1. Health literacy: Health Strategies to Improve Communication Joy Ann Cunningham, PharmD June 17 th, 2010 Medication Use in Rural America Conference National Rural Health Association

2. Objectives Define health literacy and what tasks it encompasses. Describe the health care experiences of persons with low health literacy. Discuss the impact of health literacy on medication use and patient outcomes. Review and apply techniques to improve communication with low health literacy patients. I do not have any relevant financial relationships with any commercial interest.

3. Objective 1 Define health literacy and what tasks it encompasses.

4. What is General Literacy? “ Using printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential.”

5. What is 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.”

6. What does Health Literacy Include? Health literacy encompasses many more things than just reading  Writing  Numeracy  Listening  Speaking  Conceptualization Ability to understand instructions on:  Prescription bottles  Appointment slips  Medical education brochures  Consent forms Ability to negotiate the complex health care system

7. NALS Findings 90 million (47%) of American adults have inadequacies in basic reading or computation skills  > 50% of lowest literacy level were Caucasian Mean reading level of U.S. population is 8 th grade. Levels of American literacy have not improved over the past two decades, while the complexity of the health care system has increased exponentially.

8. Findings from the NAAL 12% 14% 22% 53% Proficient: Define medical term from complex document, Calculate share of employee’s health insurance costs Intermediate: Determine healthy weight from BMI chart, Interpret prescription and over-the-counter drug labels Basic: Understand simple patient education handout Below Basic: Circle date on appointment slip, Understand simple pamphlet about pre-test instructions Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.

9. At-Risk Populations Groups most likely to suffer from low functional literacy  Poor and the homeless  Ethnic and cultural minorities  Those with less than high school degree or GED  Those above the age of 65  Immigrants and/or persons who do not have English as their primary language Everyone in the United States is susceptible to low health literacy regardless of age, ethnicity, education, or income.

10. Functional Literacy of High Risk Populations PopulationLow Literacy (%) All50 Elderly (≥ 65)81 Racial/Ethnic group: White41 Black77 Hispanic78 Education level: 0-8 yrs96 9-12 yrs81 HS/GED55 Immigrants: 0-8 yrs prior education91 9+ yrs prior education71 Weiss BD. Health literacy: A manual for clinicians. AMA and American Medical Association Foundation; 2 Adapted from Table 2-1.

11. Objective 2 Describe the health care experiences of persons with low health literacy.

12. Shame & Health Literacy What is Shame?  A painful emotion caused by a strong sense of guilt, embarrassment, unworthiness, or disgrace  A condition of dishonor or ignominy  A great disappointment Because shame is so painful, its source is often denied, leading to profound secrecy “There may be no emotion that wounds as deeply as shame, no pain so searing.” - DL Nathanson

13. Shame & Health Literacy Parikh NS, Parker RM, Nurss JR, et al. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996: 27(1).

14. Patient Cues: Low Health Literacy 10 Patient Behaviors Indicating Limited Health Literacy in Pharmacy 1. Asks for old prescription bottles to be returned, especially if they have markings or symbols 2. Refers to medications by colors and shapes rather than by names 3. Offers excuses when asked to read something (e.g. forgot glasses, will read it later) 4. Cannot describe how to take his/her medications 5. Does not know the purpose of each drug 6. Postpones decision-making (e.g. “I’ll read this when I get home and will let you know later…”) 7. Does not turn written information right-side-up when given upside down 8. Does not fill out forms while in the pharmacy or health care facility 9. Denies any questions when receiving new information/prescriptions 10. Gives oral information when presented with written forms to be completed.

15. Objective 3 Discuss the impact of health literacy on medication use and patient outcomes.

16. Health Literacy and Medication Use Persons with low health literacy have:  10-18x odds of being unable to identify all of their medications  3-4x more likely to misinterpret drug warning labels  Twice as likely to misinterpret prescription labels Medication mismanagement or nonadherence among low- literacy patients is likely related to poor comprehension and is usually unintentional. Kripalani S, Henderson LE, Chiu EY, et al. Predictors of medication self-management skill in a low-literacy population. J Gen Intern Med 2006; 21(8): 888-90. Gazmararian JA, Kripalani S, Miller MJ, et al. Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy. J Gen Intern Med 2006; 21(12): 1215-C15. Davis TC, Wolf MS, Bass PF III, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med 2006; 21(8): 847-51.

17. Misinterpretation of Warning Labels Don't take food Chew pill and crush before swallowing Chew it up so it will dissolve. Don’t swallow whole or you might choke Don't leave medicine in the sun Don't drink and drive Don’t drink alcohol. It’s poison, and it’ll kill you If allergic to dairy, don't take medicine Don’t eat for 1 hour after taking medicine Don’t take when wetDon’t need water Don’t drink hot water Use extreme caution in how you take it Medicine will make you feel dizzy Take only if you need it Davis et al 2006. Adapted from Table 3.

18. Impact on Patient Outcomes Individuals with low health literacy report:  Inability to understand written and oral information given by insurers, nurses, pharmacists, and physicians  Less knowledge about their medical conditions & treatments  Worse health status  Less understanding and use of preventive services  Higher rates of hospitalizations (2x) and longer hospital stays

19. Impact on Patient Outcomes Persons with low health literacy are more likely to have chronic disease and less likely to get the care they need Adults with functional health literacy in the bottom 20% are more likely to:  Have 3x as many RXs filled  1.5x more likely to visit a physician Health literacy is the single strongest predictor of a person’s health status. Center on Aging Society tabulations from the Medical Expenditure Panel Survey, 1998.

20. Health Literacy & Expenditures Inpatient spending per admission is increased by at least $1000 for patients with limited literacy  Howard DH, Gazmararian J, Parker R. The impact of low health literacy on the impact of Medicare managed care enrollees. Am J Med 2005; 118: 371-7. Average health care costs of persons with low literacy predicted to be 4 times greater than the general population.  Weiss BD, Blanchard JS, McGee DL, et al. Illiteracy among Medicaid recipients and its relationship to health care costs. J Health Care Poor Underserved 1994; 5(2): 99-111.

21. Health Literacy & Expenditures Adults whose functional literacy was in the bottom 20% were more than 1.5 times more likely to visit a physician than those with adequate literacy Adults whose functional literacy was in the bottom 20% were likely to have 3 times as many prescriptions filled as compared to those with adequate literacy Center on Aging Society tabulations from the Medical Expenditure Panel Survey, 1998.

22. Health Literacy & Expenditures

23. Low health literacy results in 3 to 6% greater health care expenditures Taxpayers finance a disproportionate share of additional resources used by those with low health literacy Center on Aging Society tabulations from the Medical Expenditure Panel Survey, 1998.

24. Health Literacy & Expenditures An approximation using the Medical Expenditure Panel Survey (MEPS) places the order of magnitude of cost of low health literacy to the US economy in the range of $206 - 238 billion annually  This represents between 7-17% of all personal healthcare expenditures Kirsch LS. Adult Literacy in America. A First Look at the Results of the National Adult Literacy Survey. National Center for Education Statistics, Dept of Education. 1993.

25. Health Literacy & Expenditures The savings that could be achieved by improving health literacy are estimated to be a lower bound of $106 billion and an upper bound of $238 billion annually*  This is enough funds to insure every uninsured American in the United States * 2006 Estimates Kirsch LS. Adult Literacy in America. A First Look at the Results of the National Adult Literacy Survey. National Center for Education Statistics, Dept of Education. 1993.

26. Expenditures: The Reality When one accounts for the future costs of low health literacy that result from current actions (or lack thereof), the estimated present-day cost of low health literacy is in the range of $1.6 trillion to $3.6 trillion* * 2006 Estimates

27. Objective 4 Review and apply techniques to improve communication with low- literacy patients.

28. Strategies to Improve Communication Verbal Communication Give an agenda Limit new info to key points needed now Focus on behaviors and actions Partition long lists Use examples Get feedback from the patient to verify compre- hension Repeat, repeat, repeat Written Communication Write the patient’s name on the cover Underline key points Tailor the message according to content, structure, and image specific to individual needs Refer to illustrations to reinforce written material Ask questions to verify patient understanding

29. Strategies to Improve Counseling Strategies to Improve Counseling of Patients with Limited Health Literacy Keep information simple and straightforward Avoid complex medical jargon Ask to have a family member present Use visual aids Show each medication when counseling Demonstrate how to use inhalers, nasal sprays, insulin Use education sheets that are written at the 5 th -6 th grade level Provide picture-based materials in English as well as in other languages Use open-ended questions Use the teach-back method

30. Medical Jargon The use of medical jargon can easily lead to misinformation and incorrect interpretations Jargon more likely to creep up during highly sensitive conversations We must attempt to reduce jargon in all settings, regardless of patient education “Even practitioners who have worked with low literacy patients for years are often surprised at the poor reading skills of some of their most poised and articulate patients.” Parker R, Williams MV, Davis T. Low health literacy – you can’t tell by looking. American Medical Association Foundation, 1999.

31. Advice Patients Can Understand Limit advice to key information the patient needs at this time  Reduce info to 3 main points  Printed material gives importance to the message, especially if name is handwritten on the cover Partition info into easy-to-understand parts  Offers natural break to obtain feedback from patients  Provides learning stimulus

32. Active Learning Exercise Role-Play

33. Hands On Practice! In this section, you will divide into groups of 3 Each person in the group will have a role to play:  Pharmacist / Health Care Provider  Patient  Observer Refer to the handout for instructions  After each round, “observer” will provide feedback to “pharmacist”  Switch roles after each round.

34. Discussion What was different? Was it difficult? What did you learn? Take away points for practice?

35. Conclusions Health literacy is a shared function of cultural, social, and individual factors. Nearly half of the adult population within the U.S. has inadequacies in basic reading or computation skills. Everyone in the United States is susceptible to low health literacy regardless of age, ethnicity, education, or income. Health literacy is the single strongest predictor of a person’s health status. Health illiteracy places a huge cost burden on the U.S. health care system with complicated economic implications Everyone is responsible for the implications of low health literacy – DO YOUR PART!