Combining Health Literacy Research with Adult Learning Theory
Best Practice Deborah Ambrose Genesis Rehab Services 1
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Health literacy Definition -a complex phenomenon that involves
skills, knowledge, and the expectations that health professionals
have of the publics interest in and understanding of health
information and services. Health literacy has been defined 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. People of all ages, races, incomes,
and education levelsnot just people with limited reading skills or
people for whom English is a second languageare affected by limited
health literacy. 2
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Health Literacy Low literacy is associated with poor
understanding of health concepts and poor health outcomes Three
types of literacy: prose, document and quantitative Literacy
Levels: Below basic Basic Intermediate Proficient 3
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Nearly 9 out of 10 adults have difficulty using the everyday
health information that is routinely available in health care
facilities, retail outlets, media, and communities. Limited health
literacy is associated with poorer health outcomes and higher
health care costs. Limited health literacy affects peoples ability
to: Search for and use health information Adopt healthy behaviors
Act on important public health alerts. 4
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Only 12% of Americans are considered proficient in health
literacy skills A higher percentage of adults ages 65 or older had
below basic or basic health literacy Approx. 36% of adults have
below basic or basic health literacy skills May be able to read and
understand simple appointment slip Would experience difficulty with
more complex information such as prescription drug labels Certain
demographic subgroups are at greater risk of low health literacy:
People with lower educational attainment The elderly Underserved
minority group Immigrants From: The Health Literacy of Americas
Adults - Results From the 2003 National Assessment of Adult
Literacy 5
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Many written materials used for client education require a
reading ability equivalent to grade 10 or higher The average adult
American reads between a 6 th and 8 th grade reading level Often
health literacy level is 3-4 years below the highest grade
completed in school. Education level does not correlate with
literacy skills and patients often hide poor literacy These
behaviors can suggest poor literacy: unable to name medications;
unable to explain a medicines purpose; unable to explain timing of
medication administration 6
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AOTA Documents AOTA societal statement on health literacy -
Occupational therapy can promote health through the development and
use of health education approaches and materials that are
understandable, accessible, and usable by the full spectrum of
consumers. Occupational therapy practitioners can assist in
ensuring that all health-related information and education provided
to recipients of occupational therapy or other health related
services match that persons literacy abilities; cultural
sensitivities; and verbal, cognitive, and social skills. In line
with the health communication objectives (U.S. Department of Health
and Human Services, 2010 ), AOTA strives to ensure that
occupational therapy practitioners possess appropriate
communication and education skills that can help enable all people
to gain access to, understand, and use occupational therapy and
other health-related services, information, and education to
promote self-management for optimum health and participation. -
AJOT 7
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AJOT articles Health Literacy in Occupational Therapy Practice
and Research Smith and Gutman Health Policy Perspectives
July/August 2011 Occupational therapy practitioners have the unique
opportunity to become key players in the promotion of client health
literacy related to the professions unparalleled assessment and
intervention of the person, environment, and occupation.
Occupational therapy practitioners can also provide education on
health literacy-related topics to other health care professional.
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Implications of the Affordable Care Act for Occupational
Therapy Practitioners Providing Services to Medicare Recipients -
Fisher and Friessema Health Policy Perspectives September/October
2013 In addition, occupational therapists can lead the team with an
understanding of how health literacy affects outcomes. The negative
consequences of a mismatch on health literacy skills between
practitioners and patients are numerous but include noncompliance
of services with recommendations, underutilization of services, and
increased hospitalizations. The profession of occupational therapy
is exceptionally well positioned to address health literacy issues
because practitioners are trained to analyze activity demands and
adapt them for increased participation. 9
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Occupational Therapys Role in Preventing Acute Readmissions
Roberts and Robinson Health Policy Perspectives May/June 2014
Occupational therapy practitioners are well positioned in their
roles and with their scope of practice to positively affect the
clinical outcomes for patients at risk for readmission to hospital
in all practice settings. In doing so, occupational therapists are
able to identify barriers to discharge planning, including
evaluating components such as health literacy, visual deficits, and
cognitive impairments... for carryover of education and information
and integration into daily routines. 10
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Assessments of Health Literacy Newest Vital Sign NVS a valid
and reliable screening tool available in English and Spanish from
Pfizer identifies patients at risk for low health literacy easy and
quick to administer, requiring just three minutes allows providers
to appropriately adapt their communication practices to the
patients health literacy level. 11
Short Assessment of Health Literacy SAHL new instrument,
consisting of comparable tests in English and Spanish, with good
reliability and validity in both languages with 18 test terms. each
term has a key word with a related meaning and a distractor word
unrelated in meaning to the test term to test comprehension as well
as pronunciation (decoding) of health-related terms. Administration
of the test takes only 2-3 minutes and requires minimal training.
Scores can suggest low literacy 13
Rapid Estimate of Adult Literacy in Medicine REALM and a
revised, shorter version (REALM-R) a brief screening instrument
used to assess an adult patients ability to read common medical
words a word recognition test not a reading comprehension
instrument. Adults are asked to de- code or pronounce words. less
than 2 minutes to administer and score. scores correspond to
reading grade levels 15
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16 http://www.ahrq.gov/professionals /quality-patient-
safety/pharmhealthlit/realm-r.html http://library.med.utah.edu/
Patient_Ed/workshop/hand outs/realm_test.pdf Used with permission
from T. Davis
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Test of Functional Health Literacy Assessment (TOFHLA) measures
the functional literacy level of patients, using real to life
health care materials assesses two main constructs, numeracy and
reading comprehension; it has a total of 67 items Available for
purchase from http://www.peppercornbooks.com/
http://www.peppercornbooks.com/ 17
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18 Sample questions
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Adult Learning Theory Adult learning is a collection of
theories and methods for describing the conditions under which the
processes of learning are optimized. what is it and why is it
important for use in clinical practice. To effectively educate
patients, health care providers must have an understanding of the
principles of adult learning. Theories of adult education should be
the foundation of client education. 19
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Most effective training is like to increase learned experiences
and opportunities in each of three main components of adult
learning. The more adult learning method characteristics that are
incorporated into learning, more likely learning will have optimal
positive benefits. A common element of adult learning methods that
are most effective is active learner participation The more
opportunities to practice new knowledge, the greater the likelihood
of optimal benefits. 20
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Assessment of Learning Styles ATLAS assessment of learning
style Developed by college professors Conti and Kolody to identify
a preferred learning strategy and classify the participant into 1
of 3 groups. Available on-line, geared towards younger adults but
has been used with older adults in a research article by Steven
Chesbro, PT. http://www.conti-creations.com/atlas.htm Index of
Learning Styles - The Index of Learning Styles is an on-line
instrument used to assess preferences on four dimensions
(active/reflective, sensing/intuitive, visual/verbal, and
sequential/global) of a learning style model formulated by Richard
M. Felder and Linda K. Silverman. The ILS may be used at no cost
for non-commercial purposes by individuals who wish to determine
their own learning style profile and by educators who wish to use
it for teaching, advising, or research. The 44 questions are
designed towards students primarily.
http://www4.ncsu.edu/unity/lockers/users/f/felder/public/ILSpage.html
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Only 5% to 11% of what is taught by lecture is retained in the
long run Learning is enhanced when it is immediately applicable to
real life contexts Learning depends on past and current experience
capitalize on experience Readiness to learn must exist before
effective teaching can be done Senior adults learn through their
physical senses about the world around us Senior adults better
retain what they have learned when learning is exciting, lively and
informal 22
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Adults need to know why they are learning something Adults
learn by doing Instructional activities should be varied to appeal
to different preferences Need to insure that adult learners are
motivated 23
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What now? 24
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6 strategies for busy clinicians to integrate health literacy
into OT practice and how adult learning fits Be informed about
health literacy as a professional and within your department
Standardize practice to health literacy as a profession Make
information accessible adult learning implications critical
Strengthen interactions adult learning implications critical
Intervene to increase patient's health literacy Collaborate to
increase patient's health literacy among professionals, adult
learning important Adapted from: Integrating health literacy into
occupational therapy: findings from a scoping review. Levasseur and
Carrier, 2012 25
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Be informed about health literacy Know your patients literacy
levels Know your patients learning needs and barriers Know the
cultural influences that will shape new learning
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Standardize practice to health literacy Know the AOTA societal
statement Read the aforementioned AJOT articles regarding health
literacy
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Make information accessible Using adult learning theory, build
learning experiences for all learners Design appropriate written
materials for all learners Communicate in a comprehensive way
Assess learning Use demonstrations, experimentation and repetition
to increase the effectiveness of teaching
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Strengthen interactions Encourage questions Create shame free
environment Increase time spent on giving information, observe and
listen actively
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Intervene to increase health literacy Foster empowerment by
using a client-centered approach and giving clients confidence in
their ability to take more control over their lives. Teach to
include knowledge of health and what patients can do to improve
their living conditions
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Collaborate to increase health literacy Provide education to
other health care professionals about health literacy Use adult
learning principles to insure the professional education you
provide is effective
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Putting it all together into practice Plain Language site:
Plain Language definition: Plain language (also called Plain
English) is communication your audience can understand the first
time they read or hear it. President Obama signed the Plain Writing
Act of 2010 on October 13, 2010. The law requires that federal
agencies use "clear Government communication that the public can
understand and use. To get the best health outcomes, health-related
decisions should be based on clear and correct understanding of
relevant health information and services. Clear communication, in
plain language, about health information and services will help
create and promote health literacy.
http://www.plainlanguage.gov/populartopics/
health_literacy/Thesaurus_V-10.doc 32
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The Patient Education Materials Assessment Tool (PEMAT) is a
systematic method to evaluate and compare the understandability and
actionability of patient education materials. Can score on-line
Available on-line: http://www.ahrq.gov/professionals/
prevention-chronic- care/improve/self- mgmt/pemat/pemat-p.html
http://www.ahrq.gov/professionals/ prevention-chronic-
care/improve/self- mgmt/pemat/pemat-p.html 33
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The Suitability Assessment of Materials (SAM) tool was created
by Cecilia and Leonard Doak. assesses readability of the material
and usability and suitability for a low literate user Using a
standardized scoring sheet, the evaluator scores printed materials
in the following six categories: Is the purpose of the piece
immediately evident? Literacy demand. Graphics. Layout and
typography. Learning stimulation. Cultural appropriateness. After
completing the assessment a percentage score falls into one of
three categories: superior, adequate, or not suitable.
http://aspiruslibrary.org/literacy/sam.pdf 34
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CMS toolkit: The Toolkit for Making Written Material Clear and
Effective is a health literacy resource from the Centers for
Medicare and Medicaid Services (CMS). This 11-part Toolkit provides
a detailed and comprehensive set of tools to help you make written
material in printed formats easier for people to read, understand,
and use. https://www.cms.gov/Outreach-and-
Education/Outreach/WrittenMaterialsToolkit /index.html 35
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Take Away Highlights Be educated in and aware of health
literacy Infuse adult learning principles into daily
patient/caregiver interactions Infuse health literacy concepts in
daily interactions with patients/caregivers Develop/modify written
education tools to be compliant with CMS Toolkit recommendations
Emphasize plain language in all communication Advocate for and
educate others in health literacy
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Work on modifying written information to make it all most
effective Place written education in a location that is easy to
access Utilize a cheat sheet for documentation until wording
becomes automatic Discuss health literacy at care conferences, etc
Document health literacy levels and concerns
