Claims and demonstrations of understanding

When a patient walks into your office you cannot see their level of health literacy.

There are several indicators and red flags that you can be aware of. These were discussed in Week 2 and included, for example:

• Frequently missed appointments;
• Incomplete registration forms;
• Non-compliance with medication;
• Unable to name medications, explain purpose or dosage;
• Identifying pills by looking at them, not reading labels;
• Unable to give coherent, sequential history;
• Ask fewer questions;
• Lack of follow-through on tests or referrals.

However, you may also focus on the conversation with the patient. Probably one of your main goals is not to know the exact level of health literacy but to make sure that your patients walk out of your office understanding everything you told them. But how do you know whether patients really understand what you need them to understand? One way to do this is to be aware of patient direct responses to your questions or explanations. If you ask a patient whether (s)he understands what you explained and the answer is “yes”, can you be sure (s)he understood you correctly?

This type of patient response is called a claim of understanding. We know from research in educational settings that this type of response is often sufficient for a teacher and the same is probably true for healthcare professionals. However, sometimes patient responses are formulated as demonstrations of understanding.

Nurse: To find out what your blood sugar level is at that moment in time you need a blood testing meter, a finger prick device, some test strips and a lancet. Do you know what a lancet is?
Patient: Yes that’s this thing right? (points to lancet on the table)

In the example above the patient not only claims understanding by saying ”yes”, but actually points to the object, demonstrating that their understanding is correct.

So how does this help health professionals in practice? If your patient only responds with short claims of understanding, this can be interpreted as a red flag for limited understanding and limited health literacy. In this case you can use communication strategies to elicit demonstrations of understanding, such as the teach-back strategy or chunck-and-check, which are explored further later in this course.

To read more about claims and demonstrations of understanding: Tom Koole (2010) Displays of Epistemic Access: Student Responses to Teacher Explanations, Research on Language and Social Interaction, 43:2, 183-209.