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Daytheon Sturges, PhD, PA-C, vice chair for Justice, Equity, Diversity, and Inclusion at the University of Washington School of Medicine, Seattle, recalled an encounter with a patient having difficulty managing a chronic medical condition. Throughout multiple appointments, he provided her with several different types of handouts explaining her condition and the best way to care for herself at home. As he worked to understand why the information was not "sticking," she finally admitted that she didn't understand the material: She only read at a first-grade level.

"She was finally wonderful enough to let me know that she couldn't read it," Sturges said. "So, I took out her phone and recorded the instructions so she could listen to them every day when she took her meds."

Sadly, this isn't an uncommon occurrence, said Sturges. Physician associates (PAs) are often tasked with providing vital education to patients to help them better manage their care and improve their physical and mental well-being. Yet, providing effective patient education requires a strong understanding of health literacy or the ability for patients to find, understand, and use healthcare information to inform healthcare decisions and adhere to treatment.

To help PAs provide more effective patient education, Sturges and Quanté Greenlee, PhD, MPH, PA-C, at the University of Washington School of Medicine's Fred Hutchinson Cancer Center, shared effective tools and strategies at the individual and organizational level at a Health Literary 101 session at the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston.

Understanding the Challenges

At the start of the session, Sturges emphasized that health literacy is not just an individual issue. It's important that PAs look at health literacy using a social-ecological lens because patients are influenced not just by their own beliefs but also by the communities and systems around them.

"When we are providing patient education, we are seeking to change people's knowledge, attitudes, and beliefs," he said. "Just thinking back to yourself, it can be hard to change your beliefs sometimes. It can be hard to change behaviors. We should not expect that when patients leave us, they have taken up everything we said. It's a process — and to get there you have to understand whether they even understand what you are saying."

You also have to appreciate what other variables may be influencing their beliefs — including their families, communities, and systems. These, too, affect health literacy, and not always for the better.

According to the National Center for Health Statistics, approximately 36% of adults in the United States have limited health literacy, with racial and ethnic minorities demonstrating lower than average health literacy scores than others. More importantly, 42% of people who report poor health status have below basic health literacy scores.

"As health literacy advances, your health outcomes advance," said Sturges. "But only if your patient can obtain and use the information you give them." The level of patient education is a contributing factor, but so is language. Use plain language and recognize that just because someone speaks English doesn't mean it's their preferred language. Make use of language lines and interpreters when needed.

Sturges encouraged the PAs in the audience to think of themselves as teachers as they share health information.

"Common knowledge isn't always common," he said. "You're teaching patients…" Learners have different needs. They vary from class to class and situation to situation. "Make sure you are able to assess for that when you give baseline knowledge — and then remember that repetition is important…Patients, like students, require supportive and encouraging learning environments. We want to make sure we create that in our spaces."

Assessing for Quality and Improvement

Many PAs are unaware that several free tools are available to help them assess patient education and health literacy. Greenlee first described the Simple Measure of Gobbledygook, a tool that PAs can use to determine the readability of any patient education material. By counting the number of words with three or more syllables in 10 consecutive sentences, PAs can determine if content is too challenging — or too full of "medicalese."

"It's an easy way to look at information you are providing to determine whether it is simple and easy to understand," he said.

He added that the Agency for Healthcare Research and Quality (AHRQ) also has the Patient Education Materials Assessment Tool on its website. Greenlee said it breaks down information, ranging from content to graphics, and more, to make it understandable.

"These are the things we have to think about when we are providing patients with written materials or putting information on a website," he said. Does the information encourage patients to take the needed steps to achieve the desired health outcome?

PAs can also use assessments on the AHRQ website to evaluate a patients' level of health literacy. This can help PAs better understand why some patients may be having difficulty adhering to treatment, and they can refocus their education efforts as needed.

However, Greenlee said that PAs can often make the most significant difference when encouraging their organizations to enhance their patient education offerings through quality improvement programs. Natasha Rodriguez Mancebo, PA-C, who works in a family medicine clinic in Chicago, Illinois, said this is why she was most interested in attending Sturges and Greenlee's session.

"There's so much room for miscommunication with the population I work with, which is predominantly Spanish speaking, low health literacy, with numerous barriers to access to care," she said. "I'm very interested in seeing how I can make our visits as productive as possible so I can better empower patients to take control of their health."

Greenlee recommended that PAs like Rodriguez Mancebo advocate for their organizations to participate in the US Department of Health and Human Services' National Action Plan to Improve Health Literacy — and start implementing strategies including looking for areas to improve. He suggested partnering with community institutions to develop more accessible and digestible health information, which is a great place to start, especially for organizations with limited resources.

Advocating for Better Education — and Better Care

After the presentation, both Sturges and Greenlee admitted that developing effective patient education is a challenging — but worthwhile task. Greenlee said one of the biggest hurdles remains convincing leadership of its value.

"You have to have someone in leadership who is really open to it," he said. "And that starts with your organization's mission statement. If your organization has a mission statement to improve care access or to deal with care inequities, it's up to us as PAs to bring it to their attention and say this is one way of helping to fulfill that mission."

Sturges said that he hopes that more PAs will educate themselves about health literacy and understand how it affects patient care.

"I think, once they have a better understanding, they can advocate for more effective patient education at a higher organization level," he said. "That's what it's going to take to implement some of these baseline assessments so they can develop actions in order to address and improve education and care."

Kayt Sukel is a healthcare and science writer based outside Houston.