Health Literacy: Help Your

Patients Understand

Presented by:American Medical Association Foundation & American Medical Association

Overview of Health Literacy

2006

Standardhttp://www.youtube.com/watch?v=3J3AMTXeeRY

http://www.youtube.com/watch?v=g4kha1RY-LM&feature=fvw

 

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?

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

Causes Effects Solutions

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.

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

General Literacy:

“An individual’s 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 one’s goals, and develop one’s 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

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)

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%

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)

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

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

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

Overview of Health Literacy

Video with real patients and physicians

As you watch, answer the following questions:

1. What problem is each patient facing as a result of his/her literacy?

2. Why don’t patients ask more questions?

3. What can doctors do to help?

http://classes.kumc.edu/general/amaliteracy/AMA_NEW3.swf

HonorsThis 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:

1)TALK about the questions that require discussion

2)CLASSIFY any of the blue text as either a cause, effect, or solution.

3)In 25 minutes, you will have a short quiz on the causes, effects, & solutions to health literacy.

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

Level 3

Level 2

Level 1

Level 4Level 5 - 3%

17%32%

27% -Marginal Literacy

21% - InadequateLiteracy

National Adult Literacy Survey

n = 26,000What 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

NALS Level 1: Inadequate Literacy (21%)Why/how would someone with the abilities below have trouble with his/her health?

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

Module 1

NALS Level 2: Marginal Literacy (27%)Why would someone with the abilities below have trouble with his/her health?

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

Module 1

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”

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.

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?

What do YOU think?

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

Low health literacy = problems with…

• Medications• Appointment slips• Informed consents• Discharge instructions• Health education

materials• Insurance applications

Medication

Take as directed

Dr. Literate

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

(M&R Guidelines)

• 10,000 +

• outpatient

0-3 hours diabetic

education classes

written materials

internet

telemedicine

Treatment of Acute Myocardial Infarction

Available Prescription Drugs

Treatment of new onset diabetes

35 Years Ago Today

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

Factors that contribute to health literacy:

• General literacy

• Experience with health system

• Complexity of information

• Cultural and language factors

• How information is communicated

• Aging

One-third of patients at 2 public

hospitals had inadequate health

literacy:

0

20

40

60

80

100

Atlanta LA-English LA-Spanish

%

Williams et al. JAMA 1995

Many patients struggle with health reading tasks….

• 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

% Incorrect

Inadequate health literacy

increases with age…

01020304050607080

65-69 70-74 75-79 80-84 >=85

Marginal

Inadequate

%

Gazmararian, et al. JAMA 1999

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

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

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

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.)

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)

Patients with low literacy more likely to be hospitalized

%

0

5

10

15

20

25

30

35

Literate Marginal Low Literate

Baker, Parker, Williams, et al. JGIM 1999

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

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

“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)

“Teach back” does not add time

An audio-taped physician/patientcommunication study showed“interactive educational strategy” or“teach back” did not increase timewith the patient.

• Schilinger et al. Arch Intern Med, 2003

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%

Part 2: Risk Management

Developed by Joanne G. Schwartzberg, M.D.

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

Risk Management Issues

• Failure to Navigate the Health Care

System

• Therapeutic Failures

• Workforce Issues

Failure to navigate

• No shows

• Insurance eligibility problems

• Incomplete, inaccurate forms

• “Uninformed” informed consents

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

Therapeutic failures

• Excess hospitalizations

• Longer lengths of stay

• Excess use of emergency department

• Increased malpractice risk

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.

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

Legal Issues

• Informed consent and living wills need post-college level comprehension

• Must explain verbally as well as give written—just 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