Limited Health Literacy in Hospitalized Patients

1. Limited Health Literacy in Hospitalized Patients Grant, S., Morris, N. S., MacLean, C., Repp, A., & Littenberg, B.

2. Disclosure Disclosures for Steve Grant: Physician advisor and consultant to EMMI Solutions, a medical software company that designs multimedia consent and educational materials.

3. 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)

4. Skills needed for adequate health literacy Aurally literate Numerically literate * * Visually literate * Computer literate Information literate * *

5. How big is the problem? ~77 million people, nearly 1/3 the adult US population have difficulty understanding and using health information (NAAL, 2003) People who have low health literacy generally hide it because it is stigmatized in our society The estimated added annual cost to the health care system due to low health literacy,$106-238 Billion(Vernon et al., 2007)

6. What is the impact? • Limited health literacy is associated with: • Less knowledge about chronic disease states • Worse self-management skills • Poorer health outcomes • Lowered use of preventive services • Increased hospitalization rates • All-cause mortality among older adults • Increased health care costs

7. 2003 National Assessment of Adult Literacy (N=19,000 adults) Below Basic – no more than the most simple and concrete literacy skills Basic - skills necessary to perform simple and everyday literacy activities Intermediate – skills necessary to perform moderately challenging literacy activities Proficient – skills necessary to perform more complex and challenging literacy activities

8. Adults/Health Literacy Level (NAAL,2003)

9. By Race-Ethnicity (NAAL, 2003)

10. Relationship of education to basic/below basic health literacy?

11. Limited health literacy found more among: Elderly Immigrant populations Adults with low-income Adults who have not completed high school Adults with chronic mental and/or physical health conditions Adults living in rural areas

12. Interest • To date most of our knowledge of health literacy has been derived from the outpatient setting. • Hospitals - challenging environment with complex and often unfamiliar information conveyed to patients in a very short time.

13. Purpose • To determine the prevalence and demographic associations of limited health literacy in hospitalized General Medicine patients • Identify perceived difficulty with health communication • Use of any compensatory strategies

14. Cross sectional survey of a convenience sample of patients admitted to the Internal Medicine Hospitalist Service at FAHC Eligible subjects > 18 years of age Able to provide informed consent Not previously enrolled in the study Not incarcerated Not anticipated to die during hospitalization Methods

15. Recruitment • To minimize the contribution of the acute illness data were collected within 48 hours of anticipated discharge from the hospital. • The research assistant obtained informed consent and collected all data from patients available Monday through Friday during workday hours.

16. Minimizing the impact of decreased vision • Patients were asked to wear their glasses if appropriate • We offered reading glasses if necessary • All survey questions and responses (except the assessment of reading ability) were presented in 18-point font and were also read aloud to the patient

17. Measurement Short Test of Functional Health Literacy of Adults (S-TOFHLA) • A 36-item timed reading comprehension test. • Tests a subject’s ability to read and comprehend the instructions for a radiology procedure and the Patient Rights and Responsibilities section of a Medicaid application form.

18. Blindness or decreased vision Decreased hearing Primary language other than English Memory problems or dementia Mental or neurologic problems Emotional or psychiatric problems Not enough schooling to learn to read Dyslexia or reading disorder “Do any of these problems make it hard for you to read?”

19. “What would you do if you needed help reading or understanding medical directions or health information?” Prompts • Ask a family member for help • Ask a friend for help • Ask a health care professional for help • Ask a translator for help • Use a magnifying glass

20. Demographic data • Sex • Age • Race • Marital status • Language spoken in the home • Highest level of education • Household income

21. Analysis • We used simple proportions and means with 95% confidence intervals to summarize the data. • To compare subgroups, we calculated P-values using Fisher’s exact test for categorical variables and nptrend in STATA for continuous or ordinal variables. • All analyses were performed with STATA 10 (StataCorp, College Station, Texas). • A P < 0.05 was required for statistical significance.

22. Subjects (N=103) • Mean age 66 years * • 99% English was primary language • 91% White • 61% Female • 43% Married • 47% > High school education* • 58% Annual home income < $30,000*

23. Results • Mean S-TOFLA score = 16 (range 0-36) • 60% (N=62) Limited health literacy • (n=55) Inadequate health literacy (score of 0-16) • (n=7) Marginal health literacy (score of 17-22) • 40% (n=41) Adequate health literacy (score of 18-36)

24. Etiology of reading difficulty (N=70) Blindness/low vision 34 Decreased hearing 7 Memory Problems 6 Mental/Neuro Problems 6 Not enough schooling 6 Emotion/Psych problems 4 English not first language 4 Dyslexia/reading disorder 3

25. Compensatory strategies (N=93) Ask health professional 63 Ask family member 24 Ask friend 5 Use translator 1

26. Discussion • Patients hospitalized on a general medicine unit have a higher prevalence of limited health literacy (60%) than the 33-49% that has been reported in outpatient studies (Gazmararian, 1999; Schillinger, 2002; Williams, 1998). • Our results are more similar to Wolf and colleagues (2007) who reported that 51% of primary care patients at an urban public hospital had low literacy skills.

27. Possible explanations for the high prevalence of limited literacy in hospitalized patients • Patients with low health literacy are more likely to be admitted to the hospital (Arozullah 2002; Baker 2002, 1998; Gordon 2002). • Hospitalized patients may experience changes in cognition secondary to illness, emotional distress, medical or surgical interventions, loss of support systems, or inadequate sleep (Johnson et al., 2002; Price, Garvan, & Monk, 2008; Stenuit & Kerkhofs, 2007;) potentially lowering health literacy scores. • S-TOFHLA may not be ideal measure

28. Decreased vision as etiology? • This may be due to: • factors related to organic disease • medications • Possible cover up for reading difficulties

29. Compensatory strategies • Patients’ reliance on health care professionals, family and friends to assist in understanding health information reinforces the need to reconsider existing methods of communicating information to patients. • Providing verbal and written health information to patients has been shown to improve communication, knowledge and satisfaction (Johnson, Sandford, & Tyndall, 2007).

30. Limitations • Homogenous population limits the generalizability of our results. • Convenience sampling means we likely missed some eligible patients, particularly those with brief stays who may have been less ill, less cognitively compromised.

31. Limitations • S-TOFHA is measure of print readability rather than the broader domain of health literacy. • This is a cross-sectional survey that does not allow the observation of literacy over time, measurement of incident outcomes, or the assignment of cause and effect.

32. Conclusions • Nearly two-thirds of medical inpatients have less than adequate health literacy • Most patients rely on help from a health professional or a family member when faced with challenges in reading or understanding health information. • The prevalence of marginal or inadequate literacy is substantially higher in hospitalized patients than outpatients.

33. Additional challenges in the health care environment… > 800 studies indicate that many health materials are written at reading grade levels higher that the reading skills of an average high school graduate. Limited skill set among health care professionals in successfully communicating with adults with limited literacy skills. Time pressures of the health care encounter.

34. Clear Communication is Challenging for Many We need to closely examine the timing and method of transmitting critical information to patients and their families during hospitalization

35. Thank you, What questions do you have?