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Fall 2021, Featured, Diversity, Equity, and Inclusion

Improving Health Literacy in Veterinary Medicine

Implementing strategies to clearly present information and improve client health literacy could lead to improved compliance and patient outcomes.

Christina MelvinCVT, LVT, MPH, EdD

Dr. Christina Melvin works as a full-time high school biomedical science instructor and part-time general practice veterinary nurse in Northern Virginia. She earned her Bachelor of Science in Biology from Worcester State University, Master of Public Health from the University of New England, and Doctorate in Education for Health Professions from A.T. Still University. She is a CVT in Massachusetts and LVT in Virginia. Dr. Melvin’s professional interests include One Health, health literacy, and health education. She previously started and directed a high school veterinary assistant program in Massachusetts, and is passionate about introducing veterinary medical careers to young students.

Improving Health Literacy in Veterinary Medicine
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Communication is an essential component of establishing the necessary rapport with clientele, encouraging a robust relationship that ensures patients receive prompt, appropriate, and accurate care. The ability to effectively communicate with clients improves patient care compliance, resulting in improved health outcomes, continuity of treatment, and client satisfaction.1

Positive interactions and effective client communication also reduce workplace stress and encourage a favorable atmosphere.2 Since veterinary nurses are directly involved with patient treatment and client consultation, it is necessary to promote efforts to advance communication with clients at every level of care through the comprehension of health literature. 

WHAT IS HEALTH LITERACY?

Historically, the definition of health literacy centered on creating opportunities and accommodations for human patients to obtain, understand, and communicate about health information with their providers.3 The definition evolved to include the importance of using and understanding the health information patients need, apply information to improve decision-making, and identify the need for organizations to contribute and promote equitable availability of health information.4 There has been an emphasis to improve health literacy across human health care for the past 30 years, resulting in research and guidelines that are implemented throughout the human health profession, inclusive of all patients.5

Health information is presented through several formats, such as written materials, television, social media, and the internet, which can be overwhelming and provide inaccurate information.6 According to the National Action Plan to Improve Health Literacy, there is a need to improve the accessibility and quality of health information due to an inability to decipher, use, and apply current health information.6 The National Assessment of Adult Literacy found that the majority of adults do not have proficient health literacy skills. Experts recommend that health information should be presented at a fifth- to eighth-grade reading level, and a third- to fifth-grade reading level for individuals or groups with lower reading levels.7 The ease of grasping and understanding written information (i.e., readability) is challenging due to the higher educational level of the content, and transforming content to a lower reading level can be difficult.3,8 Human health care has addressed readability concerns for several years, using various resources and tools to gauge both patient reading levels and the readability of health information.3 It is important to note that readability should not be used as the sole determining factor to attain health literacy as it only assesses syllable counts and sentence length without accounting for all the factors and complexities of writing.3 Rather, it should be used as a tool in combination with other strategies.

In veterinary medicine, there is a dearth of veterinary health literacy and readability information, and there are currently no established guidelines for veterinary health information. Despite this, most experts recommend using human healthcare guidelines.8 There are recommendations to establish guidelines based on research involving the evaluation of veterinary medical information, such as handouts, consent forms, and brochures. A 2020 study conducted by Viera and Baxter examined the readability of brochures from 3 veterinary information services.9 The majority of the handouts were at a ninth-grade reading level, with several handouts at higher reading levels. Handouts with the lowest levels (seventh and eighth grade) were shorter and used simplified language, while handouts with the highest levels (12th grade and college reading levels) used complex language and medical terminology.9 This study supports the results from a previous study by Royal, Sheats, and Kedrowicz that reviewed the readability of client handouts from dvm360.com. Their results determined the majority (9 out of 10) handouts were above a sixth-grade reading level, indicating a need to revise handouts with complex language and medical terminology. For example, changing “medications” to “pills” can improve client understanding since the term “pills” has fewer syllables, is easier to read, and uses plain language.8,9 TABLE 1 lists several examples of plain-language substitutions that can make medical terms more understandable for your clients. In addition, the researchers discovered that creating statements that are more direct can be easier to understand compared to statements that require more deciphering. Finally, a study reviewing the readability of clinical research consent forms yielded similar results, with none of the 53 forms meeting the sixth-grade reading level guidelines established in human medicine. The mean reading level of the consent forms was between 12th grade and college levels, and the authors expressed the need for staff to follow up written consent with verbal communication.10 While these studies focused on readability, the results can be applied to other forms of media such as websites, social media, and educational videos to improve veterinary health literacy. 

Veterinarians and veterinary nurses use their expertise to inform clients and the general public about veterinary health information. The ability to communicate with clients thoroughly and effectively is part of the veterinarian and veterinary nurse curricula, and communication proficiency is required for veterinarians as a core competency.1,2 According to the Committee on Veterinary Technician Education and Activities accreditation policies and procedures, the first set of skills involve client relations and communication.11 A required communication task states that students must “develop and provide client education in a clear and accurate manner at a level the client understands (i.e., oral and written form, including educational handouts).” Veterinary nurses should acknowledge and welcome their role as educators, as supporting, emphasizing, and utilizing good communication improves the veterinarian-client-patient relationship and patient care.9

IMPLEMENTING HEALTH LITERACY IN VETERINARY PRACTICE

Veterinary nurses consult with clients at various stages of patient care and must ensure veterinary health information is accurate for patient safety. The roles and responsibilities of the veterinary nurse continue to evolve, clinics and hospitals are busier than ever, and the time required to create materials for a diverse clientele makes it more challenging. Pre-made handouts, brochures, and videos make the task of disseminating information easier and timely, fulfilling client desire for additional information to help them make informed decisions about their pets.8 Accessible, science-based veterinary health information must be provided by veterinary facilities; otherwise, clients may be tempted to try to navigate the internet, seeking answers from “Dr. Google.”9

Any change that will improve communication and understanding should be implemented for the benefit of the patient, client, and staff. Small modifications to daily communicative tasks such as written correspondence, speaking and listening, and being culturally competent can improve long-term health literacy in the practice. Here are strategies to consider.

Written Materials

It is best to know as much information as possible about the targeted audience prior to presenting veterinary health information. However, this is not always feasible. If it is not possible to create educational materials, or if a facility uses a service, written materials can still be assessed for readability and understanding. First, review documents that are presented to clients. The layout of the material should be well organized and contain pictures or graphics, and sections should be separated with white space.12,13 The text should be easy to read, using a minimum of 12-point font, and should not use a hard-to-read font, italics, or all caps.3,12 Next, review the content. Medical terms and other jargon should be avoided, and plain language should be used. Plain language transforms difficult content into easier-to-understand content for the targeted audience. This is not devaluing the material. Rather, this is a skill used to share information in a way that will be understood by the targeted audience.3 For example, discharge orders can be simplified using common terms, short-syllable words, and avoiding abbreviations or contractions. Clear directions should be conveyed, such as “check the litter box twice a day” rather than “examine the litter box routinely.” Finally, if time permits, readability statistics can be assessed using Microsoft Word or online tools. Microsoft Word offers readability statistics using the Flesch Reading Ease and Flesch-Kincaid Grade Level scores, which produce scores indicating grade-level reading.13 

Speaking and Listening

Health literacy is not limited to written media. Veterinary nurses talk to clients and listen to their concerns on a daily basis. Conversations must be brief yet effective, and clients need to be able to understand the message. Select words carefully, avoiding jargon, abbreviations, and complex medical terminology.3 For example, use “low blood sugar” instead of “hypoglycemia,” and avoid interchanging the terms in a single conversation. Always be aware of tone, pacing, and body language, as this may change the meaning of the message. Finally, verify the client understands the message. The teach-back method is designed to determine if a client heard, understood, and applied the information presented by the veterinary nurse. The client should feel as if they are a partner in the understanding of the information, and encouraged to recall and repeat points from the conversation. Avoid asking the client “Do you understand?” as they may answer affirmatively even if they do not.3 For example, explain to the client that you want to be “on the same page” as they are. If they have to administer medication twice a day to their pet, ask them to apply the information presented regarding their pet’s case, such as, “What time is best for you to give these pills?” Listen to the client’s response and determine if they understand the message. Respond directly to their teach-back by reaffirming and reinforcing their response, such as “Yes, Mr. Jones, 8 in the morning and 8 at night are good times for Fluffy to take his pills.” 

Cultural Competence

Cultural competence is the acknowledgement, acceptance, and appreciation of cultures and language, fostering collaboration and effective multicultural interactions in a mutual environment.14 Veterinary nurses may interact with a diverse clientele, representing various cultures and speaking languages other than English. Therefore, it is important to learn about the diversity of the community where the practice is located. There are more than 350 languages spoken in the United States, and diversity is increasing in the population, particularly Spanish-speaking clients.15,16 Currently, language only accounts for a small percentage (2.6%) of barriers to veterinary care, but this may increase over the next 3 decades.15 Veterinary health information via educational materials, websites, and social media is starting to become available in other languages. There are several veterinary industries seeking to expand interpreter services, and companies are offering more resources in various languages.15

Bilingual staff can be helpful at improving communication, and experts recommend learning basic language of the community through continuing education.15,16 However, if there are no staff members available to speak directly with clients, there are other approaches that may be beneficial. According to Joseph Jimenez-Santos, AAS, BA, MA, graduate assistant professor of Spanish at the University of Puerto Rico, Spanish-speaking clients want to be treated with dignity and respect while addressing language barriers. For example, rather than asking a client “Do you understand English?” give the client ownership of the conversation, assessing for understanding throughout the initial interaction. Avoid patronizing speech and tone; speak with the client, not at the client. Jimenez-Santos recommends that locations with a moderate to high Hispanic population provide various bilingual veterinary health information resources in multiple formats such as handouts and digital media. Maximize efficiency and education about preventive and emergency care by using wait time to offer bilingual videos and access to websites or even create a QR code with links to improve accessibility.

Improving health literacy in veterinary medicine benefits practitioners, patients, and clients, and promotes communication and enhances relationships. Veterinary nurses have the opportunity to further advocate for their patients, educate clients, and highlight the knowledge of the profession. 

References

 

  1. Adams CL, Kurtz SM. Building on existing models from human medical education to develop a communication curriculum in veterinary medicine. J Vet Med Educ. 2006;33(1):28-37. doi: 10.3138/jvme.33.1.28
  2. Stevens BJ, Kedrowicz AA. Evaluation of fourth-year veterinary students’ client communication skills: recommendations for scaffolded instruction and practice. J Vet Med Educ. 2018;45(1):85-90.
    doi: 10.3138/jvme.0816-129r1
  3. Osbourne H. Health Literacy from A to Z. 2nd ed. In: Burlington, MA: Jones & Bartlett Learning; 2013.
  4. Centers for Disease Control and Prevention. What is health literacy? cdc.gov/healthliteracy/learn/index.html. Updated 2021. Accessed May 1, 2021.
  5. Ancker JS, Grossman LV, Benda NC. Health literacy 2030: Is it time to redefine the term? J Gen Intern Med. 2019;35(8):2427-2430. doi: 10.1007/s11606-019-05472-y
  6. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. health.gov/our-work/health-literacy/national-action-plan-improve-health-literacy Accessed April 13, 2021.
  7. 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. nces.ed.gov/pubs2006/2006483.pdf. Accessed April 15, 2021.
  8. Royal KD, Sheats KM, Kedrowicz AA. Readability evaluations of veterinary client handouts and implications for patient care. Top Companion Anim Med. 2018;33(2):58-61. doi: 10.1053/j.tcam.2018.03.005
  9. Baxter I, Viera A. Evaluating the readability of veterinary client handouts from Vetlexicon, Veterinary Partner, and ClientEd. Issues in Science and Technology Librarianship. 2020;94(1). doi: 10.29173/istl52
  10. Sobolewski J, Bryan JN, Duval D, et al. Readability of consent forms in veterinary clinical research. J Vet Intern Med. 2019;33(2):350-355. doi:10.1111/jvim.15462
  11. American Veterinary Medical Association. CVTEA accreditation policies and procedures: appendix h – veterinary technology student essential and recommended skills list.  avma.org/education/center-for-veterinary-accreditation/committee-veterinary-technician-education-activities/cvtea-accreditation-policies-and-procedures-appendix-h. Updated July 2021. Accessed August 10, 2021.
  12. Moore SA. Read all about it: health literacy and veterinary client educational materials. Top Companion Anim Med. 2018;33(2):A2. doi:10.1053/j.tcam.2018.06.002
  13. Dorman DC, Alpi KM, Chappell KH. Subject matter expert and public evaluations of a veterinary toxicology course brochure-writing assignment. J Vet Med Educ. 2013;40(1):19-28. doi:10.3138/jvme.0912.082R
  14. Centers for Disease Control and Prevention. Cultural competence in health and human services. npin.cdc.gov/pages/cultural-competence. Updated 2020. Accessed April 30, 2021.
  15. Mattson K. Speak my language. American Veterinary Medical Association. avma.org/javma-news/2019-11-15/speak-my-language. Published October 30, 2019. Accessed May 2, 2021.
  16. Landau RE, Beck A, Glickman LT, et al. Survey of US veterinary students on communicating with limited English proficient Spanish-speaking pet owners. J Vet Med Educ. 2015;42(4):324-331. doi:10.3138/jvme.0215-025R

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