Impact Studies in Health Literacy and Patient Activation - PART 2

+2

No comments posted yet

Comments

Slide 1

The National Assessment of Adult Literacy included an assessment of health literacy, providing a wealth of information about how people read, understand, evaluate and make decisions regarding health information, including texts and documents commonly used in clinic and hospital settings, public health and prevention, and the health care system in general: appointment reminders, prescription labels, information about specific conditions, how to select a family doctor and choose a health care plan.

Slide 2

The results for health literacy are closely related to literacy overall, with over one third of the adult population having basic and below basic health literacy skills and only 12% having proficient health literacy skills, meaning as much as 90 % of the adult population at sometime may have difficulty following the directions on a prescription bottle or understanding tests results, or even filling out a health history form.   While literacy and health literacy are closely related, they are not mutually inclusive. Someone with adequate literacy skills can have low health literacy, simply from the fact of not being familiar with medical terminology, for example knowing what LDL means or that hypertension means the same thing as high blood pressure. There are other factors that impact our ability to process and understand health information, including depression, pain, fatigue, anxiety, and even some medications. For example, hearing bad news, such as a diagnosis of cancer, can make it very difficult for a person to listen and understand what the doctor is saying. But mostly, the same risk factors for low literacy also apply to low health literacy: for example, poverty, race and ethnic background, level of education, and age.

Slide 3

In these two graphs, health literacy skills are separated by race (on the left) and age (on the right). Significant differences suggest disparities, particularly for populations whose native language is not English.   Looking at health literacy skills broken down by age, there is very little change over the life span through adulthood, until the age of 65 and above. This suggests that older people are more likely to have lower health literacy skills. There are many contributing factors, including the decline in vision and hearing that is a normal part of the aging process, as well as other cognitive changes including memory loss. Also, health care becomes more complicated for many older people. As much as 80% of the population over age 65 have at least one chronic disease, and, on average, is taking 11 prescribed medications.   It’s important to note that some people can be in more than one risk group. For example, an elderly Hispanic woman is more likely to have low literacy skills, particularly is she is managing one or chronic conditions.

Slide 4

So, who is at risk for low health literacy?   Older adults Racial and ethnic minorities Non-native speakers of English People with less than a high school degree or GED certificate People with low income levels People with compromised health status   Is there anyone missing from this list?

Slide 5

Everyone – that’s one thing that distinguishes health literacy from literacy. Our literacy skills are learned and usually remain stable. But health literacy can fluctuate over time. A new diagnosis, medical terms we are not familiar with, hearing “bad news” or just being sick can impact how we process and understand health information.

Slide 6

In the literacy field, we do use tests and evaluations to assess literacy levels, but we don’t typically screen for low literacy in health care settings. There is a stigma of shame and embarrassment associated with low literacy, and most people who cannot read work hard at hiding it and will often develop compensation strategies. As many as 75% of those with low literacy skills will not share this information with their health care providers, coworkers, and even spouses.   Even those with adequate literacy skills may have low health literacy skills, and likewise will usually not tell their doctor that they do not understand her instructions, and often will not ask questions because no one likes to feel stupid in front of the doctor.   So, we shake our heads yes when we are asked if we understand, and when we are asked if we have any questions we’ll usually respond, “no” and then leave the medical appointment confused, uninformed and dissatisfied.   So you can’t tell by looking, and you can’t expect patients to tell you. There are clues to watch for (missed appointments, incomplete health forms, statements like “I’ll read this later” or “I forgot my glasses” and identifying medications by sight, not by name).

Slide 7

There are also several tests or screenings for low health literacy, the three most common being:   Rapid Estimate of Adult Literacy in Medicine (REALM) Test of Functional Health Literacy in Adults (TOFHLA) The Newest Vital Sign (NVS)   REALM and TOFHLA are typically only used in research, but the newest vital sign was designed to be used during a medical appointment. A patient uses a food label to answer prose, document, and quantitative literacy questions.   Each of these tests or screenings generates a score that can be used to evaluate a patient’s health literacy skills.

Slide 8

But much of the current evidence does not support screening for literacy or health literacy within the clinical setting.   One reason is the stigma of shame and the fact that some patients may take offense. But also, if patients with low literacy avoid medical appointments because they are afraid of being “found out,” how many are more are going to skip medical appointments if they know they their literacy skills will be assessed with a test or screening at the visit?   There is also a time factor – screening can take anywhere from 3 to 15 minutes, not to mention the time for training providers how to administer the screening and evaluate the results.   But the strongest argument against screening for literacy in the clinical setting is what happens after you determine a patient has low literacy skills? Does that mean you then need to take extra time to explain medical terms, use the “teach back” method to check for understanding, provide patient education materials that are easier to read and understand? Well, these are things we should be doing for every patients, all of the time.

Slide 9

The recommendation, then, is to exercise universal precautions, which makes sense knowing that only 12% of the adult population have proficient health literacy skills. We’ve already discussed printed education materials and the recommendation to aim for a reading level of 6th-8th grade. There are other communication techniques that have evidence showing they improve comprehension and recall, as well as improve adherence to treatment and overall health outcomes.

Slide 10

In 2007, physicians, nurses and pharmacists attending continuing education programs on patient safety and health care quality were invited to participate in a survey about effective communication strategies.

Slide 11

The survey asked providers to rate strategies and recommendations designed to improve communication with patients:   What communication strategies are most effective?   What communication strategies do you use most often?   I know the graphic is hard to read, but the black lines represent effectiveness and the gray lines frequency of use. Just quickly glancing over the graph, there are several communication strategies near the bottom that are considered to be very effective, but at the same time are used less frequently. These strategies include using illustrations and models to “show” as well as “tell,” following up by having another member of the care team speak with the patient immediately following the visit with the provider or within a day or two of the visit by telephone, and having another family member or care giver present at the appointment.   But let’s look at the top of the graph.

Slide 12

I enlarged it to make it easier to read.   Using simple language ranked as the both the most effective as well as the most frequently used communication strategy.   Using printed materials was ranked as the second most used communication strategy, but it was ranked last in effectiveness. Using handouts is a quick way to get information to patients, and many patients request them, but it ranks low in effectiveness because many providers expect most patients do not read them, and as we have seen in the earlier examples, most health information is written at the 10th grade level or above, making it a challenge to read and understand for many patients.   Using the teach back method to check for understanding is ranked as effective by 90% of the providers in the survey, yet less than half report using this strategy frequently. Teach back can be used to check for understanding. It’s commonly used after going over instructions with a patient and then asking them to repeat back what they are going to do. It can—and does—happen that antibiotics prescribed to treat an ear infection are administered in the ear. Using the teach back method is a good way to check for understanding and to correct and restate directions if needed. But teach back that includes a “show” as well as “tell” are even more effective.

Slide 13

Consider this example:   Patients in a research study were screened for literacy and then given the direction “take two tablets by mouth twice daily.” The teach back method was used to check for understanding. The requirement was to indicate that two pills would be taken in the morning, and two pills in the evening, or any similar statement resulting in a total of 4 pills taken in the day, two doses of two pills separated by a time interval (two pills at breakfast, two pills at bedtime, etc.).   About 90% of those with adequate literacy skills were able to restate the directions correctly. About 84% of those with marginal literacy skills were able to restate the directions correctly. And about 71% of those with low literacy skills were able to restate the directions correctly.

Slide 14

Next, the participants were asked to demonstrate how they would take the medicine. The requirement for a correct answer was removing four pills from the bottle, and separating them in to two doses of two pills, and again stating the directions indicating a time interval between the doses.   About 80% of those with adequate literacy skills were able to demonstrate the directions correctly.

Slide 15

About 63% of those with marginal literacy skills were able to demonstrate the directions correctly.

Slide 16

But only about 35% of those with low literacy skills were able to demonstrate the directions correctly. That means about half of those who correctly restate the directions are unable to actually take the medication correctly.   Teach back that includes “show me how” helps identify and correct potential medication errors.   Another quick example from a care management program:   A nurse was doing a follow-up phone call with a patient, and while reviewing the patient’s medical record and results of his most recent medical visit, noted the provider instructed the patient to increase the amount of fiber in his diet. The nurse asked how that was going, and the patient reported that he looked at the fiber powders and supplements at the pharmacy and said he couldn’t afford them. The nurse then discussed other ways he could get more fiber into his diet. Most likely what happened, the doctor said “increase your fiber intake,” patient said “ok,” doctor said, “any questions?” patient said, “no.” A discussion about how to do this, followed by a teach back (or “tell me how you are going to add more fiber in your diet?”) would have caught this.

Slide 17

So what are the impacts of low health literacy? There are high health care costs associated with low health literacy. A health care policy report published in 2008 estimates that in the United States, low health literacy increases health care costs by hundreds of billions of dollars every year, with staggering projected costs in the future.   We also know that health care costs for patients with low literacy skills are on average 4 times higher than patients with adequate literacy skills, and there are several contributing factors.

Slide 18

People with low literacy skills are less likely to obtain preventive health services such as cancer screenings like colonoscopies and mammograms, and immunizations such as an annual flu shot.   People with low literacy skills are twice as likely to be hospitalized, and when they are, they remain in the hospital more days per each admission compared to patients with adequate literacy skills.   People with low literacy skills are less likely to adhere to treatment recommendations, are more likely to misunderstand directions for taking medications, are more reluctant to ask questions and seek clarification from their health care providers.

Slide 1

Literacy and Health Literacy The National Assessment of Adult Literacy (NAAL) was the first national survey to include measures for health literacy Clinical Prevention Navigation of the health care system

Slide 2

http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2007480

Slide 3

http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2007480

Slide 4

Who is at risk? Older adults Racial and ethnic minorities Non-native speakers of English People with less than a high school degree or GED certificate People with low income levels People with compromised health status

Slide 5

Who is at risk? Older adults Racial and ethnic minorities Non-native speakers of English People with less than a high school degree or GED certificate People with low income levels People with compromised health status EVERYONE

Slide 6

Assessing Literacy You can’t tell by looking You can’t expect patients to tell you 75% of patients with low literacy do not tell their health care providers 85% do not tell coworkers 68% do not tell spouse (Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33-39.)

Slide 7

Assessing Health Literacy Rapid Estimate of Adult Literacy in Medicine (REALM) Test of Functional Health Literacy in Adults (TOFHLA) The Newest Vital Sign (NVS)

Slide 8

http://www.ncbi.nlm.nih.gov/pubmed/18830762

Slide 9

http://www.ncbi.nlm.nih.gov/pubmed/18830762

Slide 10

http://www.ncbi.nlm.nih.gov/pubmed/17931143

Slide 11

What communication strategies are most effective? What communication strategies do you use most often? http://www.ncbi.nlm.nih.gov/pubmed/17931143 Communication Techniques

Slide 12

Communication Techniques

Slide 13

Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-94. http://www.ncbi.nlm.nih.gov/pubmed/17135578 “Take two tablets by mouth twice daily”

Slide 14

Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-94. “Take two tablets by mouth twice daily” http://www.ncbi.nlm.nih.gov/pubmed/17135578

Slide 15

Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-94. “Take two tablets by mouth twice daily” http://www.ncbi.nlm.nih.gov/pubmed/17135578

Slide 16

Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-94. “Take two tablets by mouth twice daily” http://www.ncbi.nlm.nih.gov/pubmed/17135578

Slide 17

Health Literacy What do we know? Costs associated with low literacy are poorer health, higher rates of hospitalization and an increase in total healthcare costs

Slide 18

Health Literacy Patients with Lower Health Literacy: are more likely to delay seeking care are more likely to utilize emergency care are less likely to obtain preventive health services are twice as likely to be hospitalized and remain in the hospital more days per each admission are less likely to comply with recommended treatment are more likely to make medication errors are less likely to ask questions

Summary: This presentation is an expanded version of a webinar sponsored by Krames Patient Education. Low health literacy is a barrier to care, and populations with chronic diseases are at higher risk. Research suggests activation may help compensate for lower literacy skill. This series explores effective methods to increase patient activation and to address the needs of patients with low health literacy.

Tags: doug seubert health literacy communication communications activation patient engagement empower

URL:
More by this User
Most Viewed