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Health Literacy: From Patient Care to Policy

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Title: Health Literacy: From Patient Care to Policy


1
Health LiteracyFrom Patient Care to Policy
  • David W. Baker, MD, MPH
  • Chief, Division of General Internal Medicine
  • Feinberg School of Medicine,
  • Northwestern University
  • Chicago, Illinois

2
National Adult Literacy Study
  • Can people do everyday reading tasks necessary to
    function in society?
  • Measured ability to read and comprehend everyday
    tasks
  • Reading newspaper (prose)
  • Completing forms (document literacy)
  • Balancing a checkbook (quantitative)

3
Functional 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

4
40 Million Americans Have Limited Reading Ability

Kirshner et al. National Adult Literacy Study.
1993.
5
Prose Literacy - NALS
6
Document Literacy - NALS
7
Quantitative Literacy - NALS
8
(No Transcript)
9
Can Patients Read and Understand the Materials We
Expect Them to Read?
10
Recommended Treatments After a Myocardial Infarct
  • Aspirin
  • Beta blocker
  • ACE inhibitor
  • Warfarin?
  • Low fat/cholesterol diet
  • Cholesterol-lowering drug
  • Exercise program
  • Tx for hypertension, diabetes

11
Our Expectations of Patients Continually Increase
  • Self-assessment of health status
  • glucometer
  • peak flow meter
  • bp monitoring
  • Self-Treatment
  • Insulin, steroids, diuretics
  • Health care utilization
  • Insurance coverage
  • ER, Specialists

12
Test of Functional Health Literacy in Adults
(TOFHLA)
  • Pill bottles
  • Appointment slips
  • Informed consents
  • Discharge instructions
  • Health education materials
  • Insurance applications

Medication Take as directed
Dr. Baker
13
Prescription Label If you were going to eat
lunch at noon, what time should you take the
medicine before lunch?
14
Appointment Slip (Document) When is your next
appointment? Where?
15
Quantitative Skills (Numeracy) Is your blood
sugar normal today?
16
Reading Comprehension Medicaid Rights and
Responsibilities (10th grade level)
17
Many Patients Could Not Perform Basic Reading
Tasks
Incorrect 
  • Taking Medication on an empty stomach
  • When is your next appointment?
  • Interpret blood sugar
  • Medicaid Rights and Responsibilities Form
  • 39
  • 24
  • 37
  • 34

Williams et al, JAMA 1995
18
TOFHLA CategoriesTest Of Functional Health
Literacy in Adults
  • LOW or INADEQUATE (lt 60)
  • Often misread dosing instructions and appointment
    slips.
  • MARGINAL (60-74)
  • Struggle with prescription instructions.
  • ADEQUATE (gt 75)
  • Handle most health care tasks.
  • Struggle with informed consents.

LOW
LITERATE
MARGINALLY
LITERATE
LITERATE
19
One Third of Patients Had Inadequate Functional
Health Literacy
Williams et al. JAMA 95.
20
Low Literacy by Years of School Completed

21
Inadequate Literacy More Prevalent Among Blacks,
Hispanics

22
Inadequate Health Literacy Increases with Age
84
73
51
23
Age and LiteracyNational Adult Literacy Study
Kirsch et al. NALS 93
24
Conclusions from the Literacy in Health Care Study
  • Many patients cannot perform the basic reading
    tasks encountered in health care.
  • Problem greatest among those with greatest need
  • Minorities
  • The elderly
  • People in poor health
  • Years of school completed is an inaccurate
    indicator of educational attainment.

25
Health Literacy Among the Elderly(The Prudential
Study)
  • 3260 new SeniorCare enrollees in 4 areas
    Cleveland, Houston, Tampa, and S. Florida
  • Interviewed by telephone to determine eligibility
    and willingness to participate
  • Home interview demographics, chronic diseases,
    health status, social support, mini-mental status
    examination
  • Literacy testing Short TOFHLA

26
One Third Of Medicare Managed Care Enrollees Had
Low Literacy

Gazmararian et al. JAMA 99.
27
Inadequate Literacy Varied by Study Site

28
Prevalence of Low Literacy Increased with Age

29
Literacy Declines with Age, Regardless of
Education
DW Baker. J Gerontol B Psychol Sci Soc Sci 2000
30
Effects of Literacy on Health Care and Health
Outcomes
31
Low Literate PatientsLess Likely to Know
Diagnosis
Know Diagnosis
32
Low Literate Diabetic Patients Have Less
Knowledge of Their Illness
Know normal sugar is 70 - 140
Know uncontrolled diabetes damages kidneys /
nerves
Percent
Williams, et al. Arch Int Med 98
33
Low Literate Diabetic Patients Less Likely to
Know Correct Management
Know symptoms of low blood sugar (hypoglycemia)
Know correct action for hypoglycemic symptoms
Percent
Williams, et al. Arch Int Med 98
34
Patients with Hypertension Less Likely to Know
Correct Health Behaviors
Know exercise blood pressure
Know weight loss blood pressure
Percent
Williams, et al. Arch Int Med 98
35
Low Literate Asthma PatientsHave Worse MDI Skills
p lt 0.001 across groups
Mean MDI Score 0 - 4
Williams, et al. Chest 98
36
Inadequate Literacy Affects Use of Preventive
Services
T Scott. Med Care 02
37
Patients with Inadequate Literacy More Likely to
be Hospitalized
p lt .001 for comparison of one or more admissions
p lt .001 for comparison of two or more admissions
Baker et al. JGIM 98
38
Inadequate Literacy Associated with 52 Higher
Risk of Admission
Adjusted for age, gender, socioeconomic status,
health status, and regular source of care.
Baker et al. JGIM 98
39
Medicare Patients with Low Literacy More Likely
to be Hospitalized
DW Baker. AJPH 2002
40
Inadequate Literacy Associated with 29 Higher
Risk of Admission
Adjusted for age, gender, socioeconomic
status,health status, chronic diseases, health
behaviors.
DW Baker. AJPH 2002
41
Rates of Outpatient MD Visits Similar Regardless
of Literacy
DW Baker. JGIM 2001 (abs)
42
Time to First MD Visit Similar
With No Visit
Adequate (n2094)
Inadequate (n800)
43
Patients with Diabetes and Inadequate Literacy
More Likely to Have Poor Glycemic Control
D Schillinger. JAMA 2002
44
Low Literacy Associated With Higher Rates of
Diabetic Complications
  • Adjusted OR
  • Retinopathy 2.33 (1.19 4.57)
  • Nephropathy 1.71 (0.75 3.90)
  • Amputation 2.48 (0.74 8.34)
  • Cerebrovascular Dz 2.71 (1.06 6.97)
  • Ischemic HD 1.73 (0.83 3.60)

D Schillinger. JAMA 2002
45
What We Know
  • Low health literacy is associated with
  • Less knowledge of disease and self-care,
  • Worse self-management skills,
  • Lower medication compliance rates,
  • Higher hospitalization rates,
  • Worse health outcomes.
  • Low health literacy not associated with
  • Lower use of outpatient services,
  • Higher rates of depression.

46
What We Still Dont KnowTo What Degree is
Literacy the Problem?
  • Does low literacy cause worse outcomes?
  • Inability to read and comprehend health
    information directly affects quality of care and
    self-management.
  • Is low literacy a marker for other true (but
    unobserved), causal variables such as
  • Low self-efficacy/external locus of control,
  • Community norms that do not promote favorable
    health behaviors.

47
Why Care About Mechanisms?Because Informs
Interventions
  • If low literacy (poor reading comprehension)
    causes worse outcomes, simplifying written
    materials or presenting material with alternative
    media will eliminate the problem.
  • If low literacy is a marker for other risk
    factors, just simplifying written materials may
    have little or no ameliorative effect.

48
Theory of Reasoned Action/Planned Behavior
Beliefs that behavior leads to outcome
Attitude Toward Behavior
Evaluations of behavioral outcomes
Beliefs that people think behavior is good or bad
Behavioral Intention
Subjective Norm
Behavior
Motivation to comply with these people
Beliefs about ability to enact the behavior
Perceived Behavioral Control
Anticipated resources and/or obstacles
Glanz, Lewis, Rimer 1997
49
Theory of Reasoned Action/Planned Behavior
Behavioral Beliefs
Attitude Toward Behavior
Evaluations of Behavioral Outcomes
Low Literacy
Normative Beliefs
Behavioral Intention
Subjective Norm
Behavior
Motivation to Comply
Control Beliefs
Perceived Behavioral Control
Perceived Power
Glanz, Lewis, Rimer 1997
50
Addressing the Problem
51
At The Bedside Identifying Low Literate Patients
  • High risk group did not complete high school,
    minority, elderly.
  • Does not know names of medicines
  • Frequent missed appointments
  • I forgot my glasses
  • Always comes with someone else
  • surrogate reader

52
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53
Bringing Up the Topic
  • How far did you go in school?
  • A lot of people have trouble reading things they
    get from the doctor because of all the medical
    words. Is it hard for you to read the things you
    get here at the hospital?
  • Ask patient to read prescription bottle.

54
What to Do After You Open Pandoras Box
  • Be supportive
  • Use support system!
  • Be creative
  • Tape pills to card
  • Markers on insulin syringes
  • Phone reminders
  • Repeat Back, check comprehension.

55
The main problem with communication is the
assumption that it has occurred.George Bernard
Shaw
56
For Health Care SystemsUse of Plain Language
  • Assess reading level of existing health
    information.
  • Re-write at simplest level possible (usually
    about 6th grade level).
  • Add pictographs to communicate essential points.

57
Assess Reading Level of Existing Health
Information
If you have a lung disease, such as chronic
obstructive pulmonary disease (COPD) or asthma,
there are many lung function tests a doctor can
do in his or her office or in a lab. Lung
function tests, such as measuring peak
inspiratory flow rates (PIFR) and peak expiratory
flow rates (PEFR), allow the doctor to measure
how much air you can take into your lungs with a
deep breath (inhale) and how quickly you can
expel the air from your lungs (exhale). Lung
function tests assist the doctor in diagnosing
breathing problems and in monitoring how well
your lungs are working. Flesch-Kincaid reading
level 12th
58
Easy to Simplify Health Information to 6th Grade
Level
If you have a lung disease, such as chronic
bronchitis, emphysema, or asthma, your doctor may
recommend tests to see how your lungs are
working. These tests measure how fast you can
breath air in and breath air out. These tests
help your doctor understand what is wrong with
your lungs. Sometimes, your doctor will repeat
the test to follow how well your lungs are
working. Flesch-Kincaid reading level 6.5
59
Simplified Polio Vaccine Brochure Improves
Comprehension
TC Davis. Pediatrics 96
60
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61
Pictographs Improve Comprehension
P Houts. Pt Ed Counsel 98
62
Pictographs Improve Knowledge and Compliance w/
Wound Care Instructions
  • w/o Cartoons w/ Cartoons
  • Did not read instructions 20
    2
  • Very satisfied w/ instructions 66
    97
  • Wound care questions correct
  • 0-1 33 3
  • 2-3 61 51
  • All 4 6 44
  • Compliance w/ daily wound care 54 77

C Delp, J Jones. Acad Emerg Med, 1996
63
Screening for Low Literacy Prior to Patient
Education
  • Diabetes
  • Hypertension
  • Asthma
  • Heart failure
  • Anticoagulation clinic
  • 2 Screening tests available
  • REALM
  • Short TOFHLA

64
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65
(No Transcript)
66
Does Low Literacy Affect Patient Safety?
67
WASHINGTON (AP) -- Toni Cordell-Seiple uses
different-colored markers to carefully write
"from lung doctor" or "for blood pressure" on her
husband's myriad prescription bottles. It's
easier than stopping to decipher the 10-letter,
almost unpronounceable drug names each time she
grabs one of the lookalike bottles. It's also
something of a reflexive defense for the Georgia
woman, who says she once read so poorly that she
signed hospital forms unknowingly consenting to a
hysterectomy.
68
Does Inadequate Literacy Lead to Excess Medicare
Hospital Costs?
  • 36 Million Medicare Eligible

44 Functionally Illiterate (16 million)
2262 per Person / Year
25 - 50 Higher Hospital Costs
Excess Hospital Costs 8 - 15 BILLION
69
Future Research
  • Does reading comprehension really decline with
    age? Can we prevent this?
  • How does low literacy affect patient safety?
  • To what degree does low literacy explain
  • Low socioeconomic status worse health?
  • Racial and ethnic disparities?
  • Does computer-aided education improve
    comprehension, retention, and behaviors?
  • How can we improve communication w/ all pts?
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