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Health Literacy. Presenters. Definitions. “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.” – Healthy People 2010, Health Communication Terminology.

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Health Literacy

Presenters


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Definitions

  • “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.”

    – Healthy People 2010, Health Communication Terminology


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Introduction / AMA Video

  • American Medical Association’s Health Literacy Video (23:20)

  • For a copy of this video, please visit the AMA’s catalog, and request Health Literacy Educational Kit 2007



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National Adult Literacy Survey (NALS)

  • 26,000 U.S. adults were interviewed

  • Scored on 5 levels

  • Result: 48% of U.S. population have inadequate (Level 1) or marginal (Level 2) literacy skills.


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NALS Level 1Inadequate Literacy (21%)

  • 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 Social Security application


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NALS Level 2Marginal Literacy (27%)

  • 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


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Risks of Inadequate Health Literacy

  • ½ of the U.S. population may be at risk

    • Misunderstanding

    • Mistakes

    • Excess hospitalizations

    • Poor health outcomes


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What Is It Like?

  • The following passage simulates what a reader with low general literacy 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.”


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What Is It Like?

GNINAELC – Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-der 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 damp tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.


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What Is It Like?

How do you clean the capstan?


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Factors Contributing to Health Literacy

  • Patient Factors:

    • General literacy

    • Age

    • Experience with health care system

    • Cultural and language factors

  • Situational Factors:

    • Complexity of information

    • How information is communicated


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Health Care System Factors

  • Reliance on the written word for patient instruction

  • Increasingly complex health system

    • More medications

    • More tests and procedures

    • Shorter hospital stays

      • Growing self-care requirements

      • Less hands-on patient education


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Implications

  • Problems with:

    • Interactions with providers

    • Completing forms

    • Following medication instructions

    • Appointment slips

    • Informed consents

    • Discharge instructions

    • Health education materials

    • Insurance applications

    • Finding clinic/office


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Implications

  • Overuse of emergency room

  • Incomplete history

  • Lack of informed consent (legal issues)

  • Diagnosis made at later stages

  • Unhealthy/risky behaviors


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Informed Consent

  • Informed consent and living wills often 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

  • Keep it short and avoid legal jargon


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Barriers

  • Barriers to Access

    • Insurance forms

    • Intake forms

    • Medical history questionnaire

    • Informed consents

  • Barriers to Diagnosis

    • Patient provides mistaken information

    • Patient misunderstands physician’s questions

    • Physician misunderstands patient

  • Barriers to Treatment

    • Misunderstanding of treatment directions may lead to serious mistakes or non-compliance


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Red Flags

  • Key phrases; examples

    • “I forgot my glasses.”

    • “I don’t have time to read this today.”

  • Incomplete registration forms

  • Patients are non-compliant with medications

  • When asked, patient unable to explain timing or purpose of medication

  • Angry, slippery, clowning or passive when asked questions


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Creating a Shame-free Environment

  • Setting must be welcoming, shame-free from moment patient enters

  • Think from a patient perspective, what their experience is like from start to finish

  • Creating this environment must include front staff, nurses, and other auxiliary employees


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Creating a Shame-free Environment

  • Reducing Shame – Practical Solutions

    • Have staff help with forms

    • Follow-up visits with phone calls

    • Pre-visit phone calls for new patients, asking how they prefer to receive information

    • Quality control for a patient friendly environment


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Creating a Shame-free Environment

  • Make sure patients are clear:

    • About their diagnoses

    • Know exactly what they need to do

    • How to take medications, possible side effects

    • Treatment regimen, follow-ups

    • Why this plan is in their best interest

  • Conduct a Medication Review

    • Sample included in worksheet packet


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Creating a Shame-free Environment

  • Doctor-Patient Communication

    • Be curious, listen

    • Ask before you advise

    • Give the patient time to respond

    • Discuss how you can best help the patient care for themselves

    • Ask patients how they want information communicated to them

    • Be positive, hopeful, empowering with speech


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Creating a Shame-free Environment

  • Staff-Patient Communication

    • First impressions=big difference

    • Helpful attitude

    • Check non-verbal communication

    • Have staff call patients by name

    • Respectful, caring, safe office environment

    • Treat all patients as you would your own family – parents, siblings, children, etc


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Creating a Shame-free Environment

  • Office Strategies – Office Checklist

    • What is the mood of the office?

    • What types of non-verbal communication are used around the office?

    • Is there a systems approach to education?

    • Are the messages created in the office consistent throughout the patient’s visit?

    • Does the staff have a genuine interest in the patients, their lives, and health management?


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Enhancing Patient Interaction and Communication

  • Doctor: “Your foot infection is so severe that we will not be able to treat it locally.”

  • Patient: “I hope that I don’t have to travel far, doctor. I’m afraid of flying.”

  • Have you ever experienced a scenario such as this?


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5 Steps: Enhancing Patient Interaction

  • Conduct patient-centered visits:

    • Listen more, speak less

    • Avoid clinical monologue

    • Encourage questions

    • Understand and address patient concerns

  • Explain in plain language

    • Slow your pace of speech

    • Use analogies, comparisons to everyday life

      • “Arthritis is like a creaky hinge on a door.”

    • Plain, non-medical language


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5 Steps: Enhancing Patient Interaction

  • Focus on key messages and repeat

    • Limit information by focusing on 1-3 key messages per visit

    • Review the key points, repeat several times

    • Have other staff reinforce the messages

    • Example of this in practice with Strep Throat, 3 key messages for the patient to take away

      • “Take one pill in the morning and one pill in the evening.”

      • “Take the medicine every day for 10 days, even if you feel better before then.”

      • “Stopping the pills before 10 days can result in serious heart problems.”


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5 Steps: Enhancing Patient Interaction

  • Use a “teach back” or “show me” technique to check for understanding

    • Ask the patient to demonstrate their understanding.

    • “How will you explain your condition to your spouse?”

    • “I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.”

    • Do not ask “Do you understand?”


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5 Steps: Enhancing Patient Interaction

  • Use patient-friendly materials to enhance communication

    • Show or draw simple pictures

    • Focus on key points

    • Emphasis should be on what the patient needs to do

    • Minimize information about anatomy and physiology

    • Be sensitive to cultural preferences

    • Written Material guidelines:

      • Simple words (1-2 syllables)

      • Short sentences (4-6 words)

      • Short paragraphs (2-3 sentences)

      • No medical jargon

      • Headings and bullets

      • Lots of white space; use large, serif fonts


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Other suggestions

  • Quiet room with minimal distractions

  • Give instructions to several family members, in addition to the patient

  • If you are rushed, get someone else to do it (don’t just skip or rush through)


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Other Suggestions

  • Start with the most important information first and limit new information

  • No more than one or two instructions at a time – and check on each as you go: “Chunk and Check”

  • Avoid yes-or-no-questions

  • Read over instructions – highlight important parts with color


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Culturally Competent Health Care Systems

  • Interpreters or bilingual providers

  • Cultural diversity training for staff

  • Linguistically and culturally appropriate health education and information materials

  • Tailored healthcare setting


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Use of interpreters

  • Deaf, blind or foreign language

  • Use professionals – not family

  • Look at the patient, not the interpreter

  • Use simple language, avoid abstractions, similes, metaphors – they do not translate well

  • Consult often, allow enough time

  • Schedule several patients for days when interpreters are available



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Research

  • Low health literacy leads to:

    • Lower health knowledge and less healthy behaviors

    • Poorer health outcomes

    • Greater health costs

    • Increased likelihood of hospitalization

  • Specific communication techniques (such as teach-back method) may enhance health literacy.


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Research

  • Less healthy behaviors of patients with low literacy:

    • More exposure to violence

    • Pregnant women more likely to smoke

    • Less breastfeeding

    • Less likely to get flu vaccine or pneumovax


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Research

  • Literacy is the single best predictor of health status.

  • Patients with low literacy were:

    • 69% more likely to have late stage diagnosis of prostate CA at presentation (Bennet, J Clin Oncol, 1998).

    • 4 times more likely to be non-compliant with Anti-HIV meds (Kalichman S, et al. JGIM, 1999).


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References

Health Literacy Train the Trainers Program, January 26, 2006. Sponsored by The Community and Family Medicine Department, St. Louis University School of Medicine and The Family Medicine AHEC Program Office with a grant from The AMA Foundation and the Medical Society of Virginia. References:

  • Ad Hoc Committee on Health Literacy (1999). Health literacy: Report of the council on scientific affairs. Journal of the American Medical Association, 281: 552-557.

  • Baker, D.W., Parker, R.M., William, M.V., et al. (1996). The health care experience of patients with low literacy. Archives of Family Medicine, 5: 329-334.

  • Baker, D.W., Parker, R.M., Williams, M.V., Clark, W.S., Nurss, J. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87(6): 1027-1030.

  • Barnes, L.P. (1992). The illiterate client: Strategies in patient-teaching. American Journal of Maternal Child Nursing, 17: 127.

  • Betancourt, J.R., Green, A.R., Carrillo, J.E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund, www.cmwf.org.

  • Blue, A.V. (2001). The provision of culturally competent health care. Medical University of South Carolina College of Medicine, http://www.musc.edu/deansclerkship/rccultur.html.

  • Davis, D.W., Parker, R.M., Williams, M.V., et al. (1996). The health care experience of patients with low literacy. Archives of Family Medicine, 5: 329-334.

  • Davis, T.C., Bocchini, J.A. Jr., Fredrickson, D., Arnold, C., Mayeaux, E.J., Murphy, P.W., et al. (1996). Parent comprehension in polio vaccine information pamphlets. Pediatrics,97(6): 804-810.

  • Davis, T.C., Crouch, M.A., Wills, G., Miller, S., Abdehou, D.M. (1990). The gap between patient reading comprehension and the readability of patient education materials. Journal of Family Practice, 31(5): 533-538.

  • Davis, T.C., Fredrickson, D.D., Bocchino, C., Arnold, C., et al. (2002). Improving vaccine risk/benefit communication with an immunization education package: A pilot study. Ambulatory Pediatrics, 2(3): 193-200.

  • Davis, T.C., Holcombe, R.F., Berkel, H.J., Pramanik, S., Divers, S.G. (1998). Informed consent for clinical trials: A comparative study of standard versus simplified forms. Journal of the National Cancer Institute, 90(9): 668-674.

  • Davis, T.C., Michielutte, R., Askov, E.N., Williams, M.V., Weiss, B.D. (1998). Practical assessment of adult literacy in health care. Health Education & Behavior, 25(5): 613-624.


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References

  • Doak, C.C., Doak, L.G., Root, J.H. (1996). Teaching patients with low literacy skills, 2nd Ed. Philadelphia: J.B. Lippincott Company.

  • Doak, C.C., Doak, L.G., Friedell, G.H., Meade, C.D. (1998). Improving comprehension for cancer patients with low literacy skills: Strategies for clinicians. CA: A Cancer Journal for Clinicians, 48(3): 151-162.

  • Hammerschmidt, D.E., Keane, M.A. (1992). Institutional review board (IRB) review lacks impact on readability of consent forms for research. American Journal of the Medical Sciences, 304(6): 348-351.

  • Jackson, R.H., Davis, T.C., Bairnsfather, L.E., et al. (1991). Patient reading ability: An overlooked problem in health care. Southern Medical Journal, 84(10): 1172-1175.

  • Kefalides, P.T. (1999). Illiteracy: The silent barrier to health care. Annals of Internal Medicine, 130(4): 333-336.

  • Kirsch, I.S., Jungebut, A., Jenkins, L., Kolstad, A. (1993). Adult literacy in America: A first look at the results of the national adult literacy survey. Washington, D.C.: National Center for Education Statistics, U.S. Department of Education.

  • Lasater, L., Mehler, P.S. (1998). The illiterate patient: Screening and management. Hospital Practice, 163-170.

  • Mayer, G., Kuklierus, A. What to do when your child gets sick and what to do for teen health. Institute of Healthcare Advancement, Whittier, CA, www.iha4health.org.

  • Meade, C.D., Howser, D.M. (1992). Consent forms: How to determine and improve their readability. Oncology Nursing Forum, 19(10): 1523-1528.

  • McPhee, S.J. (2002). Clinical crossroads: Caring for a 70-year-old Vietnamese woman. Journal of the American Medical Association, 287: 495-501.

  • National Academy on an Aging Society (October, 1998). Understanding health literacy: New estimates of the costs of inadequate health literacy. Presentation at Pfizer Conference on Health Literacy, Promoting Health Literacy: A Call to Action. Washington, D.C.

  • Nurss, J., El-Kebbi, I.M., Gallina, D.L., et al. (1997). Diabetes in urban African Americans: Functional health literacy of municipal hospital outpatients with diabetes. Diabetes Educator, 23(5): 563-568.

  • Ong, L.M.L., DeHaes, J.C.J.M., Hoos, A.M., Lammes, F.B. (1995). Doctor-patient communication: A review of the literature. Social Science Medicine, 40(7): 903-918.

  • Paasche-Orlow, M.K., Brancati, F.L. (2003). Readability standards for informed consent forms as compared with actual readability. New England Journal of Medicine, 348(8): 721-726.


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References

  • Parikh, N.S., Parker, R.M., Nurss, J.R., et al. (1996). Shame and health literacy: The unspoken connection. Patient Education and Counseling, 27: 33-39.

  • Parker, R.M., Baker, D.W., Williams, M.V., Nurss, J.R. (1995). The test of functional health literacy in adults. Journal of General Internal Medicine, 10: 537-541.

  • Plimpton, S., Root, J. (1994). Materials and strategies that work in low literacy health communication. Public Health Reports, 109(1): 86-92.

  • Schillinger, D., Grumbach, K., Piette, J., et al. (2002). Association of health literacy with diabetes outcomes. Journal of the American Medical Association, 288(4): 475-482.

  • Spandorfer, J.M., Karras, D.J., Hughes, L.A., Caputo, C. (1995). Comprehension of discharge instructions by patients in an urban emergency department. Annals of Emergency Medicine, 25: 71-74.

  • Sullivan, L.M., Dukes, K.A., Harris, L., Dittus, R.S., Greenfield, S., Kaplan, S.H. (1995). A comparison of various methods of collecting self-reported health outcomes data among low-income and minority patients. Medical Care, 53(4): AS183-AS194.

  • The National Work Group on Literacy and Health (1998). Communicating with patients who have limited literacy skills: Report of the national work group on literacy and health. Journal of Family Practice, 46.

  • Treachy, J.T., Mayer, D.K. (2000). Perspectives on cancer patient education. Seminars in Oncology Nursing, 16(1): 47-56.

  • Weiss, B.D., Blanchard, J.S., McGee, D.L., et al. (1994). Illiteracy among Medicaid recipients and its relationship to health care costs. Journal of Health Care for the Poor and Underserved, 5(2): 99-111.

  • Weiss, B.D., Coyne, C. (1997). Sounding board: Communicating with patients who cannot read. New England Journal of Medicine, 337(4): 272-273.

  • Weiss, B.D., Hart, G., McGee, D., D’Estelle, S. (1992). Health status of illiterate adults: Relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice, 5: 257-264.

  • Williams, M.V., Baker, D.W., Honig, E.G., Lee, T.M., Nowlan, A. (1998). Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114: 1008-1015.

  • Williams, M.V., Baker, D.W., Parker, R.M., Nurss, J.R. (1998). Relationship of functional health literacy to patients’ knowledge of their chronic disease: A study of patients with hypertension or diabetes. Archives of Internal Medicine, 158: 166-172.


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