Promoting Health Literacy with Orofacial Myofunctional Patients

Abstract

The definition of health literacy is provided along with information substantiating its importance. Focused initiatives, the consequences of poor health literacy, and at-risk populations are briefly discussed. The focus of this article is the application of health literacy principles to the discipline of orofacial myology and how the promotion of health literacy facilitates positive growth for patients, orfacial myologists, and the professions. The article concludes with a vision for a health literate society.

WHAT IS HEALTH LITERACY?

Health literacy is an issue that is receiving a great deal of attention, and rightly so. Health literacy skills are absent in over half of the United States population (National Institutes of Health, 2007); this is a disturbing fact given that these same skills and strategies often lead to a longer life, improved health, reductions in the consequences of health problems, and cost savings (National Institutes of Health, 2007). The most widely cited definition for health literacy is the degree to which individuals have the ability to acquire, process, and understand basic health information and the services needed to make suitable health decisions (Ratzan & Parker, 2000). Health literacy is not simply an issue of being able to read or being formally educated; rather, it is a more complex process that involves reading, listening, analyzing, making decisions, and applying these skills to individual health care situations (National Network of Libraries of Medicine, 2007). Areas that are typically associated with health literacy include: practitioner-patient communication, instructions to patients, publications provided to patients, consent forms, insurance forms, patient history, and assessments for allied health programs such as speech-language pathology (National Institutes of Health*).

HEALTH LITERACY IN THE FIELDS OF SPEECH-LANGUAGE PATHOLOGY AND DENTISTRY

Health literacy supports improved care and informed decisions among patients as well as enhanced communication between clinicians and patients. Many disciplines, including the fields of speech-language pathology and dentistry, are currently working to advance the issue. The American Speech-Language-Hearing Association (ASHA) has recently taken several steps to educate speech-language pathologists regarding health literacy. ASHA offers a health literacy page on its Web site, which lists data, points for professionals to consider in their daily work, and helpful links to further information (ASHA, 2006). In addition, ASHA has focused on health literacy in two of its electronic newsletters, Access Audiology and Access SLP Care. In 2006, Hester and Benitez-McCrary discussed research directions for speech-language pathologists relating to health literacy, in light of the fact that their literature review only revealed three studies from this area.

ASHA encourages investigations into the impact of communication disorders on health literacy. The American Dental Association has taken a formal position on oral health literacy, having passed at least four resolutions on the matter, supporting initiatives to improve provider communication skills and strengthen oral health literacy among all patients to support quality care and improved outcomes (American Dental Association, 2007; Crozier, 2006). Health literacy is a national and global concern. The United States Department of Health and Human Services (2000) highlights health literacy in its Healthy People 2010 initiative. The National Institutes of Health also recognizes the importance of health literacy and supports research addressing the matter. Furthermore, Canada and numerous other countries also recognize the need to promote health literate societies.

The literature overwhelmingly cites the critical need to address and improve health literacy. Available research includes studies ranging from hypertension to cancer treatment. Over 90 million adults, or nearly one-third of the population, have difficulties understanding and acting upon health information (Institute of Medicine, 2004). The American Medical Association (1999) states that poor health literacy is a stronger predictor of an individual’s health than his/her age, income, occupational status, education level, and race. Low health literacy is associated with serious economic consequences. The National Academy on an Aging Society (1999) estimated that additional health care costs of approximately $73 billion were associated with low health literacy.

WHO IS MOST AT RISK FOR LOW HEALTH LITERACY?

The most vulnerable individuals are the elderly, or those aged 65 and older, minorities, immigrants, persons from low income backgrounds, and those suffering from chronic mental and/or physical conditions (National Network of Libraries of Medicine, 2007). These same individuals are often members of the groups that are at risk for other problems, including poor access to care, higher mortality rates, longer and more costly hospital stays, and decreased screening rates for serious conditions. If health literacy is improved among these populations, then what are the possibilities for improving other facets of the health care system for them, i.e., quicker resolution of health problems, longer lifespan, shorter and less costly hospital stays, and maybe even prevention of life-threatening illnesses?

APPLYING HEALTH LITERACY PRINCIPLES TO THE FIELD OF OROFACIAL MYOLOGY

Health literacy is a pervasive, significant, and essential topic for all health care professionals. The discipline of orofacial myology, in keeping with its ability to recognize and apply contemporary ideologies, must also appreciate the importance of creating and fostering health literacy within the patients it serves. Specific applications for health literacy in orofacial myology include: (1) clearer written materials for patients and/or parents, (2) better verbal communication and counseling with patients and their families, particularly to enhance assessment and treatment, to promote compliance with homework assignments, to respond to questions and concerns and (3) increasing marketing to and training for the public about the field and the services provided (National Institutes of Health, 2007). Ultimately, health literacy helps clinicians to help their patients by empowering them with knowledge; such knowledge assists patients in making informed decisions about their condition and potential treatment, which will hopefully have a positive impact on their participation and ownership of the recommended therapy program.

Written Materials for Patients

The literature is brimming with information and techniques that the orofacial myologist may use to improve and promote health literacy with patients. The clinician must be mindful of the written materials disseminated to patients and their caregivers. Written materials are essential to proper prevention, diagnosis, and home exercise programs (Vanderhoff, 2005). However, a serious problem with written educational materials, whether clinician-generated or purchased from outside agencies, is that they are often written at a level far beyond the average person’s comprehension (Vanderhoff, 2005). Research suggests that 1 out of 5 American adults reads at the 5th grade level or below, with the average American reading at an 8th to 9th grade level; most health care materials are written above a 10th grade level (Kelly, 2003).

When preparing written materials for parents, orofacial myologists may find adapting Benway’s (2005) guidelines useful. Benway offers the following five guidelines. First, start at the beginning, assuming that the patient knows little or nothing about orofacial myofunctional disorders, treatment choices, or the next step. Second, clinicians should literally take the reader by the hand and guide the individual to the next step. Third, focus on the patient’s behavior in written materials, since the goal is often to change a behavior. In order to focus on the behavior, the orofacial myologist must focus on the desired action, not on facts or principles. Next, use clear pictures and illustrations, because a well-selected photograph or drawing can accentuate a key point or clarify a difficult concept in the clinician’s written material. Illustrations, when chosen carefully, offer a window of understanding, especially for poor readers. Finally, remove the excess in written materials, and with practice, this should become easier.

There are individuals who might argue that simplifying printed materials for patients is a disservice. However, Benway (2005) strongly states that nothing could be less true. In patient education, clear communication is fundamental. Orofacial myologists perform a service to their patients by choosing words carefully and by writing in terms that can be easily understood and acted upon. Provide patients and parents with written materials. However, go beyond simply giving them a piece of paper and allow patients time to look over the information and ask any questions about what was just read (Vanderhoff, 2005). Visuals and written materials should never be the sole means of communication between clinicians and patients (Dowse, 2004). Likely the best scenario for offering patient information is referring to written materials or visuals while simultaneously providing a verbal explanation, or the explain-ask-listen approach (Dowse, 2004; Vanderhoff, 2005).

Based on this author’s personal experience, training oneself to speak and write in jargon-free language, avoiding medical and technical lingo, is paramount! Clear written communication is important, but the way a clinician speaks to and counsels patients is probably even more critical. During the initial office visit, remember that parents of children with orofacial myofunctional disorders and patients themselves may have already read extensively about a condition, with much of the reading taking place from the Internet (Vanderhoff, 2005). The clinician must then become a filter for faulty data obtained by the parent and provide web sites that offer reputable, accurate, complete, and helpful information (Vanderhoff*, 2005). It is also the clinician’s responsibility to go a step further and provide supplemental information to that which the patient has viewed on web sites. Even though Benway (2005) suggests that clinicians should assume that the patient has little or no knowledge about a disorder, Kripalani (2004) offers a different approach when an individual is confronted with a new diagnosis, suggesting that a helpful technique to use during an initial session is to ask the patient or parent, for example, “What do you already know about tongue thrust?”

Communicating Effectively With Patients

Vanderhoff (2005) reminds professionals that effectively communicating with patients is essential to proper diagnosis and assessment. Establish rapport by encouraging a friendly exchange, allowing the patient and parent adequate time to feel comfortable in the new clinical setting (Hardin, 2005). The clinician may need to gently prod the patient or parent for complete information. Remember that children communicate differently, but they also want to be involved in their diagnostic session. Listen and respond to parents, but also afford the same courtesies to children.

Active listening is necessary, in which the clinician maintains eye contact and attention, holds an interested and open body posture, and responds with verbal and nonverbal cues to the patient, all without seeming wooden or artificial. Questions are always encouraged, as a key component of the clinician’s responsibility is to educate and inform, realizing that these actions ultimately help everyone involved. Last, don’t forget to smile! This part should be the easiest, especially if the clinician enjoys his/her job.

Demonstration and repetition are critical, especially in treatment sessions (Vanderhoff, 2005). Show patients how to perform their exercises and make sure that you ask them to follow-up by having them do the exercises independently, several times. The clinician may also use the teach-back method. If the patient struggles to teach back something that the clinician feels was clearly covered, then this is a red flag that the patient was simply nodding along without completely understanding what took place during the visit (Kripalani, 2004). The more effectively the clinician communicates during diagnostic and treatment sessions, the more likely it is that home carryover and implementation will be achieved accurately and completely. The key is to find more than one way to connect and explain ideas to patients, because the greater the variety of inputs, be they oral, visual, and/or kinesthetic, the more opportunities for the patient to retain and understand the concepts or activities (Vanderhoff, 2005).

Knowledge about a disorder is not enough for patients and parents, because they also need motivation (Vanderhoff, 2005). Orofacial myologists should not simply teach patients what to do. Instead, clinicians should go one step further and ask patients what they consider the barriers to be in their care, such as not enough time to follow through on exercises, financial factors, and so forth (Vanderhoff, 2005). In doing so, the clinician then has the opportunity to dialogue with patients regarding concerns, frustrations, and the benefits of therapy and exercises. Vanderhoff (2005) further cautions that patients are more receptive when their input is welcomed, when cultural differences are appreciated and considered, and when clinicians do not speak down to them.

There are many useful techniques in the literature for clinicians to use in communicating with patients. A study by Schwartzberg, Cowett, VanGeest, and Wolf (2007) highlighted communication techniques that were at least 80% effective. However, the authors discovered that the routine use of these techniques by pharmacists, physicians, and nurses was consistently lower than the effectiveness levels. For example, the teach-back method was found to be over 90% effective, yet the technique was routinely used only about 40% of the time. Written instructions yielded somewhat similar findings. The largest disparities in effectiveness versus routine use were found in the use of pictures, models, underlying key points, follow-up staff, and follow-up via telephone. The closest parallel was in using simple language, which was almost 100% effective, and this method is routinely used more than 90% of the time. Therefore, just because a technique is not only suggested for use and found to be effective through research, it does not mean the technique is actually being used on a consistent basis.

The Importance of Marketing Services

Low health literacy often prevents individuals from making full use of the latest treatments and contemporary clinical information (Pirisi, 2000). As a result, patients may never even be aware that they are in need of services or that their condition may be helped by an orofacial myologist. Orofacial myologists, like other health professionals, must also market their services and educate the public about the profession and its members. To accomplish this, use the same principles described earlier for the creation of written patient education materials. Beyond clear communication with consumers, marketing can be very rewarding for professionals and the International Association of Orofacial Myology. When the public is better informed about the discipline of orofacial myology, the greater the opportunities will be for the profession to grow and advance.

CONCLUSIONS

What is the ideal picture for a health literate America? Nielsen-Bohlman, Panzer, and Kindig (as cited by Cutilli, 2005) offer some inspiration and vision in their objectives: (1) Everyone has the opportunity to expand their health literacy. (2) All individuals have the chance to use reliable, easy-to-understand information that could make a difference in their overall well-being, including their everyday behaviors, such as how they eat and whether they seek professional help for health conditions. (3) Citizens are able to accurately assess the credibility of health information, whether it is provided by a health professional, commercial, web site, or another entity. (4) Culture context is infused into all health information. (5) Health professionals communicate clearly during all interactions with their patients, using everyday vocabulary. (6) There is ample time for discussions between patients and their health care providers, and patients feel comfortable to ask questions as part of bettering their condition. (7) Patients’ rights and responsibilities are presented and written in clear, everyday terms so that people can take needed action. (8) Informed consent documents are developed so that all people can give or withhold consent based on information they need and understand. Orofacial myologists are in a position to help paint this picture for a health literate society, not only for patients and their families, but across disciplines and specialty areas.