The Importance of Communication and Education toward Patient Literacy: The Relationship of Functional Health and Patient’s Knowledge of Their Chronic Disease and Metabolic Disorder

Submitted by Dr. Gary D. Goldberg, PhD

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The Importance of Communication and Education toward Patient Literacy: The Relationship of Functional Health and Patient’s Knowledge of Their Chronic Disease and Metabolic Disorder

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A study of patient’s and the registered nurses role concerning essential and idiopathic hypertension with adult onset of diabetes. Part two


The aging populations in the U.S. with ‘Essential’ Hypertension are showing inadequate health literacy, plus its impact on patients with idiopathic chronic diseases such as type II, adult onset Diabetes Mellitus are makeable.


To identify among patients with hypertension and/or with diabetes the relationship between their functional health literacy levels, and the role of the registered nurse as communicator and educator.

Health Literacy 

The healthcare providers (e.g., registered nurses, nurse practitioners, and licensed vocational nurses), can enhance the effectiveness and efficiency of the care they provide by recognizing their patients’ health literacy.  Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” [1] At its core, health literacy is about clear communication between the healthcare system and the patients; on an individual level, health literacy is about enabling patients in understanding their medical condition, and how to treat it.

Over 90 million American adults cannot read complex text or have difficulty understanding complex instructions; this means over 90 million American adults, close to one-half of the US adult population have limited health care literacy. [2]

Chronic metabolic conditions such as ‘essential’ hypertension (i.e., HT) and diseases such as diabetes (i.e., DM) require patient education to achieve adequate control and prevent adverse health outcomes. Patients with HT may need to understand how to properly take multiple medications and modify their lifestyle (e.g., low salt diet, weight control, and/or exercise) to achieve adequate B/P (HbA₁с) control. The intricacies of the diabetic diet, insulin therapy, and home glucose level (A₁с) monitoring, place even greater educational requirements on the patients. As a healthcare provider, you are aware that patient education also plays a critical role in facilitating patients’ acceptance of their diagnosis and understanding behavioral changes required for active participation in treatment. [3]

Traditional patient education relies heavily on written material about disease processes, medical management, and self-care instruction guides. Despite the availability of extensive health-care education materials with relatively consistent content, many are written at too high a level for low literate patients to comprehend essential points. [4]ʹ[5] Today, patients with inadequate literacy may not benefit from such educational efforts. This may explain why some patient education programs have been unsuccessful. [6]ʹ[7]

This problem may be more common than many health-care providers realize; reading skills are deficient in 47% to 53% of adult US citizens according to the National Adult Literacy Survey. [8] The registered nurse first, must have a solid understanding of the relationship between literacy and knowledge of the chronic disorder and/or disease. Also, the functional health literacy of patients with diabetes or HT and relationship of patients’ literacy levels to knowledge of their chronic disease and markers of disease control. Understanding the role of functional health literacy in disease management along with patient education should enhance efforts to improve patients’ knowledge of their disease and adherence to treatment plans.

Current demographic trends make health literacy increasingly significant for today’s primary care providers (i.e., RN’s LVN/LPN’s, Nurse Practitioners), who treat older adults. Older individuals are more likely to develop chronic medical illnesses and functional limitations that may profoundly affect health literacy. For example, inadequate health literacy (i.e., essential HT and/or with DM), has been linked to increased prevalence of several chronic conditions (i.e., age-related sensory changes, vision, hearing loss, and cognitive impairment), to name a few. Also, problems with the use of preventive services and glycemic control in diabetes mellitus in older adults. [9] Other consequences can include errors in self-administration of medications. [10]


As a nurse or nurse practitioner, how will your articulation be received by your patients and/or caregiver in a clinical encounter? When responding to health literacy challenges verbal communication between patient and clinician should be within the same language realm. Essential HT and/or with DM daily care maintenance will only work when the patient fully understands his and/or her health condition and without a full aggressive approach toward the illness, a shorten life-span will exist. Therefore, speak clearly and slowly toward your patient using plain, non-medical language. If need be, show or draw pictures, limit the amount of information provided to the patient due to feeling possibly overwhelmed. Also, you may repeat the information given, using a teach-back or show-me technique and create a shame-free environment for your patients.

Note: A teach-back and/or show-me technique is particularly important because they involve asking the patient to explain or demonstrate what the nurse and/or practitioner has discussed. Teach-back techniques ask the patient to explain what he/she understood and show-me techniques have the patient demonstrate a skill level learned during the healthcare encounter.

It would be almost a ‘given’ to say that as a practicing nurse, you will come across patients with metabolic X syndrome and idiopathic secondary disorders or diseases such as chronic kidney disease (i.e., CKD), cardiovascular disease (i.e., CVD), and respiratory disease (i.e., RD). Just addressing the medication therapy alone would do an injustice for the patient and his/or her family members. There must be a willing spirit to grasp and maintain life changing ways. Due to the fact that we live in a non-perfect world, each patient will not obey or follow the recommended guidelines set forth through the AHA and/or the ANA. For these special patients you may need a follow-up visit by the social worker, care-giver, or a state-funded agency that would enter the home and talk with the patient and/or with family members.

Note: It may not be enough to assume that effective communication will occur just because a shared language of communication was established. A patient’s perception of articulation extends beyond ‘correct’ language usage (i.e., Spanish language for a Spanish speaker), to include dialects (i.e., Hispanic versus Cuban or South American), and often critical, non-verbal aspects such as the presence or absence of eye contact, physical contact, and body posture. The message conveyed by a primary care nurse or clinician looking at the patient and leaning forward is strikingly different than the message conveyed if looking at the medical record chart and sitting back against the wall.

Nearly all patients prefer medical advice that is simple and easy to understand. In many cases, advice can be simplified by reducing the content to what the patient truly needs to know to follow essential instructions, because adult education theory points out that adults are most interested in information that helps solve their problems, rather than in background information. [11]ʹ[12] For example, most patients are more interested in learning what they need to do to manage their diabetes so they can resume their daily activities, and less interested in disease pathophysiology.

Improving Communication Levels

As a professional, it may be left in your hands to determine the best ways to communicate with your patients. There may be current efforts focus on revising written educational materials to a simpler level, and a few studies have shown that simpler written materials can improve knowledge. [13]ʹ[14] Sometimes you need to ask questions first, on the level of approach you or your team will be engaging. For example:

  • What is the best way to communicate medical information (e.g., metabolic syndrome), to patients?
  • What is the minimum content required for patients to achieve their self-management goals and what is the literacy demand of the task(s) we are asking the patient to carry out?
  • Would visual aids, C.D.’s and/or multimedia technologies improve patients’ understanding of their medical disorder and can they do so more effectively than simplified written materials?
  • How should clinicians and practitioners approach decision making with patients who do not understand informed consent?
  • What is the most cost-effective ways to enhance compliance when patients have poor health literacy?

Educational Indicators

The aging of the ‘baby boomers’ (e.g., 1954 through 1965), are expected to have a major implication in this arena since enhanced educational experience is a major trend among demographics. For example, one national survey of older US citizens found that the Internet is becoming an increasingly important resource: Note that less than 35 % (i.e., ±SD), of current seniors age 65 and older have gone online, but more than 75% (i.e., ± SD), of the next generation of seniors (age 50 through 64) have already done so. [15]

Today in the US according to the New York Times and the Washington Post, the national average reading and comprehended levels are between the 7th and 8th grade level of learning. [16] Of the adult US citizens close to 25% cannot read with full comprehension the news print. [17] {Please see footnote 17, for complete NALS findings}. Have your Nursing Education Department seek out health materials that are written at or below the 8th grade level. Remember that patients will probably not want to read pages and pages of words alone, so have pictures or diagrams, that can be translated in a culturally and linguistically appropriate manner; such materials are preferred for all literacy levels because they provide a baseline of information about the medical condition. There will also be patients able to function at a higher literacy level and may wish to seek out further information on their own.

Engaging Your Patients

There is a high degree of importance placed on patient participation when it demands a change in life-style and diet, due to Syndrome X and DM. At each clinical visit, brief the patient on his/or her daily life and ask if the patient has made a change for the better. By probing the issues further you may find room for improvements. Hear are a few interventions in supporting patients in actively responsive health care:

  • Have a provision of printed leaflets and health information packages on living with HT and DM.
  • Having computer-based internet health information for your patients.
  • Having target mass media campaign through the Marketing Dept.

To Improve Clinical Decision Making

  • Provide patient decision aids on HT and DM.
  • Provide training for clinicians and nurses in communication skills.
  • Coaching and question prompts for patients.

To Offer and Improve Self-Care

  • Self management education classes.
  • Teach self monitoring and self administered treatments.
  • Offer self help and/or group peer support meetings.
  • Patient centered tele-care groups (i.e., conference calls).
  • Encouraging adherence to treatment regimens.
  • Patient reporting of adverse drug events, provide patient with one number or person to call.

Relevant outcome

  • Knowledge of condition and long term complications.
  • Self care knowledge.
  • Knowledge of treatment options and likely outcomes.
  • Comprehension of information.
  • Recall of information.

Health Behavior and Health Status

  • Health related lifestyles.
  • Self-care activities.
  • Treatment adherence.
  • Severity of disease and/or metabolic disorder.
  • Physical functioning.
  • Mental functioning.
  • Clinical indicator bio-markers.

The Nurse Can Only Teach ‘That What She/he Knows’

In both medical and nursing schools, DM is taught as associated with systolic/diastolic HT, and a wealth of epidemiological data suggests that this association is independent of age and obesity. Evidence indicates that the link between DM and essential HT is hyperinsulinemia. [18] It has been shown that the insulin resistance of essential HT is located in peripheral tissues (i.e., muscle mass), and is limited to non-oxidative pathways of glucose disposal (i.e., glycogen synthesis), and correlates directly with the severity of HT. [19] ʹ[20]

Insulin resistance and hyperinsulinemia are also associated with an atherogenic plasma lipid profile. Insulin, independent of its effects on B//P and plasma lipids, are known to be atherogenic. The hormone enhances cholesterol transport into arteriolar smooth muscle cells and increases endogenous lipid synthesis by these cells.

Note: physiological maneuvers, such as calorie restriction (e.g., found in overweight patient) and regular physical exercise, can improve tissue sensitivity to insulin; evidence indicates that these maneuvers can also lower B/P in both normotensive and hypertensive patients. [21]’ [22]

The nurse practitioner should be aware of this highly important study on chronic HT, that insulin resistance appears to be a syndrome that is associated with a clustering of metabolic disorders, including non-insulin-dependent DM, obesity, HT, lipid abnormalities, and atherosclerotic cardiovascular disease. In order for the patient to understand that a change in life-style must start now, the practitioner too must have a plain of action for his/her patients.

The Joint Commission on Accreditation of Health Care Organizations have mandated that hospitals and other health organizations provide instruction understandable to patients, assess patients’ knowledge, and document such educational efforts. [23] Set goals of having at least 95% of patients with HT take action to control their B/P, and of having 75% or higher, people with DM receive education on DM. Patients’ functional health literacy must be considered when attempting to reach these goals. It appears that there are no simple methods of identifying low-literate patients and the significant shame or embarrassment associated with comprehension often makes them hide their disability.

As a nurse, using your assessment skills may lead your patients to open up to you, rather than the treating physician. Consider ‘direct involvement’ of the patients in developing educational materials, this action may empower them to improve their health while ensuring that the content effectively educates them. The future of patient education requires ingenuity and commitment of necessary resources to improve the outcome for patients with chronic diseases.

Clinical Recommendations

Both the American Medical Association and with full support of the American Nursing Association have recommended by the Council on Scientific Affairs, adopted policy at the AMA Annual Meeting back in June of 2000.[24]ʹ[25] The following statements were recommended by the AMA and shared with the ANA for a complete impact within the US:

  • Recognition that limited patient literacy is a barrier to effective medical diagnosis and treatments.
  • Work with members of the Federation (i.e., specialty, state, and local medical societies), and other relevant medical and nonmedical organizations to make the health care community aware that over one fourth of the adult population has limited and/or difficulty understanding both oral and written health care information.
  • The AMA encourages development of both the undergraduate, medical and graduates, in continuing medical education programs that train physicians to communicate with patients who have limited literacy skills.
  • The Associations encourages that the US Dept. of Education to include questions regarding health status, health behaviors, and difficulties communicating with health care professionals in the National Adult Literacy Survey.
  • The Associations encourages the allocation of federal and private funding for research on ongoing health literacy issues.


The patients’ understanding with knowledge can be improved, at least at the individual level. Patients with primary and or secondary HT with DM health problems benefit when they are involved in their care. Either in the home or at the clinic, evidence suggests that this participation can lead to a better use of resources. Shared decision-making and self-management are mutually supportive approaches, which should be given equal importance.

Preliminary studies indicate inadequate health literacy may increase the risk of frequent hospitalization. [26] Professional and public awareness of the health literacy issues must be increased, beginning with education of medical students and physicians plus improved patient-physician communication skills. The nursing institutions have seen a need for this out-reach from the community within. The continued support from the ANA will only enhance the nursing skills from student to graduates. This support is what the author would like to call the “art of medicine.”

Further Readings on Current Research in Essential and Idiopathic Hypertension with Diabetes:

  • Dr’s Colombani, AL, Careiro L, Benani A, Galinier A, Jaillard T, Duparc T, Offer G, Lorsigno A, Magnan C, Casteilla L, Pe´nicaud L, and Leliup C. ‘Enhanced Hypothalamic Glucose Sensing in Obesity: Alteration of Redox Signaling’ Diabetes Care, Oct. (2009), 58: 2189-2197; published ahead of print on July 6, 2009, doi: 10.2337/db09-0110 full abstract.
  • Dr’s Vella A, Rizza RA. ‘Application of Isotopic Techniques Using Constant Specific Activity or Enrichment to the Study of Carbohydrate Metabolism’ Diabetes Care, Oct. (2009), 58: 2168-2174, doi: 10.2337/dbo0-0318 full abstract.
  • Nath C, PhD, ‘Literacy and Diabetes Self-Management’ Amer. J. Nur. (06/2007) 107(6): 43-49.
  • Masor D, PhD, ‘Promoting Health Literacy’ Amer. J. Nur. (02/2007) Vol. 101 Issue 2-p7.


  1. National Library of Medicine Current Bibliographies in Medicine: Health Literacy (2000). NLM Pub. No. CBM 200-1, Selden CR, Zorn M, Ratzan SC, Parker RM, Eds. Bethesda, MD: The National Institutes of Health, US Dep. of Health and Human Services.
  2. Nielsen-Bohlman L, Panzer AM, Kindig DA, Eds. Health Literacy (2006) rev. ed. “A Prescription to End Confusion.” Washington, DC: National Academies Press.
  3. Grueninger, UJ, Arterial hypertension: lessons from patient education (2006). Patient Educ. Couns. 2006; 27: 37-52. Also, cited in Pub. Med. Arch. Internal Medicine, 1999; 158: 166-172. Full Text.
  4. Leichter S, Nieman J, Moore R, Collins P, Rhodes A. Readability of self-care instructional pamphlets for diabetic patients. Diabetes Care. 1991; 4:627-630. American Diabetes Association Foundation founded in 1978.
  5. Davis T, Crouch M, Wills G, Miller S, Abdehou D. The gap between patient reading comprehension and the readability of patient education materials. Journal Family Practice 1990; 31: 533-538. Also, cited in Arch. Intern. Med. 2002.
  6. Boyd M, Citro K, Cardiac patient education literature: can patient read what we give them? Journal of Card. Rehab. 2000; 6: 513-517.
  7. Dixon E, Park R. Do patients understand written health information? Nursing Outlook. 2000; 48: 378-381. Also, cited in Arch. Intern. Med. Relationship of Functional Health Literacy 2009. 
  8. Jenkins L, Kolstad A Adult Literacy in America: A Revised Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Dept. of Education; 2008.
  9. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. Journal of American Medical Association (2004); 288(4) 475-82.
  10. Weiss BD. ‘Epidemiology of low health literacy.’ In Schwartzberg JG, Van Geest JB, Wang CC, eds. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, IL: AMA Press; (2008 rev. ed.) 27-43.
  11. US Dept. of Health and Human Services. Clear and Simple: Developing Effective Print Materials for Low Literacy Readers. Bethesda, MD: National Cancer Institute Office of Cancer Communication; 2005.
  12. Davis TC, Crouch MA, et al. Rapid assessment of literacy levels of adult primary care patients. Family Medicine 2005; 24: 433-435.
  13. Overland JE, Hoskins PL, McGill, Low Literacy: a problem in diabetes education. Diabetic Med. Review 2000; 20:847-850.
  14. Braddock CH, Levinson W, Jensen AR, Pearlman, RA. How doctors and patients discuss routine clinical decisions: informed decision making in the outpatient setting. Jour. Gen. Intern. Med. 1998; 12:339-345.
  15. E-Health and the Elderly: How Seniors use the Internet for Health, Survey. Kaiser Family Foundation Pub. No. 7223, Jan. 2007.
  16. Federal Register. National Standards on Culturally and Linguistically Appropriate Services in Health Care. Vol. 65 80865-79. Washington DC; Jan. 2008 rev. ed.
  17. The National Adult Literacy Survey, (2004). Emory Univ. /UCLA study, reported in JAMA 12-96 and again in 2005, {42.6% of American patients could not comprehend directions for taking med’s on an empty stomach. Also, 50.5% could not understand a standard informed consent form. About one in every four Americans about 25% are a high school dropout. Only 15% of US citizen’s registered adults have completed a college degree program}.
  18. DeFronzo RA, Ferrannini E. Dept. of Med. Univ. of Texas Health & Science Center, San Antonio. Diabetes Care. (2000) Vol. 17 No. 8 183-194.
  19. American Diabetes Association. Standards of medical care in DM {published correction in Diabetes Care. 2006; 38: 990}. Diabetes Care. 2006; 28; S4-S36.
  20. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure {Published comments in Hypertension. 2004; 43:327}.
  21. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; Hypertension. 2004; 43:e31.
  22. Kassirer Jerome P. (Textbook): Current Therapy in Internal Medicine (Current Therapy Series), (2004) BC Decker, Inc. PA. Hypertension Therapy: Hypoaldosteronism; (i.e., enzymes involved in regulating B/P). pp 310-320.
  23. Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2004; rev.ed.
  24. US Department of Health and Human Services. Healthy People 2010 Objectives: Draft for Public Comment. Washington DC: Public Health Services; 2000.
  25. Dowe MC, Lawrence PA, Carlson J, Keyserling TC. Patients’ use of health -teaching materials at three read ability levels. Appl. Nurs. Res. 1997; 10:86-93. Reprint in July 2006 @ .
  26. Report of the Council on Scientific Affairs: JAMA. 2007 rev. 381: 552-558. @

Short Bio of Dr. Gary D. Goldberg, PhD

Over 30 years experience in the Medical field, At UCLA and Pacific Hospital of the Valley, as a Chief Technologist and Analyst, Visiting Professor and Instructor for continuing education at UCLA School of Nursing and Writer/Speaker at the School of Medicine from 1978-2008.

From 2003-2008 Dr. Goldberg has collaborated and published through Blackwell Publishing Co. (Medical Division) and Journal of Americana College of Cardiology plus 15 published abstracts with UCLA Dept. of Bio-Medical Engineering and the Dept. of Cardiology.

Current title: Clinical Professor of Medical Education with Angeles College of Nursing, in Los Angeles, Ca.

Dr. Goldberg has written two major academic course textbooks for Angele College of Nursing and has represented advanced nursing education course curriculum through the State Dept. of California and approved by the ANA for CEU(s) and the AMA CMU Level 1 Credit for physicians.

In addition, Dr. Goldberg is currently an adjunct Professor for Kaplan University, e.g., through the Washington Post Inc., South Florida. Department of Health and Science plus the Dept. of Humanities.

His wife, Cindy L. Capute, has been a registered nurse for over 17 years and has managed a 200-bed acute care facility, with over 100 professional nurses from RN’s through CNA in the Los Angeles area. She keeps her ear in-tune with up-to-date nursing data and advancements in medical education. She has co-authored with Dr. Goldberg in 2005, paper presented to the Cardiology-Electrophysiology Research Group that has changed the dynamics of elector-static reading with regards to acute atrial anomalies.

This finding allowed Dr. Goldberg, to publish the “Goldberg Protocol” for Cardiac placements in the field and under clinical supervision using a tilt-table and the 12 +3 Leads or the vector positioning for additional cardiac patient information.

To reach Dr. Gary D. Goldberg, for comments and/or professional consultation, please use e-mail address: [email protected]