Health Care and Patient Literacy In Nursing Education
Literacy in the Adult Patient in American Historical View
Over the past few decades, educators as well as government officials, employers, and media experts have focused interest on and expressed concern about literacy in the US population. Adult illiteracy continues to be a major problem in this country despite public and private efforts at all levels to address the issue through testing of literacy skills and development of literacy training programs.
Today, the fact remains that many individuals do not possess the
basic literacy abilities required to function effectively in a technologically
complex society (Rampey et al., 2016). Many adult citizens have difficulty
reading and understanding information well enough to be able to perform such
common tasks as filling out job and insurance applications, interpreting bus
schedules and road signs, completing tax forms, applying for a driver's
license, registering to vote, and ordering from a restaurant menu (ProLiteracy,
2017; Weiss, 2003).
In the early 1980s, President Ronald Reagan launched the National Adult Literacy Initiative, which was followed by the United Nations' declaration of 1990 as International Literacy Year (Belton, 1991; Wallerstein, 1992). In 1992, the US Department of Education conducted the National Adult Literacy Survey (NALS), which revealed a shockingly high prevalence of illiteracy in the country (Weiss, 2003; Weiss et al., 2005; Zarcadoolas, Pleasant, & Greer, 2006) .
For many decades prior to this Literacy
Volunteers of America and Laubach Literacy International served as advocates
for the most marginalized adult population both in the United States and around
the globe. Today, ProLiteracy, which was formed in
2002 from the merger of these two entities, is the world's largest organization
targeting adult literacy. It supports 1,000 literacy programs across the United
States and in 20 developing countries worldwide (ProLiteracy, 2017).
Patient Literacy and Health Care System
Particularly in the past 15 years resulting from the NALS report, nursing and the health professions literature has focused significant attention on the effects of patient illiteracy on healthcare delivery and health outcomes. Today, the emphasis is on health literacy that is, the extent to which Americans can read and understand health information well enough to function successfully in a healthcare environment and make appropriate decisions for themselves.
Although a great deal more research needs to be done
on the causes and effects associated with poor health literacy as well as the
methods available to screen and teach patients, much has been learned about the
magnitude and consequences of the health literacy problem (Friedman &
Hoffman Goetz, 2008; Paasche Orlow & Wolf, 2007a; Pignone, De Walt,
Sheridan, Berkman, & Lohr, 2005; Wu, Moser, De Walt, Rayens, & Dracup,
2016).
Healthy People 2010 and Healthy People 2020 also identified limited
health literacy as one of the nation's top public health agenda concerns (US
Department of Health and Human Services (USDHHS), 2000, 2014). In 2006, several
agencies of USDHHS joined forces to establish a health literacy workgroup. In
the fall of 2010, this highly diverse workgroup released the National Action
Plan to Improve Health Literacy, also known as NAP or the “Action Plan” (Baur,
2011).
The NAP was created to provide guidance to organizations, professionals,
policymakers, communities, individuals, and families in identifying actions to
take to improve the widespread pandemic of limited health literacy facing not
only the United States but other countries worldwide (USDHHS, 2010). The NAP is
not just a report on the state of the problem it is an urgent request to
identify, select, and use strategies that have the greatest potential to
produce effective, measurable improvements in health literacy (Speros, 2011).
Nurses Role In Empowering the Patient By Education
Nurses are in a unique position that enables them to act as advocates for and empower each client to obtain, understand, and act on information provided to them. Many of the NAP strategies highlight actions that organizations or professions can take to further these goals. By focusing on health literacy issues and working together, nurses can improve the accessibility, quality, and safety of health care provided, of life for millions of people in the United States. The NAP envisions a society that:
(1) provides everyone with access to accurate and actionable health information
(2) delivers person-centered health information and services
(3) supports lifelong learning and skills to promote good health.
Furthermore, the Action
Plan highlights seven goals that will improve health literacy (USDHHS, 2010):
1. Develop and disseminate health and safety information that is
accurate, accessible, and actionable
2. Promote changes in the healthcare system that improve health
information, communication, informed decision making, and access to health
services
3. Incorporate accurate, standards based, and developmentally
appropriate health and science information and curricula in child care as well
as education through the university level
4. Support and expand local efforts to provide adult education,
English language instruction, and culturally and linguistically appropriate
health information services in the community
5. Build partnerships, develop guidance, and change policies
6. Increase basic research and the development, implementation, and
evaluation of practices and interventions to improve health literacy
7. Increase the dissemination and use of evidence-based health
literacy practices and interventions.
Goals Regarding Patient Literacy
These goals cannot be achieved by a single group or organization. Instead, meeting the goals of the NAP requires collaboration intense, both challenging and empowering individuals and communities to change the health system to meet the needs of specific populations. With respect to the subject of literacy, the nurse educator's attention specifically focuses on adult client populations. Literacy levels are not an issue in teaching staff nurses or nursing students because of their level of formal education.
However, literacy levels remain a concern if the audience for in service programs includes less educated, more culturally and socioeconomically diverse support staff (Wong, 2012) or if a member of the audience has been diagnosed with a learning disability, such as dyslexia. What must be particularly concerning to the healthcare industry are the numbers of consumers who are illiterate, functionally illiterate, or marginally literate.
Researchers have discovered that people with poor reading and comprehension skills, as well as lower health literacy, have disproportionately higher medical costs, increased number of hospitalizations and reading missions, and more perceived physical and psychosocial problems than do literate persons (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Eichler, Wieser, & Brügger, 2009; McNaughton et al., 2015; Parnell, 2014; Sudore, Yaffe et al., 2006; Weiss, 2003; Weiss et al., 2005; Wu et al ., 2016).
In today's world of managed care, the literacy problem is perceived
to have grave consequences. Clients are expected to assume greater
responsibility for self-care and health promotion, yet this expanded role
depends on increased knowledge and skills. If people with low literacy
abilities cannot fully benefit from the type and amount of information they are
typically given, they cannot be expected to maintain health and manage
independently. The result is a significant negative impact on the cost of
health care and the quality of life (Dickens & Piano, 2013; Kogut, 2004;
Levy & Royne, 2009; Macabasco-O'Connell et al., 2011; Pignone et al. ,
2005; Weiss, 2014; Williams, Davis, Parker, & Weiss, 2002).
Traditionally, healthcare professionals have relied heavily on
printed educational materials (PEMs) as a cost-effective and time efficient
means to communicate health messages. An assumption was made that the written
materials to ensure informed consent for tests and procedures, to promote
compliance with treatment regimens, and to guarantee adherence to discharge
instructions.
Healthcare providers have begun to recognize that the scientific and technical terminology inherent in the ubiquitous printed teaching aids constitutes a bewildering set of written instructions little understood by many people (Ache, 2009; McClure, Ng, Vitzthum, &Rudd, 2016; Morrow, Weiner, Steinley, Young, & Murray, 2007). Kessels (2003) points out that 40% to 80% of medical information provided by health professionals is immediately forgotten, not just because medical terminology is too difficult to understand but also because delivery of too much information leads to poor recall.
Furthermore, half of the information is remembered incorrectly (Parnell, 2014).
Unless educational materials are written at a level and style appropriate for
their intended audiences, clients cannot be expected to be able or willing to
accept responsibility for self care.
An essential prerequisite for implementing health education programs is to know the literacy skills of audiences for whom these programs are intended (Quirk, 2000). Yet calls for assessment of literacy and recommendations for appropriate interventions for clients with poor literacy skills have largely been ignored. Health professionals, including nurses, are sometimes reluctant to conduct a clinical assessment of literacy skill or place this information in the health record for fear of embarrassing or stigmatizing the patient (Paasche Orlow & Wolf, 2007b).
Therefore, even though illiteracy and low literacy are quite prevalent in the US population, problems with literacy frequently continue to go undiagnosed (Doak, Doak, & Root, 1996; Zarcadoolas et al., 2006).
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