Marissa Slack
11-16-2007
Introduction/Questioning
The primary concern speech-language pathologists (SLPs) have is the successful habilitation or rehabilitation of their client’s speech, language, and hearing. This concern is certainly appropriate considering the SLP’s job description, and in no way should it be deemed otherwise. However, an issue that I would argue as an equally essential component to the success of therapy is the comprehension of information given to the client and/or the client’s parents/guardians/family by the SLP. Without the understanding of what one’s disorder entails regarding its challenges, prognosis, and expectations of the client and or parents/guardians/family of the client for successful treatment, therapy is not as effective as it could be.
Before I decided to research health literacy as it applies to the field of speech-language pathology, I considered investigating a couple of other topics related to literacy. After discovering a lack of resources for my first two topics, low socioeconomic status and its effects on literacy and literacy in Appalachia, I stumbled upon health literacy. I had little knowledge about health literacy, but was fairly certain that part of it was an individual’s ability to understand vocabulary related to health. Aside from knowing this, I had not previously thought about health literacy, especially not as an obstacle that SLPs must overcome to effectively treat the clients they serve. I quickly found seven pieces of literature to use as references, so I committed to the topic. Obviously, I had a great deal of research to accomplish because of my restricted knowledge about health literacy. However, only once I had committed myself to this issue did I learn just how little research there was to explore.
Research indicates that poor health literacy, or lack of “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”, is a serious adversity in the United States (“Health Literacy,” 2006). Only over the past five years has the problem that is health literacy been addressed at the national level (Andrulis & Brach, 2007), and literature related to health literacy within the profession of speech-language pathology is scarce, with only three studies conducted between the years 1984 and 2003 (Hester & Benitez-McCrary, 2006). Before SLPs can compensate for the presenting problem, the factors that put people at greatest risk for this adversity and the activities that those who have limited health literacy may have difficulty with must be addressed. Hence, the objectives of this paper are to delineate and discuss some of the factors that affect a client’s health literacy skills, to examine the activities individuals may have difficulty with, and to provide a basic strategic outline that speech-language pathologists can use to better ensure each client’s understanding of their speech and language health. To achieve these objectives it was necessary to ask the following five questions: What is health literacy? What populations are at greatest risk for poor health literacy? What are the implications for poor health literacy? Regarding speech-language pathology, what activities may be difficult for a client with limited health literacy? What strategies do other medical professionals utilize to ensure their patients’ understanding of health information?
Searching
Recent studies have shown that the primary factors that can influence an individual’s health literacy include, but are not limited to, race, language, and education. Because these are also factors that can have a significant impact on the traditional notion of literacy, recently defined as “an individual‘s ability to read, write, and speak in English and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one‘s goals, and to develop one‘s knowledge and potential”, that they impress on health literacy is not far-fetched (Berkman, et al., 2004). The data regarding these factors and their relationship with limited health literacy confirms the need for consideration and action by SLPs to research and employ effective techniques to improve their client’s understanding of their speech and language health.
Findings across several studies have indicated that race plays a noteworthy role in predicting an individual’s health literacy. For instance, a study assessing health literacy in African American versus Caucasian adults showed African Americans scoring significantly lower on the Rapid Estimate of Adult Literacy in Medicine (REALM) than Caucasians, except for groups that had a college education (Shea, et al., 2007). According to another article, Integrating Literacy, Culture, and Language to Improve Health Care Quality for Diverse Populations, when the National Assessment of Adult Literacy (NAAL) 2003 statistics were released, black Americans and Hispanics had the highest number of people with poor health literacy skills, 58% and 66% respectively, while those classified as white only had 28% with low health literacy (Andrulis & Brach, 2007).
Literature on the affects that aspects of language can have on health literacy reveals alarming statistics. A significant challenge that a clinician may confront concerning language and health literacy is the barrier created by a foreign language. On the Health Activities Literacy Scale (HALS), a component of the National Adult Literacy Survey (NALS) that ranges in score from 0 to 500, natives of the United States had an average HALS proficiency of 278. However, “adults who were born in Spanish-speaking countries had an average HALS proficiency of 170”, a score that is “more than 100 points, or 1.75 standard deviations, below the average HALS proficiency of adults born in the United States” (Rudd, Kirsch, & Yamamoto, 2004). Additionally, Census 2000 indicated that there were 47 million people amongst 262.4 million who spoke a language other than English in the home. Also found in Census 2000 was the number of those people who spoke a language besides English in the home who reported speaking it “very well”, “well”, “not very well”, or “not at all” (United States Census Bureau [USCB], 2003). Those who described their ability to speak English as “very well” in Spanish was 14.3 of 28.1 million, in other Indo-European languages was 6.6 of 10 million, of Asian and Pacific Island languages was 3.4 of 7 million, and of all other languages was 1.3 of 1.9 million. These statistics not only show the number of people who speak English “very well”, but also reveal the number of people who do not speak English “very well”. This demonstrates the need for an alternative and/or supplement to verbal language when SLPs communicate with patients who speak a language other than English in the household (USCB, 2003).
An additional aspect of language that can prevent adequate comprehension includes the existence of a communication disorder in the client. Unless a parent, guardian, or family member is responsible for the information, an SLP converses with the client whose reason for visiting the SLP is his/her communication disorder. Thus, special attention and alternative means of communication may be required to effectively send a message to a client (“Health Literacy,” 2006). Education is yet another facet that can affect one’s health literacy. A recent policy information report conducted by the Educational Testing Service (ETS) showed that the average score on the HALS for those people who had not finished high school or obtained a General Equivalency Degree (GED) was 220, who had graduated from high school or obtained a GED was 271, and who had education after high school was 306 (Rudd, Kirsch, & Yamamoto, 2004). To further stress the significance of these findings, in the 1990s there were roughly 52 million adults who had not completed high school or earned their GED, suggesting that each of these adults have poor health literacy (Rudd, Kirsch, & Yamamoto, 2004). Furthermore, limited health literacy does not only affect an individual client, but can also be examined from an economic perspective. For instance, a study conducted at the University of Arizona at Tucson discovered that “healthcare costs for patients enrolled in Medicare, who were identified with low literacy skills, were more than four times as high as costs for patients with high literacy ability-roughly $13,000 per year vs. $3,000 per year” (“Health Literacy,” 2006). The National Academy on Aging Society estimated that in the year 1998 an astounding $50 billion to $70 billion dollars was what poor health literacy cost society (Rao, 2007). Due to lack of research in this area as it relates to speech-language pathology, the implications have yet to be identified. For other medical professions, “longer and more frequent hospital stays, ineffective uses of prescriptions, and lack of comprehension of treatment plans” are the results of poor health literacy (Rao). Therefore, the consequences for speech-language pathology could be similar, in which case clients may be in therapy longer, fail to follow through with speech and language homework, have a lack of comprehension of treatment plans, and/or have a greater chance of needing services on multiple occasions.
To address the problem at hand, it is not enough to know what factors are red flags for limited health literacy. It is also critical to be familiar with what skills comprise health literacy specific to the field of speech-language pathology. Because there is a lack of research concerning this issue, the following are only suggestions as to what skills make up health literacy in speech-language pathology: the ability to successfully fill out a case history form, to understand a diagnosis, to comprehend treatment plans and the prognosis of a disorder, to understand the most current research in order to make an educated decision, and to carry out speech and/or language homework.
Currently, there is no formal test with which to assess health literacy skills within the field of speech-language pathology. There is also no formal inventory of possible strategies for SLPs to employ to better ensure clients’ understanding of their speech and language health. Inside the boundaries of this paper, it is impractical to develop a standardized assessment with which to provide SLPs. However, with knowledge of the populations at greatest risk sufficing for the lack of a formal assessment to classify individual clients, it is certainly possible to modify strategies employed by other medical professionals to provide alternatives to sufficient health literacy in speech-language pathology.
Aside from the more obvious and less complicated strategies to apply, such as speaking more slowly and in simple language, other options include writing down the instructions for the patient, asking the patient to go through the instructions with office personnel as a review, and asking the patient how they will implement the instructions once at home. Although each of these are valuable methods, in a recent study examining the frequency of use and effectiveness of communication techniques, specific approaches were rated by physicians, nurses, and pharmacists as most effective. These techniques include the teach-back technique, following up with a phone call, and use of models and pictures (Schwartzberg, Cowett, Vangeest, & Wolf, 2007). Ironically, although these methods were ranked as highly effective, they were also reported as those used the least (Schwartzberg, et al., 2007).
Results of one particular study reported on the teach-back technique, or when a clinician asks a patient to repeat information to verify understanding. Using the teach-back method was rated as 92.8% effective by physicians, nurses, and pharmacists, suggesting that the teach-back technique can compensate for limited health literacy not only in patients receiving services from these professionals, but from SLPs, as well. (Schwartzberg, et al.). For instance, a clinician could inform a parent about how to conduct speech homework with his/her child by giving three or four basic directions. These directions could include guidelines on how often to review homework, appropriate setting in which to conduct homework, amount of cueing to use, and when to reinforce correct target behavior. After stating these directions the clinician could then ask the client to repeat them to ensure the client processed the information.
Research has also shown that following up with the patient via telephone is a very constructive choice, as physicians, nurses, and pharmacists rated this strategy as 84.8% effective (Schwartzberg, et al.). For example, if an SLP provided a parent with verbal and written instructions on how to assist his/her child in practicing oral motor exercises at home, the SLP could call the parent to ask if he/she had any questions or needed clarification. I am definitely an advocator for this strategy because I have witnessed a parent enter the end of a therapy session with questions that should have been previously addressed. The parent said that her daughter was working on oral motor exercises at home but that she neither knew how to help her perform them correctly, nor did she have a clue as to what purpose they served. Thus, a simple phone call after important information has been relayed to a client or a client’s parent/guardian/family member can be productive.
Using models and pictures to assist a client in understanding information about a disorder could be very effective (Shwartzbher, et al.). For instance, if a client has a voice disorder, rather than relying solely on written text as a supplement to explain the disorder, a clinician could use a picture or model of a larynx while describing what is wrong. A second instance in which using a model or picture could be helpful is with a patient who has a traumatic brain injury. If the patient or a patient’s family wishes to understand why he/she has difficulty with language or has had a change in personality, a clinician could use a model or picture of the brain showing where damage occurred and why the patient was exhibiting certain deficits or traits.
Learning about the aforementioned techniques is essential to overcoming limited health literacy in clients, yet it is not enough to simply be aware of them. An SLP must possess the ability to implement these strategies. Thus, I present a final method to put to use. Over 40 years ago the “programmed” patient was developed to provide students training to be doctors with realistic patients on which to practice their newly acquired skills and knowledge (Manning & Kripalani, 2007). After two term modifications, first “simulated” patient and now “standardized” patient, the use of this learning technique is implemented today, and I believe it to be highly adaptable to speech-language pathology (Manning & Kripalani). If future SLPs had the opportunity to experience a realistic client-clinician interaction they could have the chance to improve their skills and grow comfortable with executing these techniques. As a result, when an authentic patient has difficulty with health literacy clinicians who had the opportunity to work with a “standardized” patient could be better prepared and more effective in overcoming the barrier to successful treatment.
Conclusion/Answering
After researching health literacy I gained knowledge of its general definition, what factors can negatively impact one’s health literacy, the economic implications of poor health literacy in patients, and techniques used by medical professionals that can be modified to compensate for limited health literacy in speech-language pathology. Because research on the relationship between limited health literacy and health disparities in speech-language pathology has yet to exist, I learned that there is a vast amount of data that demands exploration. The influences of language, race, and education on health literacy, in addition to factors such as culture and income not mentioned in this text, must be further investigated to better guarantee efficacious speech and language treatment of clients. It is not sufficient to only know who is at greatest risk for poor health literacy, but why and how to overcome the challenges that emerge as a result of it.
Somewhere during the long hours of digging through data in search of information pertinent to health literacy and the late nights that consisted of examining the minute amount of literature that does exist, I grew passionate about this topic. True, there is a never-ending list of issues for speech-language pathologists to explore, but this fact does not suggest that research on health literacy is any less critical to the success of speech-language therapy. Investigations of the best techniques to use to substitute for clients’ limited health literacy, as well as the long-term implications of limited health literacy, are necessities to the advancement of the field I am currently pursuing.
