Literacy, Health Communication, and Diabetes Care

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Literacy, Health Communication, and Diabetes Care

• Dean Schillinger, MD UCSF Professor of Medicine
  in Residence
• Director, Center for Vulnerable Populations SF
  General Hospital
• Chief, California Diabetes Program

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Vulnerabilities Cluster within Individuals and
Neighborhoods
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Objectives

• Review definitions and statistics re literacy and
  health literacy
• Describe research on relationship between
  literacy and diabetes outcomes
• Focus on health communication as one mechanism
• Interventions in primary care and public health

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What is Health Literacy?

• The degree to which individuals have the
  capacity to obtain, process, and understand basic
  health information and services needed to make
  informed health decisions.
• -Institute of Medicine, 2004

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1st National Assessment of Health
Literacy n19,714

• Below Basic Circle date on doctors appointment
  slip
• Basic Give 2 reasons a person with no symptoms
  should get tested for cancer based on a clearly
  written pamphlet
• Intermediate Determine what time to take Rx
  medicine based on label
• Proficient Calculate employee share of health
  insurance costs using table

National Center for Educational Statistics, U.S.
Department of Education, 2003
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1st Health Literacy Assessment
n19,714 U.S. Adults
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Proficient
14
Below Basic
53
Intermediate
Hispanic
Basic
22
Average
National Assessment of Adult Literacy (NAAL)
National Center for Educational Statistics, U.S.
Department of Education, 2003.
Medicare
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Self-reported chronic conditions among an elderly
cohort, by literacy (N2, 512)
Sudore, Schillinger JGIM 2006
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Patients with Diabetes and Low Literacy Less
Likely to Know Correct Management
Need to Know symptoms of low blood
sugar (hypoglycemia) Need to Do
correct action for hypoglycemic symptoms
Low
Moderate
High
Low
Moderate
High
Percent
Williams 1998
Williams et al., Archive of Internal Medicine,
1998
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Literacy is Associated with Glycemic Control,
N408
Adjusted OR2.03, p0.02
Adjusted OR0.57, p0.05
(Tight Control HbA1c?7.2)
(Poor Control HbA1cgt9.5)
Schillinger JAMA 2002
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Adjusted odds of self-reported diabetes
complications, for patients with inadequate vs.
adequate literacy (N408)
Schillinger JAMA 2002
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Limited Health Literacy Patients Experience more
Hypoglycemia N16,000
P for alllt0.001
Sarkar, Adler, Schillinger, in review
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Could poor communication be a mechanism?

• High self-management demands
• Increasing reliance on technology
• Large mismatch in training between health
  professionals and target populations (health
  literacy)
• Counterbalance role of mass media in consumerist
  society
• Strong inverse relationship between educational
  attainment and chronic illness burden
• Communication can be powerful motivator for
  change

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How Does Limited Literacy Affect (Verbal)
Clinical Interactions?

• Impedes understanding of technical information
  and explanations of self-care
• Impairs shared decision-making
• Speed of dialogue, extent of jargon, lack of
  interactivity determinants of effectiveness of
  communication
• Impairs medication communication, jeopardizing
  patient safety (medication discordance)
• Interaction between limited Eng proficiency and
  limited literacy

Fang et al. 2006 JGIM Schillinger et al. 2004 Pt
Ed and Counseling Castro et al, Am J Health Beh
2007 Schillinger et al. 2003 Arch Int
Med Schillinger et al 2004. AHRQ Advances in
Patient Safety
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Diabetes Patients with Limited Literacy
Experience Poorer Quality Communication, N408
Schillinger 2004
OR1.9p0.04
OR3.2plt0.01
OR3.3p0.02
OR2.4p0.02
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21
20
13
13
13
(Often/Always)
(Often/Always)
(Often/Always)
(Never/Rarely/ Sometimes)
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Medical Jargon
GLUCOMETER HEMOGLOBIN A1c DIALYSIS ANGINA RISK
FACTORS CREATININE
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Jargon Terms

• unclarified
• Glucometer
• Immunizations
• Weight is stable
• Microvascular complication
• System of nerves
• HbA1c
• EKG abnormalities
• Dialysis
• Wide Range
• Risk factors
• Kidney function
• Interact

• clarified
• Angina
• Microalbuminuria
• Ophthalmology
• Genetic
• Creatinine
• Symptoms

• washed out of your system
• receptors
• short course
• renal clinic
• blood cells
• increase your R
• screening
• vaccine

• CAT scan
• blood count
• correlate
• stool was negative
• stool
• baseline
• respiratory tract
• polyp

• from Patients own visit
• benign
• blood drawn
• blood count

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Function of Jargon
Assess Symptoms
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Provide
Deliver Test Results
Recommendations
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Provide Health
Education
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n 60
Castro, Schillinger AJHB 2007
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Dialysis Do you know what the number one cause
for people in this country being on dialysis is?
Diabetes
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• Ensures info understood/integrated into
  memorychecks for lapses
• Opens dialogue re health beliefs reinforces and
  tailors health messages
• Promotes a common understanding elicits patient
  participation

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Closing the Loop, aka Teach-Back

• Physicians assessed recall or comprehension for
  15/124 new concepts (12)
• When new concepts included patient assessment,
  patient provided incorrect response half the time
  (7/1547)
• Visits using interactive communication loop not
  longer (20.3 min. vs. 22.1 min)
• Application of loop associated with better HbA1c
  (AOR 9.0, p.02)

Schillinger Arch Int Med 2003
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IDEALL Project Improving Diabetes Efforts
Across Language and Literacy

• Community Health Network of SF/DPH
• AHRQ
• CMWF, TCE, CHCF

Schillinger Diab Care 2009
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Automated Telephone Diabetes Self-Management
Support (ATSM)

• Interactive health technology, touch tone
  response
• Weekly surveillance health education (39
  weeks9 mos)
• In patients preferred language (English, Spanish
  or Cantonese)
• Generates weekly reports of out of range
  responses
• Live phone follow-up through a bilingual nurse
  -gtbehavioral action plans

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Group Medical Visits (GMVs)
Primary Care Provider Health
Educator Pharmacist
Monthly Group Medical Visits
Cantonese-Speaking Groups
English-Speaking Groups
Spanish-Speaking Groups

• 6-10 patients in monthly group meetings (9
  months)
• In patients preferred language ( English,
  Spanish, or Cantonese)
• Facilitated by a bilingual health educator and a
  primary care provider
• A pharmacist present at end of each group visit
• Encourage patients to become active in self-care
  through participatory learning and peer education
  -gtbehavioral action plans

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Key Findings of IDEALL Program Estimating Public
Health Reach of Programs

• Composite reach product
• ATSM GMV
• Overall 22.1 4.8
• English 20.0 6.4
• Chinese 22.0 2.7
• Spanish 24.3 4.0
• Adequate Literacy 15.6 7.6
• Limited Literacy 28.0 3.6

Schillinger, et al.Health Ed and Behavior 2007
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ResultsStructure and Process Measures
pre post
Plt.05.
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Results Functional Outcomes
OR 0.37 vs UC
Rate ratio 0.5 vs UC, 0.35 vs GMV

pre post
Plt.05
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Results Physiologic Outcomes
pre post
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Automated telephony provides safety surveillance
function
Preventability

• 111 participants, 54 inadequate health literacy
• 264 events among 93 participants (86)
• 111 AEs and 153 PotAEs

Sarkar, Murphy, Schillinger et al. 2008 JGIM
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Health System Findings Cost-Effectiveness
Health Plans

• Based on functional improvements, we estimated
  that the cost per QALY for ATSM was
• gt65,000 for both set-up and ongoing costs
• gt 32,000 for ongoing costs only
• Cost effectiveness could be further improved with
  (a) scaling up or (b) metabolic outcomes improved
• A large majority of CA Medicaid health plans
  reported an interest in employing ATSM-like
  technology

Handley, Schillinger, in press Ann Fam Med
2008 Goldman, Schillinger et al. Am J Man Care
2007
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Current Project

• Partner with a local Medicaid health plan San
  Francisco Health Plan
• SFHP care managers will make ATSM response calls
• Test effectiveness when implemented in
  real-world
• Compare ATSM-ONLY with ATSM-PLUS (medication
  activation)
• ATSM-PLUS involves merging pharmacy claims data
  with ATSM data to enable care manager counseling

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Spanish
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SFHP Wallet-Size CardEnglish, Spanish and
Cantonese
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Inform, Educate and Empower

• Health Commxn Vehicles for Diabetes Prevention
• Partnerships with
• Ethnic Media
• Youthspeaks
• Adult Literacy/ESL classrooms for health
  messages, skill-building, and peer leadership
  development

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Develop policies and plans

• States pursuing medication labeling legislation
• In CA literacy and language (SB472)

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Food for ThoughtPublic Health Literacy

• Degree to which individuals and groups can
  obtain, process, understand, evaluate, and act
  upon information needed to make public health
  decisions that benefit the community
• Target populations The public
• Purpose Improve the health of the public
• Aims Engage more stakeholders in public health
  efforts address determinants of health
• Multidimensional conceptual foundations,critica
  l skills civic orientation

D Freedman et al AJPM 2009
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Literacy and DiabetesConclusions

• Mechanisms by which limited literacy affect
  diabetes outcomes likely multiple
• Apparent that improving literacy levels can
  achieve important public health objectives and
  reduce disparities
• Communication characteristics of health care
  system contribute to sub-optimal health care
• Re-structuring health care system (increasing
  interactivity, employing appropriate technology)
  can improve reach and effectiveness of health
  care, enhance quality, promote safety
• Public health is uniquely positioned to
  contribute to solutions

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