Health Literacy The Missing Link in PatientPhysician Communication

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Health LiteracyThe Missing Link in
Patient-Physician Communication

• AMA-MSS Subcommittee on Health Literacy
• Community Service Committee

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Do you know?

• Which of the following is the strongest
  predictors of an individuals health status?
• A) Age
• B) Income
• C) Literacy skills
• D) Education level
• E) Racial or ethnic group
• F) Average Beer Intake at Metro

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Do you know?

• Which of the following is the strongest
  predictors of an individuals health status?
• A) Age
• B) Income
• C) Literacy skills
• D) Education level
• E) Racial or ethnic group
• F) Average Beer Intake at Metro

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• The Problem
• Low Health Literacy

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Definitions

• Illiteracy total inability to read and write
• Functional Illiteracy ability to only
  read/write/understand below 5th grade level
• Marginal Literacy ability to only
  read/write/understand between the 5th and 8th
  grade level
• Literacy ability to read/write/understand at the
  8th grade level and above

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Health Literacy

• The ability to read, understand, and use
  healthcare information to make effective
  healthcare decisions and follow instructions for
  treatment

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• half of our adult population has deficiencies
  in reading or computational skills. (AMA Council
  on Scientific Affairs, JAMA 1999)
• Do your patients understand what you are telling
  them?

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Basic information about a colonoscopy, as
perceived by a patient with limited literacy
skills
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Scope of the Problem

• 22 of adult Americans are functionally
  illiterate an additional 27.5 are marginally
  literate
• Therefore, nearly half of American adults (90
  million patients) do not have sufficient literacy
  skills to fully function in society
• All segments of the population are affected

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• Percent of physicians who know about Health
  Literacy
• 33
• Percent of physicians who make changes in patient
  communications after learning about health
  literacy
• 66

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Education as an Unreliable Indicator of Literacy
Level

• Number of years of education not equal to amount
  learned
• 24 of Functionally Illiterate (NALS Level 1)
  people actually completed high school

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Health People 2010 Focus Areas

• Access to Quality Health Services
• Arthritis, Osteoporosis, and
• Chronic Back Conditions
• Cancer
• Chronic Kidney Disease
• Diabetes
• Disability and Secondary Conditions
• Educational and Community-Based
• Programs
• Environmental Health
• Family Planning
• Food Safety
• HEALTH COMMUNICATION
• Heart Disease and Stroke
• HIV
• Immunization and Infectious Diseases

• Injury and Violence Prevention
• Maternal, Infant, and Child Health
• Medical Product Safety
• Mental Health and Mental Disorders
• Nutrition and Overweight
• Occupational Safety and Health
• Oral Health
• Physical Activities and Fitness
• Public Health Infrastructure
• Respiratory Diseases
• Sexually Transmitted Diseases
• Substance Abuse
• Tobacco Use
• Vision and Hearing

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National Adult Literacy Survey (NALS)

• Provides the most comprehensive view of general
  literacy skills of American adults (1992)
• 5 Levels

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Summary of NALS Levels

• Level 1 Functionally Illiterate
• CANNOT
• use bus schedule, find intersection on map
• read a simple story to a child
• fill out social security application
• Level 2 Marginally Literate
• CANNOT
• use bus schedule
• read a bar graph
• write a letter of complaint
• Level 3 4 Functionally Literate
• Level 5 High-Level Literacy

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Results of the NALS

• Level 1 22
• Level 2 27.5
• Level 3 31.5
• Level 4 16
• Level 5 3

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Increased costs of low literacy

• Average annual cost of all Medicaid enrollees
  3,000
• Average annual cost of low literacy enrollees
  13,000

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Sources of Increased Costs

• Low literacy patients have
• more medication errors
• excess hospitalizations
• longer hospital stays
• more E.D. visits
• generally higher level of illness
• RESULT An excess cost of 50-73 billion per year
  to the US healthcare system

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Limited Literacy in Healthcare Setting

• Trouble understanding
• when next appt was scheduled
• medical vocabulary (bowel, polyp, colon, etc.)
• basic disease concepts
• how to use medical devices (asthma inhaler)

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Low Literacy translates into poor health outcomes

• Health Knowledge Deficits
• Diabetic patients less likely to know symptoms of
  hypoglycemia
• Patients with low literacy are less likely to
  maintain tight control of their diabetes
• Less healthy behaviors
• more smoking, including during pregnancy
• more exposure to violence
• less breastfeeding

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• High Risk Groups
• Elderly
• People with limited education
• Ethnic Minorities (Hispanic, AA)
• Recent Immigrants to the US
• People born in the US but English is a second
  language
• Low income

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Red Flags

• Behaviors
• registration forms incomplete or inaccurate
• frequently missed appointments
• noncompliance with medication
• lack of follow-through with tests or referrals
• eyes wandering over a page
• very slow to finish
• sounding out words
• looking confused

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• Responses
• I forgot my glasses
• Let me take this home so I can discuss it with
  my children

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Can you expect your patient to tell you?

• Shame and Stigma
• 68 have never told their spouse
• 75 have never told their healthcare provider
• 19 have never told anyone
• may bring decoy reading materials
• 66-75 of adults in NALS Level 1 say they read
  well or very well
• 33.6 of low literacy patients do not admit to
  having reading trouble

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Overview of Implications

• Poor Health Outcomes
• Over-utilization of health services
• Limited effectiveness of treatment
• Higher patient dissatisfaction
• Higher provider frustration

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How can you find out?

• Do social history first in patient evaluation,
  adding questions about literacy skills in a
  sensitive manner
• How happy are you with the way you read?
• What do you like to read?
• Ask questions in a safe and supportive
  environment and in a neutral, nonjudgmental
  fashion
• Brown-bag medication review
• When was the last time you took one of these
  pills?
• When was the time before that?
• Do they read the label or look at the pill?

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Remember...

• Not stupid
• All social classes
• Amazingly able to function
• The majority of people with low literacy skills
  are white, native-born Americans
• Health providers should not have racial/ ethnic
  bias

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• SOLUTION

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What can we do?

• Make your practice patient-friendly
• Communicating in an easy-to-understand language
• Creating and using patient-friendly written
  materials

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What can we do?

• Make your practice patient-friendly
• Attitude of helpfulness from clinicians and staff
• Help with office check-in and scheduling
  appointments
• Repeat important instructions

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• Communicating in an easy-to-understand language
• 6 Steps to improve communication with patients
• slow down
• use plain, non-medical language
• limit the amount of information provided, and
  repeat it
• show or draw pictures
• use teach-back or show-me technique
• create a shame-free environment

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Use plain, non-medical living room language
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• Creating and using patient-friendly written
  materials
• Written consent forms/ patient education handouts
• most forms written 10th grade to graduate level
• average US adult reads at 8th grade level

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• 2. Principles for creating patient-friendly
  written materials
• 5th or 6th grade level
• clear statements of instruction
• avoid unnecessary background info
• avoid lengthy review of anatomy or physiology
• short sentences
• large text

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• Non-written patient education materials
• Graphic Illustrations
• - pictures
• - pictographs
• Models
• Audiotapes and compact disks
• Videotapes

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Patient Empowerment

• 3 Important Questions
• What is my main problem?
• What do I need to do?
• How do I take my medicine?
• When do I need to be seen again?
• Why is it important for me to do this?
• These questions can help patients take their
  medications properly and take care of their
  health.

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• PowerPoint prepared by
• Anupama Kathiresan, Jeremiah Johnson, David
  Newton
• Medical College of Georgia
• Augusta, GA
• AMA-MSS
• Health Literacy Subcommittee, Anupama Kathiresan,
  Chair
• Community Service Committee, Stephen Patrick,
  Chair
• www.ama-assn.org/go/mss