Why is Health Literacy Essential to Improve Health Outcomes and Health Equity?
A discussion with leading experts in health education and care managementDue to the rising importance of health literacy to improving individuals’ health outcomes and well-being, as well as eliminating health disparities and achieving health equity, VirtualHealth sat down with Healthwise Chief Content Officer Christy Calhoun, MPH, and our own Director of Population Health and Value-Based Care Solutions Lori Coates, RN-BC, CCM, CCTM.
Below we provide a quick update on health literacy in the United States and then dive in with Christy and Lori to discuss the value of health literacy in improving health equity and outcomes and look at ways healthcare organizations and care teams can improve health literacy within their own populations.
The Current State of Health Literacy in America
Approximately 80 million Americans have limited or low health literacy. Health literacy issues are especially prevalent in older adults. The Centers for Disease Control and Prevention (CDC) and the National Assessment of Adult Literacy (NAAL) health literacy report: 71% of adults 61 and older had difficulty using print materials; 80% had difficulty using forms and charts, and 68% had difficulty with interpreting numbers and doing calculations.
Unfortunately, low health literacy is significantly associated with poorer health outcomes and quality of life. One study noted that poor health literacy is connected to the following.
- Decreased ability to engage in complex disease management
- Decreased ability to properly care for themselves
- Increased rates of hospitalization and longer stays
- Higher likelihood of developing more diseases & having more chronic conditions
- Experience higher mortality
Health literacy issues are also compounded by tech literacy issues and low patient recall rates.
- 75% of older adults say they require help when learning new technology
- Patients only recall about 49% of the information a doctor provides without prompting
Finally, in August 2020, the definition of health literacy was expanded by the Healthy People 2030 initiative to include two categories of health literacy.
Personal health literacy is “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others..”
Organizational health literacy is “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”
The key points of these updates account for the need for healthcare organizations to prioritize health literacy. Payers, providers, and care managers are all responsible for taking steps toward improving health literacy to enable greater health equity.
Discussion: Healthy Literacy is Pivotal for Organizations to Improve Health Outcomes and Health Equity
VirtualHealth (VH): Why is health literacy so important to address?
CHRISTY CALHOUN: Health literacy is fundamental to helping people better understand their health and play an active role in it. Healthwise’s founder, Don Kemper, believed that the most untapped resource in our industry is the healthcare consumer. That was true when Healthwise was founded in 1975, and it’s still true today. A patient’s ability to understand and manage a health condition, to care for themselves, to follow a doctor’s instructions and care plans, to take their medicine properly…all of this is improved when people have access to clear health education.
Health literacy is critical to improving health outcomes overall. And high-quality health education engages the patient in their own health, enables them to actively participate in their care plan, make better and more informed decisions, as well as reduces stress and fear. By improving health literacy, we’re positioning patients to take care of themselves and achieve better health and well-being.
LORI COATES: A person's health literacy directly impacts their engagement in their health and health care. Low to moderate health literacy often hinders patients from being able to engage in complex disease management and self-care, which can result in increased medication errors, emergency visits, admissions, avoidable readmissions, disease exacerbation, and even a higher mortality rate.
As a care manager, you can't take a cookie-cutter approach to educate members about their health. It should be very personalized and tailored to the needs of each person. Therefore, including assessing a member’s health literacy skills as part of the comprehensive needs assessment is crucial. This knowledge enables the care manager to match verbal instructions and the readability level of written educational materials to the health literacy skills of the member. You also have to be able to develop trust and rapport with the member to ensure ongoing and open communication and engagement in care management. If, as a patient, I can’t understand what you are trying to teach me, or if I can’t read, but you continue to mail me educational materials- I am likely going to disengage and stop answering the phone when you call me.
Providing education is just one part of the care manager's job. The most critical role of the care manager is ensuring that a member is able to understand and apply that knowledge- especially after they graduate from care management services and are “on their own”. Fostering and facilitating member self-advocacy, engagement, activation, and self-management; increased health care equity; and improved outcomes and reduced cost of care- that's how we make a difference!
VH: What is health literacy’s impact on health equity / improving health outcomes?
CHRISTY: Health education is an important component of health equity. To improve equity, and the quality of the care and access to it, you need your organization to be health literate. This is supported by delivering clear, easy-to-understand health education content that’s accessible to everyone, and focused on a single learning objective at a time. In times of stress due to health issues, it can be hard for people to retain a lot of information at once. So it is helpful to break health education down into focused, actionable messages with visuals that teach. And when care teams trust that education, they are able to use it with patients to strengthen relationships of care. Improving health literacy for everyone helps to level the playing field and contributes to more equitable health. We all have a shared responsibility to make sure educational materials are easily accessible, trustworthy, high-quality, accurate, free from jargon, and made for all healthcare consumers.
Health literacy plays an important role in improving outcomes, too. Studies show that when people engage with high-quality health education, it has a powerful positive effect. For example, in one study, patients with diabetes and high cholesterol received education from Healthwise over time. As a result of that engagement, people shared that they had a better understanding of the importance of taking medicine to lower their cholesterol. They were also more likely to fill their prescriptions for cholesterol-lowering medicines, and as a result, their cholesterol levels improved. People who engaged with the content more actually had better health outcomes.
Helping to better educate and inform patients about their health also improves health outcomes by helping to alleviate fear, concern, and stress. When you provide actionable steps patients can take themselves or in partnership with a health provider, you encourage better conversations between patients and care teams. This leads to helping patients feel more confident and empowered so that they can better manage their own health.
LORI: Consider health literacy a bridge to health equity and improving health outcomes. The Office of Disease Prevention and Health Promotion (ODPHP) defines social determinants of health (SDOH) as the social, economic, and physical conditions of the environments in which people are born, live, learn, work, play, worship, and age. And health literacy, health equity, and SDOH are so closely intertwined that the U.S. Department of Health and Human Services includes health literacy in one of its overarching Healthy People 2030 goals: “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.”
The ability to make healthy decisions and sustain healthy behaviors has a great deal to do with the ability to understand what is going on with your health and what you need to do to ensure positive health outcomes. It is extremely important for healthcare organizations to assess their patient populations to identify how low health literacy impacts access to care and services and decreases adherence to medications and care plans for those populations- and then develop interventions to improve health equity.
As care managers, we often have access to that population assessment information and knowledge about the demographics, beliefs, and behaviors of the populations we serve. However, knowing the community and knowing how to engage and include an individual from the community in their healthcare are different.
It is essential that care managers provide educational materials that engage members in their healthcare, enhance understanding of health information, resources and services, and increase healthy behaviors to improve health outcomes and reduce the cost of care. That means leveraging multi-media materials (print and digital), utilizing plain language; translating materials into the language of choice for the member; incorporating content that takes different learning styles into account (i.e., audio, visual, kinesthetic); and ensuring cultural competency and sensitivity. But it is not enough to mail out or hit "send" on an email with educational materials on a healthy diet attached for a member with diabetes. It is imperative that care managers use the teach-back method to ensure the member receives the materials, can read and understand the materials, has an opportunity to ask questions, and has a clear action plan in place to incorporate the changes into their lifestyle and routine.
VH: What kind of health education content enables “good” health literacy? And how can an organization identify if the content is successful?
CHRISTY: This is something we talk about at Healthwise all the time. In fact, we’re continually evolving what content looks like to enable better health literacy across all generations. It’s why we leverage user research, focus groups, surveys, and provider and patient feedback in the creation of our articles, videos, and other content types. But what really supports improved health literacy is content that meets the following requirements.
It’s trustworthy. Motivating. Clear and easy to understand, with the use of helpful visuals and videos to teach key concepts. It informs and answers key questions patients or caregivers have. And each piece of content is focused on a single learning objective, making it easy to digest and retain. For example, when we create videos, we keep them 1 to 3 minutes long because we know anything past that is too much to process and remember. We focus on a single topic like how to check your blood sugar or how to help someone recovering from a hip replacement.
And the goal with each piece is to inform and empower the patient or caregiver, and then inspire them to act – either by taking small steps to improve their health every day, having a conversation with their doctor, or making healthier choices.
LORI: From a care management perspective, once you have assessed your member's current knowledge about their condition(s) and what they want and need to know, you then must gauge their concerns, readiness to learn, preferences, and possible barriers to learning. After that, you can create a care plan based on SMART (Specific, Measurable, Achievable, Realistic, and Time-bound) goals and learning objectives, and choose educational materials and resources tailored to the member.
From there, it is all about evaluating the "teaching and learning". A couple of ways to easily assess effectiveness are:
- Observe return demonstrations to see whether the member has learned the necessary psychomotor skills for a task.
- Ask the member to restate instructions in his or her own words, to ensure understanding.
- Ask the member open-ended questions to assess for areas of instruction that need reinforcing or further instruction.
VH: How key is health literacy for patients and caregivers? Are both essential to educate?
CHRISTY: Health literacy and health education are critical across life’s various caregiving moments. At Healthwise, we provide content across the continuum, depending on how caregiving shows up in your life. You may be caring for a newborn or child, an older adult who’s getting increasingly more care at home, or a friend who’s recovering from surgery or going through a complex illness.
The best health education comes from a place of empathy and understanding of what the caregiver may be going through. People who are parenting a newborn, for example, can feel stressed out or anxious. Parents are trying to navigate the basics like feeding, bathing, calming a crying baby, and car seat safety – often for the first time in their lives, or while parenting other children, as well. So in addition to using the best evidence and science available, we also use clear step-by-step guides, focused on each caregiving moment, and videos that incorporate soothing music, calming visuals, and clear messaging to inform and create a supportive experience.
It can also be stressful for parents to help their child or teen go through tough situations, like being diagnosed with ADHD, or managing an asthma attack or diabetes as a child. In cases like these, we seek to educate both the parent and the child, reassuring and informing both so they feel more comfortable learning about what’s going on in their body or mind. This can make it easier for both parents and kids to navigate through challenging situations and feel more confident managing those situations together and independently.
Another example is the adult caregiver caring for someone who is aging or going through dementia or other complex conditions. We know that more and more care is happening in the home, and caregivers are looking for content to help people learn how to give a sponge bath or turn someone in bed to avoid pressure sores. In this case, the content is intended for a caregiver who needs step-by-step guidance, with visuals and instructions that are easy to understand and follow.
Caregiving can be stressful, draining, and emotional. So it’s important that education for caregivers include tips to help them take care of themselves – take breaks, get sleep and nutrition, ask for help from others, and incorporate mindfulness in small ways, like getting outside for a walk or taking time for deep breaths.
LORI: Adults and children with caregivers who have low health literacy are more likely to be in poor health, experience a medication error, have more frequent and potentially preventable emergency department visits and/or hospital stays, incur a higher cost of care, and encounter more barriers to care. It is essential that care managers identify a member's caregiver resources and support early on during the assessment phase, and that should also include assessing the health literacy skills of the caregiver(s). It is crucial to understand any gaps in knowledge and understanding about the member's condition(s) and healthcare needs that the caregiver may have so that those can be addressed.
Care managers should tailor health education materials and information to the health literacy level of the member and the caregiver(s), when appropriate. Care managers should also keep in mind realistic retention rates, limiting information to what members and caregivers need to know right now, and adding on new information after gauging and confirming understanding. Providing too much information at once can cause people to shut down, which closes off the ability to learn more, and may cause the member and/or caregiver to disengage from care management altogether.
Because older adults may have multiple comorbidities and complex health conditions, caring for and providing assistance to them may be challenging. There may be formal or informal caregivers to consider when providing care management services to an older adult. Caregivers can influence the healthcare decisions that older adults make or the decisions about the healthcare of an older adult that other people make. Ideally, caregivers should have the skills to support complicated health conditions and be able to help older adults understand health information. However, a caregiver with low health literacy may not be able to support a member in this way. The care manager will likely need to spend additional time to educate both the member and the caregiver to ensure everyone involved has a clear understanding of the care plan.
For pediatric patients, the parent or caregiver is usually the primary point of contact for the care manager. Low health literacy in parents or caregivers can potentially impact understanding of a child's diagnosis and treatment course, which can lead to decreased engagement in the child's healthcare, the risk for medication errors, increased utilization of emergency services, and overall poor health outcomes. According to the NIH, over half of caregivers who present with their children to the ED have low health literacy. And, low caregiver health literacy is an independent predictor of increased ED utilization in general, and utilization of ED services for non-emergent conditions. Supporting these parents and caregivers in health literacy includes identifying health literacy and language needs, helping them understand basic health information, modeling skills, and actions that help parents and caregivers make healthy choices for their child, helping parents and caregivers understand their role in the health of their children, and providing resources and plain language educational materials in the media and language of their choice.
VH: Knowing education is so important, how does the Healthwise content come to life within HELIOS? How can care managers specifically use this to help improve health literacy to drive greater health equity & better health outcomes?
CHRISTY: With HELIOS, care managers have access to Healthwise education so they can find exactly what they need for each patient or caregiver. Using Healthwise resources, a care manager can help coach someone by sending them materials from within the platform, then walking through them together. A caregiver may say, “I’m going to send you something to show you how to use crutches after hip surgery.” And then the care manager can give specific guidance to help them put the education into practice. They can provide the materials to the patient digitally afterward. And then that person can open those and use them in the moment, or go back to the content when they’re at home, so they always have that information on-hand as a refresher. This applies to other chronic condition management, too. A care manager can help someone learn to recognize and manage heart failure symptoms. And while it’s important for care managers to teach people the medical elements of managing diabetes or COPD, it’s equally important to help them address the stress of living with one more or chronic conditions. So, Healthwise education on mental health and wellness can also be shared by care managers, to help people learn how to manage emotions and practice self-compassion in times of stress.
LORI: Patient education is critical to improving adherence and health outcomes. But patients cannot meaningfully engage in self-management activities if they don’t understand their health conditions, the importance of adherence to medication and treatments, and how their current behavior is impacting their overall health.
When a patient understands their disease, they are more likely to recognize red flags and signs and symptoms of exacerbation, be able to better self-manage their condition(s) and be more adherent to the medication regimen and plan of care.
With a solution like Healthwise, care managers are able to easily access and provide the member with standardized, evidence-based health education content. Healthwise materials are written in plain language and can be tailored to meet the individual needs of a member. It also allows care managers to use a technique called “Chunk and Check”. "Chunking" out education and teaching into small segments allows the member to digest the content, ask questions and seek clarification, and be able to apply incremental changes to their lifestyle and routine. Then the care manager can ask the member to "teach it back" during subsequent contacts, to "check" for understanding and address any gaps in knowledge.
VH: How has COVID-19 impacted health literacy and education?
CHRISTY: The pandemic really exposed how important it is for all people to be able to access accurate information and healthcare services. Care managers and case managers specifically have a unique opportunity to listen and understand why people may be concerned or fearful, and provide them with the education they need in a way they can relate to.
COVID-19 showed us all the power of opening up conversations with people and inviting them to share their motivations and fears about the virus. The more you can listen and show curiosity, and try to understand their perspective and connect on their level, the more you can help encourage health changes that are based on science. Through inquiry and listening, you gain insights that you can use in health education – like real-world metaphors, language, and messages that make sense and resonate with people based on their life situations. Taking the time to understand why people are hesitant, why they may have misunderstandings, and then tailoring the approach to help them move in the right direction and get the care they need – that’s how you advance health literacy.
LORI: COVID-19 forced healthcare providers and care managers to rethink how, when, and where they provided education to patients. Healthcare appointments went from in-office to telehealth visits very quickly, and that required extra time and effort from providers to ensure the patient was engaged and understood the information being shared with them.
For care managers, home visits were no longer an option, so the use of video visits, text, and telephonic care management became the norm. Assessing health literacy, providing health education materials tailored to meet the member’s needs, and utilizing techniques to ensure a member’s understanding was even more critical than before because the opportunity for traditional face-to-face visits was off the table.
I believe we are in a much better position to assess and address health literacy and educational needs since COVID-19. We have gotten creative in our approaches and opened up the wide world of omnichannel communication (i.e., telehealth, virtual visits, texting, etc.) to ensure the right information is presented at the right time in the right way.
VH: When organizations are looking to improve health literacy among their member base, what initial first steps are most effective?
CHRISTY: You really need to set up a strategy that’s going to provide the most access to health care and health education for all people. Organizations that identify and understand the current barriers that exist for different populations, then set up systems to address them, see the most success. Specifically for health education – you have an opportunity to choose educational content that’s based on the following principles:
- Make content accessible to a broad range of diverse needs, experiences, and groups.
- Use language people use in their daily lives – think “living room and street language” that resonates with people.
- Use visuals and videos that teach, motivate and engage.
- Show empathy and try to address the underlying fears, motivations, and goals people have for their health.
- Make content accurate, based on strong science, that is trustworthy to patients.
LORI: As care managers, we have the incredible privilege and responsibility of meeting people where they are, as they are. And our two main "jobs" as the care manager are helping to prevent 1) decline and exacerbation and 2) avoidable ED visits, admissions, and readmissions. But, how do we do this?
First, take a universal precautions approach to health literacy. This means treating all patients as if they are at risk of not understanding health information. By adopting a universal precautions approach, care managers will be able to communicate with every member in a clear, concise, and actionable way. See the Health Literacy Universal Precautions Toolkit developed by the Agency for Healthcare Research and Quality (AHRQ) to learn more.
Second, it is critical for the care manager to assess their member's baseline health literacy as part of the comprehensive needs assessment. Most of the time, people don't know what they don't know. Fully assess a member's ability and readiness to learn, then serve up the information in an appropriate manner (think "chunk and check") so that they can make the best possible choices about their health and live safely and independently in the home (or where they call home.)
Third, short and frequent touches. When you determine that a member has low health literacy, consider increasing your number of contact touches and shortening the length of the call/visit. Digesting complex healthcare information is a task for all of us. That is compounded greatly when you have low-moderate health literacy. For example, your member who was just discharged with a new diagnosis of heart failure and three new medications might be easily overwhelmed with too much information in one sitting. Consider brief 15-20 minute calls to assess health literacy, gauge their knowledge and understanding of how to manage the disease, and determine where best to start educating. Frequent contact will also help identify barriers to care, prevent readmission and decline, as well as develop trust and rapport.
Tools such as the Short Assessment of Health Literacy and the Rapid Assessment of Adult Literacy in Medicine are both available in English and Spanish and can be beneficial when working with patients to determine the baseline understanding they have about their illnesses.
Other tools and resources for health care providers and care managers include:
- Use Plain Language in written and verbal communications with members and caregivers
- Consider teaching Ask Me 3® to your members so they can use this technique at every healthcare visit, every time: "What is my main problem?", "What do I need to do?"and "Why is it important for me to do this?"
- Incorporate the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) into your practice
- Sign up for the Health Literacy course at CDC TRAIN and earn Continuing Education (CE) credits
- Leverage the toolkit on the National Institute on Aging website to provide patients with helpful tips and information to facilitate better communication with their providers and care team
- Check out AHRQ's SHARE Approach Workshop to access free training for healthcare providers and care teams focused on health literacy, shared decision-making, and communication
Most important of all when assessing health literacy and providing education to your members, be consistent, take your time and be patient, give grace, and celebrate those small victories!
VH: How can you measure the effectiveness of a health literacy program?
CHRISTY: When looking at how to measure the effectiveness of a health literacy program, organizations should consider the following:
- To what degree can people find, understand and use the information to inform health-related decisions and actions?
- Do patients use the health education content and find it clear, relatable, and trustworthy?
- Ask whether the content achieved its intended purpose – did people decide to take action - through medicine, diet, or exercise - to reduce their risk of pre-diabetes progressing to diabetes?
- Care managers can also ask: What next steps will you take and how can I help you in that journey?