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Addressing Health Literacy: Critical to Good Health Outcomes. Darren A. DeWalt, MD, MPH Assistant Professor of Medicine University of North Carolina School of Medicine December 11, 2008. Patient Centered Medical Home.

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Darren A. DeWalt, MD, MPH Assistant Professor of Medicine

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Addressing Health Literacy:

Critical to Good Health Outcomes

Darren A. DeWalt, MD, MPH

Assistant Professor of Medicine

University of North Carolina School of Medicine

December 11, 2008

Patient Centered Medical Home

  • Patient centered requires understanding the skills and desires of the patient

  • Medical home implies seamless and supportive care that is coordinated

  • Helping the individual patient thrive

  • Health literacy is at the center of PCMH


  • What is health literacy?

  • Literacy in America

  • Literacy and health outcomes

  • Strategies to address low health literacy

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

How Well Do We Read and Write?

National Assessment of Adult Literacy (NAAL)

n = 19,714

●Most up to date portrait of literacy in U.S.

●Scored on 4 levels

●Lowest 2 levels 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 Education Statistics, U.S. Department of Education

2003 National Assessment of Adult Literacy










Basic or Below Basic

52% of H.S. Grads

61% of Adults ≥ 65

93 Million Adults have Basic or Below Basic Literacy

Inadequate Literacy Increases with Age

Slide by Terry Davis, PhD


  • It’s hard to be a patient

Relationship between Literacy and Health Outcomes

Health Outcomes Associated with 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

  • Cost

  • Mortality

  • 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

  • Prescription labels

DeWalt, et al. JGIM 2004;19:1228-1239










< 3rd




Asthma Patients with Low Literacy have Poorer Metered Dose Inhaler (MDI) Skills

Mean MDI


0 - 4

Williams et al. Chest 1998, 114(4):1008-1015.

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.

Can Patients Comprehend Rx Drug

Warning Labels?

Davis et al. JGIM 2006; 21: 847-851

Simple Familiar Wording Understood by Most Patients


(1st grade.)

Slide by Terry Davis

More Complex Message Limited Comprehension


(10th-12th grade.)

Slide by Terry Davis

Unfamiliar Multi-step Instructions Rarely Understood


(12th-13th grade)

Slide by Terry Davis

Comprehension Increased with Patient Literacy Level

* p<.0001, †p<.05


79%86%88% †

35%66%78% *

8%64%82% *

8%18%23% *

0%6%15% *

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.

What does this picture mean?

  • “Someone swallowed a nickel”

  • “Indigestion”

  • “Bladder”

  • “Looks like a ghost- Casper”

Slide by Terry Davis

“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

Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth Twice Daily”








  • It’s easy to make a mistake

Many things we assume people understand, they don’t.And, health outcomes are affected.

We have a problem and must alter systems of care

  • The complexity of the care system exacerbates literacy vulnerabilities

  • All aspects of our system can raise barriers

    • Appointments and referrals

    • Getting tests done

    • Paying for medicine or treatment

    • Understanding bills and insurance

The Continuum of Confusion: “Now go home and safely manage your care”

PP=Prior to seeing physician

Skills Needed by Patient

  • Read

  • Remember

  • Implement

  • Figure out complex processes

  • Relentlessly pursue….

What Works?

Improving Written Health Information

  • Most materials written well above the average literacy of the population

  • Guidelines available for better clear written health information

  • Any letter or form we send to patients should be vetted by experts in our health system

All members of team: physicians, nurses, social workers, PT/OT, dentists, nutrition, health educators, phone room, front desk staff

Principles of Clear Communication

Limit number of points

Write them down

Avoid using jargon (would your mother understand?)

Teach-back method

Improving Communication






Ask Me 3

  • What is my main problem?

  • What do I need to do?

  • Why is it important for me to do this?

Changing Systems of Care

  • Redesign how care is provided

  • Simplify care tasks

  • Make care seamless and organized

  • Integrate a well-trained workforce

Examples of System Changes

Planned Care




Usual Care

compared to

Rothman et al. Am J Med 2005; 118:276-284.

DeWalt et al. BMC Health Services Research. 6:30; 2006.

Heart Failure

47% lower hospitalization rate for those in planned care

DeWalt et al. BMC Health Services Research. 6:30; 2006.


Rothman et al. Am J Med 2005; 118:276-284.

Results According to Literacy Status

Diabetes Control: Results for Patients with Literacy Above 6th Grade Level

Rothman et al. JAMA 2004, 292(14):1711-1716.

Diabetes Control: Results for Patients with Literacy at or Below 6th Grade Level

Rothman et al. JAMA 2004, 292(14):1711-1716.

Patient Centered Medical Home

  • Success requires us to apply the principles we tested in diabetes and heart failure to all patients and all problems

  • This requires all staff to attend to the needs of individuals

  • Clear and helpful communication will help us to achieve this goal


  • Low health literacy is common and we need to consider patient understanding every time

  • Take health literacy into account for every initiative we do in clinic

  • Today: Think about whether your patient understands. Write it down for the patient. Ask them to tell you back (when appropriate).

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