those with higher levels of education such as a college degree may not understand the health information provided to them (Institute of Medicine, 2004). The consequences of low health literacy effects not only the individual, but also communities, health care delivery systems, employers, insurers, costs, and the government HEALTH LITERACY IN PRIMARY CARE 5 (Center for Health Care Strategies, 2013, p. 1). Consequences for individuals with low health literacy can result in medication errors, low rates of treatment compliance, reduced use of preventive services, unnecessary emergency room visits, longer hospital stays, and higher mortality (Center for Health Care Strategies, 2013, p. 2). In addition, the Partnership for Clear Health Communication at the National Patient Safety Foundation has found that compared to those with proficient health literacy, adults with low health literacy experience four times higher health costs, six percent more hospital visits, and two-day longer hospital stays (Center for Health Care Strategies, 2013, p. 2). Universal Precautions Health literacy rates vary between patients and assumptions about one’s health literacy level should never be made (Agency for Healthcare Research and Quality [AHRQ], 2017). One’s educational level may be insignificant when it comes to navigating and understanding healthcare information (AHRQ, 2017). With prevalent rates of low health literacy in the healthcare environment, research has indicated that rather than assessing individual health literacy, healthcare providers should use universal health literacy precautions (Hersh, Salzman, & Snyderman, 2015). In order to begin to bridge the gap between health literacy and improving health outcomes, the Agency for Healthcare Research and Quality (AHRQ) has developed a Health Literacy Universal Precautions Toolkit. This toolkit contains multiple tools that have been validated for use in providing health literate information and education to patients. Health literacy universal precautions are the steps that providers/practices take by assuming that all patients have difficulty comprehending health information and accessing health services (AHRQ, 2017). These precautions aim to simplify communication, confirm comprehension for all patients, minimize the risk of miscommunication, simplify healthcare HEALTH LITERACY IN PRIMARY CARE 6 system navigation, and supporting patients’ efforts to improve their health (AHRQ, 2017). Only 12% of United States adults have the health literacy skills needed to manage the demands of our complex health system (AHRQ, 2017). The average adult reads at the 8th or 9th grade level and 20% read at the 5th grade level or below (Brega et al., 2015, p. 35). Brega et al. (2015) suggests that educational materials provided to patients should be written at the 5th grade or 6th grade reading level (p. 35). Components that should be considered when choosing patient educational material include: limit information so that patients can make informed decisions, use numbers and simple graphics, and plain language (Brega et al., 2015, p. 92). Most importantly, educational materials should be continually evaluated and discussed with patients to determine clarity and effectiveness (Brega et al., 2015, p. 35). Teach-Back Method The use of the teach-back method has been proven to be effective in educating patients with chronic disease to improve their understanding of the disease, promote knowledge, increase adherence, confidence, and self-care skills (Dinh, Bonner, Clark, Ramsbotham, & Hines, 2016, p. 3). This method consists of asking patients to state in their own words the information that has been given to them during their visit. This allows the healthcare provider to confirm that patients have correctly understood the information (Brega et al., 2015, p. 19). The goal of the teach-back method is to increase people’s understanding of disease information being communicated in a health education session by asking them to repeat back key points of the instruction (Dinh et al., 2016, p. 5). When using this tool with patients, it is also referred to as “show me” or “closing the loop” (Dinh et al., 2016, p