Transcript Health Literacy

Clinicians and Patients:
What You Say, What They
Hear
Lorraine S. Wallace, Ph.D., Associate Professor
Department of Family Medicine
University of Tennessee Graduate School of Medicine
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Learning Objectives
• Describe the results of the National Assessment of Adult
Literacy.
• Define health literacy.
• Describe the relationship between health literacy and
health outcomes.
• Describe the mismatch between reading abilities of
American adults and patient/health education materials.
• Identify health literacy assessment tools.
• List strategies to improve clinician-patient communication
in various clinical settings.
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What is Literacy?
The ability to use printed and written
information to function in society, to
achieve one’s goals, and to develop one’s
knowledge and potential.
White, S., & McCloskey, M. Framework for the 2003.
National Assessment of Literacy (NCES 2006-473).
US Department of Education, Washington, DC.
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19 000 US adults; 16 years;
residing in households or prisons
3 Literacy Categories
• Prose
• Document
• Quantitative
4 Proficiency Levels
• Below Basic
• Basic
• Intermediate
• Proficient
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Locate the sentence that tells what Ms. Chanin ate during the swim.
84% answered correctly
5
Look at the driver’s license. Put a circle around the date on which
the license expires.
93% answered correctly
6
You want to buy some fruit juice and see this advertisement. Rank
the 4 juices in order from the least expensive to the most expensive.
Then explain your reasoning for ranking them the way that you did.
44% answered correctly
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Prose
Document
Quantitative
0
20
Below Basic
40
Basic
60
Intermediate
80
100
Proficient
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Health Literacy
Degree to which individuals
have the capacity to obtain,
process, and understand
basic information and
services needed to make
appropriate decisions
regarding their health.
IOM Definition
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Health Literacy Skills
Below Basic
Basic
Intermediate
Proficient
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Below Basic Health Literacy Skills
Sample Task:
Circle the date of a medical appointment on a
hospital appointment slip.
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Basic Health Literacy Skills
Sample Task:
Give 2 reasons a person with no symptoms of
a specific disease should be tested for the
disease, based on information in a clearly
written pamphlet.
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Intermediate Health Literacy Skills
Sample Task:
Determine healthy weight
range for a person of a
specified height, based on a
graph that relates height and
weight to body mass index
(BMI).
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Proficient Health Literacy Skills
Sample Task:
Find information required to define a medical
term by searching through a complex
document.
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“At Risk” Groups
Less/Some HS
Poor Health
Hispanic
65+ Years
Medicaid
0
20
Below Basic
40
Basic
60
Intermediate
80
100
Proficient
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Low health literacy=problems with…..
•
•
•
•
•
Pill bottles
Appointment slips
Informed consents
Discharge instructions
Patient/health education
materials
• Insurance applications
Medication
Take as directed
Dr. Literate
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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 (reliance
on written word for patient instruction)
• Aging
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Inadequate health literacy increases
with age….
%
80
70
60
50
40
30
20
10
0
Marginal
Inadequate
65-69
70-74
75-79
80-84
>=85
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Gazmararian et al. (1999). JAMA.
Our Expectations of Patients
Continually Increase
Treatment of Acute
Myocardial Infarction
Available prescription
drugs
35 Years Ago
Today
4-6 weeks bed
rest in hospital
2-4 days in hospital
650
10 000+
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Literacy and Health Outcomes
•
•
•
•
•
•
•
Understanding of medical conditions
Health-related quality of life
Delayed diagnoses
Use of preventive services
Risk of hospitalization
Adherence to medical instructions
Self-management skills
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Low Literate Diabetic Patients Less Likely to
Know Correct Management
Low
Need to Know:
symptoms of low blood
sugar (hypoglycemia)
Moderate
High
Need to Do:
correct action for
hypoglycemic symptoms
Low
Moderate
High
0
20
40
60
80
100
Percent
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Williams et al. (1998). Arch Int Med.
Literacy and Breast Cancer
Screening Knowledge
1 in 4 marginally and low-literate women who
thought they knew what a mammogram was,
actually did not.
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Davis et al. (1996). Cancer.
Literacy and Cervical Cancer
Knowledge and Distress
• Literacy was the only factor independently
associated with knowledge related to cervical
cancer.
• Low literacy was associated with increased levels
of distress among women at high risk for cervical
cancer.
• Spanish-speaking Latinas with inadequate health
literacy skills were less likely to ever had a Pap
test.
Lindau et al. (2002). Am J Obstet Gynecol.; Sharp et al.
23 (2002).
Ethn Dis.; Garbers et al. (2004). Prev Chronic Dis.
Obese Patients’ Knowledge of Obesity and
Readiness to Lose Weight
Patients with low literacy were significantly
less likely to:
understand the adverse health consequences
of obesity
understand the need to lose weight
report being ready to lose weight
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Kennen et al. (2005). South Med J.
Literacy and Healthcare Costs
Annual Healthcare Costs of Medicaid Enrollees
$12,000
$10,000
$10688
$8,000
$6,000
$4,000
$2891
$2,000
$0
Low-literacy
(<3rd-grade reading level)
Better literacy
(>4th-grade reading level)
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Weiss et al. (2004). J Am Board Fam Pract.
Educational Attainment and Reading Level
• Years of formal schooling tells us what people
have been exposed to, NOT what skills they
have acquired.” (Doak, Doak, & Root, 1996)
• Most American adults read 3-5 grade levels lower
than the highest grade level of schooling
completed.
– Average reading level in US=6-8th grade
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Davis et al. (1996). Pediatrics.; Meade et al. (1994). Am J Pub Health.
Readability of AAFP and ACOG
Patient Education Materials
Average reading level of
materials=9.4
Wallace et al. (2004). Fam Med.
Average reading level of
materials=≈9.0
Freda. (1999). Obstet Gynecol.
500+ published studies confirm these findings.
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Suitability of Web-based
Supplemental Materials
Prescription Drugs
60% of materials were rated
as not suitable (6th grade)
for their reading level.
Kaphingst et al. (2004). Patient Educ Couns.
Over-the-Counter Drugs
81% of materials were rated
as not suitable (6th grade)
for their reading level.
Wallace et al. (2006). Am J Health Syst Pharm.
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Government Sponsored Mailings
HIV/AIDS brochure (1988)
–RReading grade level 8
Inhaled anthrax postcard (2001)
–RReading grade level 10
–WWords such as priority, security, paramount,
legitimate, restrictive, endorsements, and authorities
appeared throughout the postcard.
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Jolly et al. (1995). Ann Emerg Med.
Low Literacy is Often Overlooked
Patients don’t fit the stereotype
Many patients with inadequate literacy:
• Are born in the USA (75%)
• Are White (50%)
• Hold a part- or full-time job (40%)
• Finished high school (25%)
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Low Literacy is Often Overlooked
Patients don’t volunteer it:
• Many patients do not recognize their
inadequate literacy.
• Many patients are ashamed of their
reading/literacy skills.
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Shame and Limited Literacy
90
80
70
60
% Never Told
50
about their
40
Literacy Skills
30
20
10
0
Children
Friends
Spouse
Health
CoCare
workers
Provider
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Parikh et al. (1995). Patient Educ Couns.
Low Literacy is Often Overlooked
Health professionals don’t ask about it:
• Unaware the problem exists
• Don’t know how to ask
• Don’t know how to respond
• Are unable to identify patients with limited
literacy skills
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Possible Indicators of Low Health Literacy
• Seek help only when illness is advanced.
• Have difficulty explaining medical concerns.
• Identifies drugs by pill color and shape rather than
by name.
• Does not know purpose of each medication.
• Excuses: “I forgot my glasses.”
• Lack of follow-through with tests/appointments.
• Seldom or never have any questions.
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Screening for Low Health Literacy?
• Rapid Estimate of Adult
Literacy in Medicine
(REALM)
• Test of Functional Health
Literacy in Adults
(TOFHLA)
• Newest Vital Sign (NVA)
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REALM
List 1
fat
flu
pill
dose
eye
stress
List 2
fatigue
pelvic
jaundice
infection
exercise
behavior
List 3
allergic
menstrual
testicle
colitis
emergency
medication
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TOFHLA and S-TOFHLA
THE DAY OF THE X-RAY
Do not eat __________________.
a. appointment.
b. walk-in.
c. breakfast.
d. clinic.
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Newest Vital Sign
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Health Literacy Screening Items
for Parents
3 items combined
associated with 6th grade
parental reading level:
2 items independently
associated with adequate
parent health literacy:
–<12th grade completion
>10 adults’ books in the
home
–not living with child’s other
parent
>10 children’s books in the
home
–not reading for pleasure
Bennett et al. (2004). Fam Med.
Sanders et al. (2004). Ambul Pedriatr.
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Health Literacy Screening Items
for Adults
3 items were effective in detecting inadequate
health literacy:
– “How often do you have someone help you read
hospital materials?”
– “How confident are you filling out medical
forms by yourself?”
– How often do you have problems learning
about your medical condition because of
difficulty understanding written information?”
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Chew et al. (2004). Fam Med.; Wallace et al. (2006). J Gen Intern Med.
Strategies to Improve Communication





Limit information (3-5 key points)
Use living room language
Be specific and concrete, not general
Demonstrate, draw pictures, use models
Use a “Teach Back” or “Show Me”
approach (confirm understanding)
 Be positive, respectful, caring, sensitive,
empowering
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Questions?
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