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Learning Theories and Health L iteracy

Learning Theories and Health L iteracy. PTP 783. Objectives. Review l earning theories Discuss a framework in which learning can occur in Geriatric PT practice. Discuss how health l iteracy impacts Geriatric PT practice.

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Learning Theories and Health L iteracy

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  1. Learning Theories and Health Literacy PTP 783

  2. Objectives • Review learning theories • Discuss a framework in which learning can occur in Geriatric PT practice. • Discuss how health literacy impacts Geriatric PT practice. • Identify strategies to address assessing health literacy in verbal and written communications.

  3. Can a patient learn anything a physical therapist tells them if they are not ready to learn?What are the barriers to learning?

  4. 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

  5. The Health Care System is Becoming More Complex Population >65 Non-English Speaking Medications Prescribed Specialists Hospital Stay Length Time spent with Patients Reimburse-ment More Self Management in the Home

  6. We Have a Problem:

  7. “Every system is perfectly designed to get the results it gets” “The definition of insanity is continuing to do the same thing over and over again and expecting a different result” −Albert Einstein

  8. “As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve. Health care professionals do not recognize that patients do not understand the health information we are trying to communicate. We must close the gap between what health care professionals know and what the rest of America understands.” Dr. Richard Carmona, U.S. Surgeon General 2002-2006

  9. Factors contributing to low health literacy • General literacy • Experience with health care system • Complexity of information • Cultural and language factors: • ESL • Cultural experience • How information is communicated • Aging and disease/treatment factors

  10. Informal methods to assess health literacy • Fills out intake forms incompletely • Misspelling many words • Leaves the clinic before completing forms • Gets angry about forms • Identifies medication by looking at pill rather than reading the label Weiss BD. Health literacy: a manual for clinicians. 2003

  11. National Assessment of Adult Literacy (NAAL)* n = 19,714 ● Most up to date portrait of literacy in U.S. ● Scored on 4 levels ● Levels 1 and 2 cannot: ◦ Use a bus schedule or bar graph ◦ Explain the difference in two types of employee benefits ◦ Write a simple letter explaining an error on a bill National Center for Educational Statistics, U.S. Department of Education

  12. Outcomes Associated with Health Literacy • Health Outcomes/Health Services • General health status • Hospitalization • Prostate cancer stage • Depression • Asthma • Diabetes control • HIV control • Mammography • Pap smear • Pneumococcal immunization • Influenza immunization • STD screening • Behaviors Only • Substance abuse • Breastfeeding • Behavioral problems • Adherence to medication • Smoking • Knowledge Only • Birth control knowledge • Cervical cancer screening • Emergency department instructions • Asthma knowledge • Hypertension knowledge DeWalt, et al. JGIM 2004;19:1228-1239

  13. Patient Safety Medication error: most common medical mistake • 90 million Americans have trouble understanding & acting on health information • Unfamiliar/complex text most difficult to read • 3 billion Rx written a year • Pharmacist/physician time is limited • Elderly fill 30 Rx/year, see 8 physicians, on average

  14. “How would you take this medicine?” 395 primary care patients in 3 states • 46% did not understand instructions ≥ 1 labels • 38% with adequate literacy missed at least 1 label Davis TC , et al. Annals Int Med 2006, slide by T Davis

  15. “Show Me How Many Pills You Would Take in 1 Day” John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill Slide by Terry Davis

  16. 89 84 80 71 63 35 Davis TC , et al. Annals Int Med 2006

  17. Adult Hospitalization • People with low literacy have 30-70% increased risk of hospitalization • RR = 1.29 (1.07-1.55) Medicare Managed Care • RR = 1.69 (1.13-2.53) Urban Public Hospital *Adjusted for age, gender, socioeconomic status, health status, and regular source of care. Baker et al. AJPH. 2002. 92:1278. Baker et al. JGIM. 1998. 13:791.

  18. Literacy and Mortality Health, Aging, and Body Composition Study Sudore et al. JGIM 2006; 21: 806-812

  19. Simple Familiar Wording Understood by Most Patients 84% (1st grade.) Slide by Terry Davis

  20. More Complex Message Limited Comprehension 59% (10th-12th grade. Slide by Terry Davis

  21. Unfamiliar Multi-step Instructions Rarely Understood 8% (12th-13thgrade) Slide by Terry Davis

  22. Comprehension Increased with Patient Literacy Level * p<.0001, †p<.05 <67-8>9 79% 86% 88% † 35% 66% 78% * 8% 64% 82% * 8% 18% 23% * 0% 6% 15% * % with a correct response In multivariate analysis only literacy and age predicted comprehension. Patients with low literacy (< 6th gd.) 3x more likely to incorrectly interpret warning labels. Davis et al. JGIM 2006; 21:847–851.

  23. Common Instruments • Rapid Estimate of Adult Literacy in Medicine (REALM) • Test of Functional Health Literacy in Adults (TOFHLA) • The Newest Vital Sign (NVS): • recently developed and tested

  24. REALM (Rapid Estimate of Adult Literacy in Medicine) • Word recognition and pronunciation • Read aloud a list of 66 medical words • Takes 2-3 minutes to administer • Highly correlated with other standard tests of reading ability (0.88-0.97) • Does not test comprehension • Not available in other languages

  25. fat flu pill dose eye stress smear nerves germs meals disease cancer caffeine attack kidney hormones herpes seizure bowel asthma rectal incest fatigue pelvic jaundice infection exercise behavior prescription notify gallbladder calories depression miscarriage pregnancy arthritis nutrition menopause appendix abnormal syphilis hemorrhoids nausea directed allergic menstrual testicle colitis emergency medication occupation sexually alcoholism irritation constipation gonorrhea inflammatory diabetes hepatitis antibiotics diagnosis potassium anemia obesity osteoporosis impetigo REALM Prevention & Patient Education Project Terry Davis, PhD P.O. Box 33932 Shreveport, LA 71130-3932

  26. TOFHLA (Test of Functional Health Literacy in Adults) • 17 numeracy items • 50 reading comprehension items • Tests ability to read and understand several health care related items • Takes 20-30 minutes to administer • Best for research purposes • Well correlated with REALM and WRAT (Wide Range Achievement Test) • Available in Spanish

  27. Sample TOFHLA Numeracy Question Doxycycline 100 MG Take medication on empty stomach one hour before or two hours after a meal unless otherwise directed by your doctor. If you eat lunch at 12:00 noon, and you want to take this medicine before lunch, what time should you take it? Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

  28. Sample TOFHLA Reading Comprehension Your doctor has sent you to have a _________ X-ray. a. stomach b. diabetes c. stitches d. germs You must have an ________ stomach when you come in. a. asthma b. empty c. incest d. anemia Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

  29. Short-TOFHLA • High correlation between first two reading comprehension passages and entire assessment (including numeracy items) • Administer only the first two reading comprehension passages • Takes 5-7 minutes

  30. REALM vs. TOFHLA

  31. The Newest Vital Sign (NVS) • Patients are given a nutrition label • 6 questions are verbally administered • Assesses literacy and numeracy • Takes 3 minutes • Validated against the TOFHLA • Available in English and Spanish Weiss et al., Ann Fam Med; 3(6) 2005

  32. NVS: Example Question If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Available at Pfizer Clear Communication Initiative: http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html Weiss et al., Ann Fam Med; 3(6) 2005

  33. REALM vs. NVS

  34. Which Instrument Should I Use? • If just for screening, the REALM is likely the best choice • Easiest to explain to patients • Fastest • Reasonably accurate • For research purposes, REALM is good, but may consider other instruments depending on goal of research

  35. Problems with Measuring Health Literacy • Sensitive topic • Patients go to great lengths to hide problems • May offend some • Inappropriate labeling

  36. Interventions to Improve Health Outcomes for Patients with Low Literacy • Raise awareness among providers • Develop easier to read materials • Including your brochures- readability assessment • Improve communication skills • Practice-redesign • Literacy training / adult education

  37. Educational Materials • Good health information ishard to come by • Most written at too high of a reading level • Few health care systems have comprehensively integrated educational materials in their overall care plans

  38. Educational Strategies • Teach-back method • Patient centered learning • What is required of them to learn • Survival skills • What pt. needs to know in order to get through session. • 3-5 things that are need to know • Ask Me 3 • Three questions about topic • Therapeutic alliance • Repetition/reinforcement

  39. Teach-back Explain Assess Clarify Understanding

  40. Plain Language • Speaking or writing in every day language • Limit & organize the information • Get the message quickly and clearly • Makes sense • Focus on behaviors & be realistic • Use carefully phrased words as there is a tendency to take words literally • 3-5 ‘need to know’ points

  41. Plain language • Frame the message: tell them what you are going to tell them before you do. • Give specific examples and real world examples. • Use analogies for key points. • Use repetition, rephrasing and interactivity • Verify understanding with teach-back technique.

  42. Readability • Every MS Office product has this capability • Your brochures will be tested for readability • Other resources: see the BB shell

  43. Chew et al in 2004: Used 16 health literacy screen questions on a 5 pt Likert scale followed by S-TOFHLA (n=322) 3 questions were effective: • How often do you have someone help you read hospital materials? • How confident are you filling out medical forms by yourself? • How often do you have problems learning about your medical conditions because of difficulty understanding written information? • Wallace followed up in 2006 identifying just the secondquestion above was most accurate with detecting limited health literacy skills (83.3% sensitivity). -more accurate than a screen of demographicS

  44. Some Issues • Should we measure literacy and target interventions or should we institute “universal precautions”? • When low health literacy is identified, what do we do? • Is it enough to recognize that many patients have this problem?

  45. Extras…..

  46. Kleinman’s Tool to Elicit Health Beliefs • What do you call your problem? What name does it have? • What do you think caused your problem? • Why do you think it started when it did? • What does your sickness do to you? How does it work? • How severe is it? Will it have a short or long course? • What do you fear most about your disorder? • What are the chief problems that your sickness has caused for you? • What kind of treatment do you think you should receive? • What are the most important results you hope to receive from the treatment? Dr. Arthur Kleinman, Patients and Healers in the Context of Culture.The Regents of the University of California. 1981

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