Include Family Members. As Jones, Treiber, and Jones state, “it takes a village” to assist a patient who has low health literacy.13 Not only do the various members of the healthcare team serve in important roles in the process, the family also plays a key role in overcoming low health literacy. The patient’s spouse can assist in reinforcing patient education and adherence to treatment regimens. Ideally, a family member who has a higher level of basic and health literacy should be recruited, but realistically this may be difficult to accomplish.
Slow Down. Communication can be greatly improved simply by speaking more slowly, as older adults have slower processing speeds.14 If rushed, older adults can feel frustrated and exhibit unwillingness to learn due to fear of shame or failure.11 Although time is often limited during patient visits, which makes it difficult to slow down, the additional time allocated may contribute to better patient outcomes.
Use Plain, Nonmedical Language. Clinicians can improve patient understanding by adopting simple speech patterns, such as using words with no more than 2 syllables (Table). Communication with patients with low health literacy can be improved by asking colleagues to listen to patient encounters and give feedback, or by role playing with nonmedical friends and family members.
Show or Draw Pictures. Simple pictures can be used to help patients better recall important health information. The pictures do not need to be detailed, although the use of color can make them more appealing to the eye. In a pilot study of a narrative- and pictured-based health literacy intervention for older adults, pictures were found to be appealing and comprehensible.15
Limit the Volume of Information at Each Encounter. As older adults may have difficulty multitasking and dividing their attention, each encounter should be limited to 1 or 2 key pieces of important information.11 Practitioners may overwhelm patients with information during a single encounter, which can lead to confusion and poor understanding. Patients with low health literacy may benefit from longer appointments, more frequent visits, or both.
Teach Back. Instructing patients to repeat back the information provided can serve to confirm their understanding. If the patient repeats information incorrectly, the clinician can clarify the information to ensure patient comprehension. The following is an example of a dialogue using the teach-back method:
Clinician: The sugar in your blood is high, so I want you to take 1 more unit of your insulin glargine every 2 days until your morning blood sugar is 80 to 110. I want to make sure you understand what I just said, so can you tell me what you’re going to do?
Mr C: I’m going to take 1 extra unit of insulin glargine every 2 days until my blood sugar is 80 to 110.
Clinician: That’s correct. Once you have a morning blood sugar between 80 and 110, don’t increase your insulin glargine anymore. Keep taking the same dose of insulin glargine you took to reach 80 to 110. So, how much insulin glargine will you take once your blood sugar is between 80 and 110?
Mr C: Once my blood sugar is 80 to 110, I won’t increase my insulin glargine anymore. I’ll keep taking the last dose of insulin glargine that I had been taking.
Create a Shame-Free Environment. The American Medical Association (AMA) created a video with actual patients who had low health literacy to demonstrate a woman describing her experience with a physician she consulted about her abnormal menses. She went to the hospital and signed consent for surgery, but she did not realize until her 6-week postoperative visit that her procedure was a hysterectomy. The patient said she had been too ashamed to tell the physician and the admitting office that she didn’t read well, so she didn’t fully understand the papers she signed. A body part was removed, which was never her intention, as a result of her low health literacy. As the woman’s experience shows, if patients feel shamed, they are less likely to ask questions. A shame-free environment allows patients to ask important and clarifying questions about their healthcare. Clinicians can create such an environment by developing rapport with patients and approaching them with a demeanor of acceptance that encourages them to ask questions.
Educate Staff. Clinicians should prioritize education on health literacy for the entire office staff. Many resources are available to assist in staff education about this important topic.
Use Printed Material. When selecting or creating printed patient education materials, the most effective tools for patients with low health literacy limit information to 1 or 2 objectives and use plain language, primarily 1- or 2-syllable words, bullet points, pictures, readable fonts, and more empty space on the page.16 A 12- to 14-point font size is recommended for the general population; however, a larger font size is recommended for older adults due to potential visual disturbances.11 Black font is recommended because it is much easier for the older adult to see than other font colors such as red. Although patient education materials should be written at a third- to fifth-grade level, many are often written at higher levels.17 To ensure that written material is at an appropriate level for most patients, clinicians can use the numerous online resources available.
Technology and the Older Adult
Clinicians should exhibit caution when using electronic methods to deliver patient education to the older adult. Only 42% of the US population between the ages of 55 and 74 years are regular users of computer technology.18 This gap increases with age, and women are less likely than men to have computer skills. A 2014 Pew Report states that “seniors remain unattached from online and mobile life — 41% do not use the internet at all, 53% do not have broadband access at home, and 23% do not use cell phones.”19 Although technology use among older adults is increasing, they remain slower to adopt new products or innovations.
Older adults may have multiple medical conditions, and effective control of these conditions often begins with overcoming low health literacy. Using the recommended strategies, clinicians can improve patient communication in their day-to-day practice — particularly with older adults and other patients with lower health literacy — potentially decreasing healthcare costs and improving patient outcomes through more effective communication.
Gwenn Scott RN, DNP, CNS, FNP-BC, is an assistant professor in the School of Nursing Master’s Program at the University of Texas Medical Branch in Galveston.
- Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician. 2015;92(2):118-124.
- Ratzan SC, Parker RM. Health literacy. National Library of Medicine website. www.nlm.nih.gov/archive/20061214/pubs/cbm/hliteracy.html#15. Published 2000. Accessed October 1, 2018.
- Health literacy: a prescription to end confusion. Institute of Medicine website. www.nationalacademies.org/hmd/Reports/2004/health-literacy-a-prescription-to-end-confusion.aspx. Published April 8, 2004. Accessed October 9, 2018.
- What did the doctor say? Improving health literacy to protect patient safety. The Joint Commission website. https://www.jointcommission.org/what_did_the_doctor_say/. Published February 27, 2007. Accessed October 9, 2018.
- National action plan to improve health literacy. Office of Disease Prevention and Health Promotion website. https://health.gov/communication/initiatives/health-literacy-action-plan.asp. Published 2010. Accessed October 9, 2018.
- Healthy People 2010. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/healthy_people/hp2010.htm. Published October, 2011. Accessed October 9, 2018.
- Healthy People 2010. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/healthy_people/hp2020.htm. Accessed October 9, 2018.
- Agency for Healthcare Research and Quality. National healthcare disparities report. Washington, DC: Government Printing Office; 2017.
- Rasu RS, Bawa WA, Suminski R, Snella K, Warady B. Health literacy impact on national healthcare utilization and expenditure. Int J Health Policy Manag. 2015;4(11):747-755.
- Hahn EA, Burns JL, Jacobs EA, et al. Health literacy and patient-reported outcomes: a cross-sectional study of underserved English- and Spanish-speaking patients with type 2 diabetes. J Health Commun. 2015;20(Suppl 2):4-15.
- Elliot RW. Educating older adults with chronic kidney disease. Nephrol Nurs J. 2014;41(5):522-526.
- Osorio AR. The learning of the elderly and the profile of the adult educator. Convergence. 2008;41(2-3):155-172.
- Jones JH, Treiber LA, Jones MC. Intervening at the intersection of medication adherence and health literacy. J Nurse Pract. 2014;10(8):527-536.
- Kobayashi LC, Wardle J, Wolf MS, von Wagner C. Aging and functional health literacy: a systematic review and meta-analysis. J Gerontol Series B: Psychol Sci Social Sci. 2016;71(3):445-457.
- Koops JR, Winter AF, Reijneveld SA, Hoeks JC, Jansen CJ. Development of a communication intervention for older adults with limited health literacy: photo stories to support doctor-patient communication. J Health Commun. 2016;21(sup2):69-82.
- Weiss BD. How to bridge the health literacy gap. Fam Pract Manag. 2014;21(1):14-18.
- Bailey SC, Fang G, Annis IE, O’Conor R, Paasche-Orlow MK, Wolf MS. Health literacy and 30-day hospital readmission after acute myocardial infarction. BMJ Open. 2015;5(6):e006975.
- Schmidt-Hertha B, Krasovec SJ, Formosa M (eds). Learning Across Generations in Europe. Rotterdam: Sense Publications; 2014.
- Smith A. Older adults and technology use. Pew Research Center Internet & Technology website. www.pewinternet.org/2014/04/03/older-adults-and-technology-use/. Published 2014. Accessed October 9, 2018.