Health Literacy Practices and Educational Competencies for Health Professionals: A Consensus Study

Figures & data

Table 1. Health profession education organizations represented by the expert panel

FASHP member organization	Number of representatives on panel	Percentage of sample (N = 23)
American Association of Colleges of Nursing	1	4.3
American Association of Colleges of Osteopathic Medicine	3	13.0
American Association of Colleges of Pharmacy	4	17.4
American Association of Colleges of Podiatric Medicine	—	—
American Dental Education Association	2	8.7
Association of Academic Health Centers	—	—
Association of American Medical Colleges	2	8.7
Association of American Veterinary Medical Colleges	—	—
Association of Chiropractic Colleges	1	4.3
Association of Schools and Colleges of Optometry	1	4.3
Association of Schools of Allied Health Professions	2	8.7
Association of Schools of Public Health	—	—
Association of University Programs in Health Administration	1	4.3
National League for Nursing	1	4.3
Physician Assistant Education Association	1	4.3
St. Louis College of Pharmacy	4	17.4
Total	23	100

Table 2. Delphi expert panel demographics

Characteristic	N	n (%) or years
Age in years (M)	22	51.9
Sex	21
Female		15 (71.4%)
Male		6 (28.6%)
Race(s), self-identified, multiple races possible	22
American Indian or Alaska Native		—
Asian		2 (9.1%)
Black or African American		—
Native Hawaiian or Other Pacific Islander		—
White		21 (95.5%)
Ethnicity, self-identified	22
Hispanic or Latino		1 (4.5%)
Not Hispanic or Latino		21 (95.5%)
Highest level of education attained	20
Bachelor's		1 (5%)
Master's		1 (5%)
Doctorate		18 (90%)
Years in health professions education (M)	22	19.1
Background in direct patient care	21
Yes		19 (90.5%)
No		2 (9.5%)
“Would your peers consider you to have expertise on the topic of health literacy?”	22
Yes		16 (72.7%)
No		6 (27.3%)

Table 3. Competencies and practices accepted by Delphi round

Item type	Round 1	Round 2	Round 3	Round 4	Total
Knowledge	19/24	5/5	–/–	–/–	24/24
Skill	21/28	2/4*	2/3**	2/3	27/29
Attitude	11/11	–/–	–/–	–/–	11/11
Practice	27/32	4/5	1/2^†	0/1	32/33
Total	78/95 (82.1%)	11/14 (78.6%)	3/5 (60.0%)	2/4 (60.0%)	94/97 (96.9%)

Table 4. Knowledge, skill, and attitude-based health literacy competencies for health professionals: Consensus group ratings (N = 23)

Item		Source example	Very appropriate or appropriate (%)	Very important or important (%)	Round accepted
Knowledge items
The graduate…
K1	… knows one or more definitions of health literacy. *	Nielsen-Bohlman et al., 2004	100	90.9	1
K2	… knows the basic literacy skill domains (reading, writing, speaking, listening, numeracy), and gives examples of health care related demands put on patients for each domain, including difficulties navigating health care systems.	Nielsen-Bohlman et al., 2004	100	95.5	1
K3	… knows the difference between the ability to read, and reading comprehension, and why general reading levels do no not ensure patient understanding.	Nielsen-Bohlman et al., 2004	86.4	81.8	1
K4	… knows that years of educational attainment is an inadequate marker for health literacy skills.	Nielsen-Bohlman et al., 2004	86.4	76.2	1
K5	… knows which kinds of words, phrases, or concepts may be jargon to patients.*	Weiss, 2007	95.5	100	1
K6	… estimates the prevalence of low literacy (or low health literacy) among U.S. adults, and knows that certain subgroups are at increased risk.	Kutner et al., 2005; Paasche-Orlow et al., 2005	90.9	76.2	2
K7	… knows that the average US adult reads at an 8th–9th-grade reading level, but that most patient education materials are written at a much higher reading level.	AMA Foundation, 2007	86.3	76.2	1
K8	… knows that cultural and linguistic differences between patients and health care professionals can magnify health literacy issues.	Andrulis & Brach, 2007	95.4	90.9	1
K9	… knows that adults with low literacy tend to experience shame, and hide their lack of skills from health care professionals.	Parikh et al., 1996	100	95.5	1
K10	… knows that “you can't tell who has low health literacy by looking”	AMA Foundation, 2007	84.2	73.7	1
K11	… recognizes “red flag” behaviors which may suggest a patient has low health literacy.	AMA Foundation, 2007	100	95.5	1
K12	… knows that tools are available for estimating individuals' health literacy skills, but that routine screening for low health literacy has not been proven safe or acceptable.	Paasche-Orlow & Wolf, 2008	90.5	90.9	2
K13	… knows that health literacy is context-specific; individuals with high general literacy may have low health literacy.	Nielsen-Bohlman et al., 2004	95.0	86.4	1
K14	… knows that health literacy may decrease during times of physical or emotional stress.	Nielsen-Bohlman et al., 2004	95.5	81.9	1
K15	… knows that everyone, regardless of literacy level, benefits from and prefers clear plain language communication.*	Doak et al., 1996	95.3	90.4	1
K16	… knows that transition points, or “hand-offs” in health care (e.g., moving from in-patient to out-patient settings) are especially vulnerable to patient communication errors.	AMA Foundation, 2007	90.4	77.2	1
K17	… knows rationale for, and principles underpinning the need for a universal precautions approach to all health communication interactions.*	DeWalt et al., 2010	81.0	72.2	1
K18	… knows best practice principles of plain language and clear health communication for oral and written communication.*	AMA Foundation, 2007	85.0	85.7	1
K19	… knows that patients learn best when a limited number of new concepts are presented at any given time.	Sheridan et al., 2011	81.8	85.7	2
K20	… knows examples of the direct relationship between health literacy and • knowledge about one's chronic disease(s) and medications • adherence to medications and treatment plans • receipt of preventive health services • health outcomes or risk of harm	• Weiss, 2007 • AMA Foundation, 2007 • AMA Foundation, 2007 • Berkman et al., 2011	95.2	95.2	1
K21	… recognizes potential legal implications for inadequately conveying health information to patients with low literacy or health literacy.	AMA Foundation, 2007	85.7	81.8	1
K22	… knows that low health literacy has been associated with excess healthcare costs.	AMA Foundation, 2007	81.8	77.3	2
K23	… knows the rationale for and mechanics of using a teach back or “show me” technique to assess patient understanding.*	Schillinger et al., 2003	100	100	1
K24	… knows that community resources exist for helping adults improve their general literacy skills.	AMA Foundation, 2007	86.3	72.7	2
Skill items
The graduate…
S1	… demonstrates ability to use common familiar lay terms, phrases and concepts, and appropriately define unavoidable jargon, and avoid using acronyms in oral and written communication with patients.*	Weiss, 2007	94.7	94.4	1
S2	… demonstrates ability to recognize, avoid and/or constructively correct the use of medical jargon, as used by others in oral and written communication with patients.*	Weiss, 2007	100	94.7	1
S3	… demonstrates ability to follow best-practice principles of easy-to-read formatting and writing in written communication with patients.	CMS, 2013	85.7	86.4	2
S4	… demonstrates ability to recognize plain language principles in written materials produced by others.*	CMS, 2013	81.8	81.9	3
S5	… demonstrates the ability to put information into context by using subject headings in both written and oral communication with patients.	AMA Foundation, 2007	90.9	81.8	2
S6	… demonstrates ability to write in English at approximately the 5th-6th grade reading level.	AMA Foundation, 2007	84.2	78.9	1
S7	… demonstrates the ability to perform English-to-English translation of information from a non-plain language format into a scientifically accurate low-literacy plain language format.*	Osborne, 2005	88.9	84.2	1
S8	… demonstrates ability to speak slowly and clearly with patients.	Weiss, 2007	100	89.4	1
S9	… demonstrates ability to use verbal and non-verbal active listening techniques when speaking with patients.	Osborne, 2005	94.7	100	1
S10	… demonstrates the ability to use action oriented statements to help patients know what they need to do.	Oates & Paasche-Orlow, 2009	90.9	86.4	2
S11	… demonstrates ability to select culturally and socially appropriate and relevant visual aids, including objects and models, to enhance and reinforce oral and written communication with patients.	Doak et al., 1996	100	94.8	1
S12	… demonstrates ability to make instructions interactive, such that patients engage the information, to facilitate retention and recall.	Doak et al., 1996	88.9	79.0	1
S13	… demonstrates ability to elicit the patient's full set of concerns at the outset of the encounter.	Osborne, 2005	89.5	89.5	1
S14	… demonstrates ability to negotiate a mutual agenda for the encounter at the outset of the encounter.	Osborne, 2005	90.9	77.3	3
S15	… demonstrates ability to elicit patients' prior understanding of their health issues in a non-shaming manner (e.g., asks “what do you already know about high blood pressure?”).	Doak et al., 1996	100	84.2	1
S16	… demonstrates ability to non-judgmentally elicit root causes of non-adherent health behaviors.	AMA Foundation, 2007	84.2	89.5	1
S17	… demonstrates effective use of a teach back or “show me” technique for assessing patients' understanding.*	Schillinger et al., 2003	100	100	1
S18	… demonstrates ability to “Chunk and check” by giving patients small amounts of information and checking for understanding before moving to new information.	AMA Foundation, 2007	100	89.5	1
S19	… demonstrates ability to effectively elicit questions from patients through a “patient-centered” approach (e.g., asks “what questions do you have?” rather than “do you have any questions?”).	Oates & Paasche-Orlow, 2009	94.4	89.5	1
S20	… demonstrates ability to orally communicate accurately and effectively in patients' preferred language, using medical interpreter services.	Andrulis & Brach, 2007	100	100	1
S21	… demonstrates ability to use written communication to reinforce important oral information.	Berkman et al., 2004	89.5	84.2	1
S22	… demonstrates ability to emphasize one to three “need-to-know” or “need-to-do” concepts during a given patient encounter.	Sheridan et al., 2011	88.9	77.8	1
S23	… demonstrates the ability to convey numeric information, such as risk, using low numeracy approaches, such as through examples, in oral and written communication.*	Osborne, 2005	88.8	88.8	1
S24	… demonstrates ability to write or re-write (“translate”) unambiguous medication instructions (e.g., “take 1 tablet by mouth every morning and evening for high blood pressure,” rather than “take one tablet by mouth twice daily.”	Sheridan et al., 2011	89.5	100	1
S25	… demonstrates the ability to assess the usability of web-based patient resources.*	U.S. Department of Health and Human Services, 2012b	81.8	77.3	2
S26	… demonstrates ability to ask patients about their learning style preferences (e.g., ask patients, “what is the best way for you to learn new information?”	AMA Foundation, 2007	77.3	81.8	4
S27	… demonstrates ability to use examples or analogies to improve patients' comprehension.	Doak et al., 1996	100	100	4
Skill items that did not achieve consensus after four rounds
The graduate…
Sx	… demonstrates ability to avoid, when possible, using words with three or more syllables in oral and written communication with patients.	AMA Foundation, 2007	68.2	72.7	No consensus
Sy	… demonstrates the ability to recommend adult basic literacy education programs within the context of a therapeutic relationship.	AMA Foundation, 2007	68.2	54.5	No consensus
Attitude items
The graduate…
A1	… expresses the attitude that effective communication is essential to the delivery of safe high quality health care.	AMA Foundation, 2007	89.5	94.7	1
A2	… exhibits the attitude that all patients are at risk for communication errors, and that one cannot tell who is at risk of communication errors simply by looking, or through typical health care interactions—a universal precautions approach is required with all patients.*	DeWalt et al., 2010	89.5	94.8	1
A3	… expresses the attitude that because the “culture” of healthcare includes special knowledge, language, logic, experiences and explanatory models of health and illness, every patient encounter can be considered a cross-cultural experience.	Carmona, 2006	84.2	78.9	1
A4	… expresses acceptance of an ethical responsibility to facilitate the two-way exchange of information in “shared decision making” to the degree and at the level desired by the patient and their family.	AMA Foundation, 2007	84.2	89.5	1
A5	… acknowledges patients' autonomous right to both informed consent, and “informed refusal” of recommended evaluations or treatments.	ACOG, 2004	84.2	89.5	1
A6	… expresses empathy with patients' potential sense of shame around low literacy (or health literacy) issues.	Parikh et al., 1996	79.0	79.0	1
A7	… expresses a non-judgmental non-shaming respectful attitude toward individuals with limited literacy (or health literacy) skills.	Weiss, 2007	94.4	94.7	1
A8	… expresses empathy with the common experience of the health care system as a confusing, stressful, frustrating, intimidating, and frightening physical and virtual environment for many patients.	AMA Foundation, 2007	84.2	89.5	1
A9	… expresses the attitude that every patient has the right to understand their health care, and that it is the health care professional's duty to elicit and ensure patients' best possible understanding of their health care.	AMA Foundation, 2007	89.4	84.3	1
A10	… expresses the attitude that it is a responsibility of the health care sector to address the mismatch between patients' and health care providers' communication skills and tactics.	Nielsen-Bohlman et al., 2004	78.9	73.6	1
A11	… expresses the attitude that it is a responsibility of all members of the healthcare team to be trained and proactive in addressing the communication needs of patients.	The Joint Commission, 2007	94.8	89.5	1

Table

Term	Definition
Clear health communication	Clear health communication is written or oral communication that helps patients to understand and act on health care information (Pfizer Inc., 2013).
Health literacy	Health literacy is the degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions (Somers & Mahadevan, 2010). Health literacy involves reading, writing, speaking, listening, numeracy, and cultural and conceptual knowledge (Nielsen-Bohlman et al., 2004), including navigation of health care systems (Kutner et al., 2006). Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information (Coleman et al., 2010). Health care professionals can be “health literate” by presenting information in ways that improve understanding and the ability of people to act on that information (Coleman et al., 2010).
Jargon	Jargon refers to words, phrases, or concepts, including numerical or mathematical information, which might not be fully understood, or may be misinterpreted by the recipient (Nielsen-Bohlman et al., 2004).
Numeracy	Numeracy is defined as a working knowledge of numbers (Osborne, 2005). Basic numeracy includes the knowledge and skills necessary to understand and act on numerical information and concepts encountered in routine oral and written communications. The related term, quantitative literacy, defined as “the knowledge and skills required to apply arithmetic operations, alone or sequentially, using numbers embedded in printed materials” (Kirsch et al., 1993) can be applied to oral communication as well.
Plain language	Sometimes called everyday language or living room language (AMA Foundation, 2007), plain language refers to written or oral communication that is clear, concise, organized, and jargon-free (U.S. Department of Health and Human Services, 2012a). A communication is considered to be in plain language if audience members can quickly and easily find what they need, understand what they find, and act appropriately on that understanding the first time they read or hear it (Center for Plain Language, 2012).
Teach-back	Teach back, also referred to as an interactive communication loop, is an iterative technique used to confirm understanding and correct misunderstanding of information by asking patients to explain back or demonstrate (“show back”) in their own way what they have understood (Schillinger et al., 2003).
Universal precautions for safe communication	Universal precautions for safe communication is a communication strategy that assumes that all health care encounters are at risk for communication errors, and aims to minimize risk for everyone (DeWalt et al., 2010).
Usability	Usability refers to how well users can learn and use a product to achieve their goals and how satisfied they are with that process (U.S. Department of Health and Human Services, 2012b).

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