Health Literacy: An Educationally Sensitive Patient Outcome

Health Literacy: An Educationally Sensitive Patient Outcome H. Shonna Yin, MD, MS1,2,4, Melanie Jay, MD5,2,3,4, Leslie Maness, BA1, Sondra Zabar, MD3,4, and Adina Kalet, MD, MPH3,4 1 Department of Pediatrics, Division of General Pediatrics, New York University School of Medicine, New York, NY, USA; 2Department of Population Health, New York University School of Medicine, New York, NY, USA; 3Department of Medicine, Division of General Internal Medicine, New York University School of Medicine, New York, NY, USA; 4Research on Medical Education Research Unit, Program on Medical Education Innovation and Research, New York University School of Medicine, New York, NY, USA; 5Department of Medicine, Veterans Affair New York Harbor, New York, NY, USA. We have previously proposed that by identifying a set of Educationally Sensitive Patient Outcomes (ESPOs), medical education outcomes research becomes more feasible and likely to provide meaningful guidance for medical education policy and practice. ESPOs are proximal outcomes that are sensitive to provider education, measurable, and linked to more distal health outcomes. Our previous model included Patient Activation and Clinical Microsystem Activation as ESPOs. In this paper, we discuss how Health Literacy, defined as Bthe degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,^ is another important ESPO. Between one-third and one-half of all US adults have limited health literacy skills. Providers can be trained to adopt a Buniversal precautions approach^ to addressing patient health literacy, through the acquisition of specific skills (e.g., teachback, Bchunking^ information, use of plain language written materials) and by learning how to take action to improve the Bhealth literacy environment.^ While there are several ways to measure health literacy, identifying which measurement tools are most sensitive to provider education is important, but challenging and complex. Further research is needed to test this model and identify additional ESPOs. KEY WORDS: medical education; health literacy; patient engagement; patient activation. J Gen Intern Med 30(9):1363–8 DOI: 10.1007/s11606-015-3329-z © Society of General Internal Medicine 2015 INTRODUCTION The quality of medical education influences patient outcomes, but this relationship is difficult to study.1 We have proposed that by identifying a set of Educationally Sensitive Patient Outcomes (ESPOs), medical education outcomes research becomes more feasible and likely to provide meaningful guidance for medical education policy and practice.2 ESPOs are patient outcomes that are sensitive to provider education, can be measured, and are in the pathway linking medical education interventions to patient outcomes. As others have pointed out, conducting a series of studies which Published online July 15, 2015 demonstrate these links can overcome many of the methodological complexities associated with attempting to directly link provider education to patient outcomes in a single study.3 ESPOs then become the most proximate patient outcome of provider education, but not the only one. Identifying a set of ESPOs will allow the medical education community to demonstrate return on investment in health professional education, and will provide more compelling guidance for critically important educational reform efforts.4,5 We have previously proposed Patient Activation and Clinical Microsystem Activation as ESPOs. Patient Activation is linked to health outcomes.6 Physician skills such as participatory decision making can lead to improved patient activation and better outcomes.7 Hibbard’s Patient Activation Measure (PAM) has been shown to be a reliable measure, relatively easy to administer, and has been proposed as a health care quality measure.8–10 While more definitive study is needed, we have shown that measures of patient activating skills of residents in an Objective Structured Clinical Examination (OSCE) can identify residents more likely to promote actual weight loss in obese patients.11 Similarly, we have been able to demonstrate that trainees’ lack of clinical microsystem awareness as assessed by unannounced standardized patients in actual clinical settings can threaten patient safety.12 Thus, the ESPO framework allows us to identify curricular interventions likely to lead to improvement in patient capacities directly related to important health outcomes. A number of ESPOs likely exist; health literacy is a good candidate. It can be measured, is associated with a range of health outcomes, and providers can be trained to improve a patient’s measured health literacy. HEALTH LITERACY DEFINITION Health literacy is defined as Bthe degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.^13,14 Health literacy encompasses the skills involved in all aspects of an individual’s ability to address health-related issues, including their ability to read and understand written health information (print literacy), comprehend mathematical concepts such as risks/benefits of treatment choices (numeracy), listen to and understand spoken health 1363 1364 Yin et al.: Health Literacy: Educationally Sensitive Patient Outcome information (oral literacy), and navigate the health care system (e.g., apply for insurance).15,16 Between one-third and onehalf of US adults have limited health literacy skills;14,17,18 racial/ethnic minorities, immigrants, the elderly, and low income groups are disproportionately affected.19 The link between health literacy and health outcomes is well established. Outcomes linked to limited health literacy include greater mortality and poorer global health status, increased hospitalizations, and emergency care use.20–24 Low health literacy is associated with worse asthma severity, poorer diabetic control, and obesity,22,23,25 and has been found to be a stronger predictor of outcomes than race/ethnicity, income, and education.25–27 Over the past decade, health literacy has come to be considered a critical quality and safety issue by the Institute of Medicine,14 Joint Commission,28 and the World Health Organization.29 In 2010, a National Action Plan was issued to tackle health literacy across sectors, including in education and research.30 HEALTH LITERACY AS PART OF THE CLINICAL ENCOUNTER Professional organizations, including the American Medical Association,22,31 recognize that for patients to have improved outcomes, health literacy must be addressed as part of each clinical encounter. A Buniversal precautions^ approach to the use of health literacy-informed provider–patient communication strategies is recommended,32 and includes use of plain language and avoidance of medical jargon, limiting counseling to 2–3 main concepts, and Bchunking^ of information into small (...truncated)