Committee Opinion
Number 676, October 2016
(Replaces Committee Opinion Number 585, February 2014)


Committee on Patient Safety and Quality Improvement
Committee on Health Care for Underserved Women

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement and Committee on Health Care for Underserved Women in collaboration with Whitney B. You, MD, MPH.

This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Health Literacy to Promote Quality of Care

ABSTRACT: Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services they need to make appropriate health decisions. Multiple factors affect a patient’s understanding of health information, including cultural factors, a physician’s health knowledge and communication skills, the demands of the situation, the environment in which the health information is being conveyed, and time constraints. The responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care system, from primary care physicians to community-based or public health organizations. Because of the potential effect of health literacy on patient outcomes, obstetrician–gynecologists should take the appropriate steps to ensure that they communicate in an understandable manner so patients can make informed decisions about their health care.


Recommendations

The American College of Obstetricians and Gynecologists (the College) makes the following recommendations for addressing health literacy to promote quality of care:

  • Because of the potential effect of health literacy on patient outcomes, obstetrician–gynecologists should take the appropriate steps to ensure that they communicate in an understandable manner so patients can make informed decisions about their health care.
  • Personnel at all tiers of the medical system must learn to communicate with patients in a way that takes into account each individual’s unique circumstances and abilities for comprehending health-related information.
  • Tools and methods accessible to all patients, including those with limited health literacy, should be developed to disseminate health-related information.

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services they need to make appropriate health decisions (1). In general, literacy includes three components: 1) print literacy (writing and reading), 2) oral literacy (listening and speaking), and 3) numeracy (using and understanding numbers). When patients encounter the health care system, they are expected to understand and apply verbal information pertaining to consent, diagnosis, medical advice, and treatment; have access to and use various forms of technology, including computers and smartphones; calculate and interpret numerical data; and comprehend graphs and visual information. Furthermore, patients are expected to articulate accurate information about their symptoms, concerns, and medical history. The current health care system asks consumers to make sophisticated health-related decisions using information relayed in encounters that often are brief and may not consider the individual’s distinct information needs. Individuals with the greatest health care needs may have limited skills to synthesize and interpret health information (2).

Background

According to an Institute of Medicine National Academies report, Health Literacy: A Prescription to End Confusion, nearly one half of all people in the United States have difficulty understanding health information (1). The prevalence of low literacy may leave patients inadequately prepared to interpret medical terminology and to understand complex health-related constructs and, thus, to make informed decisions about their care and adhere to medical recommendations. The clinical scenarios in which women need to make health-related decisions are often complex, and the language used to explain available therapeutic options is often unique and highly specialized.

Effect of Health Literacy

Limited health literacy is ubiquitous, and a growing body of literature demonstrates a correlation between health literacy and health outcomes (1). Adults with low health literacy are at increased risk of hospitalization, encounter barriers to accessing health services, and are less likely to understand medical advice (3–6). In addition, individuals with limited health literacy skills have poorer health status than those with adequate skills, even after controlling for a variety of sociodemographic variables (7).

Patients who have specific educational or linguistic challenges also may have limited health literacy. A compromised ability to adhere to therapeutic and medication recommendations, often construed as “noncompliance,” may be related to limited health literacy or other barriers that limit a patient’s ability or desire to follow a treatment plan. This is often the case with older patients and those with limited or no English proficiency.

In the United States, seniors 65 years and older use 30% of prescription drugs and 40% of over-the-counter drugs (8). Significant risks and consequences are posed to the senior population by inadequate comprehension of information on medication labels (9). Low health literacy also may be a problem for immigrant populations for whom English is a second language (10). According to a California survey of language access conducted by the College, 25% of College Fellows reported that one quarter of their patients have limited English proficiency, and 38% reported an increase in patients with limited English proficiency during the preceding 5 years (11).

When the concept of health literacy is taken into consideration, all facets of the medical encounter, including patient education and the informed consent process, are important to improving the patient’s health and the public’s health. Individuals with low health literacy are vulnerable to receiving lower-quality care and to exposure to medical errors because of communication barriers (12). Consequently, health literacy may have an effect on clinical outcomes and also may have ethical implications. According to the American Medical Association, “patients have the right to understand health care information that is necessary for them to safely care for themselves, and the right to choose among the available alternatives. Health care providers have a duty to provide information in simple, clear and plain language, and to check that patients have understood the information before ending the conversation” (7).

Patient–Physician Communication

Multiple factors affect a patient’s understanding of health information, including cultural factors, a physician’s health knowledge and communication skills, the demands of the situation, the environment in which the health information is being conveyed, and time constraints. Other factors include a patient’s ability to communicate effectively with the health care team, to manage and commit to her own health care needs, and to comprehend complex concepts such as probability and risk. Understanding the unique capabilities and limitations inherent to each patient will make the information provided more accessible for the patient and those who care for her.

The responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care system, from primary care physicians to community-based or public health organizations. Much of the available patient-centered education materials are written at a level of literacy above what would be expected for many adults (13). Tools and methods accessible to all patients, including those with limited health literacy, should be developed to disseminate health-related information. Personnel at all tiers of the medical system and in all settings where patients interact with that system (eg, hospitals, physicians’ offices, insurance companies, administrative offices, public health initiatives) must learn to communicate with patients in a way that takes into account each individual’s unique circumstances and abilities for comprehending health-related information.

It probably is most beneficial to tailor all methods of communication with the assumption of low or limited literacy. Each member of the medical team should be equipped with the appropriate training and resources to guide every patient through the health care system with appropriate resources to determine that the patient actually comprehends the information. Additionally, interpreters should be used for patients who do not speak fluent English or who prefer to communicate in another language.

Given the scope of low health literacy, the U.S. Department of Health and Human Services identified three objectives within the Healthy People 2020 topic area on health communication and health information technology: 1) to improve the health literacy of the population, 2) to increase the proportion of individuals who use electronic personal health management tools, and 3) to increase the proportion of individuals who report that their health care providers always involved them in decisions about their health care as much as they wanted (14).

Policy Initiatives to Address Health Literacy

Three federal policy initiatives have integrated health literacy into mainstream health policy and initiatives, stressing the importance of system-level changes for the health professional and the setting in which care is delivered:

  1. The Affordable Care Act incorporates health literacy into professional training and streamlines the procedures for enrollment into federal and state insurance programs. Health plans and insurers now are required to provide patient-oriented summaries that give consumers clear, consistent, and comparable health information in a standardized summary of benefits (15).
  2. The National Action Plan to Improve Health Literacy states that everyone has the right to health information that helps them to make informed decisions and that health services should be delivered in ways that are understandable and lead to health longevity and good quality of life (16).
  3. The Plain Writing Act of 2010 requires federal agencies to write documents clearly so that the public can understand and use them.

These federal policies related to health literacy share the goal of improving health care access and quality (17).

The Role of the Obstetrician–Gynecologist in Addressing Health Literacy

The College is committed to providing patients with clear, understandable, and actionable science-based health information to address the challenges of limited health literacy and supports the following guidelines (adapted from the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion’s Quick Guide to Health Literacy [18]):

  • Tailor speaking and listening skills to individual patients.
    • —Speak slowly and clearly.
    • — Repeat vital information.
    • — Organize information into two or three short components.
    • — Ask open-ended questions using the words “what” or “how” to start the sentence (eg, “What questions do you have for me?” rather than “Do you have any questions?”).
    • — Use medically trained interpreters when necessary (eg, to assist in the informed consent process).
    • — Check for comprehension by asking patients to restate the health information in their own words (eg, “Tell me how you are going to take this medication.”). This is particularly useful during the informed consent process.
    • — Encourage staff and colleagues to use plain language that is culturally sensitive and to obtain training in improving communication with patients (19). For more information, refer to Committee Opinion No. 587, Effective Patient–Physician Communication [20]).
  • Tailor health information to the intended user.
    • — When developing health information, make sure it reflects the target group’s age, social and cultural diversity, language, and literacy skills.
    • — When developing information and services, include the target group in the development (pretest) and implementation (posttest) phases of the process to ensure the program is effective.
    • — In preparing health information, consider cultural factors and the influence of culture on health, including race, ethnicity, language, nationality, religion, age, gender, sexual orientation, income level, and occupation (19).
  • Develop written materials.
    • — Keep the messages simple.
    • — Limit the number of messages (the general guideline is four main messages).
    • — Focus on action. Give specific recommendations based on behavior rather than the medical principle (eg, “Take a warm-water bath two times a day” instead of “Sitz baths may help healing.”).
    • — Use the active voice instead of the passive voice (eg, “These pills can make you sick to your stomach” instead of “Nausea may be caused by this medication.”).
    • — Use familiar language and avoid jargon (eg, “You may have itching” instead of “You may experience pruritus.”).
    • — Use visual aids, such as drawings or models, for key points. Make sure the visual messages are culturally relevant.
    • — Use at least a 12-point type size to make the messages easy to read.
    • — Leave plenty of white space around margins and between sections.

Because of the potential effect of health literacy on patient outcomes, obstetrician–gynecologists should take the appropriate steps to ensure that they communicate in an understandable manner so patients can make informed decisions about their health care.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/HealthLiteracy.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.

References

  1. Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004. [PubMed] [Full Text
  2. Parker RM, Gazmararian JA. Health literacy: essential for health communication. J Health Commun 2003;8(suppl 1):116–8. [PubMed
  3. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791–8. [PubMed] [Full Text
  4. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274:1677–82. [PubMed
  5. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166–72. [PubMed] [Full Text⇦ 
  6. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545–51. [PubMed] [Full Text
  7. Weiss BD. Health literacy and patient safety: help patients understand. Manual for clinicians. Chicago (IL): AMA; 2007. 
  8. Salom IL, Davis K. Prescribing for older patients: how to avoid toxic drug reactions. Geriatrics 1995;50:37–40, 43; discussion 44–5. [PubMed
  9. Morrell RW, Park DC, Poon LW. Effects of labeling techniques on memory and comprehension of prescription information in young and old adults. J Gerontol 1990;45:P166–72. [PubMed
  10. Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. J Health Care Poor Underserved 2005;16:152–66. [PubMed
  11. American College of Obstetricians and Gynecologists. Strengthening communication capacity: California’s OB/GYNs enhance language access for limited English proficient patients. Sacramento (CA): ACOG District IX; 2006. Available at: https://www.acog.org/-/media/Districts/District-IX/MembersOnly/2006LanguageAccessSolutionsReport.pdf. Retrieved June 30, 2016. 
  12. National Quality Forum. Improving patient safety through informed consent for patients with limited health literacy: an implementation report. Washington, DC: NQF; 2005. Available at: http://www.qualityforum.org/Publications/2005/09/Improving_Patient_Safety_Through_Informed_Consent_for
    _Patients_with_Limited_Health_Literacy.aspx
    . Retrieved June 30, 2016. 
  13. Powers RD. Emergency department patient literacy and the readability of patient directed materials. Ann Emerg Med 1988;19(2):124–6. [PubMed
  14. Department of Health and Human Services. Healthy People 2020. Available at: http://healthypeople.gov/2020/default.aspx. Retrieved June 30, 2016. 
  15. Center for Health Care Strategies. Health literacy implications of the Affordable Care Act. Hamilton (NJ): CHCS; 2010. Available at: http://www.chcs.org/media/Health_Literacy_Implications_of_the_Affordable_Care_Act.pdf. Retrieved June 30, 2016. 
  16. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National action plan to improve health literacy. Washington, DC: HHS; 2010. Available at http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. Retrieved June 30, 2016. 
  17. Koh HK, Berwick DM, Clancy CM, Baur C, Brach C, Harris LM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly ‘crisis care.’ Health Aff (Millwood) 2012;31:434–43. [PubMed] [Full Text
  18. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Quick guide to health literacy. Available at: http://health.gov/communication/literacy/quickguide/Quickguide.pdf. Retrieved June 30, 2016.
  19. Cultural sensitivity and awareness in the delivery of health care. Committee Opinion No. 493. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1258–61. [PubMed] [Obstetrics & Gynecology
  20. Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93. [PubMed] [Obstetrics & Gynecology

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Health literacy to promote quality of care. Committee Opinion No. 676. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e183–6.

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