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How to ensure your patients understand you

Health outcomes improve and NHS costs fall if health literacy problems are addressed, says Dr Linda Miller.

Practices should ensure patients understand by avoiding use of unexplained medical terms and jargon (Photograph: IStock)
Practices should ensure patients understand by avoiding use of unexplained medical terms and jargon (Photograph: IStock)

The WHO predicts that the percentage of deaths globally due to chronic diseases is increasing. Its forecast for 2015 is that 41m out of 64m deaths will be from chronic disease.

As GPs are aware, to manage this burden on healthcare, there is now greater emphasis on self-management and patient empowerment. Self-management is, however, more difficult for patients with low health literacy.

Health literacy defined
The WHO 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'.

In the UK, about 11.4% of adults have low health literacy. GPs have a vital role in assessing health literacy, improving communication and facilitating self-management, but many are unaware of the extent of the problem and lack the confidence to discuss it with patients.

Health literacy is not just a problem for those with reading, writing, numeracy and language difficulties, or cognitive or sensory impairment. The complexity of healthcare systems, written information and IT can challenge even highly educated patients.

GPs should not underestimate the impact of ill health on cognition. Serious illness and comorbidities involve multiple healthcare teams for patients to navigate around, and ever more complex decisions.

TOP TIPS FOR ENSURING PATIENTS UNDERSTAND YOU
  • Use plain English, speak slowly and explore prior knowledge before giving explanations.
  • Avoid using unexplained medical terms and jargon.
  • Try the 'chunk and check' approach: give the patient two or three pieces of information, then check their understanding.
  • Use the 'teach back' technique for this: ask patients to reiterate what they have been told by saying, for example: 'I just want to check that I've explained this clearly'; 'How are you going to take this medicine?' or 'What are you going to do when you get home?'
  • Follow up by telephone or face-to-face to check understanding.
  • Simplify medication instructions by saying, for example: 'At night for cholesterol.

 

Morbidity and mortality
A five-year prospective UK study published this year has shown that a third of elderly people were unable to understand basic written instructions relating to use of medicine.

After adjusting for cognitive function, age, baseline health status, health behaviours and socioeconomic factors, the 12.5% in the low health literacy category were twice as likely to die, the researchers found.

Patients with low health literacy may have poorer uptake of screening, present later, and have poorer medication compliance and self-care. There is a correlation with smoking, poor diet and lack of exercise, and lower self-reported physical and mental health.

Economically, this translates into more costly emergency treatment, increased admissions, longer hospital stays and medicines use problems, such as wastage and complications.

Identifying low literacy
Doctors overestimate patients' health literacy, particularly in patients from ethnic minorities. The new registration check is an ideal opportunity to identify health literacy concerns.

Patients may conceal illiteracy out of shame. For example, they may claim to have left their spectacles at home, or simply agree with everything you say.

Use of tests is controversial and can be time-consuming. In comparison, the Single Item Literacy Screener (SILS) asks: 'How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?'

Possible responses are: 1 (never), 2 (rarely), 3 (sometimes), 4 (often) and 5 (always). Those scoring above 2 potentially need help.

An alternative screening question you could use is: 'How confident are you about filling out medical forms by yourself?'

Go to www.nchealthliteracy.org for more information about health literacy tools.

Patient-centred approach
Coaching for health is a patient-centred approach to discussing health. It explores the patient's values, goals and ideal health outcomes. A collaborative approach, it encourages patients to be resourceful in managing their own health. Contact your deanery or visit mentoring.londondeanery.ac.uk/coaching-for-health for more details.

Written information
Much written information for patients is complicated. Registration forms, leaflets and consent forms contain jargon. Signage is often confusing - for example, 'Phlebotomy' rather than 'Blood tests'.

Your practice can ensure that written information for patients (including on your website) is in plain English.

You can also use readability measures to check that your information leaflets are easy to understand. Examples of readability tools available on the internet include the Flesch-Kincaid readability test, Gunning Fog Score, Automated Readability index, SMOG and Coleman-Liau index. These look at sentence length and/or numbers of syllables in words. To try them out, visit www.readability-score.com

  • Dr Miller is a portfolio GP in London
CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Audit patients with documented literacy problems and English as a second language. Compare this with recognised incidences. Add a single literacy question to your new patient health check template to identify literacy difficulties. Re-audit.
  • Try the 'talk back' technique and keep a reflective log of misunderstandings identified and corrected.
  • Think of alternative ways of explaining to reduce miscommunication, and use them.
  • Devise a practice education session on health literacy and encourage your team to develop a library of visual aids for use in consultations.
  • Check practice leaflets, signage and website using a readability rating tool (see main text).

Save this article and add notes with your free online CPD organiser at gponline.com/cpd

Take clinical tests and claim certificates for CPD at myCME.com



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