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Opinion
HEALTH CARE POLICY AND LAW
VIEWPOINT
Cliff Coleman, MD,
MPH
Department of Family
Medicine, Oregon
Health & Science
University, Portland;
and Center for Ethics
in Health Care, Oregon
Health & Science
University, Portland.
Samantha Birk, MS
Center for Ethics in
Health Care, Oregon
Health & Science
University, Portland.
Jennifer DeVoe, MD,
PhD
Department of Family
Medicine, Oregon
Health & Science
University, Portland.
Corresponding
Author: Cliff Coleman,
MD, MPH, Center for
Ethics in Health Care,
Oregon Health &
Science University,
3181 SW Sam Jackson
Park Rd, UHN-86,
Portland, OR
97239-3098
(colemanc@ohsu.edu).
Health Literacy and Systemic Racism—Using Clear Communication to Reduce Health Care Inequities
People need health information that is easy to understand to make informed decisions about health and health care. To knowingly restrict access to health information on the basis of race or ethnicity would be an indefensible violation of professional and ethical standards that would be met with outrage in the medical
community. Yet, inadequate communication training in the US medical education system, and insufficient accountability for delivering easy-to-understand health information at the organizational level, all too often does
just this. Despite required communications courses, curricular guidelines, and institutional policies, medical trainees and practicing clinicians commonly make health
information unnecessarily complicated by failing to use a variety of clear communication best practices, such as avoiding undefined medical jargon.1-4 This failure to communicate health information in its simplest and easiestto-understand form unjustly favors people who have
more education and higher health literacy. It systematically disadvantages American Indian and Alaska Native–, Black-, and Hispanic-identifying patients, who
experience lower average health literacy skills than their Asian/Pacific Islander and non-Hispanic White counterparts.5
The adverse effects of low health literacy on patient outcomes are broad and well described.3-7 Health literacy is one modifiable factor mediating the link between socioeconomic status and health disparities,7 and it is a better predictor of racial and ethnic health disparities than income and education.4 Although improving
individuals’ health literacy is an important national goal that will require input from education and other sectors outside of health care, concurrently ensuring consistent clear communication practices in all health care
settings would help reduce the adverse effects of lower health literacy.1,3,4,6 Failure to adequately train and support clinicians’ clear communication habits, and to hold
health care systems accountable for clear communication practices, promotes injustice. “Universal precautions” policies for delivering clear communication1,2,4
could help mitigate a form of systemic racism in health
care that may not be apparent.
Personal Health Literacy Disparities
The Healthy People 2030 national health objectives
identify health literacy as a “foundational principle”
in their overall framework, defining personal health literacy as an individual’s “…ability to find, understand,
and use information and services to inform healthrelated decisions and actions…”6(pS259) Personal health
literacy skills—a function of one’s education—are unevenly distributed across populations, with lower skills
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disproportionately affecting 48% of American Indian
and Alaska Native–, 58% of Black-, and 66% of Hispanicidentified individuals compared with 31% of Asian/
Pacific Islander–identified individuals, and 28% of nonHispanic White–identified individuals.5
Organizational Health Literacy
In contrast to personal health literacy, organizational health literacy is “…the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions…”6(pS259) This involves the production of easy-to-understand clear communication
by health care personnel. A robust set of consensusbased clear communication educational competencies and best practices has been identified.1 Health literacy is an educationally sensitive patient outcome, in that clinicians can be taught to use clear communication practices to mitigate the effects of lower health literacy.4,6 Yet, clinicians often overestimate patients’ health literacy skills and provide spoken and written information that is too complex or confusing to be of maximum benefit.1-5 For example, among 215 mostly college-educated adults, 25% misinterpreted the meaning of the seemingly straightforward phrase,
“You are to have nothing by mouth after 4:00 PM.”2
Clinicians frequently use undefined or unnecessary jargon, such as saying hypertension when saying high blood pressure would suffice. They also contribute to information overload by giving too much information too fast and at the wrong time, and they do not routinely elicit patients’ clarifying questions effectively;
they also do not routinely confirm patients’ understanding with a teach-back technique.1,3
Systemic Racism in Health Communication
Lack of organizational health literacy and clear communication policies are preventable, structural features of
US health care that contribute to systemic racism. Typical written and spoken health information is unnecessarily complex, is written at too high of a reading level,
is presented using unfamiliar jargon terms, and requires too high of numeracy skills for the average patient.1,3 This creates systemic disadvantages for patients with lower health literacy, who are more likely to identify as American Indian or Alaska Native, Black, or Hispanic individuals.5 The issue of unequal access to high-quality, understandable, and usable health information, by virtue of population differences in educationally determined health literacy, has received little
attention as a form of systemic racism.
(Reprinted) JAMA Internal Medicine August 2023 Volume 183, Number 8
© 2023 American Medical Association. All rights reserved.
Downloaded from jamanetwork.com by University of Rochester user on 05/07/2024
753
Opinion Viewpoint
Universal Precautions for Clear Communication to Reduce Systemic Inequities and Racism
For complex reasons, clinicians cannot reliably predict which patientswillunderstandwhichhealthinformationatagiventime.1,3 What looks to clinicians like good communication on the surface often belies significant confusion, misunderstandings, and informational gaps among patients and caregivers. A universal precautions approach to health communication is needed, wherein health information and advice are presented in their most understandable and actionable forms as the default for all patients at all times, regardless of education level
or perceived health literacy skills.1,2,4 The universal precautions approach requires habitual use of clear communication skills to minimize unnecessary complexity, and it allows greater accessibility to information for people with lower health literacy while improving communication for people with higher skills as well.1
Next Steps
In the 2 decades since the Institute of Medicine released its groundbreaking report, Health Literacy: A Prescription to End Confusion,3 many medical training programs have begun teaching about health literacy and clear communication. Educational outcome studies show
improved knowledge, skills, and attitudes among trainees1,4 and improved outcomes for patients.4 Such curricula, however, are not yet producing a workforce that consistently demonstrates the clear communication habits needed to eliminate racial and ethnic inequities in access to health information.1,4,6 Adopting universal precautions
practices for clear communication will require changes in how clinicians are taught to speak and write with clarity while maintaining accuracy. The challenges of achieving this goal should not be underestimated; communicating complex medical information in ways
that are consistent with the health literacy of patients can be hard
2013;18(suppl 1):82-102. doi:10.1080/10810730.2013.
829538
ARTICLE INFORMATION
Published Online: June 26, 2023.
doi:10.1001/jamainternmed.2023.2558
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Susan Tolle,
MD, Center for Ethics in Health Care, Oregon Health
& Science University, for her helpful feedback in developing this article. Dr Tolle was not
compensated.
REFERENCES
1. Coleman CA, Hudson S, Maine LL. Health literacy practices and educational competencies for health professionals: a consensus study. J Health Commun.
754 work. Innovative tools are also needed for assessing jargon and information overload during spoken exchanges, as well as different incentives for professional behavior in some situations. For example, empowering patients with easier-to-understand information could result in lost revenue from fewer encounters and avoidable procedures. Training programs and accrediting agencies, such as the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, should set and enforce measurable competency-based standards for a core set of clear
communication practices.1
Graduating health professionals should be assessed for their ability to avoid unnecessary and undefined jargon, avoid information overload, elicit patients’ clarifying questions, and confirm adequacy of communication by using the teach-back technique, among other patient-centered communication skills.1 Clear communication skills should be observationally assessed using tools such as behavioral checklists during encounters with real and standardized patients.4 Health system accreditation agencies, such as The Joint Commission, should in turn set objective practice standards for ensuring that clear communication has occurred, and that it is delivered equitably across racial and ethnic, education, and health literacy skill groups. The assessment of such standards should be based on measures of patients’ functional understanding or observed health behaviors, rather than just self-report.
Unnecessarily complex health information is an overlooked source of systemic racism for populations who have lower health literacy, with implications for a broad array of adverse health-related outcomes.3-7 Policy interventions that promote universal precautions for clear communication among health care trainees and working professionals are an approach to reducing this form of racial and
ethnic inequity in health care.
2. Gotlieb R, Praska C, Hendrickson MA, et al.
Accuracy in patient understanding of common medical phrases. JAMA Netw Open. 2022;5(11):
e2242972. doi:10.1001/jamanetworkopen.2022.
42972
3. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds.
Health Literacy: A Prescription to End Confusion.
The National Academies Press; 2004. doi:10.17226/
10883
4. Yin HS, Jay M, Maness L, Zabar S, Kalet A.
Health literacy: an educationally sensitive patient outcome. J Gen Intern Med. 2015;30(9):1363-1368.
doi:10.1007/s11606-015-3329-z
5. Kutner M, Greenberg E, Jin Y, Paulsen C.
The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy.
National Center for Education Statistics, US Dept of Education; 2006.
6. Santana S, Brach C, Harris L, et al. Updating health literacy for Healthy People 2030: defining its importance for a new decade in public health.
J Public Health Manag Pract. 2021;27(suppl 6):
S258-S264. doi:10.1097/PHH.0000000000001324
7. Stormacq C, Van den Broucke S, Wosinski J.
Does health literacy mediate the relationship
between socioeconomic status and health
disparities? integrative review. Health Promot Int.
2019;34(5):e1-e17. doi:10.1093/heapro/day062
JAMA Internal Medicine August 2023 Volume 183, Number 8 (Reprinted)
© 2023 American Medical Association. All rights reserved.
Downloaded from jamanetwork.com by University of Rochester user on 05/07/2024
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