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    3 steps to boost health literacy

    What do patients and their families really understand about their healthcare and what can pediatricians do about it?


    Herman and Jackson17 used Head Start sites to evaluate use of a low literacy health book that taught parents how to respond to common childhood illnesses and symptoms. The training lasted approximately 2 hours. The book covers 50 common pediatric problems and symptoms such as fever, pink eye, nose bleeds, and earaches.

    Each family’s doctor and ED visits were tracked for 3 months before training and for 6 months following training. Following the intervention, there was a 40% decrease in clinic visits corresponding to 1.5 fewer visits per year. There was a 58% decrease in ED visits corresponding to a decrease of 0.5 visits per year. These improvements translated to a 29% decrease in missed school days and a 42% decrease in missed workdays by caregivers.17

    Yin and colleagues18 examined the impact of health literacy on the manner in which dosing instructions were delivered to caregivers as well as the instruments used. The study looked at the dose accuracy measured by caregivers using dosing cups, droppers, dosing spoons, and oral syringes. Overall dosing cups had significantly more dosing errors compared with the other administration instruments, and patients with poor health literacy had significantly more dosing errors across all dosing instruments. Patients with poor health literacy had significantly more problems with the dosing cups, indicating that greater health literacy is needed when dispensing medication with dosing cups. In a follow-up study, Yin found that counseling and provision of a dosing instrument in the ED significantly reduced dosing errors for children being prescribed liquid medication.19

    Recommended: Improving the patient visit

    Given the recent issues and national concern related to overdoses with pediatric cough and cold medicines, the pediatrician may want to consider education for parents to use an alternative dosing instrument because most cough and cold medications come packaged with a cup.

    Finally, although oral instructions are the most common education given to caregivers for administration of medication, few studies have examined alternative strategies and their impact on dosing errors. The HELPix intervention (Health Education and Literacy for Parents [HELP] Project from New York University School of Medicine/Bellevue Hospital Center, New York) uses plain language, pictogram-based medication instruction sheets to assist with adherence and correct dosing.20The instruction sheets are used as part of medication counseling and include a process referred to as “teach back,” wherein patients are asked to demonstrate what they will do to the healthcare provider performing the counseling. The intervention takes 1.5 to 3 minutes depending on how complicated the dosing regimen is. Whereas health literacy was not measured as part of this study, this ED primarily serves at-risk families of low socioeconomic status and low educational attainment, both of which are risk factors for poor health literacy. The pictogram-based, plain-language intervention led to a 42% absolute risk reduction in dosing errors, requiring a number needed to treat of 2 to prevent 1 dosing error.20 Adherence and knowledge were also significantly greater among the intervention group.

    What you can do in your practice

    Given the demand and time constraints of practice, pediatricians may wonder if research findings or other health-literacy interventions can be implemented efficiently into their practice. Here are several things you can do to make your practice more health-literacy friendly:

    1.    Be a good communicator. Clear oral communication is essential for optimal care as physicians are unlikely to be able to predict which patients or parents will have problems understanding medical information.21 The helpful Ask Me 3 communication tool specifies that patients minimally need to be able to answer 3 questions related to their medical problems or goals.22These key questions are:


    1.    What is the main problem?

    2.    What actions does the patient or parent need to take?

    3.    Why are the actions important?

    Answers to these 3 questions provide the pediatrician with an assessment of their patient’s understanding of what was communicated to them about a problem. The Ask Me 3 program (created by the Partnership for Clear Health Communication, National Patient Safety Foundation, North Adams, Massachusetts) empowers patients to obtain more knowledge about their medical conditions and medications.

    2.    Use teach-back. Asking the patient or parent to explain to the provider the “need to know” information makes sure the provider explained the concepts in an understandable manner. For example, a pediatrician could ask a parent, “If you had to explain to your spouse/babysitter/grandparent how to give this antibiotic, what would you say?” Providing patients/parents/caregivers with education in the teach-back format is associated with decreased postoperative infection rates, improved parental assessment of communication, improved outcomes in chronic disease, and improved understanding of medication dosing and discharge instructions.11,23-26

    NEXT: Using plain language to communicate

    Pat F Bass III, MD, MS, MPH
    Dr Bass is Chief Medical Information officer and professor of Medicine and of Pediatrics, Louisiana State University Health Sciences ...


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