Health literacy in solid-organ transplantation: a model to improve understanding

Figures & data

Figure 1 Health literacy model in transplantation (HeaL-T): patient-level factors, healthcare-level factors, and outcomes associated with health literacy in the solid-organ transplant population.^a,15,16

Notes: Health literacy is associated with several patient-level (eg, age, cognitive function) and caregiver factors. Health literacy also influences, and is influenced by, caregiver and healthcare-level factors including access and utilization of healthcare, provider-patient interaction, and self-management/adherence. These factors may also influence each other; for example, a patient’s adherence may be influenced by an interaction with a provider. Health outcomes are affected by all of these factors that stem from health literacy, and these outcomes can also influence healthcare-level factors as well as health literacy. For example, a patient who does not understand how to take his/her medication (health literacy), and is thus nonadherent (healthcare-level factor), is hospitalized (outcome). During the hospitalization (outcome), the patient has an effective educational interaction with a provider (healthcare-level factor) and develops an understanding of why and how to take his/her medication (health literacy). Going forward, the patient’s adherence increases and his/her outcomes improve. The HeaL-T is adapted with permission from Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(Suppl 1):S19–S26.^{15 a}Studies from both the general population and transplant population were reviewed, particularly when literature in the transplant population was scarce.

Table 1 Relationships between patient-level factors and health literacy

Low health literacy is associated with:

• Older age • Minority race/ethnicity • Primary language other than English • Lower education level • Unemployed • Lower income/living in poverty • Not married • Cultural/environmental challengesa • Public or no health insurance statusa • Deceased donor • Poorer physical/mental health • Increased comorbidities • Negative health beliefs/attitudesa • Limited verbal abilitya • Limited cognitive function • Increased vision/hearing impairmentsa

Note:

a Association with health literacy primarily based on reviews of studies in the general patient population when transplant studies were scarce or non-existent.

Table 2 Intervention strategies, tools, and resources to address low health literacy^{9,22,91–105,108–110}

Intervention strategies, tools, and resources
• Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit: https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html  ○ Includes tools to address verbal and written communication, self-management and empowerment, and support system, among other targets
• Health Literacy Tool Shed: https://healthliteracy.bu.edu/  ○ Resource for identifying measures of health literacy
• Readability Test Tool: https://www.webpagefx.com/tools/read-able/  ○ This is one example of a website that checks readability level of written materials, but it is by no means the only resource available  ○ Microsoft Word also has a function to determine the grade/readability level of documents
• Assign caseworker to each patient to provide health literacy support to patients and caregivers
• Conduct multiple assessments of patient and caregiver health literacy, pre- and posttransplant, to better target intervention strategies
• Implement interprofessional (eg, physician, nurse, pharmacist) team-based approach to patient-centered care
• Provide trained interpreters for patients whose primary language is not English
• Train healthcare providers to improve skills in working with patients with low health literacy
• Use open-ended questions and Teach-Back
• Universal precautions  ○ Easily understandable instructions  ○ Asking patients/caregivers how they are going to follow treatment instructions  ○ Offering help in completing healthcare forms
• Written materials:  ○ Avoid medical/healthcare jargon  ○ 5th grade reading level or below  ○ Large font size  ○ Small increments of information (3–5 points at a time)  ○ Culturally appropriate/sensitive
• Alternate teaching methods:  ○ Videos  ○ Animation  ○ Graphics/illustrations  ○ Flashcards  ○ QR-barcoded bottles that link to web-based information
• Technology/mobile health tools and interventions  ○ Patient portals: access to health data and disease state/medication information  ○ Self-management support apps  ○ Text message reminders to support treatment adherence  ○ Web-based educational programming that is culturally appropriate/sensitive  ○ Talking pill bottles
• Additional tools to support self-management/adherence:  ○ Pillboxes  ○ Blister packs  ○ Medication list (eg, illustrated with pictures of medication and simplified to express time of daily dose and/or if medication should be taken with food)  ○ “Smart” lids/dispensers

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