A Practical Approach to Health Literacy: A Primer for Athletic Training Educators

Patient Education Project and Health Literacy Rubric Criteria

Rubric criteria (Table 2) were developed to assess athletic training students' health literacy competence in some of the elements essential to athletic training clinical practice. The following section presents the health literacy–specific criteria included in the rubric along with context for assessment methodology. These descriptions also act as a primer to guide the development of didactic instruction modules.

Table 2 Patient Education Project and Health Literacy Rubric Criteria

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Plain Language

One essential principle in both written and verbal communication is the concept of using plain language (ie, words that are easy for everyone to understand). It is best to avoid medical jargon and abbreviations in conversation with patients to ensure understanding.^2,7 There are some readily available plain language dictionaries and other useful resources through credible organizations and websites (Table 1). Another example of language that may be open to interpretation is the use of words that can be subjective, such as “suggest” or “might.” The patient may find these too vague to follow or understand.² It is helpful to be clear and concise, especially when people are anxious or injured. Also, words that imply measurement or scale, such as “minimal” or “moderate,” which are often used with pain scales, may need to be qualified and quantified for better understanding and consistency.² For example, the advice to get “adequate” sleep at night can be interpreted differently. Providing patients with more concrete parameters can help with compliance and outcomes.

Additionally, ATs should be mindful of the potential need for conceptual understanding required to grasp conditions, treatment options, and care plans. Anatomy, physiology, and biology, as well as numeracy concepts in pharmacology and nutrition can be challenging for patients. Providers should be able to explain these concepts in more accessible ways using plain language to increase patient understanding.

Visual Aids

One strategy that can support understanding of conceptual information is to use visual aids. Clinicians should build a personal collection of images or drawings to illustrate anatomical structures, signs and symptoms of injuries, and physiology of illness. Additionally, visual aids can be used to provide home care or discharge reminders as many patients and caregivers prefer written materials in addition to verbal instructions.¹³ Clinicians may perceive certain phrases or descriptors as common or universal, but that is not always true for the patient. For example, the names of certain exercises (eg, “dead bug”) may differ between health care providers or other information sources. It is helpful to provide website sources that include visual aids. If internet access is a challenge for the patient, the clinician may take photos or videos of either the patient or themself performing the exercises during the appointment to create visual reminders and cues.¹⁴ The AT can print a supply of visual aids in advance of discussions with patients or have copies on file so that they are easily retrieved from a laptop, tablet, or phone.

Consumer Health Information (Web-Based Resources)

ATs can also prepare health education resources by compiling some reliable and credible web-based resources, such as MedlinePlus¹⁵ that patients can explore later. By partnering with patients as consumers of health information, ATs can reduce confusion when navigating or interpreting internet-based information. Researchers found that patients prefer when clinicians provide suitable websites to support patient education.¹⁶ The key is to be prepared in advance with ready access to commonly recommended information fact sheets and trusted online resources.

Checking for Understanding

Checking for understanding is an essential step to ensure clear communication and patient safety. While there are many strategies, the teach-back method is commonly used in many health care professions.^17,18 The teach-back method puts responsibility on the provider to ensure patient understanding, while still actively engaging the patient. The key strategies in the teach-back method are to use open-ended questions and demonstrations with the patient.^17,18 The AT starts by checking for understanding using phrases that emphasize provider responsibility (for instance, “I want to make sure I explained that clearly” and “Can you repeat that back to me?”). In the case where the patient is expected to perform a skill independently, the provider asks the patient to practice or demonstrate with supervision. Next, as the patient repeats or demonstrates instructions, the AT should find opportunities for positive reinforcement or corrective information. The process of checking for understanding continues until both the clinician and the patient are satisfied.^17,18 If the AT needs to provide excessive correction or the patient is having trouble understanding, the AT should take that opportunity to figure out why and determine how they can adjust their communication so that the patient understands. For example, the AT should first address concerns if the patient is upset or anxious about the injury or illness, identifying whether there may be a cognitive or sensory impairment or difficulty, making accommodations for cultural differences or preferences, or modifying the environment if it is loud and distracting.

Before the patient leaves the appointment, the AT should end with one more open-ended question to invite questions or need for any further clarification.¹⁹ For example, asking the patient, “What questions do you have for me?” removes the ability to answer with a “no,” and it shows the patient that questions are welcome.¹⁹ Health care appointments can be stressful, and patients may forget their questions, or they may not have the confidence to engage in discussion for fear that they may not understand the jargon or concepts. Cultural or generational differences may also play a role in what is acceptable in terms of asking questions to authorities or providers. It is important to create a culture that invites questions, and to partner with and empower patients in their care.¹⁹

Shared Decision-Making

Health literacy techniques can also improve shared decision-making. Empowering patients through health literacy can increase self-advocacy and encourage active engagement in care plans and the informed consent process.⁶ Improved patient outcomes are connected to both patients asking questions and speaking up during appointments and to the shared decision-making process.⁶ ATs can support patients by giving them tools for asking questions or by offering to act as a liaison during appointments with other health care providers to help with understanding medical forms and complex concepts or procedures (eg, informed consent).

Athletic training students are instructed and assessed on the following shared decision-making elements.

Cultural Humility (or Sensitivity)

Another key health literacy skill is cultural humility or sensitivity. The National Culturally and Linguistically Appropriate Services standards provide a blueprint for health care professionals and organizations to “provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.”²⁸ ATs must consider how religion, culture, ethnic customs, and other factors may impact the way that health advice is received.^2,7,24 The AT should be familiar with common cultural practices with respect to diet, interpersonal contact, and decision-making that could impact the treatment course. For example, eye contact and physical touch may be considered offensive in some cultures.² While it is critical to avoid stereotyping any individual patient, the AT may address cultural differences by respectfully inquiring, “Is there anything I should know about your culture, beliefs, or religious practices that would help me take better care of you?”⁹

An awareness of the use of idioms (ie, sayings and phrases) that are common to the English language is important. Words, gestures, and phrases are not always universal and may create confusion when a patient is trying to follow a conversation. For example, “feeling blue” doesn't represent the same sad emotion in all cultures, so someone may not pick up on the expression as a question about depression.² These sayings can be so ingrained that it requires intentional awareness and training to avoid creating confusion and misunderstanding in communication with patients. There are numerous cultural humility training resources available to health care professionals (see Table 1 for examples). Short training videos, tip sheets, and websites that provide detailed information on specific cultural customs and beliefs that may impact the health care of certain individuals may be accessed online and incorporated into educational preparation and continuing education.

Didactic Instruction

The model professional athletic training program organizes the health literacy concepts and skills described above through several module presentations:

• Module I: Introduction to Health Literacy, which provides an overview of health literacy definitions and literature, the connection to quality care aims, and an overview of foundational principles and skills (ie, plain language, visual aids, health consumer information).

• Module II: Approaches to Patient-Centered Care (part 1), which introduces cultural humility and social determinants of health definitions,²⁴ concepts, and implementation strategies.

• Module III: Approaches to Patient-Centered Care (part 2), which introduces both tools for checking for understanding and concepts and techniques for shared decision-making (ie, empowering patients, asking questions, and informed consent).

• Module IV: Professional Responsibility and Communication, which uses the AHRQ Health Literacy Universal Precautions Toolkit health literacy assessment for providers,⁹ and IP communication strategies (ie, closed-loop communication, SBAR).

The model professional program begins didactic instruction with broad health literacy concepts (modules I and II) in the first semester to set a foundation for application of information in future courses. Additional health literacy concepts and specific tools (modules III and IV) are then continuously threaded throughout the curriculum. For example, in courses related to examination and assessment, and therapeutic intervention, athletic training students are introduced to specific tools such as SBAR, teach-back method, and Ask Me 3, as well as the informed-consent process. This design allows for scaffolding of health literacy outcomes as students progress through the curriculum. Courses in which to integrate modules may be selected based on faculty expertise and course learning objectives. Individual programs and educators should decide which and/or how much content to present in each module, and where modules best align in their curriculum.

Simulation-Based Experiences

Simulation-based experiences (SBE) are carefully designed and controlled to create realistic learning environments for health care students to practice skills safely and autonomously.²⁹ Essential elements of the SBE include developing appropriate learning objectives and assessment tools; incorporating intentional design of the environment and/or case (eg, faculty/content expert(s) create scripts and context); providing students with pre-brief or orientation to the activity and expectations; supervising and facilitating student SBE performance to maintain safety and fidelity; and a conducting a structured debriefing session to discuss learning objectives and student performance (eg, discuss what went well, what should be done differently).²⁹ While some SBEs may use equipment such as manikins or other resources such as simulated participants (SPs) to mimic patient encounters and interactions, there is a broad spectrum of experiential learning activities that may be implemented by professional programs that do not have access to resources or simulation-trained faculty. For example, applying best practices to case studies, role-playing, or partnering with other health care education programs can be implemented with minimal resources.³⁰

This model professional athletic training program integrates SBEs using SPs consistently throughout the curriculum, including 2 immersive simulation-based weeks and at least 2 SBEs in each clinical course in which cases (ie, SP scripted responses, objective findings, environmental and physical fidelity) are developed by faculty and content experts. The faculty use results from a needs assessment in combination with conditions highlighted in the CAATE educational standards¹² and specific course learning objectives to determine the topics for cases. Individual programs and educators should begin with a needs assessment to identify critical learning objectives associated with a course and/or gaps in student knowledge, skills, or clinical experiences.²⁹ For example, faculty have designed SBEs to assess concussion, mental health conditions, asthma, and various orthopedic injuries; to standardize experiences with certain tasks such as developing and instructing injury prevention, human performance, or rehabilitation programs; and to participate in difficult conversations with stakeholders. Additionally, faculty use SBE to assess student's knowledge and skills related to high-risk/low-frequency events (eg, activating the emergency action plan (EAP), cervical-spine injury, exertional heatstroke).

As ATs often practice in collaboration with other health care providers,²⁷ athletic training students may benefit from shared learning experiences with other health care education students or providers. Interprofessional education in simulation (Sim-IPE) is an enhanced type of SBE that can be designed by educators to provide a chance to practice health literacy and IP communication skills in real contexts.³¹ For example, faculty from this model professional program coordinate SBEs with various professions (eg, nursing, social work, medical interpreting, pharmacy, EMS). During Sim-IPE, athletic training students focus on executing techniques and tools, such as closed-loop communication or SBAR, with feedback from peer professionals, as well as exploring their role in supporting shared decision-making and patient advocacy. Students can also hone IP communication skills through documentation in a simulated electronic medical records system and/or include a written SBAR script if no Sim-IPE is available.

Depending on the objectives of the experience, formative and/or summative assessment with the rubric criteria can be used during an SBE. Beyond traditional athletic training skills (eg, performing an evaluation, developing a differential diagnosis), SBE learning objectives emphasize application of health literacy when communicating with SPs throughout the patient encounter, and effective IP communication. This model professional athletic training program uses the health literacy rubric as both formative feedback during debriefing sessions to guide discussion about health literacy skill development as well as a summative assessment of the student's holistic clinical performance. SBEs provide an authentic opportunity to assess students' health literacy and communication skills, especially the use of plain language, checking for understanding, cultural humility, and shared decision-making. One benefit of using SPs is that they can react to the athletic training student to prompt health literacy skills. SPs are instructed to question medical jargon or terminology, abbreviations, and cultural idioms used by the student. Athletic training students demonstrate shared decision-making by explaining their examination procedures, differential diagnoses, and recommended interventions clearly, gaining continuous consent from SPs, and empowering the patient to participate in the process. Additionally, students can demonstrate cultural humility by asking the patient about personal and cultural preferences and any barriers to care recommendations or plans. For example, the athletic training student should engage patients in decision-making and informed consent when referring the patient to a specialist, discussing the potential for surgical intervention, or transporting the patient to the hospital.

Problem- or Project-Based Learning

Active learning strategies such as problem- and project-based learning (PBL) are effective pedagogic strategies that help students critically interpret and apply their health literacy knowledge and skills to complex questions or scenarios.³² The model professional program implements PBLs in 2 ways. First, problem-based learning activities are incorporated in didactic condition-specific modules through embedded unfolding patient cases (eg, patient complaining of chest pain and shortness of breath presented in cardiovascular and respiratory content). As the case unfolds, students are posed increasingly complex and comprehensive questions or information to consider as they move through the content. Students then answer these questions and related health literacy prompts in which they are asked to identify health literacy elements within the case (or the lack thereof), describe how they believe these elements impact patient outcomes, and make suggestions for improvement of health literacy. Faculty then facilitates discussion about the case and health literacy learning objectives.

An example of a project-based assignment used by this model professional program to comprehensively apply and assess students' health literacy is a patient-education project due at the end of the semester. Athletic training students select or are assigned a patient case (eg, from an SBE, a case study from a clinical experience [following all HIPAA regulations], or developed by the instructor). They then design comprehensive patient education including an oral presentation as if they are speaking to the patient, along with accompanying written materials (eg, visual aids, web-based resources). Specifically, students are required to provide background information on the condition, make intervention recommendations, and suggest prevention strategies to address the key elements of informed consent as well as consider the patient's social determinants of health.