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Doctor-Patient Relationships: Understanding the Importance of Health Literacy in Patient Care


Quick Screening Tests for Health Literacy Single question screens Assessment instruments REALM-R: Rapid Estimate of Adult Literacy in Medicine-Revised NVS: ... – PowerPoint PPT presentation

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Title: Doctor-Patient Relationships: Understanding the Importance of Health Literacy in Patient Care

Doctor-Patient Relationships Understanding the
Importance of Health Literacy in Patient Care
  • Jennifer Hensley, MD
  • Catherine Nicastri, MD
  • State University of New York, Stony Brook
  • Department of Medicine, Division of Geriatrics

Can you read this?
  • Your naicisyhp has dednemmocer that you have a
    ypocsonoloc. Ypocsonoloc is a test for noloc
    recnac. It sevlovni gnitresni a elbixelf gniweiv
    epocs into your mutcer. You must drink a laiceps
    diuqil the thgin erofeb the noitanimaxe to naelc
    out your noloc.

How many adult Americans have difficulty reading
and understanding health information?
  1. 9 million
  2. 90 million
  3. 50 million
  4. Fewer than 1 million

Definition of 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.
  • It involves the ability to use and interpret
    text, documents and numbers effectively

The Scope of Low Health Literacy
  • In 2003, the National Assessment of Adult
    Literacy (NAAL)
  • 90 million Americans (39 of adults) have limited
    health literacy
  • One in five adults read at the 5th grade level or
  • Average American reads at the 8th to 9th grade
  • More than 66 of US adults age 60 and over have
    inadequate or marginal literacy skills

Examples of Health Literacy Tasks
  • Proficient Skills 13
  • Calculate employees share of health insurance
    cost for year using a table on monthly cost
  • Intermediate Skills 53
  • Determine timing, administration and interactions
    based on info from drug label
  • Basic Skills 22
  • Give 2 reasons why a person with no symptoms
    should be screened based on a clearly written
  • Below basic skills 14
  • Circle date of medical appointment on hospital
    appointment slip

Who is at risk for low health literacy?
  1. Elderly
  2. Ethnic Minorities
  3. Those with low income and education levels
  4. Those with high income and education
  5. A, B, and C
  6. All of the above

Highest Risk for Limited Health Literacy
  • Elderly
  • Low income
  • Unemployed
  • Did not finish high school
  • Minority ethnic group (Hispanic, African
  • Recent immigrant to US who does not speak english
  • Born in US but English is 2nd language

Health System Problems Encountered by Persons
with Limited Literacy Skills
  • 26 Did not understand when their next
    appointment was scheduled
  • 42 Did not understand instructions take
    medication on an empty stomach
  • 78 Misinterpret warnings on prescription
  • 86 Could not understand rights and
    responsibilities section of a medicaid

Impact of Low Health Literacy
  • Individuals have less knowledge about their
    health problems
  • Make more medication or treatment errors
  • Fail to seek preventive care
  • More hospitalizations
  • Higher health care costs
  • Less able to comply with treatments
  • Poorer health status

Shame and Health Literacy the unspoken
  • Adequate Health Literacy
  • Low Health Literacy
  • 49 Feel bad/never tell
  • 60 Feel ashamed
  • 94 Hide problem
  • 51 Feel bad/never tell
  • 60 Feel ashamed
  • 78 Hide problem

Who knows you have trouble reading?
  • Never told
  • Spouse
  • Children
  • Relatives
  • Co- workers
  • Friends
  • No one
  • 53
  • 57
  • 86
  • 62
  • 67
  • 19

Physician Assessment of Health Literacy
  • Physicians often under recognize limited health
  • Most physicians attempt to measure literacy
    level by their patients highest grade of
  • Rely on their patients own assessment of their
    reading skills
  • Overestimate their patients ability to understand
    medical information
  • Often provide information to patients in a level
    of complexity that patients do not understand

What can we do?
  • Recognize signs of limited health literacy
  • Screen for health literacy
  • Learn clear communication techniques
  • Educate patients on Ask-Me-3

Ms Kelly Green
  • Ms Kelly Green is a 54 year old caregiver to her
    mother who is bringing her to your office for a
    follow up visit. Her mom has history of dementia,
    hypertension, hypothyroidism and arthritis. She
    was just discharged from the hospital for
    Uncontrolled Hypertension.

Office Visit
Did Ms. Green give any clues that she may have
limited health literacy?
Signs (Clues) of Low Health Literacy
  • Behaviors
  • Forms incomplete or inaccurately completed
  • Frequently missed appointments
  • Noncompliance with medication regimens
  • Lack of follow-up with lab tests, imaging or
  • Responses to written information
  • I forgot my glasses. Ill read this when I get
  • I forgot my glasses. Can you read this to me?
  • Let me bring this home so I can discuss it with
    my children
  • Responses to questions about medications
  • Unable to name medications
  • Unable to explain what the meds are for
  • Unable to explain timing of medication

If you suspect Ms. Greens health literacy is
limited what screening tests could you perform?
Quick Screening Tests for Health Literacy
  • Single question screens
  • Assessment instruments
  • REALM-R Rapid Estimate of Adult Literacy in
  • NVS The Newest Vital Sign

Single Question Screens
  • How often do you need to have someone help you
    when you read instructions, pamphlets, or other
    written material from your doctor or pharmacy?
  • Never Rarely Sometimes Often
  • How confident are you filling out medical forms
    by yourself?
  • Extremely Quite a bit Somewhat A little
    bit Not at all
  • Both been validated in English

  • Word recognition test consisting of 11 medical
  • 1st 3 words are not scored (fat, flu, pill)
    left to decrease test anxiety and enhance patient
  • Administration time lt2 minutes
  • Only available in English
  • Score of 6 or less considered to be at risk for
    limited health literacy
  • Forms and instructions available at

(No Transcript)
The Newest Vital Sign
  • Read and analyze a nutrition label of ice cream
  • 6 questions
  • Administration time 3 to 5 minutes
  • Scores
  • 0-1 Limited literacy
  • 2-3 Possible limited literacy
  • 4-6 Adequate literacy

The Newest Vital Sign Ms Kelly Green
Lets try it out
  • I am asking everyone visiting the clinic to
    help us learn how well they can understand the
    medical information that doctors give them.
    Would you be willing to help us by looking at
    some health information and then answers a few
    questions about that information. Your answers
    will help the doctors learn how to provide
    medical information in ways that patients will
    understand. It will only take about 3 minutes.

(No Transcript)
NVS Answers
  1. 1000 calories
  2. Any of the following correct
  3. 1 cup
  4. ½ the container
  5. 2 servings
  6. 33 grams
  7. 10
  8. No
  9. Because it has peanut oil

Will patients agree to have their literacy skills
assessed in clinical practice?
  • Controlled trial
  • 20 different practices in South Florida
  • Intervention group routine literacy assessment
    with NVS during check in (289)
  • Control group No screening (303)
  • Surveyed at end of visit with Art of Medicine
    Survey Questionnaire (AMSQ)- validated patient
    satisfaction survey

  • Intervention Group
  • 289 asked to undergo screening
  • 284 agreed (98.3)
  • 46.1 limited health literacy on NVS screen
  • 271 completed AMSQ
  • Control Group
  • 303 completed AMSQ
  • No difference between groups on patient

How can we communicate with our patient better?
  • Ms. Green scored a 3 on the Newest Vital Sign

  • What health providers provide
  • What do patients want?
  • Clear and simple information
  • Want to know what they need to do
  • Medical words and complicated explanations
  • Too much information
  • Information that is often irrelevant to what
    patients need to do

How can you help your patients understand?
Steps to Improving Communication and Understanding
  • Recognize the problem
  • Eliminate barriers for communication
  • Confirm that patients understand what they need
    to understand teach back
  • Find a way that works for your patient to
    understand and remember
  • Ask me 3
  • Literature
  • Written instructions

Open and Shame Free Environment
  • Adopt an attitude of helpfulness
  • Convey safe and nonjudgmental environment
  • Plain signage
  • Be on alert to clues

Eliminate Barriers
  • Hearing and visual impairments
  • Medical interpreters/ translators
  • Should be qualified
  • Visual aids for low literacy
  • Multi-Media
  • Interactive Computer programs/TV
  • Video/audiotape
  • Body language

Speak in plain language
  • Use clear and easy to follow language
  • Be specific and use examples
  • Beware of words with multiple meanings (stool,
    gait, dressing) and clarify when using
  • Avoid complicated words and over use of medical
  • Avoid acronyms and new words (CT scan, RUQ U/S,
  • Give them a health context for numbers
  • Encourage questions and take a pause

Taboo A game of speaking in plain language
  • Rules of the game
  • One person gets a card with a medical term
    target word on it
  • You need to describe the target word without
    using the taboo words listed on the card to your
  • You can use taboo words if it is immediately
    defined in laymans terms
  • You have 2 minutes to do this

Common medical words that patients with limited
literacy may not understand
  • Blood in stool
  • Bowel
  • Colon
  • Growth
  • Lesion
  • Polyp
  • Rectum
  • Screening
  • Tumor

What percentage of patients forget what the
Doctor told them as soon as they leave the office?
  1. 80
  2. 50
  3. 10
  4. lt10

Implications for Not Understanding the Physician
  • Up to 80 of patients forget what the doctor
    tells them
  • 50 of what they remember is recalled incorrectly
  • 30 US patients leave their MDs office with
    unanswered questions
  • 2 out of 5 do not follow advice because it is too
    difficult or because they disagree with it

Convey the important points to remember!
Verify they understand
  • Teach Back
  • Encourage Questions
  • Ask-Me-3

Verify they understandTeach Back Approach
  • Do not ask a patient, Do you understand?
  • Ask a patient to explain or demonstrate how they
    will undertake a recommended treatment or
  • I want to be sure that I did a good job
    explaining your blood pressure medications,
    because this can be confusing. Can you tell me
    what changes we decided to make and how you will
    now take the medication? Or Can you explain
    what I just told you to make sure I covered
  • If patient cannot explain correctly, assume that
    you have not provided adequate teaching. Re-teach
    the information using alternate approaches.

Teach Back Approach
Encouraging patients to ask more questions during
the exam will increase the length of their visit?
  • True
  • False

Teach your patient to be proactive Whats
  • New patient education program designed to promote
    communication between patient and Health Care
    Provider to improve health outcomes
  • Quick and effective tool
  • Can foster clear communication between provider
    and patient
  • Studies have shown that patients who understand
    health instructions make fewer mistakes taking
    medication or preparing for a procedure
  • Study also showed a higher level of satisfaction
    from patients and a feeling of improved
    communication using Ask-Me-3 compared to a
    control group
  • For downloadable free materials, posters and

Ask me 3
What is my main problem?
What do I need to do?
Why is it important for me to do this?
Provide Patients with Written Instructions
  • Do not abbreviate!
  • SOB is not a flattering term in laymans
  • BID does not necessarily mean twice a day.
  • Add pictures to communicate your points
  • 1/5 adults read at a level below 5th grade
    simplify to a lower grade level
  • Materials should be written in fifth to eighth
    grade level
  • Define complicated terms/ limit syllables

Ms. Green
Health Literacy and Psychosocial issues
  • Depression/Anxiety
  • Caregiver stress
  • Dementia
  • Limited Health Literacy is a psychosocial issue

Health Literacy and Psychosocial issues
Literature search
  • Literacy Education as Treatment for Depression in
    patients with limited literacy and Depression
  • J GEN INTERN MED 2006 21823828.
  • Understanding the impact of family caregiver
    cancer literacy on patient health outcomes
  • Patient Education and Counseling 2008
  • Relationship of Empathy to Appraisal, Depression,
    Life Satisfaction, and Physical Health in
    Informal Caregivers of Older Adults
  • Research in Nursing Health, 2001, 24, 4456

Health Literacy and Psychosocial issues
Literature search
  • Does a higher Education level protect against
    anxiety and depression? The HUNT study
  • Social Science and Medicine 2008
  • Health Literacy and Cognitive Performance in
    Older Adults
  • JAGS 2009 Vol 571475-1480

Conclusion Steps to improving understanding
  • Recognize the problem
  • Screen patients and caregivers when appropriate
  • Use communication techniques to foster
  • Plain language
  • Teach-Back
  • Visual Cues
  • Encourage patients to be pro-active (Ask-Me-3)
  • Give patient-friendly written instructions or
    patient education handouts

Thank you for your attention!