doctor-patient relationships : understanding the importance of health literacy in patient care
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Can you read this?Can you read this?
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How many adult Americans have difficulty How many adult Americans have difficulty reading and understanding health reading and understanding health
information?information?
A. 9 million
B. 90 million
C.50 million
D.Fewer than 1 million
Definition of Health LiteracyDefinition of 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.
It involves the ability to use and interpret text, documents and numbers effectively
The Scope of Low Health LiteracyThe Scope of Low Health Literacy
In 2003, the National Assessment of Adult Literacy (NAAL)
90 million Americans (39% of adults) have limited health literacy
One in five adults read at the 5th grade level or below.
Average American reads at the 8th to 9th grade level
More than 66% of US adults age 60 and over have inadequate or marginal literacy skills
Examples of Health Literacy TasksExamples of Health Literacy Tasks
Proficient Skills: 13%
`Calculate employee’s share of health insurance cost for year using a table on monthly cost
Intermediate Skills: 53%
Determine timing, administration and interactions based on info from drug label
Basic Skills: 22%
Give 2 reasons why a person with no symptoms should be screened based on a clearly written pamphlet
Below basic skills: 14%
Circle date of medical appointment on hospital appointment slip
Who is at risk for low health literacy?Who is at risk for low health literacy?
A. Elderly
B. Ethnic Minorities
C. Those with low income and education levels
D. Those with high income and education
E. A, B, and C
F. All of the above
Highest Risk for Limited Health Highest Risk for Limited Health LiteracyLiteracy
Elderly
Low income
Unemployed
Did not finish high school
Minority ethnic group (Hispanic, African American)
Recent immigrant to US who does not speak english
Born in US but English is 2nd language
Health System Problems Encountered by Health System Problems Encountered by Persons with Limited Literacy SkillsPersons with Limited Literacy Skills
26% Did not understand when their next appointment was scheduled
42% Did not understand instructions: “take medication on an empty stomach”
78% Misinterpret warnings on prescription labels
86% Could not understand rights and responsibilities section of a medicaid application
Impact of Low Health LiteracyImpact of Low Health Literacy
Individuals have less knowledge about their health problems
Make more medication or treatment errors
Fail to seek preventive care
More hospitalizations
Higher health care costs
Less able to “comply” with treatments
Poorer health status
Shame and Health Literacy: the Shame and Health Literacy: the unspoken connectionunspoken connection
Adequate Health Literacy
49% Feel bad/never tell
60% Feel ashamed
94% Hide problem
Low Health Literacy
51% Feel bad/never tell
60% Feel ashamed
78% Hide problem
"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counseling. 1996. 27: 33-39
Who knows you have trouble Who knows you have trouble reading?reading?
Never told:
Spouse
Children
Relatives
Co- workers
Friends
No one
53%
57%
86%
62%
67%
19%
"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counselling.
1996. 27: 33-39
Physician Assessment of Health Physician Assessment of Health LiteracyLiteracy
Physicians often under recognize limited health literacy
Most physicians’ attempt to measure literacy level by their patients highest grade of education
Rely on their patients’ own assessment of their reading skills
Overestimate their patients ability to understand medical information
Often provide information to patients in a level of complexity that patients do not understand
What can we do?What can we do?
Recognize signs of limited health literacy
Screen for health literacy
Learn clear communication techniques
Educate patients on Ask-Me-3
Ms Kelly GreenMs Kelly Green
Ms Kelly Green is a 54 year old caregiver to her mother who is bringing her to your office for a follow up visit. Her mom has history of dementia, hypertension, hypothyroidism and arthritis. She was just discharged from the hospital for Uncontrolled Hypertension.
"
Office VisitOffice Visit
Signs (Clues) of Low Health LiteracySigns (Clues) of Low Health LiteracyBehaviors
Forms incomplete or inaccurately completed
Frequently missed appointments
“Noncompliance” with medication regimens
Lack of follow-up with lab tests, imaging or referrals
Responses to written information
“I forgot my glasses. I’ll read this when I get home.”
“I forgot my glasses. Can you read this to me?”
“Let me bring this home so I can discuss it with my children”
Responses to questions about medications
Unable to name medications
Unable to explain what the meds are for
Unable to explain timing of medication administration
If you suspect Ms. Green’s health If you suspect Ms. Green’s health literacy is limited what screening tests literacy is limited what screening tests
could you perform?could you perform?
Quick Screening Tests for Health Quick Screening Tests for Health LiteracyLiteracy
Single question screens
Assessment instruments
REALM-R: Rapid Estimate of Adult Literacy in Medicine-Revised
NVS: The Newest Vital Sign
Single Question ScreensSingle Question Screens
“How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”
Never Rarely Sometimes Often Always
“How confident are you filling out medical forms by yourself?”
Extremely Quite a bit Somewhat A little bit Not at all
Both been validated in English
The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Prac. 2006;7:21.
Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874-877
REALM-RREALM-R
Word recognition test consisting of 11 medical terms
1st 3 words are not scored (fat, flu, pill): left to decrease test anxiety and enhance patient confidence
Administration time: <2 minutes
Only available in English
Score of 6 or less considered to be at risk for limited health literacy
Forms and instructions available at www.adultmeducation.com
A Shortened Instrument for Literacy Screening. JGIM 2003; 18:1036-1038
The Newest Vital SignThe Newest Vital Sign
Read and analyze a nutrition label of ice cream
6 questions
Administration time 3 to 5 minutes
Scores:
0-1 Limited literacy
2-3 Possible limited literacy
4-6 Adequate literacy
The Newest Vital Sign: Ms Kelly The Newest Vital Sign: Ms Kelly GreenGreen
Lets try it out:Lets try it out:
“I am asking everyone visiting the clinic to help us learn how well they can understand the medical information that doctors give them. Would you be willing to help us by looking at some health information and then answers a few questions about that information. Your answers will help the doctors learn how to provide medical information in ways that patients will understand. It will only take about 3 minutes.”
NVS: AnswersNVS: Answers
1. 1000 calories
2. Any of the following correct:
1. 1 cup
2. ½ the container
3. 2 servings
3. 33 grams
4. 10%
5. No
6. Because it has peanut oil
Will patients agree to have their literacy Will patients agree to have their literacy skills assessed in clinical practice?skills assessed in clinical practice?
Controlled trial
20 different practices in South Florida
Intervention group: routine literacy assessment with NVS during check in (289)
Control group: No screening (303)
Surveyed at end of visit with Art of Medicine Survey Questionnaire (AMSQ)- validated patient satisfaction survey
Will patients agree to have their literacy skills assessed in clinical practice? Health Ed Res
2008;23(4): 603-611
ResultsResults
Intervention Group
289 asked to undergo screening
284 agreed (98.3%)
46.1% limited health literacy on NVS screen
271 completed AMSQ
Control Group
303 completed AMSQ
No difference between groups on patient satisfaction
Will patients agree to have their literacy skills assess in clinical practice? Health Ed Res
2008;23(4): 603-611
How can we communicate with our How can we communicate with our patient better?patient better?
Ms. Green scored a 3
on the Newest
Vital Sign
CommunicationCommunication
What do patients want?
Clear and simple information
Want to know what they need to do
What health providers provide…
Medical words and complicated explanations
Too much information
Information that is often irrelevant to what patients need to do
How can you help your patients How can you help your patients understand?understand?
Steps to Improving Communication and Steps to Improving Communication and UnderstandingUnderstanding
Recognize the problem
Eliminate barriers for communication
Confirm that patients understand what they need to understand: teach back
Find a way that works for your patient to understand and remember
Ask me 3
Literature
Written instructions
Open and Shame Free EnvironmentOpen and Shame Free Environment
Adopt an “attitude of helpfulness”
Convey safe and nonjudgmental environment
Plain signage
Be on alert to clues
Eliminate BarriersEliminate Barriers
Hearing and visual impairments
Medical interpreters/ translators
Should be qualified
Visual aids for low literacy
Multi-Media
Interactive Computer programs/TV
Video/audiotape
Body language
Speak in plain languageSpeak in plain language
Use clear and easy to follow language Be specific and use examples Beware of words with multiple
meanings (stool, gait, dressing) and clarify when using
Avoid complicated words and over use of medical jargon
Avoid acronyms and new words (CT scan, RUQ U/S, HDL)
Give them a health context for numbers Encourage questions and take a pause
Taboo: Taboo: A game of “speaking in A game of “speaking in plain language”plain language”
Rules of the game
One person gets a card with a medical term “target word” on it
You need to describe the target word without using the taboo words listed on the card to your group
You can use taboo words if it is immediately defined in layman’s terms
You have 2 minutes to do this
Common medical words that patients with Common medical words that patients with limited literacy may not understandlimited literacy may not understand
Blood in stool
Bowel
Colon
Growth
Lesion
Polyp
Rectum
Screening
Tumor
The role of inadequate health literacy skills in colorectal cancer screening." Cancer Invest.
2001:19:193-2000
What percentage of patients “forget” what What percentage of patients “forget” what the Doctor told them as soon as they leave the Doctor told them as soon as they leave the office?the office?
A. 80%
B. 50%
C. 10%
D. <10%
Implications for “Not Implications for “Not Understanding” the PhysicianUnderstanding” the Physician
Up to 80% of patients forget what the doctor tells them
50% of what they remember is recalled incorrectly
30% US patients leave their MD’s office with unanswered questions
2 out of 5 do not follow advice because it is too difficult or because they disagree with it
"Patients' memory for medical information," Journal of Royal Society of Medicine2003:96:219-222“Diverse Communities. Common Concerns: Assessing Health care Quality for Minority Americans. The Commonwealth Fund. March 2002.
Convey the important points to Convey the important points to remember!remember!
Verify they understandVerify they understand
Teach Back
Encourage Questions
Ask-Me-3
Verify they understand:Verify they understand:Teach Back ApproachTeach Back Approach
Do not ask a patient, “Do you understand?”
Ask a patient to explain or demonstrate how they will undertake a recommended treatment or intervention.
“I want to be sure that I did a good job explaining your blood pressure medications, because this can be confusing. Can you tell me what changes we decided to make and how you will now take the medication?” Or “Can you explain what I just told you to make sure I covered everything?”
If patient cannot explain correctly, assume that you have not provided adequate teaching. Re-teach the information using alternate approaches.
Teach Back Approach:Teach Back Approach:
Encouraging patients to ask more Encouraging patients to ask more questions during the exam will increase questions during the exam will increase the length of their visit?the length of their visit?
A. True
B. False
British Medical Journal,sept 2002. vol. 325:682-683
Teach your patient to be proactive: Teach your patient to be proactive: What’s Ask-Me-3?What’s Ask-Me-3?
New patient education program designed to promote communication between patient and Health Care Provider to improve health outcomes
Quick and effective tool
Can foster clear communication between provider and patient
Studies have shown that patients who understand health instructions make fewer mistakes taking medication or preparing for a procedure
Study also showed a higher level of satisfaction from patients and a feeling of improved communication using Ask-Me-3 compared to a control group
For downloadable free materials, posters and brochures: www.npsf.org/askme3
www.AskMe3.org
Ask me 3Ask me 3
What is my main problem?
What do I need to do? Why is it
important for me to do this?
Diagnosis
Treatment
Context
Provide Patients with Written Provide Patients with Written Instructions Instructions
Do not abbreviate!
SOB is not a flattering term in layman’s language!
BID does not necessarily mean twice a day.
Add pictures to communicate your points
1/5 adults read at a level below 5th grade; simplify to a lower grade level
Materials should be written in fifth to eighth grade level
Define complicated terms/ limit syllables
Ms. GreenMs. Green
Health Literacy and Psychosocial Health Literacy and Psychosocial issuesissues
Depression/Anxiety
Caregiver stress
Dementia
Limited Health Literacy is a psychosocial issue
Health Literacy and Psychosocial Health Literacy and Psychosocial issues: Literature searchissues: Literature search
Literacy Education as Treatment for Depression in patients with limited literacy and Depression
J GEN INTERN MED 2006; 21:823–828.
Understanding the impact of family caregiver cancer literacy on patient health outcomes
Patient Education and Counseling 2008
Relationship of Empathy to Appraisal, Depression, Life Satisfaction, and Physical Health in Informal Caregivers of Older Adults
Research in Nursing & Health, 2001, 24, 44±56
Health Literacy and Psychosocial Health Literacy and Psychosocial issues: Literature searchissues: Literature search
Does a higher Education level protect against anxiety and depression? The HUNT study
Social Science and Medicine 2008
Health Literacy and Cognitive Performance in Older Adults
JAGS 2009 Vol 57:1475-1480
Conclusion: Steps to improving Conclusion: Steps to improving understandingunderstanding
Recognize the problem
Screen patients and caregivers when appropriate
Use communication techniques to foster understanding
Plain language
Teach-Back
Visual Cues
Encourage patients to be pro-active (Ask-Me-3)
Give patient-friendly written instructions or patient education handouts
Thank you for your attention!Thank you for your attention!
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