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

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.

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.

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.

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.

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 http://ahrq.gov/qual/literacy Contrasted with more targeted interventions to improve health communication

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.

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

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

Health Literacy Policy Roundtable http://iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_Ten_HLit_Attributes.pdf Slide: Schillinger, 2012

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

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

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.

Reducing Health Literacy Demands

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 http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_HLit_Attributes.pdf. 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):1309-1321. 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), S96-104. Weiss, B.D. (2007). Health Literacy and Patient Safety: Help Patients Understand (2nd edition). Chicago, IL: AMA Foundation. Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf 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.