Residents' perceptions of their health literacy skills and training needs across specialties

BACKGROUND: Low health literacy (HL) is common, particularly in underserved communities. HL deficits have been associated with patient safety issues and poor health outcomes. Provider use of HL-informed communication strategies, including plain language verbal and written communication, and use of “teach back” to confirm patient understanding, has been linked to improved patient outcomes, therefore; a “universal precautions” approach is recommended. A recent survey of medical schools found that 72 % of the 133 U.S. allopathic medical schools included HL in their curriculum, with a only a median time spent of 3 h in total (Coleman & Appy, 2012). As part of a needs assessment of residents at our institution, we surveyed residents across 7 programs to determine their previous training in HL, current practices, comfort level with HL skills and desire for further training. This allowed us to assess overall need and to identify differences by specialty. METHODS: Data was collected from residents via an online survey (Qualtrics) during the 2013-2014 academic year. Residency programs surveyed included Emergency Medicine (EM), Internal Medicine (IM), Obstetrics/Gynecology (OB), Orthopedics (OR), Pediatrics (PED), Primary Care (PC), and Surgery (SUR). Completed responses were received from 269 residents (of 394 total), for a response rate of 68% overall. This ranged from a 100% response rate from OR down to 57% from EM. HL questions for the survey were adapted from Schwartzberg et al. (2007) and Turner et.al. (2009). The following domains were assessed: 1) prior HL training (1Q), 2) use of HL techniques (8Q), 3) perceived skill in key HL techniques (3Q), 4) desire for HL training (1Q). Prior HL training was assessed with a question about whether they had HL training, and if so, where they received it. Use of HL techniques was rated on a 5-point Likert scale from1 (never) to 5 (always); techniques included teach-back, providing easy to read written materials, underlining key points on written materials. A Overall HL Use score was calculated by averaging responses (Cronbach's alpha=.88). Perceived skill in key HL techniques was, rated on a 4-point scale from 1 (not at all skilled) to 4 (very skilled); skills assessed included teach-back, choosing appropriate written materials, and converting medical terms into plain language. A HL Skills score was calculated by averaging responses (Cronbach's alpha=.70). Finally, participants were asked to respond to open-ended questions re: what HL training they would like. RESULTS: Sixty-five percent of residents reported prior training related to HL, with the majority of this being in medical school; educational formats used included didactics and OSCEs. Across specialties, 84 % of OR residents reported having had previous training, while IM was the lowest at 47 %. Statistically significant differences in reported Overall HL Use across programs was determined by one way ANOVA (F (6, 268)=8.77, p=.0.0001). Post hoc Tukey test revealed that SUR Overall HL Use score was significantly higher than the other specialties, (p=0.05). No other significant differences were found. For the HL Skill score, one way ANOVA was significant (F(6265)=3.48, p= 0.002). Tukey post-hoc analysis revealed that SUR was again the highest scorer, with scores significantly higher than both IM and OB (p=0.05). When asked what future training residents wanted, there were consistent themes across the specialties. Many residents wanted to know where to find easily accessible printed material suitable for low-literacy patients, ways to match health education literature to patients' HL levels, and pragmatic strategies for integrating HL approaches in a busy clinical setting with diverse patient populations. CONCLUSIONS: Most residents across multiple specialties report at least some training in HL during medical school, although the extent of such training is not known. There are differences between specialties with respect to self-reported use of and comfort with HL approaches, with surgeons feeling the most prepared and internal medicine and obstetrics trainees less so. In spite of their reported skill level, all groups identified need for further HL training. Additionally, this study assessed self-report of HL skill and use. To better understand differences by specialty assessing actual HL skill and use from an observational study is planned.