April 2026 – Tarrant County Physician Online

Understanding Before Access: Why PATC Is Measuring Health Literacy More Intentionally

Project Access Tarrant County

By Kathryn Keaton

This article was originally published in the March/April 2026 issue of Tarrant County Physician.

At Project Access Tarrant County, we have always believed that the “access” in our name involves more than seeing a specialist—it also includes comprehension. A growing body of research confirms what community health organizations have long observed: Health literacy is directly tied to healthcare utilization, outcomes, and cost.

Health literacy, as defined by Healthy People 2030, is “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”¹ PATC is uniquely positioned to help our patients improve health literacy not just for their PATC service, but also for their future lifetime of healthcare.

A 2025 systematic review found that limited health literacy is consistently associated with higher healthcare costs, increased hospitalizations, and greater emergency department use—all areas PATC aims to reduce in Tarrant County.² Literacy is not a secondary social factor; it is a healthcare variable. Health literacy influences how patients navigate outpatient, inpatient, emergency, and digital health systems (even more so in immigrant populations)—and PATC is changing how we approach this issue in our patient base.

Moving Beyond “High School or Not”
Historically, many healthcare systems—including safety-net organizations—have captured each patient’s education level in broad terms. Emerging research shows that education level alone does not reliably predict a patient’s ability to understand medical terminology, consent forms, referral instructions, or post-procedure care plans. Studies have demonstrated that even patient-facing surgical materials are frequently written above recommended reading levels.

A decade ago, the AMA and National Institute of Health recommended that medical materials be written at an eighth grade or below reading level,³ but today, most experts agree that material should be written at a sixth grade or below reading level.⁴

When written information assumes advanced comprehension, patients are placed at risk of misunderstanding critical instructions. Just last year, a PATC patient almost canceled her vital surgery because she mistakenly thought she was instructed to stop her diabetes medication for a full week leading up to her surgery. She had enough health literacy to question those instructions, but not enough confidence to question their accuracy.

To respond more intentionally, PATC is refining how we capture and evaluate education and health literacy across our patient population.

What We’re Changing

Narrowing our educational ranges
Rather than broad categories, we now collect more targeted education data. This allows us to examine patterns in referral completion, adherence, and communication preferences.
Identifying whether education occurred inside or outside the United States
Educational systems vary widely across countries. A high school diploma earned abroad may reflect a different exposure to English-language healthcare terminology or system navigation. Recent national research examining health literacy by Hispanic ethnicity reinforces this nuance.⁵
Implementing SAHL evaluations for each adult patient

PATC is incorporating the Short Assessment of Health Literacy (SAHL), a validated screening tool created in 2010 by Health Services Research that directly measures a patient’s ability to recognize and understand common medical terms.

Unlike education level, SAHL evaluates functional comprehension—an essential factor in specialty care navigation. The tool is curated in both English and Spanish, with other languages available.⁶

Why Literacy Directly Impacts Care
Health literacy affects:

Medication adherence
Chronic disease management
Completion of specialty referrals
Understanding of pre-procedure instructions
Post-surgical recovery compliance

Systematic reviews across multiple countries show that lower health literacy is associated with delayed care, increased acute utilization, and poorer chronic disease management—even in universal healthcare systems, insurance coverage alone does not eliminate access barriers.⁷

For uninsured patients navigating specialty referrals—often involving multiple providers, consent forms, preparation instructions, and follow-up plans—comprehension is foundational. When literacy gaps are not identified, missed appointments may be labeled as “noncompliance.” In reality, they may reflect confusion, fear, or uncertainty.

Connecting Data to Our Broader Health Literacy Efforts
Importantly, PATC’s shift is not just about collecting more data. It strengthens and informs our broader health literacy initiatives, including:

Simplifying written instructions
Evaluating readability of patient-facing materials
Reinforcing clear text-based communications (CareMessage)
Informing topics for future Salud en Tus Manos curriculum
Literacy is not just a patient issue—it is a system design issue. By measuring literacy more intentionally, PATC can ensure that communication strategies match patient needs.

Access Requires Understanding
Healthcare systems are becoming increasingly complex and digital. Artificial intelligence tools, online portals, and automated communications can enhance access—but only if patients can understand and use them effectively.

Access to care is not complete when an appointment is scheduled. It is complete when a patient understands what that appointment means—and what to do next.

By refining how we measure education and incorporating validated literacy screening, PATC is strengthening the foundation of specialty care coordination—because access begins with understanding.

References:

Office of Disease Prevention and Health Promotion, “Health Literacy in Healthy People 2030,” Healthy People 2030, U.S. Department of Health and Human Services, accessed March 12, 2026, https://odphp.health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030.
Francesca Tusoni et al., “What Is the Impact of Health Literacy on Healthcare Costs? A Systematic Review and Evidence Synthesis,” BMJ Open 15, no. 12 (2025): e108816, https://bmjopen.bmj.com/content/15/12/e108816.
Patrick J. L. Fitzgerald et al., “Readability of Patient Education Materials on the American Association for Surgery of Trauma Website,” Journal of Surgical Research (2014), https://pmc.ncbi.nlm.nih.gov/articles/PMC4139691/.
Cheryl A. Tucker, “Promoting Personal Health Literacy Through Readability, Understandability, and Actionability of Online Patient Education Materials,” Journal of the American Heart Association 13, no. 8 (2024): e033916, https://www.ahajournals.org/doi/10.1161/JAHA.124.033916.
Athena K. Ramos et al., “Health Literacy by Hispanic Ethnicity and its Association with Healthcare Experiences, Self-rated Health, and Quality of Life,” Journal of Immigrant and Minority Health (2026), https://doi.org/10.1007/s10903-026-01848-5.
Shoou-Yih Daniel Lee et al., “Short Assessment of Health Literacy—Spanish and English,” Health Services Research 45, no. 4 (2010): 1105–1120, https://doi.org/10.1111/j.1475-6773.2010.01119.x.
R Schönegger, C Von Reibnitz, and Hans-Peter Wiesinger, “Health Literacy and Healthcare Utilisation in Universal Healthcare Systems: A Systematic Review,” European Journal of Public Health 35, no. 4 (October 2025), https://doi.org/10.1093/eurpub/ckaf161.1476.

The Evolving Challenges in Medicine: A Look at the Long-term Impact of the COVID-19 Pandemic

Public Health Notes

By Catherine Colquitt, MD, TCPH Medical Director

This article was originally published in the March/April 2026 issue of Tarrant County Physician.

The opportunities, rewards, and privileges of practicing medicine are many, but the pressure of practice can at times be stressful or overwhelming. Our colleagues straining to cope may be reluctant to report or seek treatment for depression, anxiety, or substance abuse disorders. Many of these conditions have been exacerbated by the COVID-19 pandemic and its aftermath.

Tarrant County Public Health (TCPH) has for many years offered chronic disease self-management programs which host lay group support programs customized to each participant’s needs. These are facilitated by a trained lay leader with input from the rest of the support group and are tracked to mark progress on the journey toward successful chronic disease self-management, including anxiety, depression, and obsessive-compulsive disorder, among other chronic conditions. However, many physicians and other healthcare workers already feel too over-extended to participate in a time-consuming peer support program such as TCPH offers.

While healthcare worker (HCW) burnout is lower now than at the height of the COVID-19 pandemic, HCW burnout and stress have not returned to the pre-pandemic baseline according to most sources, including a large study of Veterans Health Administration (VHA) HCWs surveyed annually in 140 VA Medical Centers from 2018 to 2023. In response to survey data, the VHA implemented “several system-level programs to revise organizational practices and policies” to reduce or mitigate burnout. These include reducing workloads by hiring more staff, increasing telehealth and telework options, and introducing “whole health practices” in employee healthcare in which much attention is directed at mitigating the mental health impact of medical conditions and stressors at work or home affecting VHA employees.¹

Scientific Reports released a study evaluating anxiety
and depression among HCWs two years after the COVID-19 infection began. A remarkably high percentage (50.8 percent) of their sampled HCWs reported “long COVID,” which authors defined as “persistence of multi-system symptoms for more than twelve months, including fatigue, shortness of breath, brain fog, depression, and anxiety.” The authors used PHQ-9 and GAD-7 scales to assess anxiety and depression in HCWs two years after COVID infection (higher scores indicate more instances of anxiety and depression, while lower scores indicate fewer). They found that students had the highest PHQ-9 and GAD-7 scores, with doctors, nurses, and administrative staff reporting lower PHQ-9 and GAD-7 scores. Authors concluded that “policymakers and healthcare administrators should consider optimizing mental health support systems,” including “implementing regular mental health screenings, providing personalized psychological interventions, offering counseling services, reducing work-related stress, and promoting the use of mental health assessment tools to improve the psychological well-being” of healthcare workers, especially students and those who have long COVID.²

Center for Infectious Disease Research and Policy summarized a Morbidity and Mortality Weekly Report study of US HCWs surveyed online in 2022 and 2023 in which 26 percent of participants “reported symptoms of mental illness but only 20% sought treatment during the previous year, mainly because of difficulty getting time off from work and worries about confidentiality and cost.” HCWs were surveyed using PHQ-2 and GAD-2 tools and cited work stress, burnout, inadequate staffing, greater workload or job demands, fear of COVID-19, and COVID-19 misinformation as their leading stressors.³

Like our patients, we physicians escape through connections to our chosen online communities, but perhaps we should more often step out of our comfort zone to ask a colleague how they are doing in a manner which suggests that we really care to know, and this might lead to a colleague expressing concern for our well-being as well. Who among us is at risk for self-harm? According to actuarial data, the typical physician at risk is 45 years old; Caucasian; amid some marital discord or divorced, separated, or single; self-treating with alcohol or drugs; a “workaholic”; and a risk-taker. Our hypothetical colleague may also have chronic pain or some other serious medical comorbidity, is concerned about a looming change in status (financial, professional, social) and may be frankly overwhelmed by the increasing demands of work. Our colleague will likely also have access to medications or firearms with which to act.^4,5,6

Psychiatric concerns in physicians are often left unaddressed until far advanced just as we often under-diagnose psychiatric conditions in our patients. Furthermore, we may fear the possible professional repercussions of asking for help with a psychiatric illness, opening ourselves up to the scrutiny and judgment of physician health programs, credentials committees, colleagues, or lawyers.

It is my personal hope that we will all use our training, honed by the COVID-19 pandemic, to minister to those suffering and in pain in the ways unique to our healing arts. COVID-19 has changed us all in ways we don’t yet fully realize.

References:

Debra C. Mohr et al., “Burnout Trends Among US Health Care Workers,” JAMA Network Open 8, no. 4 (2025): e255954, https://doi.org/10.1001/jamanetworkopen.2025.5954.
Lin Zhang et all., “Anxiety and Depression in Healthcare Workers 2 Years After COVID-19 Infection and Scale Validation,” Scientific Reports 15 (2025): Article 13893, https://doi.org/10.1038/s41598-025-98515-w.
Mary Van Beusekom, “1 in 4 US Healthcare Workers Report Mental Distress During COVID, Survey Suggests,” Center for Infectious Disease Research and Policy, January 20, 2025, https://www.cidrap.umn.edu/covid-19/1-4-us-healthcare-workers-report-mental-distress-during-covid-survey-suggests.
Latoya Hill et al., Physician Workforce Diversity by Race and Ethnicity, Kaiser Family Foundation, July 22, 2025, https://www.kff.org/racial-equity-and-health-policy/physician-workforce-diversity-by-race-and-ethnicity/.
Daniel Saddawi-Konefka, Christine Yu Moutier, and Jesse M. Ehrenfeld, “Reducing Barriers to Mental Health Care for Physicians: An Overview and Strategic Recommendations,” JAMA 334, no. 10 (2025): 987–995, https://doi.org/10.1001/jama.2025.12587.
Hirsh Makhija et al., “National Incidence of Physician Suicide and Associated Features,” JAMA Psychiatry, published online February 26, 2025, https://doi.org/10.1001/jamapsychiatry.2024.4816.

I am a Doctor. . .

Feature Narrative

By Sergio Sanchez Zambrano, MD

This article was originally published in the September/October 2025 issue of Tarrant County Physician.

Recently, while evaluating annotations by a young medical student for potential publication in our journal, I objected to the fact that the author was referring to herself as a “provider.”

I do not know of ANY other profession as altruistic and generous as that of being a doctor.

I manifested my respect to the medical student for her generosity and the extent of her altruism. At that time, a Christmas present given to me by my wife came to mind—a copy of a poem written by Robert Louis Stevenson from Scotland (November 13, 1850–December 3, 1894). It is called “Eulogy of the Doctor.”

Robert Louis Stevenson’s prose is unique and needs no additional commentary; hence, I will simply “copy and paste.”

Eulogy of the Doctor

There are men and classes of men that stand above the common herd the soldier, the sailor, the shepherd not infrequently, the artist rarely, rarelier still the clergyman, the physician almost as a rule.. He is the flower of our civilization and when that stage of man is done with, only to be marveled at in history he will be thought to have shared but little in the defects of the period and to have most notably exhibited the virtues of the race. Generosity he has, such as is possible only to those who practice an art and never to those who drive a trade: discretion, tested by a hundred secrets; tact, tried in a thousand embarrassments; and what are more important, Herculean cheerfulness and courage. So it is that, he brings air and cheer into the sick room and often enough, though not so often as he desires, brings healing.

There is nothing else that I could add other than encouragement to all the doctors, young and old, to remember that we are not providers. We are DOCTORS.

I am just saying . . .