Clinicians and Patients:What You Say, What They Hear Lorraine S. Wallace, Ph.D., Associate Professor Department of Family Medicine University of Tennessee Graduate School of Medicine
Learning Objectives • Describe the results of the National Assessment of Adult Literacy. • Define health literacy. • Describe the relationship between health literacy and health outcomes. • Describe the mismatch between reading abilities of American adults and patient/health education materials. • Identify health literacy assessment tools. • List strategies to improve clinician-patient communication in various clinical settings.
What is Literacy? The ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential. White, S., & McCloskey, M. Framework for the 2003. National Assessment of Literacy (NCES 2006-473). US Department of Education, Washington, DC.
3 Literacy Categories Prose Document Quantitative 19 000 US adults; 16 years; residing in households or prisons 4 Proficiency Levels • Below Basic • Basic • Intermediate • Proficient
Locate the sentence that tells what Ms. Chanin ate during the swim. 84% answered correctly
Look at the driver’s license. Put a circle around the date on which the license expires. 93% answered correctly
You want to buy some fruit juice and see this advertisement. Rank the 4 juices in order from the least expensive to the most expensive. Then explain your reasoning for ranking them the way that you did. 44% answered correctly
Degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health. IOM Definition Health Literacy
Below Basic Health Literacy Skills Sample Task: Circle the date of a medical appointment on a hospital appointment slip.
Basic Health Literacy Skills Sample Task: Give 2 reasons a person with no symptoms of a specific disease should be tested for the disease, based on information in a clearly written pamphlet.
Intermediate Health Literacy Skills Sample Task: Determine healthy weight range for a person of a specified height, based on a graph that relates height and weight to body mass index (BMI).
Proficient Health Literacy Skills Sample Task: Find information required to define a medical term by searching through a complex document.
Low health literacy=problems with….. • Pill bottles • Appointment slips • Informed consents • Discharge instructions • Patient/health education materials • Insurance applications Medication Take as directed Dr. Literate
Factors that contribute to health literacy: • General literacy • Experience with health system • Complexity of information • Cultural and language factors • How information is communicated (reliance on written word for patient instruction) • Aging
Inadequate health literacy increases with age…. % Gazmararian et al. (1999). JAMA.
Our Expectations of Patients Continually Increase 35 Years AgoToday Treatment of Acute 4-6 weeks bed 2-4 days in hospital Myocardial Infarction rest in hospital Available prescription 650 10 000+ drugs
Literacy and Health Outcomes • Understanding of medical conditions • Health-related quality of life • Delayed diagnoses • Use of preventive services • Risk of hospitalization • Adherence to medical instructions • Self-management skills
Low Literate Diabetic Patients Less Likely to Know Correct Management Need to Know: symptoms of low blood sugar (hypoglycemia) Need to Do: correct action for hypoglycemic symptoms Low Moderate High Low Moderate High Percent Williams et al. (1998). Arch Int Med.
Literacy and Breast Cancer Screening Knowledge 1 in 4 marginally and low-literate women who thoughtthey knew what a mammogram was, actually did not. Davis et al. (1996). Cancer.
Literacy and Cervical Cancer Knowledge and Distress • Literacy was the only factor independently associated with knowledge related to cervical cancer. • Low literacy was associated with increased levels of distress among women at high risk for cervical cancer. • Spanish-speaking Latinas with inadequate health literacy skills were less likely to ever had a Pap test. Lindau et al. (2002). Am J Obstet Gynecol.; Sharp et al. (2002). Ethn Dis.; Garbers et al. (2004). Prev Chronic Dis.
Obese Patients’ Knowledge of Obesity and Readiness to Lose Weight • Patients with low literacy were significantly • less likely to: • understand the adverse health consequences of obesity • understand the need to lose weight • report being ready to lose weight Kennen et al. (2005). South Med J.
Literacy and Healthcare Costs Annual Healthcare Costs of Medicaid Enrollees $10688 $2891 (>4th-grade reading level) (<3rd-grade reading level) Weiss et al. (2004). J Am Board Fam Pract.
Educational Attainment and Reading Level • Years of formal schooling tells us what people have been exposed to, NOT what skills they have acquired.” (Doak, Doak, & Root, 1996) • Most American adults read 3-5 grade levels lower than the highest grade level of schooling completed. • Average reading level in US=6-8th grade Davis et al. (1996). Pediatrics.; Meade et al. (1994). Am J Pub Health.
Average reading level of materials=9.4 Readability of AAFP and ACOG Patient Education Materials • Average reading level of • materials=≈9.0 Wallace et al. (2004). Fam Med. Freda. (1999). Obstet Gynecol. 500+ published studies confirm these findings.
Suitability of Web-based Supplemental Materials Prescription Drugs 60% of materials were rated as not suitable (6th grade) for their reading level. Over-the-Counter Drugs 81% of materials were rated as not suitable (6th grade) for their reading level. Kaphingst et al. (2004). Patient Educ Couns. Wallace et al. (2006). Am J Health Syst Pharm.
Government Sponsored Mailings HIV/AIDS brochure (1988) • RReading grade level 8 Inhaled anthrax postcard (2001) • RReading grade level 10 • WWords such as priority, security, paramount, legitimate, restrictive, endorsements, and authorities appeared throughout the postcard.
Low Literacy is Often Overlooked Patients don’t fit the stereotype Many patients with inadequate literacy: • Are born in the USA (75%) • Are White (50%) • Hold a part- or full-time job (40%) • Finished high school (25%)
Low Literacy is Often Overlooked Patients don’t volunteer it: • Many patients do not recognize their inadequate literacy. • Many patients are ashamed of their reading/literacy skills.
Shame and Limited Literacy Parikh et al. (1995). Patient Educ Couns.
Low Literacy is Often Overlooked Health professionals don’t ask about it: • Unaware the problem exists • Don’t know how to ask • Don’t know how to respond • Are unable to identify patients with limited literacy skills
Possible Indicators of Low Health Literacy • Seek help only when illness is advanced. • Have difficulty explaining medical concerns. • Identifies drugs by pill color and shape rather than by name. • Does not know purpose of each medication. • Excuses: “I forgot my glasses.” • Lack of follow-through with tests/appointments. • Seldom or never have any questions.
Screening for Low Health Literacy? • Rapid Estimate of Adult Literacy in Medicine (REALM) • Test of Functional Health Literacy in Adults (TOFHLA) • Newest Vital Sign (NVA)
REALM List 1 List 2 List 3 fat fatigue allergic flu pelvic menstrual pill jaundice testicle dose infection colitis eye exercise emergency stress behavior medication
TOFHLA and S-TOFHLA THE DAY OF THE X-RAY Do not eat __________________. a. appointment. b. walk-in. c. breakfast. d. clinic.
Health Literacy Screening Items for Parents • 3 items combined associated with 6th grade parental reading level: • <12th grade completion • not living with child’s other parent • not reading for pleasure 2 items independently associated with adequate parent health literacy: >10 adults’ books in the home >10 children’s books in the home Bennett et al. (2004). Fam Med. Sanders et al. (2004). Ambul Pedriatr.
Health Literacy Screening Items for Adults 3 items were effective in detecting inadequate health literacy: • “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 condition because of difficulty understanding written information?” Chew et al. (2004). Fam Med.; Wallace et al. (2006). J Gen Intern Med.
Strategies to Improve Communication • Limit information (3-5 key points) • Use living room language • Be specific and concrete, not general • Demonstrate, draw pictures, use models • Use a “Teach Back” or “Show Me” approach (confirm understanding) • Be positive, respectful, caring, sensitive, empowering