HEALTH LITERACY: CRN'S CLINICAL CASE REVIEW
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March 13, 2023, 9:38pm EDT
Matilde E. Ladnier, MBA, RD, LD
CRN Chair
It would be fair to say that twenty-five years ago I was health illiterate, and I didn’t realize it. I needed to learn what patient’s lab results indicated or why one patient had a BUN of 85 while another was at 45, despite similar weight, height, and sex, as well as about different medications, side effects, etc. I had a college degree and did my internship the world-renowned Houston Medical Center, but I only had basic knowledge of the causes of renal disease and the complications that come with the different renal replacement therapies. In the beginning of my career, I would provide patients educational materials, created by previous renal dietitians that worked at the facility before me. It was later that I created my own educational materials as needed and as I became more literate in renal nutrition.
Most people, including myself, have a somewhat loose understanding of the term “health literacy”. The actual definition of health literacy was updated in August 2020 by the Centers for Disease Control (1).
There are two types of health literacy:
Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
Organization health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
In my first ten years as renal dietitian, I was fortunate to work with nephrologists who were also professors. I attended weekly meetings in a teaching hospital where most of our patients came from, and this gave me the opportunity to learn a great deal about new patients and hospitalized patients. I remember one nephrologist making a comment while rounding on a new patient and saying, “Matilde, you know more about this new patient than our fellow does.” Those first ten years helped me become a better clinician and become more health literate. When a patient realizes that you know their medical history in advance and you explain why they need to start on a new medication or treatment, you earn their trust. When trust is there, they pay better attention to what you are saying. Most of our patients hear so much new information from doctors, nurses, social workers, dietitians, etc. Further, we often tend to use medical terms they are not familiar with, and then simply ask for an affirmation of what is being said. Then we wonder why they get confused, overwhelmed, even upset, and worst of all, end up with poor or no adherence to our recommendations. Whenever I am asked about a special skill I have, I say I am able to talk to patients in layman’s terms, so they understand the reasoning behind their new treatment, diet plan, medication, and so on. I too am still learning, and I am a firm believer that everyone can learn new terminology and hopefully use this knowledge to make better decisions. Everyone has a part to play in improving health literacy: not only healthcare providers, but also businesses, educators, community leaders, government agencies, health insurers, the media, etc.
I believe a lot of misunderstanding, poor adherence, and poor attitudes from our patients stem not only from lack of understanding our “health terms”, but also how that information affects them and their decisions. We need to focus on providing our patients with enough information for them to make “well-informed” decisions rather than “appropriate” ones. Large organizations need to provide the tools and training to be able to improve “health literacy”. Schools providing education to the future healthcare providers need to add in their curriculum how to improve communication with their patients.
One recent example was that I had a new hemodialysis patient in his late twenties who decided to do peritoneal dialysis so he can go back to work. Phosphorus-binders were obtained via PAP since he did not have insurance, but his three-month phosphorus average was 8 mg/dl and PTH >1200. I provided information about high inorganic phosphorus foods/drinks to avoid, when to take phosphorus binders, how many, etc. Finally, I decided to talk to him about calciphylaxis. I know he checks the internet often so I wrote down how to spell it so he could look it up. I started the conversation by telling him, “I am not doing a good job with you; I have not told you about some complications that might happen if your phosphorus and PTH average continues to be this high.” I gave him a short questionnaire to name the foods high in phosphorus and he listed them correctly, and I also recommended that he keep a log of everything that he is eating and drinking, to hopefully figure out possible culprits. His latest phosphorus level resulted on a 4.5 mg/dl and PTH 800, so we congratulated him and told him he will do well in PD. We need to educate our patients in simple terms and give them some homework to help them make decisions based on the information given.
There are many resources about health literacy such as the CDC website. You can listen to Dr. Rima Rudd, health literacy expert at the Harvard T.H. Chan School of Public Health, addressing staff at the Centers for Disease Control and Prevention. Her presentation is titled Health Literacy Research Finding and Insights: Increasing Organizational Capacity for Shaping Health Messages.
It is my hope and belief that when we, the healthcare providers, improve communication with our patients, healthcare outcomes will improve and hopefully simultaneously provide savings for the providers, the patients, and society in general.
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