Health Literacy: Help Your Patients Understand

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Health Literacy Help Your Patients Understand
Overview of Health Literacy

• Presented by
• American Medical Association Foundation
  American Medical Association

2006
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Please write everything in blue word for word.
Answer any red questions in your notebooks.

• Objective
• Analyze health literacy and the role it plays in
  health disparities.
• What causes health illiteracy?
• What effects does health illiteracy have on
  health disparities?
• What solutions exist to solve this problem?

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Make the table below in your notebook and fill it
out with the blue notes as they relate to health
literacy.
Causes Effects Solutions

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True or False?

• Most people with a literacy problem are poor,
  immigrants, or minorities.
• People will tell you if they have a problem
  reading.
• The number of years of schooling is a good
  general guide to determine literacy level.

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What do you think health literacy means? (1 min
to write, 1 min to share)

• General 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
• 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.
• Healthy People 2010

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What do YOU think?

• In what ways do you think health literacy (or
  illiteracy) might cause problems in healthcare
  today? List as many answers as you can think of.
• Individually (2 min)
• Partners (1 min)
• Share out (3 min)

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Up to ½ of US population may be at risk for

• Medical misunderstandings
• Medical Mistakes without patient consent
• Excess hospitalizations
• Poor health outcomes
• Increased healthcare costs by 50-75

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What do you think?

• Why might health literacy be a bigger problem
  today than 20 years ago?
• Individually (2 min)
• Partners (1 min)
• Share out (3 min)

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Why are they (1/2 U.S. Population) at risk?

• Reliance on the written word for patient
  instruction has increased
• Increasingly complex health system
• More medications
• More tests and procedures
• Growing self-care requirements

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What can we do to help?

• Understand the problem
• Identify the barriers faced by both patients and
  clinicians
• Identify and implement strategies to enhance
  health literacy
• Advocate for system change

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Overview of Health Literacy

• Overview of the problem and implications
• Video with real patients and physicians
• Discussion of barriers faced by patients
• Practical strategies to address the problem

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Overview of Health Literacy

• Video with real patients and physicians
• As you watch, answer the following questions
• What problem is each patient facing as a result
  of his/her literacy?
• Why dont patients ask more questions?
• What can doctors do to help?
• http//classes.kumc.edu/general/amaliteracy/AMA_NE
  W3.swf

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Honors

• This presentation was taken from a UIC college
  course on Health Disparities in the College of
  Medicine. It is now YOUR job to go through the
  remaining slides and
• TALK about the questions that require discussion
• CLASSIFY any of the blue text as either a cause,
  effect, or solution.
• In 25 minutes, you will have a short quiz on the
  causes, effects, solutions to health literacy.

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1993 National Adult Literacy SurveyWhat
conclusions can you draw from this graph?
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National Adult Literacy Survey

• n 26,000?What does this mean??
• Most accurate portrait of literacy in U.S.
• Scored on 5 levels
• Result 48 of US population have inadequate or
  marginal literacy skills

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NALS Level 1 Inadequate Literacy (21)Why/how
would someone with the abilities below have
trouble with his/her health?
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)Why would
someone with the abilities below have trouble
with his/her health?
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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What is it like?

• The following passage simulates what a reader
  with low general literacy (NALS Level 1) sees on
  the printed page.
• Read the entire passage out loud.
• You have 1 minute to read.
• Hint The words are written backwards and the
  first word is cleaning

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GNINAELC Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna natspac
revenehw uoy eciton na noitalumucca fo tsud dna
nworb-red edixo selcitrap. Esu a nottoc baws
denetsiom htiw lyporposi lohocla. Eb erus on
lohocla sehcuot eht rebbur strap, sa ti sdnet ot
yrd dna yllautneve kcarc eht rebbur. Esu a pmad
tholc ro egnops ot naelc eht tenibac. A dlim
paos, ekil gnihsawhsid tnegreted, lliw pleh
evomer esaerg ro lio.
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What is it like?

• Take 2 minutes to reflect silently in your
  notebooks
• How did it make you feel?
• How did you feel when you figured it out?
• How did it make you feel if someone near you was
  reading faster?

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What do YOU think?

• What health documents do people need to be able
  to read?

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Low health literacy problems with

• Medications
• Appointment slips
• Informed consents
• Discharge instructions
• Health education materials
• Insurance applications

Medication Take as directed
Dr. Literate
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Changes in the health care systemWhat
conclusions can you draw from this chart?

• 4 - 6 weeks bed rest
• in hospital
• 650
• 3 weeks in hospital
• 2 hours a day of diabetic education classes

• 2-4 days in hospital
• (MR Guidelines)
• 10,000
• outpatient
• 0-3 hours diabetic
• education classes
• written materials
• internet
• telemedicine

Treatment of Acute Myocardial Infarction Availab
le Prescription Drugs Treatment of new onset
diabetes
35 Years Ago
Today
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Healthcare Today vs. 35 Years Ago

• Patients spend much less time in hospitals and
  clinics today
• Patients are expected to read more and educate
  themselves more

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Factors that contribute to health literacy

• General literacy
• Experience with health system
• Complexity of information
• Cultural and language factors
• How information is communicated
• Aging

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One-third of patients at 2 public hospitals had
inadequate health literacy

Williams et al. JAMA 1995
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Many patients struggle with health reading
tasks.
Incorrect

• Take medicine every 6 hours 22
• Take medicine on empty stomach 42
• Upper GI instructions (4th grade) 21
• Medicaid Rights (10th grade) 46
• Williams et al. JAMA 1995

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Inadequate health literacy increases with age

Gazmararian, et al. JAMA 1999
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What do we know from a decade of research?

• Low health literacy leads to
• Lower health knowledge and less healthy
  behaviors.
• Poorer health outcomes
• Greater health costs
• Specific communication techniques may enhance
  health literacy.
• AHRQ, 2004 IOM, 2004 Schwartzberg, 2005

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Less healthy behaviors for patients with low
literacy.

• More exposure to violence
• Pregnant women more likely to smoke
• Less breastfeeding
• Less likely to get flu vaccine or pneumovax
• Davis, 1996 Williams, 1998 Davis, 1999 Arnold,
  2001

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Low literacy related to problem behaviors in
children/adolescents

• 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
• Stanton, 1990 Hawthorne, 1997 Davis, 1999

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Poor health outcomes for diabetic patients

• Diabetic patients with low health literacy have
  poorer glycemic control than patients with
  adequate literacy.
• (Schillinger D, et al. JAMA. 2002.)
• Diabetic children (ages 5-17) had poorer glycemic
  control if their parents had lower literacy
  skills.
• (Ross LA, et al. Diabetic Med. 2001.)

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Patients with low literacy have poorer health
outcomes

• 69 more likely to have late stage diagnosis of
  prostate CA at presentation. (Bennett, J Clin
  Oncol 1998)
• 4 times more likely to be non-compliant with
  Anti-HIV meds. (Kalichman S, et al. JGIM 1999)

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Patients with low literacy more likely to be
hospitalized

Baker, Parker, Williams, et al. JGIM 1999
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Estimated 50 billion annual costs of poor
health literacy

• We all pay!
• 39 paid by Medicare through FICA taxes on
  workers
• 17 paid by employers
• 16 paid by patients out-of-pocket
• 14 paid by Medicaid
• The remaining 14 comes from other public and
  private sources.

Estimated by the National Academy on an Aging
Society using 1998 figures
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Summary Specific strategies to enhance health
literacy

• Create a shame-free environment
• Enhance assessment strategies
• Improve interpersonal communication with patients
• Create and use patient-friendly materials

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Teach back works

• Asking that patients recall and restate what
  they have been told is one of 11 top patient
  safety practices based on strength of scientific
  evidence. (AHRQ, 2001 Report on Making Health
  Care Safer)
• Physicians application of interactive
  communication to assess recall or comprehension
  was associated with better glycemic control for
  diabetic patients. (Schilinger D. Arch Intern
  Med. 2003 163)

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Teach back does not add time

• An audio-taped physician/patient
• communication study showed
• interactive educational strategy or
• teach back did not increase time
• with the patient.
• Schilinger et al. Arch Intern Med, 2003

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What have other docs tried?

• Medication reviews helped to identify and address
  health literacy problems
• Maps on the back of appointment letters cut down
  on no shows
• Maps on the back of requisition slips increased
  completed lab work
• Organized, simplified pre-op instructions, both
  written and verbal, cut surgical same-day
  cancellations from 5 to 0.8

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Who to contact for more information
Module 1

• Website
• www.amafoundation.org/go/healthliteracy
• E-mail
• healthliteracy_at_ama-assn.org
• Other resources
• See Participant Guide

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Closing Thought
Module 1

• follow the counsel of Aristotle, to speak as
  the common people do, to think as wise men do
  and so should every man understand him, and the
  judgment of wise men follow him.
• Roger Ascham (1515-1568)

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

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Sources of Potential Errors and Injury

• Unclear about dose
• Misread label guess by first letter
• Recognize by looking
• Misnaming medication
• Misunderstanding spoken instructions
• 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

• 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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(No Transcript)
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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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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