Limited Health Literacy in Hospitalized Patients

Grant, S., Morris, N. S., MacLean, C., Repp, A., &

Littenberg, B.

Disclosure

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

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)

Skills needed for adequate health literacy

Aurally literate

Visually literate

Information literate

Numerically literate

Computer literate

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)

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

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

Adults/Health Literacy Level (NAAL,2003)

0

20

40

60

80

100

120

Millions

Below Basic 14%

Basic 22%

Intermediate 53%

Proficient 12%

By Race-Ethnicity (NAAL, 2003)

Relationship of education to basic/below basic health

literacy?

0

10

20

30

40

50

60

70

80

< HS graduate76%

HS graduate44%

VocTech 37%

AD graduate19%

College graduate13%

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

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.

Purpose To determine the prevalence and

demographic associations of limited health literacy in hospitalized General Medicine patients

a) Identify perceived difficulty with health communication

b) Use of any compensatory strategies

Methods

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

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.

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

MeasurementShort 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.

“Do any of these problems make it hard for you to read?”

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

“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

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

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.

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*

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)

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  

Compensatory strategies (N=93)

 Ask health professional 63

Ask family member 24

Ask friend 5

Use translator 1

 

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.

Possible explanations for the high prevalence of limited literacy in hospitalized patients

1. Patients with low health literacy are more likely to be admitted to the hospital (Arozullah 2002; Baker 2002, 1998; Gordon 2002).

2. 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.

3. S-TOFHLA may not be ideal measure

Decreased vision as etiology? This may be due to:

factors related to organic disease medications Possible cover up for reading

difficulties

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).

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.

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.

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.

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.

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

Thank you,

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