Opening the Door to Effective Health Care Access: Nurses Address Health Literacy

“I had some papers but I didn’t know they were prescriptions. I walked around for a week without my medication. I was ashamed to go back to the doctor, but a woman saw the papers and told me they were prescriptions. It’s bad to not know how to read. After getting my medicine I had to come back and ask how to take them because I was going to the bathroom too much. They told me I was taking double the medication I was supposed to. I had 2 bottles and was taking one from each bottle. It turned out they were the same medication. But since I didn’t know how to read I didn’t know.” (1)

At certain points along this person’s health care journey his or her error had an opportunity to be prevented. Yet the patient’s shame and inhibition, and the lack of time and wrong assumptions on the part of the provider kept the patient from learning the information he or she needed.

What strategies can nurses use to tactfully ascertain health literacy? What patient behaviors give the nurse clues to their level of health literacy? One can also ask: What range of patient actions are affected by a health literacy deficit? Health literacy is more than the ability to read and write. It is obtaining information, accessing and navigating the health care system, the actual clinical experience, and following through on treatment and prevention.

The beginning of any patient’s health care experience is fraught with many variables. These include how sick the patient is, their previous health care encounters, and how many providers they have interacted with and whether those have been positive experiences. The WHO definition of health literacy includes a component of motivation.(2) Although there is an unlimited amount of information on health care, the amount of information does not mean that access will increase. For example, subsidized programs exist for preventive mammograms for low income Mexican-American women yet few take advantage of this. Their hesitancy is based on a host of factors which include low health literacy.

The beginning of the health care experience will depend on both the provider and patient and each one’s assumptions about the other correct or not. Establishing trust will depend on how open minded the provider is and their keen sense of observation to mine the clues of the patient’s level of health literacy.

Unless a patient arrives at the emergency department with severe illness or trauma their entry into the health care system begins with the completion of a form. This action involves both reading and writing which can be intimidating for someone with low health literacy. How can nurses prepare patients to enter the system without trepidation? Offer help in a confidential manner to fill out the forms, for example by reading it out loud, or make the phone call for the referral appointment. Provide directions to the medical site. Multipurpose medical centers increase access because the patient does not have to find another location to go for their test or specialist appointments.

Nurses can assist patients to dialogue in a productive manner with providers. If a patient feels respected and supported they will be able to communicate more effectively. Nurses can guide patients to become engaged partners in their treatment. If they know in advance what they need to do they will be more prepared to actively participate in their care. Nurses can tell them to bring their all their medications, a list of their symptoms and questions to ask, their test results and to be accompanied by a family member who can be an extra set of eyes and ears to recall the important information.

Nurses can also become adept at interpreting the nonverbal cues that patients with low health literacy display. These include the following: When reading the patient holds the page very close to his or her eyes. They may use their finger to follow the text, or their eyes will not focus in a purposeful manner when reading. Too many no or incorrect answers to questions are also clues. Patients may also appear either indifferent or display signs of nervousness. They may withdraw, and in the most extreme case of avoidance miss their appointments. Patients with low literacy levels do not want to reveal their problem as they fear reprisal and stigmatization.

Studies have shown both provider and patient tend to overestimate the patient’s reading ability. Even if the nurse knows or can find out the last level of education completed this is not a good indication of reading ability as people tend to read several grades below the last grade level completed in school.

Gauging a patient’s literacy level is important but nurses should avoid overtly testing for health literacy as this may alienate the patient. However, there are two non threatening methods that could provide a gauge of the patient’s level of health literacy. When a nurse knows the patient’s literacy level they can match their verbal instructions and written material to his or her level. The first are three questions: How often do you have someone help you read hospital materials? How confident are you filling out medical forms by yourself? How often do you have problems learning about your medical condition because of difficulty understanding written information? The five point Likert scale ranges from very confident to not at all confident.(3)

The second is called the Newest Vital Sign. The patient is asked to read an ice cream label and then answer six questions. A score of less than 4 correct could indicate low health literacy.(4)

Universal precautions and cultural sensitivity also play a large part in the success of a patient appointment. For example, the depiction of a clock as round with a series of numbers on the edge is less prevalent than in the past and may not be universally known. The same goes for the instruction to take a teaspoon of medicine. For some cultures, there is only one size of spoon, or perhaps a spoon is not a part of their individual eating habits. Therefore this instruction would have no meaning and could lead to apparent noncompliance.

The stress of a visit to the medical center will reduce any patient’s level of health literacy, and his or her ability to recall important information and instructions. As indicated from the opening scenario, health literacy is a patient safety challenge. Addressing health literacy is breaking down the first barrier to address health disparities in a proactive manner.

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