Knowledge Hub 04: Communication and Health Literacy

Learning Objectives

By the end of this Knowledge Hub, you will be able to:

1. Recognize challenges in health literacy, communication, and education.
2. Understand how to develop and evaluate education materials for readability.
3. Explain strategies to improve health information communication and education.
4. Discover techniques on how to de-escalate a situation through focused communication.

Introduction

Communication can be affected by a variety of factors; in this hub, we will cover some of the communication barriers and how communication relates to literacy. Literacy and health literacy are both detrimental factors in the patient’s ability to understand and comprehend medical information provided to them. In this hub, we will work to understand how low health literacy affects health outcomes and what strategies we can utilize to combat these disparities. We all also cover how to communicate with patients in a way that is useful for any level of literacy. We will also discuss common barriers to communication in healthcare settings and how healthcare providers can combat barriers to increase continuity and understanding (Center for Health Care Strategies [CHCS], 2013).

1. Recognize challenges in health literacy, communication, and education.

1.1 What is literacy in Canada?

Literacy is defined as “the ability to understand and use reading, writing, speaking and other forms of communication as ways to participate in society and achieve one’s potential” (Canada’s Public Health Association [CPHA], p. 10, 2017).

1.2 What are the literacy rates for different populations in Canada?

Alberta, BC, Saskatchewan, and the Yukon show higher levels of literacy than the Canadian average (CPHA, 2017). About 42% of Canadians 16-65 are below the minimum level of proficiency necessary to meet modern life demands (CPHA, 2017).

1.3 How to identify patients who have difficulty with literacy?

Identifying patients who have difficulty with literacy can be seen in informal assessments and formal patient assessments (CHCS, 2013). Informal assessments may be seen through behaviours and poor communication from the patient as they may attempt to hide this from their healthcare team due to fear of stigma and feeling shame (CHCS, 2013). Formal assessments can help address health literacy systematically by administering tools to understand the level of the patient (CHCS, 2013). Examples of behaviours that may indicate a low health literacy level are unable to provide a complete and sequential medical history, failing to complete medical forms, frequently missing appointments, being unable to name medications or reason for taking said medications and rarely asking questions to healthcare providers (CHCS, 2013).

1.4 What is health literacy?

Health Literacy is defined by the CDC as “the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others” (Centers for Disease Control and Prevention [CDC], 2020).

1.5 What is the significance of health literacy in Canada?

Health literacy is significant in Canada as a low health literacy level can negatively impact an individual’s ability to maintain their overall health and well-being (CHCS, 2013). Many choices and skills are required to navigate their health and the healthcare system in Canada such as what to eat, whether or not to smoke, how to understand insurance paperwork, how to pay medical bills, how to fill out medical forms, when to see a doctor, and how to read medication labels and information (CHCS, 2013).

1.6 What are the health literacy rates for different populations in Canada?

People with low health literacy are less likely to understand how to take their medications, the side effects, and also identify their medications (ABC Life Expectancy Canada, 2023). 60% of Canadian adults have low health literacy and are unable to understand, obtain, or act on health information and health services to make their own appropriate health decisions (ABC Life Expectancy Canada, 2023). Approximately 50% of Canadian adults with disabilities experience literacy barriers (CPHA, 2017).

1.7 What is the relationship between health literacy and health outcomes?

The relationship between health literacy and health outcomes is strongly related and can have incredible impacts on Canadian health outcomes (CHCS, 2013). Some examples of impacts low health literacy can have on health outcomes are longer hospital stays and increased re-admissions, low rates of treatment compliance, medication errors, decreased ability to find healthcare resources and lack of knowledge about risk factors for diseases and possible health effects (CHCS, 2013).

2. Understand how to develop and evaluate education materials for readability.

2.1 Health Literacy for Healthcare Professionals

A survey of nearly 700 professionals and policymakers found almost 30% were unaware of the term health literacy, 34% said that the term is used in their organizations (23% were not sure) and 68% said that their organizations provide direct services but more than 30% were unsure of their clients’ literacy levels (CPHA, 2017). Almost 60% indicated that staff in their organizations did not know where to find resources to support health literacy efforts (CPHA, 2017). The majority of organizations addressed health literacy through informal practices, while 32% had practice standards in place and only 7% indicated that their organizations had policies on health literacy in place (CPHA, 2017).

2.2 How to create educational materials with readability for patients using an example from BC Cancer?

Use plain language and clear design

1. Avoid medical jargon
2. Keep it short and simple
3. Explain health and medical terms
4. Assume patients have minimal background knowledge

Focus on key messages

1. Identify ‘need to know’ vs ‘nice to know’
2. Build in resources and cues to increase knowledge
3. Be careful to avoid overwhelming the patient

Promote teach-back techniques

1. Ask patients to explain the information back to you in their own words to determine if teaching was sufficient
2. Improves communication and patient outcomes

Create a shame-free environment to invite questions

1. Ask the patient if they have any questions or concerns after giving them information
2. Take time to work through concerns and questions
3. Maintain eye contact

(BC Cancer, 2018; Schwartz & Filipov, 2018).

Refer to the patient guide at http://www.bccancer.bc.ca/our-services/patient-guide (BC Cancer, 2024).

Refer to patient information at http://www.bccancer.bc.ca/health-professionals/clinical-resources/pharmacy/patient-information (BC Cancer, 2024).

2.3 How to find reputable information?

You may have questions about your health, be curious about some health advice you have received, or maybe you just want to browse health information online. Not all information is the same, some sources will provide misleading data (National Institute on Aging, 2023). In this section, we will provide some trustworthy websites, as well as some tools to determine if a site is helpful. We can start by looking for websites from government organizations. Health Canada (2023) is provided by the Government of Canada, and HealthLinkBC (2023) is provided by the Government of British Columbia. There are other websites that you may visit. It is important to consider who runs the website (National Institute on Aging, 2023). It could be a government, a university, a non-profit organization, or a business. Next find out who is responsible for the information on the website (National Institute on Aging, 2023). This could be somebody wanting to make money or a healthcare professional who has looked over everything. If the website can be trusted, there will be a way to contact those in charge of the website. You may find personal stories that comfort you, but remember that a website is trustworthy when it is created with evidence that comes from research. If you find something online that you want to incorporate into your wellness plan, please speak to your healthcare team, as they have the training to verify online information (National Institute on Aging, 2023). Health evidence is always changing, so it is important to seek out the most current information (National Institute on Aging, 2023). Look for a date when the information was put on the website. It is also good to think about why the website was created (National Institute on Aging, 2023). Perhaps it was to give readers insight, or it could be to make a sale. Websites may ask to use “cookies,” which can be made to improve your experience on the website (National Institute on Aging, 2023). While this may be so, this could mean your privacy has been compromised. It is good to check for the website’s policies on privacy, you may also stop cookies from appearing by disabling them in you’re the settings of your web browser. Web browsers include Google, Safari and Microsoft Edge. Some websites may ask for your personal information, but be alert as not all websites are secure (National Institute on Aging, 2023). At the top of the browser will be the website’s address. If there is a “https” then this website is secure, which means that when collecting personal information, a password and username combination will be needed (National Institute on Aging, 2023). It is best to be careful about opening links that you did not search for (National Institute on Aging, 2023). If you are accessing unsecured Wi-Fi in public, do not input your personal information into a website (National Institute on Aging, 2023). Some websites may tell you they provide a cure for your health, they may even say they are supported by a reputable organization (National Institute on Aging, 2023). Unless a reputable website, such as Health Canada (2023), is providing the evidence, be careful about using this information.

You may find “apps” on your smartphone that state they are intended to give you medical information (National Institute on Aging, 2023). They may ask for your personal information but always know that an “app” is different from giving your doctor your health details. Just as with visiting a website, there are best practices for navigating social media (National Institute on Aging, 2023). Make sure that the source of the social media post is trustworthy.

You may be interested in searching for medical research, and finding the most updated evidence that reflects your health journey. Some journal articles may require a subscription, one that is possessed by students for example. There are journal articles online you can find online that do not require money. The reference for Thompson Rivers University (2019) provides helpful tips for creating a search. The reference for Thompson Rivers University (2021) has helpful information for figuring out if the information in an article, whether that is a journal article or a magazine, is credible or useful. Now that you know what is trustworthy and a framework for how to find it, explore online and use the principles of safe searching explained in this section.

See the Australian Commission on Safety and Quality in Health Care. (n.d.). https://www.safetyandquality.gov.au/consumers/finding-good-health-information-online

2.4 What are the tools available to evaluate the readability of patient education materials?

FOG (Frequency of Gobbledygook): determines a grade level based on the number of words, sentence length and also several polysyllabic words (CHCS,2013).

Flesh-Kincaid Grade Level and Flesch Reading Ease Score: assesses readability based on the number of syllables per word and words per sentence (CHCS,2013).

Fry Readability Formula: evaluates the readability of documents using sample sizes of 100 words, and identifies difficult sentences and words (CHCS,2013).

SMOG (Simple Measure of Gobbledygook): analyses reading level in sentence and paragraph format (CHCS,2013).

SAM (Suitability Assessment of Materials): focuses on contact, literacy demand, layout, graphics, cultural appropriateness, learning stimulation, and audio-visual materials (CHCS, 2013).

https://www.noslangues-ourlanguages.gc.ca/en/blogue-blog/readability-formulas-eng

3. Explain strategies to improve health information communication and education.

3.1 What are the communication needs of patients, families, and healthcare professionals?

Patients understand the information and can comprehend it, be involved in decision-making, learn to live with their choices and find a way to accept the disease and possible death (Jeffrey, 2006). Families know how to support their loved ones and remain hopeful, how to advocate for their loved ones and how to assist with the collection of information (Jeffrey, 2006). Healthcare Professionals know how to accurately deliver and teach information, learn to engage in a patient-centered approach to empower the patient to participate in their care and ensure technology and science do not overlook patient preferences and needs (Jeffrey, 2006).

3.2 What are the cultural needs of patients, families, and healthcare professionals in Canada?

Video 1.

This video from The Canadian Medical Protective Association (CMPA) provides advice and key learnings on culture and physician care. Culture incorporates a mix of beliefs and behaviours that define the values of communities and social groups. All physicians have their cultural backgrounds, and most doctors practicing in Canada are accustomed to providing care to patients from different backgrounds. Moreover, physicians are increasingly aware of how culture can shape the practice of healthcare and influence health outcomes. While it is common to speak of cultural awareness and cultural sensitivity, physicians and other providers are increasingly recognizing the importance of cultural competence and providing cultural safety to patients.

Video 2.

Cultural competency for health professionals is critical in the world of health promotion. It ensures respectful and high-quality care. The Kentucky Inclusive Health Collaborative has worked closely with KY’s Office of Health Equity to reinvigorate the state’s focus on health literacy and cultural competency. This video emphasizes why health professionals should be mindful of the diverse lived experiences of the patients they serve. This includes demographics, cultural differences, systematic barriers, and implicit bias. This video follows a few people who they are, and what they talk about regarding cultural competency.

Video 3.

This video relates to the patient’s religious custom, this patient is refraining from certain medical procedures due the religious observation and custom. Instead of assuming the patient is refusing treatment, healthcare professionals interview and clarify the reason for refusal. Post understanding the situation healthcare professionals respect the patient’s customs and modify the treatment plan to meet and accommodate the patient’s needs. As a professional, it is nearly impossible to know every single belief, custom or culture. But when in doubt always ask the patient. Understand, research the situation and if possible refine the plan to meet the patient’s beliefs. Cultural competency leads to better patient care outcomes. Not every patient situation and care will meet cultural requirements but as professionals it is of utmost importance we do our best to respect patient’s beliefs, and customs and amend care when possible. While it is important to look at a patient as a whole person from a physiological, psychological, spiritual, and social perspective, it is also important to take a patient’s culture and cultural background into consideration when deciding how to care for that patient. After all, the values and beliefs passed down to that patient from generation to generation can have as much of an effect on that patient’s health and reaction to treatment as the patient’s environment and social life. This video was solely recorded by Manasa Khan for educational purposes. This video does not relate to a particular situation or a person living or dead.

3.3 Explain the barriers to effectively communicating with patients with examples.

There are numerous barriers to communication between patients and the healthcare team. Examples of some barriers include information overload (too many statistics or options), pain, fatigue, or other symptoms (drowsy from medications, actively experiencing pain) and environmental issues (noise, other distractions). Use of medical jargon (renal/kidney, cardiac/heart), anxiety and embarrassment (difficulty engaging in sensitive conversations with a stranger), time constraints (busy unit, other patients, limited availability of doctors/specialists) and values or beliefs (assumptions, prejudices, language) are other barriers (Ali, 2018).

3.4 Explain the mitigation strategies to effectively improve communication with patients with examples.

Information overload

• possibly include a relative for another pair of ears
• suggest patient take notes
• give written information
• record conversation with patient consent

Pain, fatigue, or other symptoms

• “Is this the best time for this conversation?”
• Validate and acknowledge their pain
• Break information into smaller sessions

Environmental issues

• Find a quiet corner, room, or office
• Check if your patient has hearing aids
• Keep in mind sensitive topics in the presence of other patients/healthcare workers

Use of medical jargon

• Use plain language
• Use appropriate vocabulary for age and audience
• Use easier to relate to metaphors
• Avoid statistics

Anxiety and embarrassment

• Give clear instructions to ease stress
• Look for signs of embarrassment (blushing, joking, fidgeting)
• Avoid judgmental statements
• Encourage questions

Time constraints

• Be honest and open with patients about interruptions or time limits
• Arrange a specific time frame for conversations

Values or beliefs

• Be aware of your biases
• Avoid judgment about cultural beliefs
• Avoid assumptions

(Ali, 2018).

4. Discover techniques on how to de-escalate a situation through focused communication.

4.1 What de-escalation strategies can you use to help patients who become anxious, emotional, stressed, and unhappy?

De-escalation means “transferring your sense of calm and genuine interest in what the patient wants to tell you by using respectful, clear, limit setting [boundaries]” (Brockway, 2023).

1. Move to a private area
2. Be empathetic and non-judgmental
3. Respect person’s space
4. Keep your tone and body language neutral
5. Avoid- overreacting
6. Focus on the thoughts behind the feelings
7. Ignore the patients’ challenging questions or refrain from asking challenging questions
8. Set boundaries
9. Choose boundaries wisely
10. Allow silence
11. Allow time for decisions

(Brockway, 2023)

4.2 Explain the serious illness conversation illness guide, tools and resources for patients, families, and healthcare professionals in BC Canada

BC Cancer has developed a comprehensive tool to help healthcare workers guide through serious illness conversations. This guide was created to encourage earlier discussions on this advanced care planning and ensure all necessary topics are covered in one gentle conversation (BC Cancer, 2015). The tool also includes sample questions and language to use with patients.

Set up the conversation:

• Introduce purpose.
• Ask permission

Assess Illness understanding and information preferences

• What does the client understand?
  How much information do they want going forward?

Share Prognosis:

• Frame with a “wish/ worry” statement or “hope/worry”
• Allow silence, explore emotions

Explore key topics:

• Goals
• Fears & worries
• Sources of Strength
• Critical abilities
• Trade-offs
• Family

Close the Conversation:

• Summarize what you have heard
• Make a recommendation, check in with the patient
• Affirm your commitment to the patient

Document your conversation and communicate with other key professionals in care

Please explore the entire document here: Serious Illness Conversation Guide

Refer to serious illness conversations at https://www.bc-cpc.ca/serious-illness-conversations/ (BC Centre for Palliative Care, 2024).

Refer to serious illness conversations resources at https://www.bc-cpc.ca/serious-illness-conversations-resources/ (BC Centre for Palliative Care, 2024).

Refer to Nursing at http://www.bccancer.bc.ca/health-professionals/clinical-resources/nursing (BC Cancer, 2024).

Summary

In this knowledge hub, we discussed the levels of literacy and how this level varies across different populations in Canada. By recognizing behaviours of low health literacy through assessments, healthcare providers can work to understand how to best support the client during their cancer journey. Health literacy focuses on the ability of patients to comprehend healthcare information and make informed choices. Health outcomes and health literacy are strongly linked and can lead to decreased access for patients, lack of risk factor knowledge, and longer hospital stays. Communication has multiple barriers that influence the way patients work with their healthcare team. For example, culture can affect the way patients learn, listen, and communicate with their team. Barriers to communication such as cancer symptoms, time constraints, and excessive use of medical jargon can hinder the ability of a patient to uptake information and further hinder their ability to use said information to make decisions in their care. By embracing effective communication strategies, we can increase understanding and support patients during difficult conversations surrounding end-of-life care (CHCS, 2013; CPHA, 2017; Ali, 2018).

References

1. ABC Life Expectancy Canada. (2023). Health Literacy. https://abclifeliteracy.ca/health-literacy/
2. Ali, M. (2018). Communication skills 2: overcoming barriers to effective communication: NT. Nursing Times , 114, 40
3. BC Cancer. (2018). Health Literacy Fact Sheet . http://www.bccancer.bc.ca/about-site/Documents/Health-literacy-fact-sheet.pdf
4. BC Cancer. (2015). Serious Illness Conversation Guide. http://www.bccancer.bc.ca/new-patients-site/Documents/SeriousIllnessConversationGuideCard.pdf
5. Brockway, L. (2023). Tips for de-escalating angry patients. Texas Medical Liability Trust. https://hub.tmlt.org/tmlt-blog/tips-for-de-escalating-angry-patients
6. Brooks, L., Manias, E., Bloomer, M. (2019). Culturally sensitive communication in healthcare: A Concept Analysis. Collegian. ( Pages 383-391). https://doi.org/10.1016/j.colegn.2018.09.007 .
7. Canada’s Public Health Association (CPHA). (2017). A Vision for. Health Literate Canada. https://www.cpha.ca/sites/default/files/uploads/resources/healthlit/report_e.pdf
8. Centers for Disease Control and Prevention (CDC). (2020). Health Literacy. https://www.cdc.gov/healthliteracy/learn/index.html
9. Center for Health Care Strategies, Inc. [CHCS]. (2013). What is Health Literacy? Retrieved from https://www.chcs.org/media/CHCS_Health_Literacy_Fact_Sheets_2013_1.pdf
10. Jeffrey, D. (2006). Patient-Centred Ethics and Communication at the End of Life (1 ed.): CRC Press.
11. Schwartz, F., Filipov, M. (2018). Public Health Ontario Grand Rounds: Health Literacy. Public Health Ontario. https://www.publichealthontario.ca/ /media/documents/H/2018/health-literacy.pdf
12. Stossel, L. M., Segar, N., Gliatto, P., Fallar, R., Karani, R. (2012). Readability of patient education materials available at the point of care. J Gen Intern Med, 27 (9), 1165-1170. doi:10.1007/s11606-012-2046-0

Resources

1. BC Cancer. (2024, April). patient guide. Provincial Health Services Authority, BC Cancer, British Columbia. http://www.bccancer.bc.ca/our-services/patient-guide
2. BC Cancer. (2024, April). patient information. Provincial Health Services Authority, BC Cancer, British Columbia.

http://www.bccancer.bc.ca/health-professionals/clinical-resources/pharmacy/patient-information

1. BC Centre for Palliative Care. (2024, April). serious illness conversations. BC Centre for Palliative Care, British Columbia.

https://www.bc-cpc.ca/serious-illness-conversations/

1. BC Centre for Palliative Care. (2024, April). serious illness conversations resources. BC Centre for Palliative Care, British Columbia.

https://www.bc-cpc.ca/serious-illness-conversations-resources/

1. BC Cancer. (2024, April). Nursing. Provincial Health Services Authority, BC Cancer, British Columbia. http://www.bccancer.bc.ca/health-professionals/clinical-resources/nursing

Videos

The Canadian Medical Protective Association (CMPA). (2014, Sep 5). Culture and healthcare: When medicine and culture intersect. [Video]. Youtube. https://youtu.be/c0TquroTHxo?si=GdvrUeIhc7taNajp

HDI Health and Wellness. (2021, Mar 19). Cultural Competency in Health. [Video]. Youtube. https://youtu.be/vHePY3J5wJs?si=8CpsqMV30CuQfGzs

Khasanov, R. (2017, Oct 22). Cultural Competence Example. [Video]. Youtube. https://youtu.be/CEPukt7Yw6A?si=BIeTo40BIaK0NBq_

Images

Mike Finn. (2016). [Rainbow fruit bowl]. Flickr. https://flic.kr/p/F9jG7n

Focal Foto. (2022). [Doctor holding various pills for patient treatment]. Flickr. https://flic.kr/p/2nRgaG1