Health literacy the missing link in patient physician communication
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Health Literacy The Missing Link in Patient-Physician Communication. AMA-MSS Subcommittee on Health Literacy Community Service Committee. Do you know?. Which of the following is the strongest predictors of an individual’s health status? A) Age B) Income C) Literacy skills

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Health LiteracyThe Missing Link in Patient-Physician Communication

AMA-MSS Subcommittee on Health Literacy

Community Service Committee


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Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) Age

B) Income

C) Literacy skills

D) Education level

E) Racial or ethnic group

F) Average Beer Intake at Metro


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Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) Age

B) Income

C) Literacy skills

D) Education level

E) Racial or ethnic group

F) Average Beer Intake at Metro


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The Problem:

Low Health Literacy


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Definitions

  • Illiteracy: total inability to read and write

  • Functional Illiteracy: ability to only read/write/understand below 5th grade level

  • Marginal Literacy: ability to only read/write/understand between the 5th and 8th grade level

  • Literacy: ability to read/write/understand at the 8th grade level and above


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Health Literacy

  • The ability to read, understand, and use healthcare information to make effective healthcare decisions and follow instructions for treatment


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Basic information about a colonoscopy, as perceived by a patient with limited literacy skills


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Scope of the Problem patient with limited literacy skills

  • 22% of adult Americans are functionally illiterate; an additional 27.5% are marginally literate

  • Therefore, nearly half of American adults (90 million patients) do not have sufficient literacy skills to fully function in society

  • All segments of the population are affected


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Education as an Unreliable Indicator of Literacy Level patient with limited literacy skills

  • Number of years of education not equal to amount learned

  • 24% of Functionally Illiterate (NALS Level 1) people actually completed high school


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Health People 2010 Focus Areas patient with limited literacy skills

  • Access to Quality Health Services*

  • Arthritis, Osteoporosis, and

    Chronic Back Conditions

  • Cancer

  • Chronic Kidney Disease

  • Diabetes

  • Disability and Secondary Conditions

  • Educational and Community-Based

    Programs

  • Environmental Health*

  • Family Planning

  • Food Safety

  • HEALTH COMMUNICATION

  • Heart Disease and Stroke

  • HIV

  • Immunization and Infectious Diseases*

  • Injury and Violence Prevention*

  • Maternal, Infant, and Child Health

  • Medical Product Safety

  • Mental Health and Mental Disorders*

  • Nutrition and Overweight*

  • Occupational Safety and Health

  • Oral Health

  • Physical Activities and Fitness*

  • Public Health Infrastructure

  • Respiratory Diseases

  • Sexually Transmitted Diseases*

  • Substance Abuse*

  • Tobacco Use*

  • Vision and Hearing


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National Adult Literacy Survey (NALS) patient with limited literacy skills

  • Provides the most comprehensive view of general literacy skills of American adults (1992)

  • 5 Levels


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Summary of NALS Levels patient with limited literacy skills

  • Level 1: Functionally Illiterate

    • CANNOT:

      • use bus schedule, find intersection on map

      • read a simple story to a child

      • fill out social security application

  • Level 2: Marginally Literate

    • CANNOT:

      • use bus schedule

      • read a bar graph

      • write a letter of complaint

  • Level 3 & 4: Functionally Literate

  • Level 5: High-Level Literacy


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Results of the NALS patient with limited literacy skills

  • Level 1: 22%

  • Level 2: 27.5%

  • Level 3: 31.5%

  • Level 4: 16%

  • Level 5: 3%


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Increased costs of low literacy patient with limited literacy skills

  • Average annual cost of all Medicaid enrollees: $3,000

  • Average annual cost of low literacy enrollees: $13,000


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Sources of Increased Costs patient with limited literacy skills

  • Low literacy patients have:

    • more medication errors

    • excess hospitalizations

    • longer hospital stays

    • more E.D. visits

    • generally higher level of illness

  • RESULT: An excess cost of $50-73 billion per year to the US healthcare system


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Limited Literacy in Healthcare Setting patient with limited literacy skills

  • Trouble understanding:

    • when next appt was scheduled

    • medical vocabulary (bowel, polyp, colon, etc.)

    • basic disease concepts

    • how to use medical devices (asthma inhaler)


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Low Literacy translates into poor health outcomes patient with limited literacy skills

  • Health Knowledge Deficits:

    • Diabetic patients less likely to know symptoms of hypoglycemia

    • Patients with low literacy are less likely to maintain tight control of their diabetes

  • Less healthy behaviors:

    • more smoking, including during pregnancy

    • more exposure to violence

    • less breastfeeding


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  • High Risk Groups patient with limited literacy skills

    • Elderly

    • People with limited education

    • Ethnic Minorities (Hispanic, AA)

    • Recent Immigrants to the US

    • People born in the US but English is a second language

    • Low income


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Red Flags patient with limited literacy skills

  • Behaviors

    • registration forms incomplete or inaccurate

    • frequently missed appointments

    • noncompliance with medication

    • lack of follow-through with tests or referrals

    • eyes wandering over a page

    • very slow to finish

    • sounding out words

    • looking confused


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  • Responses patient with limited literacy skills

    • “I forgot my glasses”

    • “Let me take this home so I can discuss it with my children”


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Can you expect your patient to tell you? patient with limited literacy skills

  • Shame and Stigma

    • 68% have never told their spouse

    • 75% have never told their healthcare provider

    • 19% have never told anyone

  • may bring decoy reading materials

  • 66-75% of adults in NALS Level 1 say they read “well” or “very well”

  • 33.6% of low literacy patients do not admit to having reading trouble


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Overview of Implications patient with limited literacy skills

  • Poor Health Outcomes

  • Over-utilization of health services

  • Limited effectiveness of treatment

  • Higher patient dissatisfaction

  • Higher provider frustration


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How can you find out? patient with limited literacy skills

  • Do social history first in patient evaluation, adding questions about literacy skills in a sensitive manner

    • “How happy are you with the way you read?”

    • “What do you like to read?”

  • Ask questions in a safe and supportive environment and in a neutral, nonjudgmental fashion

  • Brown-bag medication review

    • “When was the last time you took one of these pills?”

    • “When was the time before that?”

    • Do they read the label or look at the pill?


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Remember... patient with limited literacy skills

  • Not stupid

  • All social classes

  • Amazingly able to function

  • The majority of people with low literacy skills are white, native-born Americans

    • Health providers should not have racial/ ethnic bias


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SOLUTION: patient with limited literacy skills


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What can we do? patient with limited literacy skills

  • Make your practice patient-friendly

  • Communicating in an easy-to-understand language

  • Creating and using patient-friendly written materials


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What can we do? patient with limited literacy skills

  • Make your practice patient-friendly

    • Attitude of helpfulness from clinicians and staff

    • Help with office check-in and scheduling appointments

    • Repeat important instructions


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  • Communicating in an easy-to-understand language patient with limited literacy skills

  • 6 Steps to improve communication with patients

    • slow down

    • use plain, non-medical language

    • limit the amount of information provided, and repeat it

    • show or draw pictures

    • use teach-back or show-me technique

    • create a shame-free environment


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Use plain, non-medical “living room” language patient with limited literacy skills


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2. Principles for creating patient-friendly written materials

  • 5th or 6th grade level

  • clear statements of instruction

  • avoid unnecessary background info

  • avoid lengthy review of anatomy or physiology

  • short sentences

  • large text


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Patient Empowerment materials

  • 3 Important Questions:

    • What is my main problem?

    • What do I need to do?

      • How do I take my medicine?

      • When do I need to be seen again?

    • Why is it important for me to do this?

  • These questions can help patients take their medications properly and take care of their health.


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PowerPoint prepared by: materials

Anupama Kathiresan, Jeremiah Johnson, David Newton

Medical College of Georgia

Augusta, GA

AMA-MSS

Health Literacy Subcommittee, Anupama Kathiresan, Chair

Community Service Committee, Stephen Patrick, Chair

www.ama-assn.org/go/mss