Evaluation of the Health Literacy Curriculum at a Southeastern Medical School

doi:10.21203/rs.3.rs-4659697/v1

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Research Article

Evaluation of the Health Literacy Curriculum at a Southeastern Medical School

https://doi.org/10.21203/rs.3.rs-4659697/v1

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Background

Health literacy (HL) is crucial for making informed health decisions. Over one-third of US adults have limited HL, leading to adverse health outcomes. Despite its importance, HL education lacks standardization in medical training. This study evaluates the University of South Carolina School of Medicine Greenville’s (USC SOMG) HL curriculum to propose recommendations for HL instruction.

Methods

A convergent parallel mixed methods design was used to assess the HL curriculum through a curriculum review, student survey, and faculty interviews. The study utilized thematic analysis for qualitative data and statistical analysis for quantitative data, focusing on prior and current HL training, confidence in HL application, and perceptions of HL education.

Results

The curriculum at USC SOMG incorporates active learning strategies, emphasizing HL, and patient communication. Most participants reported high confidence in their HL knowledge and skills. The preferred teaching methods were hands-on clinical interactions, observing clinical interactions, and interactive lessons. Barriers to using HL interventions included time constraints and lack of real-world experience. Faculty recommended time prioritization and collaborative strategies to overcome these barriers.

Conclusions

USC SOMG’s HL curriculum combines didactic and active strategies longitudinally, preparing students to feel confident in their ability to engage with patients experiencing LHL. This demonstrates the curriculum’s strength and potential as a model for other schools. However, for broader implementation, standardized requirements and competency-based assessments are recommended to ensure consistent HL education across medical programs, focusing on practical application and overcoming identified barriers. This could markedly enhance patient outcomes by equipping future providers with essential HL skills.

health literacy

medical education

patient communication

Health literacy (HL) is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others^1–2. More than one-third of adults in the US have limited HL (LHL), which has been associated with higher mortality rates, health disparities, and increased medical costs^3–5. Its links with social determinants of health and poorer health outcomes make HL a concern for healthcare professionals involved in health promotion, disease prevention, and the management of chronic diseases^4,6–7. As such, there is a growing recognition of the importance of HL, but progress in this area is still lacking².

Two decades ago, the National Academies of Science, Engineering, and Medicine issued its "Prescription to End Confusion," a call to action to address HL rates within the US⁸. One of its key recommendations was training health professional learners to effectively communicate with patients with LHL ^6,8. The Agency for Healthcare Research and Quality (AHRQ) supports universal HL precautions⁹, and HL is included in the US Medical Licensing Examination (USMLE) content guidelines for Step 1 and Step 2K exams¹⁰. However, there are no standardized requirements for teaching providers explicitly about HL within the current Liaison Committee on Medical Education (LCME) guidelines¹¹. While the 2025-26 LMCE curriculum guidelines include HL-related concepts such as communication skills, experts have argued that standardized interventions to address LHL should be included explicitly¹².

Although a 2010 study found 72% of allopathic medical schools include HL in their curricula¹³, the average time spent on HL is three hours^9,12–13. Without adequate training, future providers have fewer skills and lower confidence in addressing patients with LHL¹². Short-term HL training has been found to effectively increase students’ HL knowledge and confidence in patient communication¹². However, more longitudinal formats have successfully promoted a deeper understanding of HL, suggesting HL training should consist of multiple sessions over time^14–15. Medical institutions can empower future providers to address individuals with LHL and improve health outcomes¹³. However, without appropriate guidance on content, structure, and teaching approaches for HL training, medical schools may not address HL education properly¹⁴. The purpose of this paper is to evaluate the health literacy curriculum at the University of South Carolina Greenville (USCSOMG) to make informed recommendations to medical educators.

Methods Design, sampling, and setting

A convergent parallel mixed methods design was used to evaluate the HL curriculum at the University of School of Medicine Greenville (USCSOMG), including their Family Medicine Graduate Medical Education (GME) program through the Family Medicine Residency Program Greenville (FMRGVL). The survey participants were USCSOMG students and FMRGVL residents. The sampling frame included a total of 432 individuals, 113 first-year (M1) medical students, 110 second-year (M2) medical students, 98 third-year (M3) medical students, 93 fourth-year (M4) medical students, and 18 family medicine residents. Learners were recruited to participate through class presentations, email/list-serv, short text messages, and GroupMe messaging. To be included in the study, individuals had to be current learners in either program. Five current faculty members within the programs conducted interviews. Faculty members were identified using purposive sampling method and chosen due to the presence of some form of HL or HL-related concepts in their curriculum, as identified by a fellow USCSOMG faculty member.

Measures

The survey (Appendix 1) assessed medical learners' prior and current HL training, comfort with and knowledge of HL concepts, and opinions of HL education in medical schools. The survey was adapted from a measure developed by Mackert and colleagues¹⁶ used to assess the long-term effects of HL education for medical students¹⁵, and the components of the AHRQ Health Literacy Universal Precautions Toolkit⁹. General demographics were not included to maintain the anonymity of survey respondents. Question types included multiple-choice, ranking, and open-ended responses.

The faculty interview guide (Appendix 1) contained open-ended questions to gather information on the faculty member’s role at the USCSOMG, as well as information and opinions on their explicit and latent HL curriculum.

Procedures and statistical analysis.

Anonymous online surveys created in Qualtrics were sent out using the same recruitment methods. Survey collection took place from January 17, 2024, to March 1, 2024, and multiple text and email reminders were sent out to students to encourage participation over the course of the collection period. A $5 Starbucks gift card was offered for participation. A snowball sampling method was used to reach eligible participants. The survey QR code was shared with learners by some USCSOMG faculty members during class and through email. For a survey to be considered "complete," participants had to answer all the initial categorical questions and at least one of the Likert scale questions. 84 individuals responded to the survey, and 71 individuals completed the survey.

Five interviews were conducted with faculty members who include HL in their curriculum to assess their curriculum and opinions on barriers to addressing HL. Interviews were completed over Microsoft Teams and were 20–45 minutes long, with a mean time of 31 minutes and a standard deviation of 8.7 minutes. The interviews were recorded and transcribed, and oral consent was obtained before each interview. Interview data was numerically labeled and deleted upon study completion.

Thematic analysis was the primary qualitative method for analyzing USCSOMG curriculum materials, faculty interviews, and open-ended survey responses from medical learners. Interview transcripts and open-ended responses were imported into Microsoft Word and codes were generated by color-coding segments of data that were relevant to evaluating the HL curriculum. Codes were then consolidated into themes and pertinent quotes within each theme were extracted.

RStudio, version 4.3.2, with alpha set at 0.05 was used to analyze quantitative survey results. Survey respondents were grouped into pre-clinical (M1-M2 students), clinical (M3-M4 students), and residents. Likert scale questions were grouped into Strongly Agree/Agree, Neutral, and Disagree/Strongly Disagree. Some categorical questions were also grouped, e.g., 0–3 hours, 4–10 hours, and 11–15 + hours spent on HL education and none/little to none, sometimes, a decent amount/almost always use HL interventions in real-world patient interactions. Ranking questions were dichotomized, e.g., a ranking of 1/2 or any other ranking. All percentages were computed using the number of responses to each specific question in the denominator to address missing responses.

Descriptive statistics were run for categorical and continuous variables. Kruskal-Wallis tests were conducted to determine response differences for Likert scale and ranking questions between pre-clinical, clinical, and residency groups, and Shapiro-Wilk tests were used to test for normality. The data violated the assumptions needed for parametric testing; therefore, non-parametric tests were used.

The University of South Carolina Institutional Review Board determined this project as exempt from review (#Pro00132250).

Curriculum Review

Both programs utilize interprofessional education with faculty members coming from a variety of disciplines beyond clinical medicine and provide education on HL and patient communication.

The University of South Carolina School of Medicine Greenville (USCSOMG) includes HL training within its first-year Integrated Practice of Medicine (IPM) curriculum. IPM courses are taught across all four years of medical school and in small groups, with year-long courses for the first two years and one to four-week-long sessions in years three and four¹⁷. USCSOMG is updating its curriculum to improve patient-centered care, adding semesters on doctoring, the healthcare system, and societal aspects of medicine (Figure 1). First-year students are given a lecture on HL and tasked with creating brochures on HL using plain language. Brochures must include the definition of HL, the impacts of HL on health outcomes, how to assess HL, how to help patients with LHL, information on the teach-back method, statistics about HL, and strategies that healthcare systems can put in place to help patients with LHL. IPM and clinical faculty also work to incorporate training on motivation interviewing, patient teach-backs, medicine reconciliation, and other HL interventions throughout their lessons in the form of role-playing, simulated patient interactions, and discussions. First-year students also have EMT rotations, allowing them to have hands-on experience with patients of varying HL levels before they enter the clinical environment.

In the FMRGVL, videos of residents' interactions with patients are reviewed using the Patient-Centered Observation form from the University of Washington¹⁸. This form allows the instructor to assess how well the resident addresses biopsychosocial aspects of patient care and utilizes good communication techniques, including patient teach-backs. The program also holds Equity M&Ms, which aim to educate residents on concepts related to health equity and encourage discussion of HL, patient teach-backs, and other contributors to healthcare affected by the social determinants of health¹⁹.

Student Survey and Faculty Interviews

Quantitative

Participants

After removing incomplete survey responses, survey respondents included 55 pre-clinical students, 6 clinical students, and 10 residents. Of the residents, most had attended a school other than USCSOMG for their undergraduate medical education (80%).

HL Training and Interventions

A majority of the respondents (87.3%) had some or a high level of HL training prior to starting medical school or residency. This prior training included previous coursework in public health/health sciences during undergrad, clinical experiences, working as a medical scribe, and summer internships. Variations in training, use of interventions, and opinions on barriers to intervention usage are summarized in Table 1.

Opinions on and Confidence with HL Training Education

Most respondents felt they had a strong understanding of what HL is and how to assess patient understanding. Satisfaction with the curriculum and confidence in communicating with patients are further explored in Table 2. Rankings of the importance of HL topics and the effective ways to learn HL skills are reported in Table 3.

Results of Kruskal Wallis Test

No statistically significant difference was found between pre-clinical, clinical, and residency groups for responses to the Likert scale or ranking questions at the alpha = 0.05 confidence level (Table 2-3).

Qualitative

Of the respondents who chose to answer the open-ended question about how to navigate a mock patient scenario, 93% of respondents explained they would address the possibility of the patient having LHL in various ways including, using layman terms, patient teach-backs, and shared decision making.

Five themes were identified from interviews with faculty members, and these include 1) The importance of active learning in HL education, 2) Strengths of the curriculum, 3) Lacking aspects of the curriculum, 4) Barriers to using HL interventions, and 5) Advice from faculty to address barriers. Key quotes from faculty and medical learners for each theme are summarized in Table 4.

When asked about a standardized hours requirement, all faculty members indicated this might be difficult to implement because HL is often threaded throughout multiple lessons, especially those on the social determinants of health and population health, and is not explicitly tested. One faculty member summarized this, stating, "My concern is that if you make things stricter and add more guidelines, people will push back against that and only do what they have to do.” Multiple faculty members recommended competency-based HL testing throughout medical school. For example, one faculty member recommended “a mandated simulation experience of some sort specifically around HL and assessing it…so you can see how they do in the first year around working with patients with low HL, and then the second year, third year and fourth year to how they're progressing in their skills and how they are engaging with patients”. Similarly, another faculty member recommended implementing “some sort of high-level objective or competency around awareness of public health or time spent in communities.”

Mixed

The integration of quantitative and qualitative findings in this study is further augmented by the use of color-coding, a visual tool that allows for a clear and direct connection between the two sets of data (Tables 1-4). The colors serve as a bridge, highlighting where the qualitative comments and quantitative data intersect and diverge, thereby facilitating a deeper understanding of the patterns emerging from the research.

During analysis, color-coding was applied to align the qualitative narratives with corresponding quantitative findings, making it visually evident how individual experiences reflect broader statistical trends. For instance, the color-highlighted qualitative comments regarding the substantial value of spoken communication in patient care complement the quantitative data that indicate a majority of the curriculum focused on this aspect (82.2%). Similarly, the qualitative feedback on the challenges of implementing HL interventions due to time constraints and advice on how to address this barrier were color-matched to the quantitative barrier of "Limited time during patient visits" reported by 68.3%. Qualitative data about concerns over limited clinical experiences were color-matched to the quantitative barriers of “lack of relevant clinical experiences” reported by 38.1%. The top three average rankings for the most effective ways to teach HL were also color-matched to qualitative data from faculty members who included these active learning strategies in their discussion of curriculum content.

The strategic use of color also aids in drawing attention to areas of discrepancy. While a large percentage of participants reported receiving HL training, qualitative remarks colored correspondingly show an expressed uncertainty about its practical application, particularly in clinical settings. This visual method underscores the need for enhanced educational strategies that not only address HL concepts but also ensure their practical utility and relevance in clinical practice. The color-coding technique used here is not merely an aesthetic choice but a deliberate analytical tool.

Summary of Main Findings

This study critically evaluates the integration of health literacy (HL) training within medical education curricula at USCSOMG and the FMRGVL. A comprehensive curriculum review reveals a dedicated approach to HL, incorporating interprofessional education and a variety of teaching strategies, including motivational interviewing and shared decision-making. Our quantitative findings indicate a substantial majority of medical learners (87.3%) have had some level of HL training before or during their current programs. However, satisfaction with HL education varied, with pre-clinical students reporting higher levels of satisfaction and confidence in their ability to communicate health information to patients, as opposed to clinical students and residents. No significant differences were noted across the groups regarding their opinions on HL education.

Despite this training, our qualitative data suggests students and residents perceive notable gaps in translating theoretical knowledge into clinical practice, specifically in written communication and applying HL in patient scenarios. Notably, the curriculum's strong focus on spoken communication and patient support systems is echoed in the respondents' qualitative assessments of the program's strengths. The identified barriers, such as time constraints and lack of real-world experience, reflect a disconnect between curriculum design and clinical application, underscoring the need for curricular adjustments that prioritize hands-on HL training. Faculty advice further emphasizes this point, suggesting collaborative strategies to overcome these barriers in clinical practice. The innovative use of color-coding in our mixed-methods approach effectively highlights the congruences and discrepancies between the qualitative and quantitative data, allowing for a nuanced understanding of HL training's impact.

Importance of teaching style

The respondent ranking of teaching style is reflected in current literature, with multiple studies citing the importance of interprofessional education¹² and hands-on applications of HL knowledge in the form of clinical experiences or simulated patient interactions, small group discussions, and active learning^14–15,20. These teaching strategies are largely reflected in the curriculum at USCSOMG and the FMRGVL during first-year EMT rotations, IPM courses, simulated patient scenarios, and small group discussions, likely leading to high levels of HL knowledge and use among medical learners in both programs. Faculty members also come from a variety of disciplines, increasing the breadth of perspectives medical learners in these programs are taught. A similar study found that less than 10% of participants, internal medicine residents, felt confident in HL knowledge or use of skills for identifying and communicating with LHL patients ²¹. The marked difference in medical learners’ confidence and variation in the literature suggests a need for a more detailed study to contrast curricula and associated confidence with HL to determine what methods work best. However, medical programs may benefit from adopting a curriculum structure that includes HL as a longitudinal topic and interprofessional education, as evidenced by the high levels of confidence with HL and HL interventions seen in medical learners from USCSOMG and FMRGVL.

Recommendations for medical educators and accreditation organizations

This study demonstrates the importance of HL training across all years of medical education. Based on the results of the study, medical educators should ensure common barriers to using HL interventions are addressed, such as lack of time during patient visits, concerns over language barriers with patients, and lack of comfort in using interventions. As per USCSOMG faculty recommendations, concerns over lack of time can be addressed by teaching medical learners to prioritize the use of patient teach-backs for high-yield aspects of the appointment, to utilize their time in the learning environment to practice effective communication with patients, and to explore the use of telehealth follow-ups to address limited time during in-person visits. These strategies to address LHL and student barriers have been reiterated in a study that polled 25 HL experts in 2017²² and studies aiming at improving HL interventions among medical providers²³.

While a mandatory hour requirement may not be feasible due to the progressive nature of HL education and the current curriculum load in medical schools, it would be beneficial to implement a competency-based HL exam each year of medical school to ensure students are taking in all of the information and are comfortable interacting with patients of all literacy levels. Based on student desires and past literature^12,14, this competency exam would be best implemented in the form of a simulated patient scenario each year to further help students apply theoretical knowledge to the real world. Learners also should receive feedback from both their fellow students and faculty each year, potentially in the form of a standardized observation form like the one used in the FMRGVL⁶. To emphasize the importance of HL to medical learners and address both student and faculty concerns identified in this study and past research¹², the LCME should also explicitly include HL in their required curriculum content. This will ensure that students are more focused on HL training and practice.

Furthermore, the measure used in this study may be repurposed to assess students' opinions on their HL education to address the need for instruments that measure the HL knowledge, skills, and attitudes of students after educational intervention⁶. The measure can be used to help medical schools reform and adapt their curriculum to reflect student needs and equip future providers to navigate HL. Through ongoing evaluation of student needs and delivering comprehensive HL education annually, medical schools and residency programs can better equip their students to enhance patient health outcomes.

Limitations and future directions

Sample sizes for each group were relatively small, which limits the power of the study and the ability to generalize survey results to medical schools outside of USCSOMG. Instrument bias and recall bias may have affected survey results because the number of HL-focused questions may have primed students to consider HL more than they may have during a typical patient interaction. M1/M2 response rates were higher because a snowball sampling method was used to gather survey responses using initial M1/M2 student contacts, and the survey QR code was shared during the health literacy lesson given to M1/M2 students. Although the survey was anonymous, some degree of social desirability bias may have also skewed survey responses. Students who are more interested in HL may have been more likely to participate, resulting in selection bias. Evaluating learners' confidence in their abilities may not accurately reflect their actual skills due to the potential for self-assessment bias. Future research should use Objective Structured Clinical Examinations (OSCEs) or video observations for a more objective measure of learners' competencies. However, despite the limited power of the survey, study findings still correlate with past literature, which supports a higher emphasis on HL education and the importance of active and longitudinal learning.

While research has long highlighted health literacy's crucial role in healthcare outcomes, there remains a need for more explicit guidelines from accrediting bodies and medical educational institutions. The revised curriculum at USCSOMG, employing a combination of didactic and active strategies in a longitudinal format, equips students to feel confident in their ability to engage with patients experiencing LHL. This demonstrates the curriculum's strength and potential to serve as a model for other schools looking to bolster their curriculum on this meaningful topic, given its implications for patient care. However, explicit guidance is essential within current LCME standards for comprehensive integration of health literacy education, offering students greater focus on and practice in HL interventions. Implementing an annual competency exam to evaluate medical learners' health literacy skills and monitoring curriculum effectiveness is vital. The survey tool developed for this project could support medical schools in tailoring their curriculum to meet student needs and enhance health literacy outcomes.

health literacy

LHL

limited health literacy

USCSOMG

University of South Carolina School of Medicine Greenville

FMRGVL

Family Medicine Residency Program Greenville

AHRQ

The Agency for Healthcare Research and Quality

USMLE

US Medical Licensing Examination

LCME

Liaison Committee on Medical Education

Ethics approval and consent to participate

The University of South Carolina Institutional Review Board approved this project #Pro00132250. Informed consent was gathered by both survey participants and interview participants. Survey participants were prompted to click “next” if they consented to participation and oral consent was given by interview participants.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Funding

This project was supported in part by an Honors College Thesis Grant from the University of South Carolina Honors College.

Authors’ contributions

All authors played an equal role in project conceptualization, investigation, and methodology. FA conducted data curation, analysis, project administration, and visualization and wrote the first draft of the manuscript. NN, SST, and ABK oversaw the project and edited manuscript drafts. All authors read and approved the final manuscript and made significant contributions to the project.

Acknowledgments

Not applicable

Authors’ information

Faith Albertson: Faith Albertson is a recent graduate from the University of South Carolina Honors College and an incoming Master of Public Health candidate at the University of North Carolina Gillings School of Global Public Health with a concentration in Health Policy. Her primary research interests are health literacy, health equity, and medical education reform.

Dr. Ann Blair Kennedy: Dr. Ann Blair Kennedy is an associate professor in the Biomedical Sciences Department at the University of South Carolina School of Medicine Greenville and in the Family Medicine Department at Prisma Health and Director of the University of South Carolina Patient Engagement Studio, Greenville, SC.

Dr. Shannon Taylor: Dr. Shannon Stark Taylor is a licensed clinical health psychologist and serves as the Director of Behavioral Science for the Prisma Health Family Medicine Residency Greenville. She holds appointments as a Clinical Associate Professor at the University of South Carolina School of Medicine Greenville and the Clemson University School of Health Research. She has expertise in quantitative research methods and statistics and behavioral randomized controlled trials. Her background is in psychological processes and interventions for chronic pain. Currently, her primary research interests are provider well-being, physician-patient communication, and Diversity, Equity, and Inclusion, and medical education on these topics.

Dr. Nabil Natafgi: Dr. Nabil Natafgi is an Assistant Professor of Health Services Policy & Management at the Arnold School of Public Health, and Associate Director of the Patient Engagement Studio, University of South Carolina. Dr. Natafgi's current work is focused on evaluating the effectiveness and impact of telehealth applications on care delivery and outcomes. He also has experience in qualitative data collection and analysis and community-based participatory research, working closely with academic, patient, community, and other stakeholder partners. He co-led two PCORI-funded projects to develop Virtual Patient (VIP) Engagement Studio that aims to use technology to engage patients and caregivers in the development, implementation, and dissemination of research projects. He also collaborates with clinical and academic partners at Prisma Health, Clemson University, and Furman University on projects aimed at improving the virtual care delivery process using telemedicine and the programmatic evaluation of various behavioral health initiatives across the care continuum. His research encompasses a variety of methodological approaches including both quantitative and qualitative analyses, with emphasis on mixed methods and a special interest in the engagement of patients, community members, healthcare providers, and other stakeholders.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Clinical Trial Number:

Not Appliable

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Table 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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You are reading this latest preprint version

Evaluation of the Health Literacy Curriculum at a Southeastern Medical School

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Methods Design, sampling, and setting

Measures

Results

Discussion

Summary of Main Findings

Importance of teaching style

Recommendations for medical educators and accreditation organizations

Limitations and future directions

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1