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Patient Education & Health Literacy

Physicians entered the room of a patient hospitalized with arthritis. The patient asked a question. The attending physician gladly answered with detailed explanations. As the patient nodded, the doctor asked, "Do you have any other questions?" "No," the patient replied. After the physicians left the room, the patient turned to a researcher who happened to be sitting with him and asked, "Now, what did he say?"

By Michelle Vanderhoff

The researcher was Christopher Lorish, PhD, who was working on a project on arthritis patient education and adherence. According to Lorish and other researchers, physical therapists (PTs), and other health professionals, what occurred in the hospital room is an all-too-common event: Patients do not always fully understand their diagnosis or treatment. As a result, they may not follow through-or do so correctly-with their home care programs, medications, or preventive care.

• Native language.
• Socioeconomic status.
• Gender, race, and ethnicity.
• Influences of mass media, advertising/marketing, and the plethora of health information sources available electronically.
• Listening and speaking skills.
• Ability to read and do math.
• Cognitive delays, memory problems, or psychological disorders (eg, depression), and others.

Even patients with adequate general literacy skills may not always be getting the most out of their appointments. For example, those familiar with health literacy issues ask: Do you use "medicalese" when speaking with your patients? Are you willing to explain a patient's diagnosis and plan of care orally and with written materials? Do you consistently encourage patients to participate actively in their plan of care by eliciting information about possible barriers to carrying out their home exercise program? Do you allot adequate time to each of your patients to answer any questions they might have about their condition, intervention, or prescribed exercises?

Patient education "encompasses a tremendous amount of what we do" as physical therapists, says Bella J May, PT, EdD, FAPTA. May has practiced physical therapy for 50 years in both clinical and academic settings. "PTs should consider themselves educators," May says.

Indeed, health promotion and patient education long have been objectives of patient care for health professionals across the board. The Guide to Physical Therapist Practice and the Code of Ethics both specifically address health promotion and patient education as responsibilities of the PT.^2,3 The "Healthy People 2010" campaign actively encourages health professionals of all stripes to provide improved, accurate, and understandable information to patients.4 The "Patient Bill of Rights" entitles people to be actively involved in their treatment and make informed decisions about their care.⁵

Explain, Ask, and Listen

Although many health care providers primarily rely on oral communication with their patients and clients, Lorish says patients forget a good bit of what they're told. For that reason, "health care providers need to think of multiple methods to transmit information," keeping in mind certain objectives:

• Informing the patient about his or her condition, and how to deal with it
• Addressing the patient's understanding
• Ensuring a patient has future access to the information, such as materials they can refer to

May agrees that to effectively serve patients, PTs should provide education in as many forms as possible. May asserts: "The greater the variety of inputs-oral, visual, and kinesthetic-the more opportunities exist for the learner to retain and understand the concepts or activities being taught."

Lorish, an associate professor at the University of Alabama Department of Medical Education, says that "knowledge isn't enough." Patients also need motivation. Instead of simply teaching the patient what he or she should do, Lorish advises, PTs should ask the patient what he or she considers barriers to completing a plan of care, such as not enough time, environmental reasons ("it's too hot to walk outside"), or financial factors. This gives the PT the opportunity to suggest alternatives.

May adds that patients can only handle a certain amount of information. "They can't remember 20 exercises at one time" so it's important to "select what is most clinically important to learn." On the other hand, while PTs must explain things in simple, understandable language, May cautions, "Don't teach down to them."

Effective oral communication is not just beneficial to patient adherence, but also to diagnosis and assessment. Paul Ogbonna, PT, EdD, practices in an outpatient clinic with pediatric and adult patients with developmental disabilities, and also consults for a geriatric facility. He explains that in order to make a proper assessment, a PT may need to gently prod the patient to provide complete information. For example, when he asked one geriatric patient how she broke her ankle, she answered simply, "I fell." After asking how and where, and finally involving the woman's daughter, he learned that she had slipped on a wet floor at a shopping mall.

It may be necessary to involve caregivers (with the patient's permission) in the patient education process. This is especially true in a pediatric practice. "Kids communicate in a completely different way," Ogbonna says, and "we have to educate the parents."

The question arises: How can a PT tailor his or her approach to each individual patient? Active listening is one tool. Describing how he assesses a patient's communication needs, Ogbonna says that when he begins speaking with a patient and asking questions, "the way they answer is indicative" of how to continue the conversation. May agrees and urges PTs to ask patients indirect questions to determine how the patients prefer to learn, and to ask for feedback. "Patients are more receptive when you ask them" instead of telling them, she states, and when a PT learns a patient's practical concerns, such as "I have three steps going into my house," the patient can be shown the relationship between the exercise program and the concern.

Judith R Gale, PT, DPT, MPH, OCS, works with patients with osteoporosis and diabetes, a significant number of whom are Native American. It is crucial, she says, to learn about any cultural barriers that may exist in order to educate patients about their condition and achieve adherence to exercise programs. For example, she reports, some of her patients and clients from the Omaha tribe will not carry out exercise programs individually; the Omaha culture is a very social one and people tend to participate in activities in groups. Individual patients fear they may be perceived as acting "better than others" if they perform their exercises separately. Therefore, if Gale prescribes a walking program for one patient from the Omaha tribe, she will suggest that, instead of riding in the van to the senior center, all the seniors walk there together. Gale is assistant professor of physical therapy at Creighton University.

Write It Down

No matter how well PTs communicate verbally with their patients, those interviewed for this article agree that written materials are necessary to proper diagnosis, prevention, and home exercise programs. Laura Geuron, PT, a physical therapist at Gillette Children's Specialty Healthcare in St Paul, Minnesota, became alarmed at the rate of foot problems in her patients with spina bifida. A large number of adult patients had sustained lower extremity amputations or had severe ulcerations on their feet. "It's devastating when people suffer from problems that they might have prevented," says Geuron. "I wanted to know what we can do better as PTs to help prevent" these situations, "not just to help people live longer, but have a better quality of life."

Geuron conducted a survey of 119 clinics to find out what clinics were doing regarding foot care. Of the 45 respondents, only one clinic had a formal evaluation form for a PT or nurse to complete. In the area of patient education, some clinics stated: "We teach them about shoe fitting," but only one had a handout with instructions for patients. This led Geuron to develop provider guidelines and patient education materials that will be used throughout Gillette.

In addition, Geuron says, "we realized we didn't have a comprehensive, systematic approach" to identifying patients' special needs. A number of the facilities' patients have executive disorders, poor recall, or undiagnosed learning disabilities. The staff now has modified its approach so that whichever team member identifies a need on the first visit will notify the others; the team will tailor the treatment to the patient's needs. The team can include a nurse, orthotist, PT, psychologist, and a speech therapist. All team members have formal written guidelines for educating the patient on foot care and provide take-home packets to patients.

However, some of Ogbonna's geriatric patients and those with limited literacy need help describing their symptoms and understanding their condition and treatment. For example, he gives patients a drawing of a person in prone and supine positions, and asks them to draw arrows to where they have pain, and to describe the pain, such as "ache" or "shooting pain."

Many PTs who offer brochures or posters download them from reliable Web resources, order them from APTA, or purchase them from companies that provide patient education materials for a fee. (See "Resources" for a partial listing.) Others write them themselves.

One problem with a significant amount of written educational materials--whether purchased or self-produced--is that they frequently are written at a level far beyond the average person's comprehension. According to the Pfizer Clear Health Communication Initiative Web site, "One out of five American adults reads at the 5th grade level or below, and the average American reads at the 8th grade level, yet most health care materials are written above the 10th grade level."6 According to www.askme3.org, an organization devoted to promoting increased awareness about health literacy, limited literacy skills are a stronger predictor of an individual's health status than age, income, employment status, education level, and racial or ethnic group.7

The key to writing readily understandable text is "plain language," which is easier to read than "medicalese." People are more likely to "hang in there" long enough to read the entire document, according the Clear Language Group Web site.8 Other attributes of a well-done brochure that are not always considered are: design, the use of colors, and the amount of white space. Lorish recommends short sentences, short words (the fewer syllables, the better), white space, and visuals. There are a number of tools to evaluate readability, including the Fry Test.9

For PTs who wish to produce new materials, here are some basic guidelines:

• Use easy-to-follow layouts and simple pictures.
• Write information at an appropriate reading level.
• Replace complicated medical or technical words with plain language.
• Use pictures and diagrams that clarify written concepts.
• Focus materials on desired behavior rather than on medical facts.
• Make information culturally sensitive and personally relevant.

After offering written materials to clients, give them time to read it over, and ask if they have any questions about what they read, suggests Lorish.

Demonstration and Repetition

The third element of effective patient education (after "Explain, Ask, and Listen" and "Write It Down") is demonstration and repetition. Although written materials reinforce verbal explanations, patients often "learn better by manipulation," says May. This point was reiterated by most interviewed for this article. Show the patients how to do their exercises, but make sure to ask them to do it a few times by themselves.

Other forms of visual reinforcement include informational CDs, computer-based materials, and videos that show people doing exercises. May suggests making a video of the patient performing the exercises correctly, so he or she can refer to it later at home. Although these types of materials are still relatively new to the profession, a growing number of PTs are using them to supplement their other education materials.

The key, those interviewed for this article suggest, is to be a creative practitioner and to find more than one way to communicate with your patients and clients, thereby achieving the best outcomes possible.
______________________
Michelle Vanderhoff is editor and project manager in APTA's publications department.

References
1. Health Literacy: A Prescription to End Confusion. Washington, DC: Institute of Medicine of the National Academies, Committee on Health Literacy; 2005.
2. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.
3. APTA Code of Ethics, HOD 06-00-12-23. Available at:www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/Content Display.cfm&CONTENTID=16885. Accessed July 13, 2005.
4. Healthy People 2010 Chapter 7: Educational and Community-Based Programs, Chapter 11: Health Communication. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion; Available at: www.healthypeople.gov. Accessed July 13, 2005.
5. Consumer Bill of Bill of Rights and Responsibilities Chapter 4: Participation in Treatment Decisions. Washington, DC: President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry; 1998. Available at: www.hcqualitycommission.gov/cborr/. Accessed July 13, 2005.
6. Pfizer Clear Health Communication Initiative Web site. Available at: http://pfizerhealthliteracy.com/whatis_stats.html. Accessed July 13, 2005.
7. Ask Me 3 Web site. Available at: www.askme3.org. Accessed July 13, 2005.
8. Clear Language Group Web site. Available at: www.clearlanguagegroup.com. Accessed July 13, 2005.
9. The Fry Testing Readability Formula. Available at: www.pfizerhealthliteracy.com/TheFryTestingReadabilityFormula.pdf. Accessed July 13, 2005.

_{PT Magazine - September 2005}