1. Jonathan B. VanGeest, PhD
Health Literacy and the Provider/System Role in Improving Communication and Reducing Bias
Jonathan B. VanGeest, PhD
Department of Health Policy and Management
College of Public Health
Kent State University
Diversity Rx Eighth National Conference on Quality Health Care for Culturally Diverse Populations

2. Health Literacy Is…
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
Not simply a patient problem
One with implications for quality shared by the provider, healthcare system, and community in partnership with the patient
Implications for treatment as well as disease prevention/health promotion
Health Literacy refers to a constellation of reading and numeracy skills required to function in the health care environment.
This includes:
1.) Reading prescription bottles, 2.) Figuring out appointment slips, 3.) Understanding informed consent documents, 4.) Understanding discharge
instructions, 5.) Following diagnostic test instructions, 6.) Reading health
education materials, etc.
Results from the NAAL suggest that 36% of Americans are at or below BASIC health literacy (able to understand a simple patient education handout). Only 12% are PROFICIENT.
Underserved populations have the lowest HL skills: Elderly, Minorities, Immigrants, the poor, persons with limited education, etc.
Health literacy by race/ethnicity: 28% of Whites, 58% of African Americans, and 66% of Latinos at or below BASIC.
By Age: 59% of people over 65 years of age at or below BASIC.

3. A Crosscutting Factor Impacting the Delivery of Health Care
Access to care
Preventive service use, participation in medical decision-making, reduced adherence
Worse health outcomes
Self reported health status/QOL, risk behaviors, mortality, poor health outcomes (multiple indicators), risk of medical error, etc.
A stronger predictor of health than age, SES, education level, and race (Weiss, 2007)
Not simply access, but misuse of health services. LHL associated with more ED visits, re-hospitalizations, and increased cost.

4. Addressing Health Literacy
Risk populations:
Racial and ethnic minorities, the elderly, immigrant populations, poor
Health communication occurs in a social context
Provider-patient interaction shaped by their differing social roles and their different needs
Power differential – Expert Authority/Patient vulnerability
Physician power and patient weakness make the physician-patient relationship necessarily a fiduciary one
Greater burden on the clinician to improve communication and ensure patient understanding (Lee, Arozullah & Cho, 2003)
Risk – stereotypes and biases.

5. Challenges Most patient instructions are written Verbal instructions
Often complex, delivered rapidly
Easy to forget in stressful situation
Increasingly complex health system
More medications, tests and procedures
Greater self-care requirements
Participatory/informed decision-making
Disease prevention/health promotion messages
Clinicians often unaware of patient’s health literacy
Unable to tailor the clinical encounter to the needs of patients
Initially identified solely as a patient deficit/education issue
Risk – falling back on biases and stereotypes and stereotypes associated with risk profile.

6. Universal Precautions
Use simple, everyday language
Stick to a 2-3 key points
Draw pictures, write down key instructions for patients to take home
Effectively solicit questions: “What questions do you have?”
Ask patients to “teach-back” the main points to confirm understanding
20 Tools
Quick Start Guide
Path to Improvement
Appendices
Over 25 resources such as sample forms, PowerPoint presentations, and worksheets
Contrasted with more targeted interventions to improve health communication

7. Applications of Best Practices
Recommended strategies to improve communication have been tried by physicians, nurses, and pharmacists, but are not yet routinely incorporated into clinical practice (Schwartzburg, Cowett, VanGeest, & Wolf, 2007)
Continues to be a problem. MSM example. Medical education.

8. Clinician Role
Identifying patients at risk due to low health literacy is productive
Health behaviors such as correct medication use and preventive measures (e.g., exercise, smoking cessation) are improved when patients with LHL were given visual aids, easy readability brochures or videotapes
Teach back validated as a technique to improve communication
Practical assessment tools now available that can be completed in the clinical setting
Tailoring communication to meet the needs of at-risk patients
Improved application of established best practices
Patient Centered Care
Improved quality and reduction of disparities
Key is education. Common tool box

9. System Role
A health literate organization makes it easier for people to navigate, understand, and use information and services to take care of their health (Brach et al. 2012)
Most HL research has focused on characterizing patients’ deficits, how best to measure a patient’s health literacy, and on clarifying relationships between a limited health literacy and outcomes
Growing appreciation that health literacy represents a balance between individuals' health literacy skill and the demands and attributes of the healthcare system
Interest and commitment from multiple stakeholders to address system-level factors contributing to the high literacy demands of the healthcare system
Enactment of the Patient Protection and Affordable Care Act (ACA) provides both opportunities and challenges for individuals with limited health literacy
- Insurance reform and Medicaid expansion
- Patient Centered Medical Homes
- HITECH Act

10. Health Literacy Policy Roundtable
Slide: Schillinger, 2012

11. CDC Health Literacy Planning Tool
Tool available from CDC’s health literacy site
Slide: Schillinger, 2012

12. Pharmacy HL Assessment Tool
AHRQ and RWJF
Other tools include a training program on communication for pharmacy staff, and a script for telephone reminders to refill prescriptions.
3 Parts:
Assessment tour by objective auditor
Pharmacy staff survey
Pharmacy patient focus group guide
Available from the AHRQ Pharmacy Health Literacy Center
Slide: Schillinger, 2012

13. Goals
The Institute of Medicine states that "efforts to improve quality, reduce costs, and reduce disparities cannot succeed without simultaneous improvements in health literacy" (IOM, 2004)
An "under-recognized silent epidemic to an issue of health policy and reform"
Not just clinicians – Receptionists should teach back appointment times, billing clerks should break down the steps patients have to take to be reimbursed by insurers, etc.
Patient Empowerment – the second half of the HL definition
Key – Clinical encounter is a dialog.
Address both sides to be effective.
However, not a level playing field. EXPERT AUTHORITY
Not tailored to the specific needs of patients.

14. Reducing Health Literacy Demands

15. References
Brach, C., Dreyer, B., Schyve, P., et al. (2012). Attributes of a Health Literate Organization. Washington, D.C.: The National Academies Press. Retrieved from Lee, S.Y., Arozullah, A.M., & Cho, Y.I. (2004). Health literacy, social support, and health: A research agenda. Social Science and Medicine, 58, (7): Nielsen-Bohlman, L., Panzer, A.M., & Kindig, D.A. (Eds). (2004). Health Literacy: A Prescription to End Confusion. Washington, D.C.: The National Academies Press. Schillinger, D. (2012). The other side of the coin: 10 attributes of “health literate” healthcare organizations. San Francisco, CA: Presentation at the 2012 Annual Meeting of the American Public Health Association. Schwartzberg, J.G., Cowett, A., VanGeest, J., & Wolf, M.S. (2007). Communication techniques for patients with low health literacy: A survey of physicians, nurses and pharmacists. American Journal of Health Behavior, 31 (Suppl 1), S Weiss, B.D. (2007). Health Literacy and Patient Safety: Help Patients Understand (2nd edition). Chicago, IL: AMA Foundation. Retrieved from
Key – Clinical encounter is a dialog.
Address both sides to be effective.
However, not a level playing field. EXPERT AUTHORITY
Not tailored to the specific needs of patients.