Health Literacy: Help Your Patients Understand

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Health Literacy Help Your Patients Understand
Module 1 Overview of Health Literacy

• Presented by
• American Medical Association Foundation
  American Medical Association

10/03
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• The Clinical Impact of Poor Health Literacy on
  Clinical Care
  
• Robert C. Moravec, MD
• 2006

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• Slow down when talking to patients

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True or False?
Module 1

• Most people with a literacy problem are poor,
  immigrants, or minorities.
  
• People will tell you if they have a problem
  reading.
  
• The number of years of schooling is a good
  general guide to determine literacy level.
  

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Up to ½ of US population may be at risk for
Module 1

• Medical misunderstandings
• Mistakes
• Excess hospitalizations
• Poor health outcomes

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Why are they at risk?
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• Reliance on the written word for patient
  instruction
  
• Increasingly complex health system
• More medications
• More tests and procedures
• Growing self-care requirements

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Definitions
Module 1

• General Literacy
• An individuals ability to read, write, and
  speak in English, and compute and solve problems
  at levels of proficiency necessary to function on
  the job and in society, to achieve ones goals,
  and develop ones knowledge and potential.
• National Literacy Act of 1991
• Health Literacy
• The degree to which individuals have the
  capacity, to obtain, process, and understand
  basic health information and services needed to
  make appropriate health decisions.
• Healthy People 2010

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National Adult Literacy Survey
Module 1

• n 26,000
• Most accurate portrait of literacy in U.S.
• Scored on 5 levels
• Result 48 of US population have inadequate or
  marginal literacy skills

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1993 National Adult Literacy Survey
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NALS Level 1Inadequate Literacy (21)
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• Able to
• Sign name
• Find a country in an article
• Total a bank deposit entry
• Cannot consistently
• Understand the gist of an article.
• Use a bus schedule
• Enter information on a SS application

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NALS Level 2 Marginal Literacy (27)
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• Able to
• Find intersection on street map
• Locate information in newspaper article
• Determine difference in price on tickets
• Cannot consistently
• Use a bus schedule
• Identify information from a bar graph
• Write a brief letter of complaint

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2003 National Assessment of Adult Literacy

• Average quantitative literacy scores of adult
  increased 8 points between 1992 and 2003.
  
• Average prose and document literacy did not
  differ significantly
  
• Various race groups varied in the overall scores

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Overview of Literacy Levels

• Below Basic No more that the most simple and
  concrete literacy skills
  
• Basic Perform necessary and everyday literacy
  skills
  
• Intermediate skills necessary to perform
  moderately challenging literacy activities
  
• Proficient can perform more complex and
  challenging literacy activities

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Overview of Literacy Levels2003

• Below Basic 14 for both
• Basic 29 Prose
• 22
  Document
  
• 36 - 43 Marginal
  Literacy
  
• Intermediate 44 Prose
• 53
  Document
  
• Proficient 13 for both

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2003 National Assessment o Adult Literacy

• Blacks
• Prose literacy - 8 points
• Document literacy 6 points
• Asian / Pacific Islanders
• Prose literacy 16 points

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2003 National Assessment o Adult Literacy

• Hispanics
• Document literacy - 18 points
• White
• Prose and document literacy no change

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What is the impact of only Level 2 (marginal)
literacy?

• Individuals reading at level 2 can read simple
  materials, but have difficulty with words and
  numbers. Thus they struggle to decipher bus
  schedules or make sense of bar graphs. They also
  struggle with writing a simple letter explaining
  an error on a bill.
• All health care directions are words and
  numbers.

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What can we do to help?
Module 1

• Understand the problem
• Identify the barriers faced by both patients and
  clinicians
  
• Identify and implement strategies to enhance
  health literacy
  
• Advocate for system change

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What is it like?
Module 1

• The following passage simulates what a reader
  with low general literacy (NALS Level 1) sees on
  the printed page.
  
• You have 1 minute to read.
• Hint The first word is cleaning

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GNINAELC Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna natspac
revenehw uoy eciton na noitalumucca fo tsud dna
nworb-red edixo selcitrap. Esu a nottoc baws
denetsiom htiw lyporposi lohocla. Eb erus on
lohocla sehcuot eht rebbur strap, sa ti sdnet ot
yrd dna yllautneve kcarc eht rebbur. Esu a pmad
tholc ro egnops ot naelc eht tenibac. A dlim
paos, ekil gnihsawhsid tnegreted, lliw pleh
evomer esaerg ro lio.
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What is it like?
Module 1

• How do you clean the capstan?

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Low health literacy problems with
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• Medications
• Appointment slips
• Informed consents
• Discharge instructions
• Health education materials
• Insurance applications

Medication Take as directed
Dr. Literate
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Changes in the health care system
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• 4 - 6 weeks bed rest
• in hospital
• 650
• 3 weeks in hospital
• 2 hours a day of diabetic education classes

• 2-4 days in hospital
• (MR Guidelines)
• 10,000
• outpatient
• 0-3 hours diabetic
• education classes
• written materials
• internet
• telemedicine

Treatment of Acute Myocardial Infarction Avai
lable Prescription Drugs Treatment of new onset
diabetes
35 Years Ago
Today
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Factors that contribute to health literacy
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• General literacy
• Experience with health system
• Complexity of information
• Cultural and language factors
• How information is communicated
• Aging

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One-third of patients at 2 public hospitals had
inadequate health literacy
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Williams, Parker, Baker, et al. JAMA 1995
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Many patients struggle with health reading
tasks.
Module 1
Incorrect

• Take medicine every 6 hours 22
• Take medicine on empty stomach 42
• Upper GI instructions (4th grade) 21
• Medicaid Rights (10th grade) 46

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Inadequate health literacy increases with age
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Gazmararian, et al. JAMA 1999
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What do we know from a decade of research?
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• Low health literacy leads to
• Lower health knowledge and less healthy behaviors.

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Less healthy behaviors for patients with low
literacy.
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• More exposure to violence
• Pregnant women more likely to smoke
• Less breastfeeding
• Less likely to be get flu vaccine or pneumovax

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Low literate diabetic patients less likelyto
know correct management.
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Know symptoms of low blood sugar (hypoglycemia)
Know correct action for hypoglycemic symptoms
Percent
Williams, et al. Arch Int Med 1998
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Poor health outcomes for diabetic patients
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• Diabetic patients with low health literacy have
  poorer glycemic control than patients with
  adequate literacy.
  
• (Schillinger D, et al. JAMA. 2002.)
• Diabetic children (ages 5-17) had poorer glycemic
  control if their parents had lower literacy
  skills.
  
• (Ross LA, et al. Diabetic Med. 2001.)

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Patients with low literacy have poorer health
outcomes
Module 1

• 69 more likely to have late stage diagnosis of
  prostate CA at presentation. (Bennet, J Clin
  Oncol 1998)
  
• 4 times more likely to be non-compliant with
  Anti-HIV meds. (Kalichman S, et al. JGIM 1999)

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Patients with low literacy more likely to be
hospitalized
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Baker, Parker, Williams, et al. JGIM 1999
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Poor reading skills correlate with less knowledge
of asthma
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Know must stay away from allergens.
Know need to see MD even when not having an asth
ma attack.
p 0.001
Correct
Williams, Baker, Honig et al. Chest. 1998
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One-third of SeniorCare enrollees had inadequate
literacy
Module 1

Gazmararian, et al. JAMA 1999
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Reading errors for SeniorCare enrollees with
inadequate literacy
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• Take medicine every 6 hours 48
• Interpret blood sugar value 68
• Identify next appointment 27
• Take medicine on empty stomach 54
• Upper GI instructions (4th grade) 76
• Medicaid Rights (10th grade) 100

Gazmararian, et al. JAMA 1999
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Health knowledge deficits for patients with low
literacy
Module 1

• Patients with asthma less likely to know how to
  use an inhaler
  
• Patients with diabetes less likely to know
  symptoms of hypoglycemia
  
• Patients with hypertension less likely to know
  that weight loss and exercise lower blood
  pressure
  
• Mothers less likely to know how to read a
  thermometer.
  

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Mothers with low literacy
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• Greater risk of depression
• Less knowledge about adverse effects of smoking
• Less breast-feeding
• Less able to read a thermometer

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Research also shows that
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• Literacy is a predictor of health status
• It is a stronger predictor than age, income,
  employment status, education level, or racial and
  ethnic group

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Estimated 50 billion annual costs of poor
health literacy
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• We all pay!
• 39 paid by Medicare through FICA taxes on
  workers
  
• 17 paid by employers
• 16 paid by patients out-of-pocket
• 14 paid by Medicaid
• The remaining 14 comes from other public and
  private sources.
  

Estimated by the National Academy on an Aging
Society using 1998 figures
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Video The patients voice...
Module 1

• This video was made by the AMA in 2003
• You will see real patients and real physicians
  talking about literacy issues
  

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The shame of low literacyThe patients voice.
Module 2

• Mrs. Walker It paralyzes your every thought.
• Mr. Bowman This is your greatest fear.
• Mrs. Grigar I hide it.it drains you.
• Mr. Bell I blame them, they dont respect me.
  
  

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Strategies to enhance health literacy
Module 2

• Enhance assessment techniques
• Create a shame-free environment
• Improve interpersonal communication with
  patients
  
• Create and use patient-friendly written
  materials
  

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Patients wont tell you.
Module 2

• of patients who have never told about their
  illiteracy
  
• Supervisor 91
• Children 53
• Spouse 68
• Anyone 19
• What do you think the is for their physician?
• Parikh N, et al. Patient Educ Couns, 1996.

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In a doctors office, patients may feel..
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• Fearful
• Anxious
• Angry
• Stupid
• Embarrassed
• Ashamed
• Suspicious, on guard
• Other emotions?

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Red Flags Patients may seek to protect
themselves by.
Module 2

• Seeking help only when illness is advanced
• Walking out of the waiting room
• Making excuses
• Pretending they can read
• Becoming angry, demanding
• Clowning around, using humor
• Being quiet, passive
• Detour, letting doctor miss the concern

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Use the social history to ask
Module 2

• Ask about education, reading, learning styles
  be non-judgmental.
  
• Use this discussion to open a space for the
  patient to talk about literacy issues.

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Shame-free communication means..
Module 2

• Be curious, listen
• Ask before you advise
• Give the patient time to respond
• Take the patients concern seriously
• Discuss how you can best help the patient care
  for themselves
  
• Ask patients how they want information
  communicated to them
  
• Be positive, hopeful, empowering

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Use a medication review to identify
problems
Module 2

• Ask patients to bring in all their medications
• Ask them to name and explain the purpose of each
  one
  
• Discuss exactly how and when they take each one
• Use this discussion to identify areas of
  confusion and to answer questions

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All staff need to be involved in..
Module 2

• Understanding the scope of the problem
• Identifying patient barriers to care
• Creating strategies to address the barriers
• Implementing and assessing the effectiveness of
  these strategies
  
• Conducting on-going follow-up and evaluation

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Failure to communicate
Module 3

• Doctor Your foot infection is so severe that
  we will not be able to treat it locally.
  
• Patient I hope I dont have to travel far,
  doctor. Im afraid of flying.

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Practice Plain, non-medical language
Module 3

• Anti-inflammatory
• Benign
• Contraception
• Hypertension
• Oral
• Echocardiogram

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2. Explain things clearly using plain
language.
Module 3

• Slow down the pace of your speech
• Use analogies
• Arthritis is like a creaky hinge on a door.
• Use plain, non-medical language
• Pain killer instead of analgesic

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3. Focus on key messages and repeat.
Module 3

• Limit information by focusing on 1-3 key messages
  per visit
  
• Review each point and repeat several times
• Have other staff reinforce key messages.

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4. Use teach back or show me techniques.
Module 3

• Ask patient to demonstrate understanding
• What will you tell your spouse about your
  condition?
  
• I want to be sure I explained everything
  clearly, so can you please explain it back to me
  so I can be sure I did.
  
• Do not ask,
• Do you understand? .

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Teach back works
Module 1

• Asking that patients recall and restate what
  they have been told is one of 11 top patient
  safety practices based on strength of scientific
  evidence. (AHRQ, 2001 Report on Making Health
  Care Safer)
• Physicians application of interactive
  communication to assess recall or comprehension
  was associated with better glycemic control for
  diabetic patients. (Schilinger D. Arch Intern
  Med. 2003 163)

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5. Use patient-friendly educational
materials to enhance interaction.
Module 3

• Show or draw simple pictures
• Focus only on key points
• Emphasize what the patient should do
• Minimize information about anatomy and
  physiology
  
• Be sensitive to cultural preferences.

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Guidelines for creatingpatient-friendly written
materials
Module 3

• Simple words (1-2 syllables)
• Short sentences (4-6 words)
• Short paragraphs (2-3 sentences)
• No medical jargon
• Headings and bullets
• Lots of white space.

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What are the barriers to patients?
Module 1

• Barriers to Access
• Barriers to Diagnosis
• Barriers to Treatment

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Module 1
Guiding Principles

• Provide easy-to-understand information for ALL
  patients.
  
• Ensure the environment is patient-friendly and
  shame-free for ALL patients.

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What have other docs tried?
Module 1

• Medication reviews helped to identify and address
  health literacy problems
  
• Maps on the back of appointment letters cut down
  on no shows
  
• Maps on the back of requisition slips increased
  completed lab work
  
• Organized, simplified pre-op instructions, both
  written and verbal, cut surgical same-day
  cancellations from 5 to 0.8
  

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What is HealthEast doing?
Module 1

• Surgery Admit Unit assessment of literacy by RNs
• Surgery consent form revised from 14th grade to
  6th grade level
  
• Anesthesia consent form revised from 16th grade
  to 4th grade level.
  
• Culturally appropriate and multiple languages
• Other forms needing review
• Admissions, discharge, and finance and billing
• Staff and physician education

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Review Five steps to enhance your interactions
with patients
Module 3

• 1. Conduct patient-centered visits
• 2. Explain things clearly in plain language
• 3. Focus on key messages and repeat
• 4. Use a teach back or show me technique to
  check for understanding
  
• 5. Use patient-friendly educational materials to
  enhance interaction.

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Summary Specific strategies to enhance health
literacy
Module 1

• Create a shame-free environment
• Enhance assessment strategies
• Improve interpersonal communication with
  patients
  
• Create and use patient-friendly materials