Patient education is the foundation of physical therapist practice and the key to optimizing outcomes for patients. Preeminent professional sources for physical therapy practice, the Guide to Physical Therapist Practice, the Code of Ethics for the Physical Therapist, and Standards of Ethical Conduct for the Physical Therapist Assistant, recognize that health promotion and patient education are essential responsibilities of the physical therapist.1–5 Furthermore, risk factor assessment and reinforcement of proper health management strategies are necessary tools for physical therapists.6,7 With the projected increase in the number of individuals with multiple health conditions, it is imperative for the physical therapy community to optimize the health of their patients, regardless their diagnosis, which further necessitates appropriate and effective patient education strategies.2,8–10
When considering patient education, it is important to note that barriers such as limited health literacy can alter the effectiveness of rehabilitation interventions, such as promoting lifestyle behavior changes, which can lead to negative consequences on health outcomes.11,12 To maximize the quality of patient education to ensure that patients are receiving information that fits their learning needs and literacy levels, physical therapists need to have an understanding of health literacy. The purpose of this review is to define health literacy, describe the prevalence and consequences of limited health literacy, identify signs and “red flags” of limited health literacy, provide information on screening and assessment tools to recognize health literacy problems, discuss intervention strategies for patients with limited health literacy, and discuss implications of health literacy for physical therapist education.
The most widely recognized definition of health literacy was formulated by the National Library of Medicine and further adopted by Healthy People 2010.13 It defines health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”14 The World Health Organization included in its definition not only the cognitive aspects of comprehending, analyzing, and applying health information to make appropriate health decisions, but also the social skills needed to interact with the community.14 Together, these definitions can be generally described as a person's ability to comprehend health information and use that information to make informed decisions about one's health and medical care, thus giving individuals the knowledge and skills to optimally function and navigate in the health care environment.15,16
These skills include being able to discern healthy lifestyle choices, obtain knowledge of disease etiology and management, identify appropriate preventative and health care services, and carry out self-care tasks. Specifically, these skills are necessary to read consent forms, prescription information, food labels, rehabilitation instructions, and appointment slips, or to fill out a health insurance form, or calculate a health care bill.8,17,18 They also allow for improved compliance with a physical therapy plan of care and ultimately lead to better health and medical care outcomes.19
PREVALENCE AND CONSEQUENCES OF LIMITED HEALTH LITERACY
The 2003 National Assessment of Adult Literacy (NAAL) estimated that approximately 89 million Americans had only “basic” or “below basic” health literacy skills with older adults aged 65 years and older, representing the largest group in the United States who have limited general literacy and health literacy skills.8,17,18,20–22 People with limited health literacy tend to be male and members of minority or marginalized population groups, and/or those who have immigrated to the United States. They also tend to have less than a high school education and lower incomes and they are more likely to live in poverty, have poor health-related behaviors, and have less access to health care.8,16,18,22–27
Limited health literacy can have negative consequences on health outcomes because of a lack of knowledge of healthy lifestyle choices, disease etiology and management, and not being able to identify and access appropriate preventative and health care services, and carry out self-care tasks. In addition, limited health literacy increases the risk of hospitalization, the overall cost of health care, and mortality rates.8,14–18,22–24,27–30 Those with limited health literacy were more likely to report difficulties with instrumental activities of daily living and activities of daily living, due to poor or diminished physical health and pain that interfered with normal work activities.25 Higher proportions of those with limited health literacy rate their health as “fair” to “poor” and have higher rates of diabetes, hypertension, obesity, depressive symptoms, and more physical limitations.8,14,17,22,24,25 Older adults with limited health literacy also may demonstrate a higher incidence of heart failure, arthritis, and multiple health conditions and have a greater need for complex medical management.24,25 Furthermore, limited health literacy may exacerbate the effects of low socioeconomic status on health and health access and may interfere with effective chronic disease management.22
SIGNS OF LIMITED HEALTH LITERACY
Identification of “red flags” may indicate signs of limited health literacy, which could require further screening and incorporation of intervention strategies to optimize health outcomes.31 Notable “red flags” are listed in Table 1. Being aware of these signs is an important first step in identifying the possibility of limited health literacy. However, health care professionals may incorrectly identify patients with poor literacy skills and thus overestimate a patient's health literacy level.12 For instance, therapists may use the number of years of school completed by a patient as an indicator of health literacy.18 This assumption may be misleading as individuals with adequate literacy skills who have completed high school or college and have “white-collar jobs” may still struggle with medical terminology and medical concepts. They may also have difficulty comprehending and analyzing health care information in either oral or written format.15,32 In addition, individuals with lower health literacy skills may become skillful in “hiding” their literacy problems.33 They may respond a certain way when receiving written information, for example, asking the therapist to read written information to them or stating that they forgot their glasses and will read it later.31 All of these potential signs can serve as triggers to physical therapists that health literacy may be compromised.
HEALTH LITERACY SCREENING AND ASSESSMENT TOOLS
Various instruments have been developed to measure health literacy. Most of these tools focus on reading comprehension, the task of putting letters together to make words or sentences, and understanding what the words and sentences mean.34 It is recommended that time-efficient screening tools be utilized so that therapists can quickly create an approach to patient education that will match the patient's health literacy needs. Direct assessment of health literacy skills can be performed on individual patients or on a sample of patient populations, that is, patients utilizing a particular health care facility.35 Common health literacy tests include the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), the shortened version of the Test of Functional Health Literacy in Adults (S-TOFHLA), the Short Assessment of Health Literacy for Spanish-Speaking Adults, the Newest Vital Sign, and the Single Item Literacy Screener. While these screening tools are helpful, current screening tools do not measure the full extent of health literacy such as oral literacy skills (listening and speaking), health knowledge, reading fluency, memory span, and the ability to navigate in health care environments.17,27,30 Published literature has not yet determined if one screening tool is more effective than another in measuring the skills necessary for functioning in a health care environment or in predicting health outcomes.15 Table 2 lists the advantages and disadvantages of the aforementioned screening tools.
INTERVENTION STRATEGIES FOR PATIENTS WITH LIMITED HEALTH LITERACY
Health literacy should be considered throughout a patient's health care experience with recognition of limited health literacy an important first step in helping patients take control of their health. Physical therapists and physical therapy assistants may be the first health care practitioners to identify patients’ health literacy issues. Table 3 lists resources that are available to educate health care professionals and support staff on health literacy and how the health care experience can be enhanced to benefit those with limited health literacy. An example of such an enhancement might be to ensure that the health care facility is “patient friendly.” Intervention strategies at this level may involve simplifying intake and registration forms and placing easy-to-read signage throughout the facility to make the experience less stressful for the patient. As support staff may identify issues before a therapist, for example by how registration forms are filled out, it is important that everyone on the patient's health care team is knowledgeable of potential signs of limited health literacy and can appropriately assist patients from the beginning of their health care experience.31,32
While it is difficult to determine which interventions are most effective, there are limited studies that have examined how interventions to improve health literacy, including the use of various forms of patient education, can positively affect disease incidence or prevalence, increase the use of appropriate health care services, decrease health care costs, or diminish the health disparities based on race, ethnicity, culture, or age.35,44 Conversely, factors such as limitations in patient-provider communication and failure of health care providers to promote self-management skills and recognize patient barriers to communication and comprehension can contribute to poor outcomes in those with limited health literacy.20
Physical therapists can utilize the communication strategies outlined in Table 4 to create an effective educational experience to fit their patients’ needs. These guidelines can be tailored to a variety of patient populations with differing levels of literacy comprehension. The main goal in communicating successfully with individuals with limited health literacy is to foster motivation and give patients a sense of control over their condition.20
The physical therapy evaluation is a critical opportunity for the physical therapist to utilize communication strategies that can help identify what the patient values and determine mutual goals, in addition to identifying the presence of limited health literacy.19 The evaluation also can provide the physical therapist with an opportunity to assess learning styles to assist the patient in ascertaining which teaching strategies (visual, auditory, or hands-on) will be most useful for them.5,19,45 One way to determine learning styles is to ask the patient about their hobbies and how they became proficient with the hobby. For example, did they read, watch a video, or take a class to learn about the hobby?19 Patient answers provide clues to learning style preferences and can point to literacy issues. In addition, during the evaluation, the physical therapist can also discover what barriers exist to completing the plan of care, such as not enough time, environmental reasons, financial factors, or if the service of an interpreter is needed.5 Effective communication can further build trust with the patient by demonstrating respect for cultural diversity. This can be done by asking patients about their perception of the cause of their illness or problem, the social organization of their families, their expression of pain, cultural health beliefs, experiences with health care, and who is the health care decision maker in the family unit.19 By utilizing appropriate communication strategies during the evaluation process, the physical therapist can begin to identify health literacy issues and subsequently develop suitable patient education materials and a comprehensive plan of care.
Printed Materials and Health Literacy
Most health education materials are written at the 10th-grade level or more and may be too complex for patients with limited health literacy to understand.5,8,35 The average American reads between an eighth- and ninth-grade level and the reading skills of Medicaid participants are at a fifth-grade level.5,35 According to the 2003 NAAL, for adults with “basic” or “below basic” health literacy, most documents such as patient education brochures and pill bottles are too complex to read and understand.20 Physical therapists who consider purchasing or creating their own printed patient education materials need to aim for simplicity, at a fifth-grade readability level or at the lowest reading level at which the content can be coherently transcribed.19,35,47 The Fry Readability Formula and Simple Measure of Gobbledygook are tools that can be used to determine readability and to ensure that printed patient education materials are appropriate for those individuals with limited health literacy.19,49,50 Tables 5 to 7 list guidelines and resources for developing printed patient education materials.
Health Information Access
There are differences in how older adults (aged 65 years and older) and baby boomers (aged 50–64 years) locate health information.8,45,51 The NAAL data showed that approximately 78% of older adults reported receiving health-related information from health care professionals, 68% from radio and TV, and only 15% reported getting information from the Internet.8 A national Kaiser Family Foundation survey of older Americans found that less than a third (31%) of older adults (aged 65 years and older) had ever gone online, and those 50 to 64 years old rated the Internet first among media sources for health information. The proportion of older adults who use the Internet is expected to increase dramatically over the coming years as the baby boomers age.51 Health promotion efforts, particularly over the Internet, have targeted baby boomers as they tend to have more experience with computers (vs older adults).45 Several forms of health information exist for those patients who prefer to get information from the radio and TV rather than from written sources such as newspapers, books, magazines, and the Internet.47 These forms may include audiotapes, compact discs, and videotapes.31,35 Table 8 guides patients to reliable and accurate sources of health information. It is vital for a physical therapist to understand these differences in order to provide patients with health information resources in a format that is compatible with their preferred style of receiving information. Patients may also need to be referred to adult reading and literacy programs.32
IMPLICATIONS FOR PHYSICAL THERAPIST EDUCATION
The profession of physical therapy can contribute to the nationwide outreach to help those with limited health literacy reducing health disparities and improving health outcomes. Fostering a sense of responsibility to accept this task begins with entry-level physical therapist education. Health literacy training that encompasses recognition of “red flags,” administration of screening tests, and incorporation of intervention strategies, including how to create patient education materials, will enhance holistic management of patients, including older adults and those with multiple, chronic conditions.35 In addition, it is recommended that assessment of future physical therapists’ abilities to promote health education and teach self-management strategies take place in physical therapist education programs with skills critiqued throughout the curriculum.52
The high prevalence of limited health literacy of older adults in the United States plays a significant role in reduced health outcomes for patients and creates challenges in the comprehensive management of physical therapy clients. The shifting demographics of the aging population and the expected increase in multiple chronic conditions among adults further demands that the physical therapy profession play a leading role to effect optimal health outcomes for patients. Through increased awareness of limited health literacy, patient education, and targeted intervention strategies, physical therapy practitioners can assist patients in overcoming limitations and enhancing the quality of their health and medical care.
The authors thank Judith Stoecker, PT, PhD, and Joyce Lenz for their assistance with the preparation of this manuscript.
1. Chase L, Elkins J, Readinger J, Shepard KF. Perceptions of physical therapists towards patient education. Physical Therapy. 1993;73(11):57–65.
2. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2003.
5. Vanderhoff M. Patient education and health literacy. PT Mag. 2005;13:42–46.
6. Dean E. Physical therapy in the 21st century (part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5/6):330–353.
7. Dean E. Physical therapy in the 21st century (part II): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5/6):354–368.
8. White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav. 2008;32(3):227–242.
9. Hoffman D, Rice D, Sung HY. Persons with chronic conditions: their prevalence and costs. JAMA. 1995;276:1473–1479.
10. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269–2276.
11. Levasseur M. Do rehabilitation professionals need to consider their clients’ health literacy for effective practice? Clin Rehabil. 2010;24:756–765.
12. Bass PF III, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Acad Med J Assoc Am Med Coll. 2002;77(10):1039–1041.
14. Ishikawa H, Yano E. Patient health literacy and participation in the health-care process. Health Expectat. 2008;11:113–122.
15. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–1239.
16. Baker DW, Parker RM, William MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–798.
17. Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009;7:204–211.
18. Cutilli CC. Health literacy in geriatric patients: an integrative review of the literature. Orthop Nurs. 2007;26(1):43–48.
19. Chang M, Kelly AE. Patient education: addressing cultural diversity and health literacy issues. Urol Nurs. 2007;27(5):411–417.
20. Oates DJ, Paasche-Orlow MK. Health literacy: communication strategies to improve patient comprehension of cardiovascular health. Circulation. 2009;119:1049–1051.
21. Kutner M, Greenberg E, Jin Y, et al. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: National Center for Education Statistics, US Department of Education; 2006.
22. Sudore RL, Yaffee K, Satterfield S, et al. Limited literacy and mortality in the elderly: the health, aging and body composition study. J Gen Intern Med. 2006;21:806–812.
23. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.
24. Sudore RL, Mehta KM, Simonsick EM, et al. Limited health literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54:770–776.
25. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946–1952.
26. Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8):1278–1283.
27. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(suppl 1):S19–S26.
28. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267–275.
29. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005;118(4):371–377.
30. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(suppl 1):S19–S26.
32. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2010.
33. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27(1):33–39.
34. Cutilli CC. Do your patients understand? Orthop Nurs. 2005;24(5):372–377.
35. National Work Group on Literacy and Health. Communicating with patients who have limited literacy skills: report of the National Work Group on Literacy and Health. J Fam Pract. 1998;46:168–176.
36. Davis TC, Long SW, Jackson RH, et al. Rapid Estimate of Adult Literacy in Medicine: a shortened screening instrument. Fam Med. 1993;25(6):391–395.
37. Mancuso JM. Assessment and measurement of health literacy: an integrative review of the literature. Nurs Health Sci. 2009;11:77–89.
38. Parker RM, Baker DW, Williams MV, Nurss JR. The Test of Functional Health Literacy in Adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10(10):537–541.
39. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.
40. Lee SY, Bender DE, Ruiz RE, Cho YI. Development of an easy-to-use Spanish health literacy test. Health Serv Res. 2006;41(4, Pt 1):1392–1412.
41. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the Newest Vital Sign. Ann Fam Med. 2005;3:514–522.
43. Morris NS, MacLean CD, Chew LD, Littenberg B. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7.
44. Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy: a systematic review. J Gen Intern Med. 2005;20:185–192.
45. Sinden D, Wister AV. E-health promotion for aging baby boomers in North America. Gerontechnology. 2008;7(3):271–278.
47. Hironaka LK, Paasche-Orlow MK. The implications of health literacy on patient-provider communication. Arch Dis Child. 2008;93:428–432.
52. Dean E. Epidemiology as a basis for contemporary physical therapy practice. In:Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St Louis, MO: Mosby Elsevier; 2006:3–36.
health literacy; older adults; patient education© 2012 Academy of Geriatric Physical Therapy, APTA