A Health Campaign of Uniformed Services University, www.usuhs.edu, and theCenter for the Study of Traumatic Stress, Bethesda, Maryland, www.CSTSonline.org

Health Literacy:

Addressing Communication Barriers to Foster
Patient Self-Care and Family CareA recent study published in Annals ofcare is most often due to lack of
There is increasing recognition that
Emergency Medicine (Engel et al., 2009)
knowledge and understanding of thefollowed emergency room patients
health care system — that is, lack ofa patient’s lack of preparedness forafter discharge, and found that 78%
health literacy. This can be attributed
self-care is most often due to lack of
did not understand one or more of thein part to the anxiety and fear that
following: 1) their diagnosis,
many patients experience in healthcare
knowledge and understanding of the2) their emergency room treatment,settings that interferes with thehealth care system — that is lack of3) instructions for their at-home care,
processing of information.
health literacy.
or, 4) warning signs of when they should
Other factors that contribute to thereturn to the hospital. Nearly 50% didlack of health literacy are not due to the
not understand two or more of thesepatient. Health literacy depends also
areas and the greatest confusion involved home care, i.e.
on effective communication skills on the part of a physician
medication instruction, wound care, rest, and when toor health professional, and importantly, an establishedschedule a follow-up visit.
relationship between patient and doctor, often difficult to
Traditionally, these behaviors have been explained under accomplish in the short exchanges of present medical care.
concepts such as non-compliance, but there is increasingrecognition that a patient’s lack of preparedness for selfMilitary Unique Challenges for Health Literacy
A number of these factors can be particularly
problematic in military life and culture:■ Frequent family moves present a challenge for patientsand doctors to establish relationships over time.

■ The military has many young parents who are under

great stress.

■ There are many single, first time parents who may live

apart from extended family support.

■ Parents who may not understand health instructions

compromise their ability to care for their family.

■ Not understanding instructions for the care of a sickchild can compromise that child’s health and result in
additional clinic or emergency room visits.

■ Health literacy is also important for the family of

the combat injured; they play an essential role in therecovery of the injured soldier.

Strengthening health communication skills to enhancepatient understanding for improved self and family careinvolves some specific steps. Below are some practicalsuggestions and a tool — a communication techniquereferred to as “teach back.”
Action Steps■ Have paper and pencils or pens available for patients towrite down important information at the time of theirvisit.

■ If you are a provider who addresses health issues suchas diabetes, gastrointestinal issues, and mental healthproblems, have health literature on these subjects inaccessible places in your office for patient education andhand it personally to patients who you think it will help.

■ If your office or clinic has a website that provides patientcare information, ensure that your patient knows how toaccess this. Give them a business card or other written
paper with the address on it — write a note on it fromContinued

you about when they should access it so it is felt as apersonal invitation for them to use it.
■ If your clinic or practice utilizes nurse practitioners orcase managers, make sure your patients know who they
are and how they can contact these individuals withquestions about their self-care.

Teach Back: A Communication Plan
■ Employ the “teach back” approach to patientcommunication: After you have communicated thediagnosis, treatment plan, etc., ask the patient to“repeat back” the instructions to you. This provides anopportunity to hear what the patient has heard and toclarify any discrepancies in how they understood thecare plans.

■ Ask the patient if there is anything in the self-care planthat would make it difficult or impossible for them
to follow, and then address those issues in a practicaland helpful manner. If need be, refer them to the casemanager to specifically address these barriers to theirhealth care plan.

■ Relate the diagnoses and follow-up plans in terms

that the patient and family members can understand.
If agreeable to the patient, invite in any other family
member that has come with them so that two people
rather than one, hears the plan and action steps.

■ If a language barrier is anticipated in the visit, either

accommodations for a trained interpreter to be present.
If a patient is older and has hearing or vision problems,arrange for appropriate aids and services to ensure
the patient is fully able to engage in the healthcare
conversation.
■ Employ the “dual discharge” approach: the physician

talks to the patient about the results, treatment
plan, and follow up care; a nurse follows up withcomputerized discharge instructions and goes over thesame material again.

Good Communication Fosters Patient Self-Care
One of the most obvious but subtle contributors to
impaired health literacy is that patients are often not awareof what they do not understand. Using the “teach back”
approach can help physicians and health care providers
recognize what the patient has not understood, and clarify
information and care instructions before the patient leaves
the clinic, emergency room, or office. Helping patientsprocess important information can optimize health caredelivery and better ensure patient health.
Resource
Engel, K. G., Heisler, M., Smith, D. M., Robinson, C. H.,
Forman, J. H., & Ubel, P. A. (2009). Patient comprehensionof emergency department care and instructions: Are
patients aware of when they do not understand? Annals ofEmergency Medicine, 53(4), 454–461.

you or your office staff should arrange for appropriate

Courage to Care is a health promotion campaign of Uniformed Services University
and its Center for the Study of Traumatic Stress (CSTS). CSTS is the academic
arm and a partnering Center of the Defense Centers of Excellence 5DCoE) for
Psychological Health and Traumatic Brain Injury.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University
4301 Jones Bridge Road, Bethesda, MD 20814-4799
www.CSTSonline.org