Tag Archives: health literacy patient outcomes

Health Literacy, Health Outcomes, & Instructional Design Needs

Health literacy is considered by many to be a “patient problem” and patient-centered care is one of those nice ideals available if you don’t practice health care in the real world. For many physicians, if symptoms have been diagnosed and treatments prescribed, the  job has been done. The patient should be less concerned about the touchy-feely stuff like “communicating” and more concerned about clinical outcomes.

Health care recipients are often bullied into buying into this point of view. Indeed, I’ve heard many conversations where people are asked, “What would you prefer, a skilled doctor or a doctor with a good bedside manner?” as if they must necessarily choose and as if clinical skill erases “minor difficulties” such as poor communication—if only the patient would listen, comply, do as he or she is told.

Patient centered-care = clinical skill

As noted in a previous post, physician-patient communication is a two-way street and the education of medical professionals must instill an understanding that patient-centered care is an integral part of improving clinical outcomes (see, e.g., Stewart, 1995; Kinmonth et al., 1998; Berkman, Dewalt, Pignone, Sheriden, & Lohr, 2004; Schillinger et al., 2004). You cannot truly be a skilled physician without patient-centered care. Further, gauging the health literacy needs of patients is an important part of this type of practice. You cannot practice patient-centered care without considering the unique health literacy needs of your patients.

Health literacy and health outcomes

Many, including health care professionals, don’t see the direct connection between  poor health literacy and poor health outcomes, including loss of life. The Agency for Healthcare Research and Quality (AHRQ) recently released an updated of its 2004 review of  health care service use and  health outcomes related to differences in health literacy levels (Berkman et al., 2011).

Differences in health literacy level were consistently associated with:

  • Increased hospitalizations
  • Greater emergency care use
  • Lower use of mammography
  • Lower influenza vaccination rates
  • Poorer ability to take medications appropriately
  • Poorer ability to interpret labels and health messages
  • Poorer overall health status and higher mortality among seniors

The AHRQ report  further uncovered emerging data that suggest the importance of social supports, patient self-efficacy (a patient’s confidence in his/her ability to impact changes in his/her own health), and perceptions of shame on health outcomes. The AHRQ report results also reinforce prior studies suggesting that health literacy is  an important driver of health disparities associated with differences in race, ethnicity, and age.

What makes for an effective intervention?

The many different variables present in different intervention studies made it difficult to draw general conclusions about which interventions worked best. However, the AHRQ report noted that components associated with effective interventions included:

  • High intensity
  • Theory basis
  • Pilot testing before full implementation
  • Emphasis on skill building
  • Removing distracting, nonessential information
  • Prioritizing information
  • Presenting information consistently (e.g., using the same units to describe baseline risk and treatment benefit)
  • Using relevant images or icons to illustrate concepts/procedures, particularly those involving numbers
  • Using video to enhance narratives
  • Delivery of the intervention by a health care professional

To instructional designers out there, this list may seem like preaching to the choir. However, it makes a point worth noting, that the SME  (health care professionals, in this case) is an important human factor in the successful implementation of a health literacy-based intervention. This means that in addition to developing good materials  to enhance patient skills, “training the trainers” should not be neglected. Health care providers are typically de facto educators of health care recipients.

Bottom line

The full AHRQ report is worth reading. Many of the studies that were noted as providing insufficient or mixed results do not rule out a potential link to poor health literacy but point to a need to replicate the studies with better controls (see, e.g., Table 5).  The report does demonstrate that for many important measures of health status (such as those listed above), proficient  health literacy plays a critical role.

Because health literacy is often slotted into the bailiwick of medical communications, instructional design considerations can take a back seat to technical considerations. However, the AHRQ report supports the need for good instructional design in developing effective health literacy interventions. This design should not limit its focus on patients as a target audience but should consider the two-way nature of communications between health care providers and health care recipients. Health literacy is not just a “patient problem.”


Berkman, N.D., Sheridan, S.L., Donahue, K.E., Halpern, D.J., Viera, A., Crotty, K., et al. (2011).  Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011.) Retrieved from http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf

Kinmonth, A.L., Woodcock, A., Griffin, S., Spiegal, N., Campbell, M.J. (1998). The Diabetes Care From Diagnosis Research Team. Randomised
controlled trial of patient centred care of diabetes in general
practice: impact on current wellbeing and future disease risk. British Medical Journal, 317(7167), 1202-1208.

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., &  Bindman, A. (2003). Closing the loop: physician communication with diabetic patients who have low health literacy. Archives Internal Medicine, 163 (1), 83-90.

Stewart MA. (1995).  Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal, 152(9),1423-1433.