Module 1 Appendix:

1
Module 1 Appendix
Module 1

• Part 1 Pediatrics
• Part 2 Risk Management
• Part 3 Interpreter Resources
• Part 4 General

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Module 1 Appendix
Module 1

• Part 1 Pediatrics
• Developed by Mary Ann Abrams, M.D.

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Mothers with low literacy

• Greater risk of depression (Zaslow MJ, et al.
  Women Health. 2001.)
• Less knowledge about adverse effects of smoking
  (Arnold CL, et al. Prevent Med. 2001.)
• Less breast-feeding (Kaufman H, et al. Southern
  Med J. 2001.)
• Less able to read a thermometer (Fredrickson DD,
  et al. Kansas Med. 1995.)

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Low literacy related to problem behaviors in
children/adolescents
Module 1

• Increased teacher reported problem behavior
• Increased use of tobacco
• Increased use of alcohol
• Increased violence
• More likely to carry a gun
• More likely to require medical treatment after
  physical fight

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Pediatric Health Literacy Challenges

• Language barriers may be more important for
  pediatrics than for other specialties
• Information processing demands placed on parents
  may be greater--divided attention noise level
• gt1 person to communicate with--parent child
• Developmental issues

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Changing Demographics (Children 0-17)
Based on US Census Bureau Projections.
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Spanish Skills of Pediatricians

• 30 of pediatricians speak Spanish.
• 32 of pediatricians always provide
  translation/interpretation for Spanish-speaking
  only families.
• 15 always translate written materials into
  Spanish.

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Information Processing Demands

• A lot of information limited time
• Noise-levels in pediatric offices
• Divided attention of parents
• Demands can be compounded by fatigue or anxiety
• 40-80 of medical information provided by
  practitioners is forgotten immediately (J R Soc
  Med, 2003 219-222)

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Pediatric Health Literacy Opportunities AAP
Efforts

• Web-based HL resource for residency training
  programs
• Pediatrics and health literacy conference
• Condition-specific guidebook focusing on health
  literacy
• Research to support guide pediatric HL efforts
  (periodic survey, office-setting demonstration
  study)

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Module 1 Appendix
Module 1

• Part 2 Risk Management
• Developed by Joanne G. Schwartzberg, M.D.

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Sources of Potential Errors and Injury
Module 1

• Unclear about dose
• Misread label guess by first letter
• Recognize by looking
• Misnaming medication
• Misunderstanding spoken instructions
• Polypharmacy stuffed plastic bag
• Workforce pharmacy technician
• Shame

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Risk Management Issues

• Failure to Navigate the Health Care System
• Therapeutic Failures
• Workforce Issues

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Failure to navigate

• No shows
• Insurance eligibility problems
• Incomplete, inaccurate forms
• Uninformed informed consents

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Therapeutic failures

• Incomplete, inaccurate medical history leads to
  incorrect diagnosis and treatment
• Non-compliance with health care directions
• - prescription labels
• - preparation for outpatient procedures
• - discharge instructions

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Therapeutic failures

• Excess hospitalizations
• Longer lengths of stay
• Excess use of emergency department
• Increased malpractice risk

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Workforce Issues

• Support staff in hospital, clinic, nursing home
  may have limited literacy themselves. (Mr.
  Wheelhouse)
• ESL and ABE programs are often provided in the
  hospital through human resources for janitorial,
  housekeeping and other staff.

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Workforce Issues

• Culturally and linguistically appropriate
  services
• Patient may have limited literacy in both
  languages
• Interpreter may have limited literacy or may be
  of different class and unable to simplify
  translation

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Legal Issues
Module 1

• Informed consent and living wills need
  post-college level comprehension
• Must explain verbally as well as give
  writtenjust handing them the form to sign is not
  informed consent
• Legal right to understand alternatives for care
  and cost of care
• Avoid legal jargon/keep short

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Module 1 Appendix
Module 1

• Part 3 Interpreter Resources
• Developed by Claudette Dalton, M.D. and Fern R.
  Hauck, M.D., M.S.

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Commonwealth Fund 2001 Healthcare Quality Survey

• 6,772 adults surveyed
• Communication problems reported more commonly for
  African Americans (Af A), Hispanics (H) and Asian
  Americans (As A)
• H and Af A adults highest uninsured rates
• H and As A patients had greatest difficulty
  understanding information from doctor
• Less than one half of limited English proficient
  patients always or usually had interpreters
• Af A, H, and As A more often felt that they had
  been treated disrespectfully or with little
  understanding of their culture

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Use of Interpreters

• Deaf, blind or foreign language
• Use professionalsnot family
• Seat LEP interpreter a little behind and to the
  side of the patient and introduce both of you
  formallyseat a deaf interpreter behind and to
  the side of the doctor.
• Look at the patient, not the interpreter
• Simple language, no conditional questions with
  subjunctive tense
• Consult often, allow enough time
• NEVER ASK, Do you understand?

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Culturally Competent Healthcare Systems

• Interpreters or bilingual providers
• Cultural diversity training for staff
• Linguistically and culturally appropriate health
  education and information materials
• Tailored healthcare settings
• Task Force on Community Preventive Services,
  2002.

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Examples of Local Resources

• Foreign Language
• For appts contact
• Spanish/others
• Immediate services contact
• Spanish/day
• All languages
• weekend/night
• Multi-lingual, dual handset phone contact
• day/weekend/nights
• Language Bank

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Examples of Local Resources

• Hearing impairment
• Sign Language Interpreters
• State wide telephone relay number
• TTY (voice)
• Video phone interpreters
• http//hsc.virginia.edu/medcntr/depts/patient-ed/p
  rovider/sign.html Strategies for Communicating
  with Patients who are Deaf or Hard of Hearing

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Examples of Community Resources

• Literacy Volunteers of America- local chapter
• Adult Learning Centers
• Interpreters
• Language Bank
• Promotoras de Salud
• Other

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Module 1 Appendix
Module 1

• Part 4 General Slides

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NALS Level 1Inadequate Literacy (21)
Module 1

• Able to
• Sign name
• Find a country in an article
• Total a bank deposit entry
• Cannot consistently
• Understand the gist of an article.
• Use a bus schedule
• Enter information on a SS application

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NALS Level 2 Marginal Literacy (27)
Module 1

• Able to
• Find intersection on street map
• Locate information in newspaper article
• Determine difference in price on tickets
• Cannot consistently
• Use a bus schedule
• Identify information from a bar graph
• Write a brief letter of complaint

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Poor reading skills correlate with less knowledge
of asthma
Module 1
Know must stay away from allergens.
Know need to see MD even when not having an
asthma attack.
p 0.001
Correct
Williams, Baker, Honig et al. Chest. 1998
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Health knowledge deficits for patients with low
literacy
Module 1

• Patients with asthma less likely to know how to
  use an inhaler
• Patients with diabetes less likely to know
  symptoms of hypoglycemia
• Patients with hypertension less likely to know
  that weight loss and exercise lower blood
  pressure
• Mothers less likely to know how to read a
  thermometer.

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One-third of SeniorCare enrollees had inadequate
literacy
Module 1

Gazmararian, et al. JAMA 1999
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Reading errors for SeniorCare enrollees with
inadequate literacy
Module 1

• 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

Gazmararian, et al. JAMA 1999
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Research also shows that
Module 1

• Literacy is a predictor of health status
• It is a stronger predictor than age, income,
  employment status, education level, or racial and
  ethnic group