Health Literacy

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Health Literacy

• Mark V. Williams, MD, FACP
• Professor of Medicine
• Director, Hospital Medicine Unit
• Emory University School of Medicine
• Executive Medical Director, EHCA
• Editor-in-Chief, Journal of Hospital Medicine
• Past President, Society of Hospital Medicine

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Disease Management Complexity

• Medications 30 years ago vs. today
• LOS in the hospital
• 30 years ago vs. today
• Self-assessment of disease severity
• Glucometer, peak flow meter, bp monitoring,
  weight
• Self-Treatment
• dosing, inhalers, diet, exercise, polypharmacy
• Mistakes

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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

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(No Transcript)
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1993 National Adult Literacy Survey
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Level 4
Level 5 - 3
Level 3
Level 1
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Level 2
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Health Literacy

• Pill bottles
• Appointment slips
• Informed consents
• Discharge instructions
• Health education materials
• Insurance applications

Medication Take as directed
Dr. Literate
The ability to read, understand and acton health
care information.
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Health LiteracyIOM Definition

• Degree to which individuals have the capacity to
  obtain, process, and understand basic information
  and services needed to make appropriate decisions
  regarding their health.

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TOFHLATest Of Functional Health Literacy in
Adults

• Uses actual materials from hospital setting.
• LOW or INADEQUATE (lt 60)
• often misread dosing instructions and appointment
  slips.
• MARGINAL (60-74)
• struggle with prescription instructions.
• ADEQUATE ( 75)
• handle most health care tasks.
• struggle with informed consents.

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Many Patients Cant ReadHealth-related Materials

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Inadequate Health Literacy Increases with Age
84
73

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What do these peoplehave in common?

• Richard Branson Virgin Airways/Records
• Charles Schwab Discount Broker
• John Chambers CEO of Cisco
• Craig McCaw Cellular Industry

And the answer is not that they are billionaires!
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One Third of Enrollees Had Low Literacy

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Low LiteracyIncreases with Age

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Less Educated have Poorer Health Literacy

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READING ERRORS for Medicare Enrollees with
Inadequate Literacy

• 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

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Relevance

• Prevalence of inadequate health literacy
• Current health system does not acknowledge the
  problem
• Use of written word to communicate
• Navigation
• Completing forms
• Barrier to health care

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Low Literate PatientsLess Likely to Know
Diagnosis
Know Diagnosis
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Low Literate Patients Less Likely to Know Name
and Purpose of Medications
Correct
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Patients with Hypertension Less Likely to Know
Correct Health Behaviors
Know exercise ? blood pressure
Know weight loss ? blood pressure
Percent
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Poor Reading Skills Correlate with Less Knowledge
of Asthma
Know must stay away from allergens.
Know need to see MD even when not having an
asthma attack.
Correct
p 0.001
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Poor Reading Skills Correlate with Less Knowledge
of Asthma
Know asthma meds have side effects. p 0.02
Know technique affects dose delivered via MDI. p
lt 0.001
Correct
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Low Literate Asthma Patientshave Poorer MDI
Skills
Mean MDI Score 0 - 4
p 0.0001
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Low Literate Diabetic Patients have Less
Knowledge of Their Illness
Know normal sugar range
Know uncontrolled diabetes damages kidneys /
nerves
Percent
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Provider Patient Communication Challenges

• 40-80 of medical information is immediately
  forgotten.
• Almost half of information is remembered
  incorrectly.
• The more information given, the more information
  forgotten

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Health Literacyand Diabetes Outcomes

• Cross sectional observational study of 408
  English- and Spanish-speaking primary care
  patients with Type 2 diabetes
• Inadequate health literacy associated with
• Worse glycemic control
• Higher rates of retinopathy
• Health literacy accounted for up to 0.72
  percentage points of HbA1c

Schillinger, JAMA 2002288475-482
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Health Literacy andDiabetes Outcomes
Outcome Adequate Inadequate
Tight glycemic control 33 20
Poor glycemic control 20 30
Report Retinopathy 19 36
Schillinger, JAMA 2002288475-482
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Odds of Self-reportedDiabetes complicationsInade
quate vs. Adequate Health Literacy
Complication OR (95 CI) p value
Retinopathy (documented) 2.68 (1.6 - 4.6) .001
Nephropathy 1.71 (0.8 - 3.9) .20
Lower ext. Amputation 2.48 (0.7 - 8.3) .14
Cerebrovascular Dz 2.71 (1.1 - 7.0) .04
Ischemic heart disease 1.73 (0.8 - 3.6) .15
Schillinger, JAMA 2002288475-482
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Prostate Cancer

• Patients with low literacy 69 more likely to
  have late stage diagnosis at presentation.
• Low literacy more significant predictor of late
  stage diagnosis than race or age.

Bennet, J Clin Oncol 1998
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Compliance with Anti-HIV Meds

Patients with low literacy are 4 times more
likely to be non-compliant
Kalichman S, et al. JGIM 1999
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Colorectal Cancer Screening

• Terms not understood
• Colon
• Bowel
• Rectum
• Screening / Blood in Stool
• Polyp / Tumor
• Growth / Lesion

Davis T, et al. Cancer Investigation 2000
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Preventive Health Care

• Inadequate health literacy associated with lower
  self-reported preventive service use

Influenza Vaccine OR 1.4
Pneumococcal Vaccine OR 1.3
Mammogram OR 1.4
Pap smear OR 1.7
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Patients with Low LiteracyMore Likely to Report
Poor Health
Poor     Health
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52 Increase in Odds of Hospitalizationfor
Patients with Low Literacy
Odds Ratio
Adjusted for age, gender, socioeconomic status,
health status, and regular source of care.
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Why Excess Hospitalizations?

• Less knowledge of self-care?
• Worse compliance with treatment?
• Worse general health behaviors?
• Less ability to negotiate the  health care
  system?

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RAND Study

• Education plays a major role in general health
• Patients with chronic diseases
• Better able to follow complex medical regimens if
  they have a college degree
• proven experience in dealing with detailed and
  complex chores that have to be done constantly
• Less educated benefited most from intensive
  treatment programs
• Frequent physician visits telephone reminders
• Physicians should adjust the intensity of their
  care based on the educational background of their
  patients.

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AHRQ Evidence Report 2004Literacy Health
Outcomes

• Low literacy LINKED to
• Poor understanding of information
• Medication errors
• Poor health
• Limited health access
• Substandard medical care
• Adverse health outcomes
• Disparities

Analysis of Literature 1980-2003
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Costs of Low Health Literacy

• 50 billion annually?
• National Academy on an Aging Society
• Poorer quality medical care
• Malpractice suits
• lack of informed consent

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Shame and Low Literacy

• 40 admit shame
• Patients dont tell anyone
• 2/3 have not told their spouses
• 1/2 have not told their children
• 19 have never told anyone
• 90 believe it helpful for doctors to know
• 31 opposed to documentation on hospital card

Physicians who act as literacy police to
identify patients withlimited literacy skills,
will only chase patients out of their office.
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Low Literacy is Overlooked

• Patients dont fit the stereotype
• Many people with inadequate literacy
• Are born in USA (75)
• Are white (50)
• Hold full or part -time job (40)
• Finished high school (25)

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Low Literacy is Overlooked

• Patients dont volunteer it
• Many patients do not recognize their inadequate
  literacy
• Many are ashamed of their reading problem and
  hide it
• Not willing to have their reading ability
  measured or recorded in medical record

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Low Literacy is Overlooked

• Clinicians dont ask about it
• Unaware the problem exists
• Dont know how to ask
• Dont know how to respond
• Dont want to open a Pandoras box

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Time for a Different Approach

• Recognize shifts in medical care
• acute to chronic care
• hospital to outpatient care
• increased learning demands
• Recognize limitations of current approach for
  dealing with inadequate literacy
• most people learn better with audio or visual
  aids, regardless of reading level

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6 Simple Steps

1. Slow down
2. Use living room language
3. Show, draw pictures
4. Limit information repeat instructions
5. Use a teach back or show me approach to
   confirm understanding
6. Be respectful, caring, sensitive

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Do you understand?Do you have any questions?
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Potential Strategies

• Suggested by other physicians
• Bring family member/friend bring all meds
• Offer help w/forms
• Limit instruction
• Repeat concepts more than once
• Ask pt to repeat, teach back
• Write it down in simple language
• Follow up w/call

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A New Paradigm

• Determine patients learning capabilities
• Systematic, programmed learning
• Use audiovisual aids as adjuncts or primary
  learning materials
• Comprehension testing for key points
• Show me or Teach back
• GOAL PATIENT EMPOWERMENT

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Teach back works

• 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 glucose control for
  diabetic patients. (Arch Intern Med/Vol 163, Jan
  13, 2003, Closing the Loop)

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Disease Management Low Literacy

• Low literate patients with diabetes benefit most
  from targeted interventions
• Lower HbA1c (OR 4.6)
• No difference among literate patients
• No difference in control of bp

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AMA Foundations Health Literacy Initiative
provides tools

• Video and Manual for Clinicians
• Power Point slides with facilitator notes
• Participant Guides
• Faculty Guide
• Evaluation questionnaires
• Feedback and networking
• Small grants
• www.amafoundation.org

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More Effective Term for Health Literacy Clear
Health Communication

• Health literacy
• Not well known among providers and patients
• Seen as negative among all stakeholders
• Clear Health Communication
• Research indicates
• Simple and easy to understand
• Communicates that better health is achieved
  through a more effective exchange of information

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Ask Me 3

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

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Partnership for Clear Health Communication Ask
Me 3

• Purpose Improve communication between patient
  and provider
• What 3 questions patients can ask their
  provider to improve understanding
• Who Targeting patients and providers
• When Launched at the Day of Understanding.
  Communicated all year
• How Executed Delivered by Partnership members
  at medical meetings, local markets, etc.

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Pictograms Spoken instructions 14 Spoken
Pictogram 85 After 4 weeks 71 Peer
Educators Dr. Gil Friedel
Houts, Pt Ed Counseling, 2001