Health Literacy: Help Your Patients Understand Presented by: American Medical Association Foundation & American Medical Association Overview of Health Literacy 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?

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

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? MA_NEW3.swf

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: 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 Survey What conclusions can you draw from this graph? Level 3 Level 2 Level 1 Level 4 Level 5 - 3% 17% 32% 27% - Marginal Literacy 21% - Inadequate Literacy

National Adult Literacy Survey l n = 26,000  What does this mean?? l Most accurate portrait of literacy in U.S. l Scored on 5 levels l 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 system What conclusions can you draw from this chart? weeks bed rest in hospital 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 AgoToday

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: % Williams et al. JAMA 1995

Many patients struggle with health reading tasks…. Take medicine every 6 hours22% Take medicine on empty stomach42% Upper GI instructions (4th grade)21% Medicaid Rights (10th grade) 46% Williams et al. JAMA 1995 % Incorrect

Inadequate health literacy increases with age… % 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 ) Diabetic children (ages 5-17) had poorer glycemic control if their parents had lower literacy skills. (Ross LA, et al. Diabetic Med )

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 % 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/patient communication study showed “interactive educational strategy” or “teach back” did not increase time with 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%

Who to contact for more information: Website: – Other resources –See Participant Guide Module 1

Closing Thought “…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 ( ) Module 1

Mothers with low literacy Greater risk of depression (Zaslow MJ, et al. Women Health ) Less knowledge about adverse effects of smoking (Arnold CL, et al. Prevent Med ) Less breast-feeding (Kaufman H, et al. Southern Med J ) Less able to read a thermometer (Fredrickson DD, et al. Kansas Med )

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 Module 1

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 >1 person to communicate with--parent & child Developmental issues

Changing Demographics (Children 0-17) Based on US Census Bureau Projections.

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.

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; )

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)

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

Module 1 Appendix: Part 3: Interpreter Resources Developed by Claudette Dalton, M.D. and Fern R. Hauck, M.D., M.S. Module 1

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

Use of Interpreters Deaf, blind or foreign language Use professionals—not family Seat LEP interpreter a little behind and to the side of the patient and introduce both of you formally—seat 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?”

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.

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:

Examples of Local Resources Hearing impairment –Sign Language Interpreters –State wide telephone relay number –TTY— (voice) –Video phone interpreters – t-ed/provider/sign.html “Strategies for Communicating with Patients who are Deaf or Hard of Hearing” t-ed/provider/sign.html

Examples of Community Resources Literacy Volunteers of America- local chapter Adult Learning Centers Interpreters Language Bank Promotoras de Salud Other:

Module 1 Appendix: Part 4: General Slides Module 1

Poor reading skills correlate with less knowledge of asthma Know need to see MD even when not having an asthma attack.* % Correct Know must stay away from allergens.* * p = Module 1 Williams, Baker, Honig et al. Chest. 1998

Health knowledge deficits for patients with low literacy… 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. Module 1

One-third of SeniorCare enrollees had inadequate literacy… % Gazmararian, et al. JAMA 1999 Module 1

Reading errors for SeniorCare enrollees with inadequate literacy: 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% Module 1 Gazmararian, et al. JAMA 1999

Research also shows that: Literacy is a predictor of health status It is a stronger predictor than age, income, employment status, education level, or racial and ethnic group Module 1