Adequate health literacy plays a key role in effective communication between providers and patients. The 2003 National Assessment of Adult Literacy (NAAL) indicated that 36% of adults in the United States (US) had less than adequate levels of health literacy (basic or below basic) and several disparities existed among different demographic and socioeconomic groups [
Curriculum should be designed to teach medical learners the knowledge and skills to determine health literacy levels of their patients and use techniques designed to overcome communication barriers caused by limited health literacy. Research has shown that medical residents often misjudge their patients’ risk for limited health literacy [
Several interventions have been developed to improve health outcomes among adults with limited health literacy [
A 2009 health literacy assessment (measured by the Newest Vital Sign) showed that 69% of our patients had less than adequate health literacy [
We conducted a quasi-experimental study with Family Medicine (FM) residents at a county-supported indigent care clinic (
Given the number of patients seen by residents that have low health literacy, we wanted to design a curriculum to specifically address this population. A brief letter describing the curriculum has been published previously [
Two groups of FM residents were evaluated: (1) a didactic group (
Our data was collected from several sources, including a pretest, posttest, and postdidactic evaluation, online follow-up survey, and OSCE score sheets. Current FM residents (didactic group) completed pre- and posttests to determine if the training had an immediate impact. The online follow-up survey was given three months after the OSCE to determine the residents’ usage of the skills taught in training.
Residents were asked eight multiple choice and fill-in-the-blank questions to determine health literacy knowledge. Questions ranged from definitions and national prevalence estimates to warning signs and consequences of limited health literacy. Residents were asked to rate their attitudes about health literacy and confidence in their ability to recognize and treat patients with limited health literacy on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).
After didactic training, residents were asked to evaluate the didactic on the same 5-point Likert scale. Residents evaluated whether or not the presentation improved their patient care, medical knowledge, practice-based learning, and/or improved interpersonal/communication skills. Qualitative feedback was given to determine strengths and ways of improving the training (see Table
During the OSCE, lay health promoters evaluated the residents using a questionnaire with a three-point grading scale: (1) expertly performed, (2) adequately performed, and (3) did not perform. Each station was graded independently and had both general and specific questions. The grade sheet also allowed for comments from the grader regarding the residents’ overall performance (see Table
OSCE components.
OSCE station | Measures | Scoring | ||
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Did not perform (0 pts) | Adequately performed |
Expertly performed | ||
(1) Obtaining the Newest Vital Sign (NVS) |
Explained the purpose of the NVS to the patient. | Examiner clearly did not perform this function. | Examiner explained the purpose of the Newest Vital Sign (NVS) and read questions to patient. |
Examiner explained the purpose of the NVS in a nonjudgmental way, read questions, and gave the patient time to provide an answer. |
Read the questions on the NVS to the patient. | ||||
Scored the NVS according to instructions. | ||||
Used NVS score to determine patient health literacy. | ||||
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(2) Teach-back method for asthma |
Sat while speaking with patient. |
Examiner clearly did not perform this function. | Examiner was relaxed and confident and seemed to care about the patient. The examiner gave information that was usually clear and easily understandable. Most of the words used by the examiner were easily understood. The patient felt comfortable repeating back what the examiner taught. | Examiner was relaxed and confident and cared about the patient. He/she sat down and gave the patient information about how to use the 2 inhalers in a way that was easy to understand. The patient did not feel overwhelmed. Examiner used more than just words to teach how to use the inhalers. The patient was able to “teach back” all information given correctly. The patient felt respected through the entire visit. The examiner never used words that the patient did not understand. The patient felt confident to go home and use these 2 inhalers without further instruction. |
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(3) Explain the DASH diet to hypertensive patient using Ask Me 3 |
Explained that the main problem is high blood pressure. | Examiner clearly did not perform this function. | Examiner explained the DASH diet using words and terms the patient could understand. |
Examiner explained the DASH diet using nonmedical words and terms that the patient could understand. The examiner reviewed all Ask Me 3 questions with the patient. |
Used the word high blood pressure to describe main problem. | ||||
Described the DASH diet to help reduce blood pressure. | ||||
Gave the patient examples of what to eat in the DASH diet. | ||||
Explained why it is important to lower blood pressure. | ||||
Used nonmedical terms. | ||||
Used words/abbreviations and lay terms. | ||||
Defined Ask Me 3. | ||||
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(4) Working with an interpreter |
Positioned interpreter behind or to the side. | Examiner clearly did not perform this function | Through most of the encounter, examiner faced the patient, spoke to the patient and not the translator, used the first person, employed plain language (not jargon or medical terms), and refrained from conversing with the interpreter. | Through the entire encounter, the examiner faced the patient, always made eye contact with the patient, always used the first person, did not have extra conversations with the interpreter, and used plain language. |
Introduced themselves to the patient through an interpreter. | ||||
Maintained eye contact with the patient. | ||||
Spoke to the patient and not to the interpreter. | ||||
Used the first person when talking to patient. | ||||
Refrained from carrying on side conversations with interpreter. | ||||
Used plain language. | ||||
Used brief statements and provided interpreter with time to relay information. |
Three months after completion of the training, residents were asked to complete a 3-minute online survey (5 questions plus demographics) and give feedback. There were questions about their experience including how they have incorporated the skills they learned from the health literacy curriculum in their daily practice. Residents were asked if they have utilized or incorporated any elements from the health literacy training in their interactions with patients (yes or no) and if so, what elements were used (Newest Vital Sign, teach-back method, Ask Me 3, working with a translator, and/or other). They were also asked to provide feedback on what they found most helpful during the training, what was least helpful, and to describe their experiences of incorporating health literacy into their practice.
Data analysis was performed using SPSS version 18.0. Means and standard deviations were used to report knowledge scores and attitudes. McNemar’s test was obtained for each item of the knowledge assessment to determine improvement on specific questions measured. The Wilcoxon signed-rank test was used to determine whether total scores from the pre- and posttest and attitudes were significantly different. The Mann-Whitney
There were more female residents (56%) than males (44%) and most residents were in their first year (39%) compared to second (33%) and third years (29%) of training. Over half of the residents were Asian (56%) compared to 12% Hispanic, 12% White, and 8% Black. Race/ethnicity of 3 residents (12%) was unknown or not reported. Four residents had fluent Spanish-speaking skills. Two residents were native Spanish speakers.
Table
Health literacy knowledge
Knowledge | Pretest |
Posttest |
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(1) How many Americans read at or below the 5th grade level according to NALS | 5 (29.4) | 4 (22.2) | 0.625 |
(2) How many Americans have fair to low health literacy | 5 (27.8) | 6 (33.3) | 1.000 |
(3) Definition of health literacy | 6 (33.3) | 14 (77.8) | 0.008± |
(4) Age groups likely to have low health literacy and worse health outcomes | 14 (77.8) | 15 (83.3) | 1.000 |
(5) Communication styles among patients with limited health literacy | 13 (72.2) | 10 (55.6) | 0.250 |
(6) Three questions that the Ask Me 3 Program comprises | 2 (11.1) | 17 (94.4) | 0.000 |
(7) Definition of the “teach-back” method | 12 (66.7) | 16 (88.9) | 0.125 |
(8) Health literacy assessment methods currently used. | 13 (72.2) | 17 (94.4) | 0.125 |
Total score mean (SD) |
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Attitudes | Pretest |
Posttest |
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(1) Health literacy is a serious medical issue | 4.50 (0.51) | 4.33 (0.49) | 0.180 |
(2) It is my responsibility, as a physician, to address my patient’s health literacy | 4.17 (0.51) | 4.33 (0.49) | 0.180 |
(3) I am confident I can recognize a patient with low health literacy | 3.72 (0.67) | 4.06 (0.56) | 0.058 |
(4) I have the appropriate level of skills and training to help my patients with low health literacy | 3.78 (0.65) | 4.00 (0.61) | 0.157 |
(5) Patients with low health literacy should be referred to a health educator or a social worker for health education | 3.61 (0.98) | 3.44 (1.29) | 0.467 |
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OSCE station scores | Control |
Didactic |
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(1) Obtaining the Newest Vital Sign (NVS) | 5.0 (1.53) | 5.8 (1.99) | 0.459 |
(2) Teach-back method for asthma | 17.4 (5.53) | 17.1 (5.00) | 0.480 |
(3) Explaining the DASH diet to a hypertensive patient using Ask Me 3 | 11.9 (3.24) | 12.0 (2.61) | 0.760 |
(4) Working with an interpreter | 15.9 (0.39) | 14.5 (2.72) | 0.075 |
+Significant,
±Significant,
§Five-point Likert Scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly disagree); Wilcoxon signed rank test was used to test significance.
Postdidactic evaluation
Questions | Mean (SD) |
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(1) This presentation met my needs | 4.33 (0.49) |
(2) The presenters were knowledgeable | 4.47 (0.64) |
(3) The techniques used were effective to teach the subject matter | 4.33 (0.72) |
(4) The stated objectives were met | 4.47 (0.52) |
(5) The amount of time allowed for material was appropriate | 4.27 (0.80) |
(6) The presentation enhanced my ability to provide care that is patient centered, |
4.40 (0.51) |
(7) This presentation provided me with medical knowledge of established and evolving |
3.93 (1.03) |
(8) This presentation assisted me in developing skills and habits that will help me to |
4.33 (0.49) |
(9) This presentation assisted me in the development of interpersonal and |
4.33 (0.62) |
(10) Overall rating of this session |
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(11) What are the three most important things you learned during this training? | |
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(12) What are the three greatest strengths of this training? | |
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(13) What additional assistance or resources, if any, will you need to be able to implement what you have learned at this training? | |
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(14) If you were given the task of revising, adjusting, or redesigning this training, what would you change? | |
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Table
First and second year residents evaluated the didactic favorably (Table
A majority of residents (87.5%) stated they believed the health literacy curriculum improved their patient care. A majority of residents (83%) stated that they have used the skills they learned in their training during their interactions with patients. The most utilized skills reported were the teach-back method (77.8%) and working with a translator (77.8%) compared to measuring patient health literacy with the NVS (27.8%) and teaching patients about Ask Me 3 (33.3%). Eighty-seven percent (87%) stated that the training aided their medical knowledge, and ninety-three percent (93%) stated the training improved their communication skills with their patients. When asked if they incorporated any components of the health literacy training into their practice and to describe their experience, one resident stated: “
The purpose of this study was to develop and evaluate a curriculum to train Family Medicine residents to effectively communicate with patients with limited health literacy. Our curriculum consisted of didactic training and a 4-station health literacy OSCE designed to teach residents to (1) administer, interpret, and document the results of the Newest Vital Sign; (2) utilize patient-centered, clear health communication and confirmation of understanding techniques; (3) practice the teach-back method and Ask Me 3 methods of communication; and (4) appropriately use an interpreter.
We found that residents showed a significant increase in health literacy knowledge after participating in a health literacy didactic and OSCE with standardized patients. A few educational interventions have been implemented to train physician residents on how to effectively communicate with low health literate patients [
Our OSCE is innovative because it included a formal assessment of resident performance, it compared residents based on experience, and it utilized lay health promoter expertise. Although we did not find significant differences between the control and didactic group, control group residents had higher scores on the teach-back method for asthma and working with a translator stations. Since the control group residents were at the end of their residency training, the results may be due to experience and increased confidence. Previous studies of medical student and resident health literacy OSCEs have only reported program design and basic improvement of skills [
A great strength of this study was its reproducibility to other residency and health professional education environments. The active learning in the didactic was reinforced through the OSCE and it gave the residents an opportunity to practice with the promotoras and not just each other. Three months after the training, the knowledge gained from the intervention persisted. Residents reported using the teach-back method and improved their skills working with a translator. Furthermore, they also reported improvement in confidence and use of health literacy skills. Some limitations may have affected our results. Our study was conducted at 1 training site and included a small sample size. Future studies can be designed to include a larger number of residents and potential collaboration with other departments. There were logistical limitations with scheduling of residents and funding of promotoras as standardized patients. The promotoras were also only female. Two components of the training were the DASH diet and educating patients on how to use asthma inhalers. After the intervention, a few residents expressed a lack of confidence in counseling patients on the DASH diet and educating patients on how to use asthma inhalers.
Our health literacy OSCE addresses the urgent need to train medical learners and improve communication with low literacy patients. It provides a training model that can be used with residents and other students in the health professions. It meets Accreditation Council for Graduate Medical Education (ACGME) and Association of American Medical Colleges (AAMC) program requirements for patient communication skills. For example, although no specific core competencies on health literacy knowledge are currently required, Family Medicine residents are required to be able to communicate effectively with patients from different socioeconomic and cultural backgrounds [
The authors report that they have no conflict of interests.
This study was funded by a small grant from the University of Texas Academy of Health Science Education.