NUR5063 Module 3 health literacy and shared decision tool example

Three Ways to Keep a Fast: A Picture-Based Shared Decision Tool in Nepali for Adults With Diabetes Who Fast on Ekadashi

Student Name

American College of Education

NUR5063: Patient-Centered Care

Module 3 Assignment

Instructor Name

January 26, 2027

The Decision Nobody Was Discussing

The cultural needs assessment in Module 2 found that many older Bhutanese Nepali women seen at the composite Northeast Ohio diabetes center fast twice a month on Ekadashi and during festivals, some without food or water for a full day, and that none of the women in the listening sessions had talked about fasting with a clinician. Three described episodes of low blood sugar while fasting. The center's only fasting guidance was a line in an English handout advising patients with diabetes not to fast.

That advice fails in two ways. It ignores a practice that carries religious meaning, so patients keep fasting and stop mentioning it. It also assumes a patient can read it. Low health literacy is linked with worse use of care and worse outcomes, including more hospital admissions and emergency visits and a poorer ability to take medicines correctly and understand labels (Berkman et al., 2011), and many elders in this community cannot read Nepali, let alone English. The real question is not whether a patient should fast but how a patient who will fast can do it safely, and that question has more than one reasonable answer. A question with several reasonable answers, where the right one depends on what the patient values, is exactly the kind of decision that calls for shared decision making.

Designing the Tool

No guideline addresses Ekadashi fasting, so the clinical content was adapted from practical guidance written for Muslim patients who fast during Ramadan, which groups patients by risk and advises that those at higher risk either avoid fasting or fast only with a medicine plan and glucose checks agreed beforehand (Hassanein et al., 2017). The center's endocrinologist and pharmacist reviewed the adaptation. The card offers three options. The first is a phalahar fast, in which the patient eats fruit, milk and other foods the tradition allows, with the usual medicines. The second is a full fast with a medicine plan the prescriber has written for fasting days and glucose checks at set times. The third is to keep the day through prayer and temple attendance without fasting, an option several women said older relatives had chosen with their priest's blessing. Every option shows the same stop rule: if the reading is low or the patient feels shaky, sweaty or confused, the fast is broken with juice or sugar and the family is told.

The format follows the evidence on pictures in health teaching. Houts et al. (2006) found that pictures closely linked to spoken or written text markedly improve attention and recall, that patients with low literacy benefit most, and that people with very low literacy do best with spoken directions plus pictures to take home. The card therefore uses one simple drawing for each option and for the stop rule, drawn with women from the community rather than borrowed from a stock set, with captions of no more than five words in Nepali. Each panel has a printed code the patient's phone camera can read, which plays a 40-second recording in Nepali by a community health worker. The patient's personal fasting-day medicine plan is filled in on the back by the nurse, using drawings of the patient's own pills.

Testing It With the People It Is For

A draft card was reviewed by six women from the community association, aged 52 to 76, four of whom could not read. Each was shown the card with its audio and then asked to explain in her own words what each option meant and what she would do if she felt shaky. Two changes came from this. A drawing of a glucose meter was mistaken for a phone by three women and was replaced by a drawing of a finger with a drop of blood. The word used for low sugar in the first recording was one the women associated with weakness in general, so the recording was redone with the phrase the women themselves used. In a second round, all six explained the stop rule correctly.

Using the Tool in a Three-Talk Conversation

Elwyn et al. (2017) describe shared decision making as a conversation that moves through three stages: team talk, where the nurse signals that there is more than one good path and invites the patient to help choose; option talk, where the paths are laid side by side; and decision talk, where what the patient cares about settles the choice. The card is designed to be used in that order.

In practice, with Mrs. G., the 64-year-old patient from the Module 1 cases, the nurse used a trained interpreter and began with team talk by saying that many women at the center fast, that there are safe ways to do it, and that the choice would be hers and her family's. Mrs. G. asked that her daughter-in-law stay. In option talk, the nurse went through the three panels while the audio played, then asked what mattered most to her about the fast. Mrs. G. said that fasting was a promise she had made for her late husband and that she could not give it up, but that she had eaten fruit on fasting days in the camp in Nepal when she was ill. In decision talk, she chose a phalahar fast on ordinary Ekadashi days and a full fast only on the anniversary of her husband's death, with a written plan from her prescriber for that day. The nurse recorded the choice as hers, sent it to the prescriber and scheduled a phone check the day after her next fast.

Confirming Understanding With Teach-Back

The conversation closed with teach-back. The nurse asked Mrs. G. to show her daughter-in-law, using the card, what she would eat on her next Ekadashi and what she would do if she felt shaky. She pointed to the fruit panel, then to the stop rule, and said she would drink juice and call her son. The nurse also asked the daughter-in-law to explain the stop rule, since she would be present on fasting days. Teach-back worked in 19 of the 20 studies gathered by one systematic review, with benefits ranging from knowledge recall to readmissions and quality of life, although the ways services put it into practice were seldom reported (Talevski et al., 2020). For that reason, the center will record teach-back as a separate step in the visit note, stating what the patient explained correctly and what had to be taught again.

Limits and Next Steps

The card has been tested for understanding with six women, not for its effect on low blood sugar events, and its clinical content is adapted from guidance written for another religious fast. Men who fast and patients on insulin will need their own versions. The next module places this tool inside a broader program that engages families across the transition from hospital to home, where many of the same literacy and decision problems appear at a moment of much higher risk.

References

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155(2), 97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005

Elwyn, G., Durand, M. A., Song, J., Aarts, J., Barr, P. J., Berger, Z., Cochran, N., Frosch, D., Galasiński, D., Gulbrandsen, P., Han, P. K. J., Härter, M., Kinnersley, P., Lloyd, A., Mishra, M., Perestelo-Perez, L., Scholl, I., Tomori, K., Trevena, L., ... Van der Weijden, T. (2017). A three-talk model for shared decision making: Multistage consultation process. BMJ, 359, Article j4891. https://doi.org/10.1136/bmj.j4891

Hassanein, M., Al-Arouj, M., Hamdy, O., Bebakar, W. M. W., Jabbar, A., Al-Madani, A., Hanif, W., Lessan, N., Basit, A., Tayeb, K., Omar, M., Abdallah, K., Al Twaim, A., Buyukbese, M. A., El-Sayed, A. A., & Ben-Nakhi, A. (2017). Diabetes and Ramadan: Practical guidelines. Diabetes Research and Clinical Practice, 126, 303-316. https://doi.org/10.1016/j.diabres.2017.03.003

Houts, P. S., Doak, C. C., Doak, L. G., & Loscalzo, M. J. (2006). The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence. Patient Education and Counseling, 61(2), 173-190. https://doi.org/10.1016/j.pec.2005.05.004

Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4), Article e0231350. https://doi.org/10.1371/journal.pone.0231350