Health LiteracyHealth Literacy

The Missing Link in Patient-Physician The Missing Link in Patient-Physician CommunicationCommunication

AMA-MSS Subcommittee on Health LiteracyAMA-MSS Subcommittee on Health Literacy

Community Service CommitteeCommunity Service Committee

Do you know?Do you know?

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

A) AgeA) AgeB) IncomeB) IncomeC) Literacy skillsC) Literacy skillsD) Education level D) Education level E) Racial or ethnic groupE) Racial or ethnic groupF) Average Beer Intake at MetroF) Average Beer Intake at Metro

Do you know?Do you know?

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

A) AgeA) AgeB) IncomeB) IncomeC)C) Literacy skills Literacy skillsD) Education level D) Education level E) Racial or ethnic groupE) Racial or ethnic groupF) Average Beer Intake at MetroF) Average Beer Intake at Metro

The Problem:The Problem:

Low Health Low Health LiteracyLiteracy

DefinitionsDefinitions IlliteracyIlliteracy: total inability to read and write: total inability to read and write Functional IlliteracyFunctional Illiteracy: ability to only : ability to only

read/write/understand below 5th grade read/write/understand below 5th grade levellevel

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

LiteracyLiteracy: : ability to read/write/understand ability to read/write/understand at the 8th grade level and aboveat the 8th grade level and above

Health LiteracyHealth Literacy

The ability to The ability to readread, , understandunderstand, , and and useuse healthcare information to healthcare information to make effective healthcare make effective healthcare decisions and follow instructions decisions and follow instructions for treatmentfor treatment

“… “… half of our adult population has half of our adult population has deficiencies in reading or deficiencies in reading or computational skills.” computational skills.” (AMA Council on Scientific (AMA Council on Scientific

Affairs, Affairs, JAMAJAMA 1999) 1999)

Do your patients understand what Do your patients understand what you are telling them?you are telling them?

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

literacy skillsliteracy skills

Scope of the ProblemScope of the Problem

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

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

All segments of the population are affectedAll segments of the population are affected

Percent of physicians who know about Percent of physicians who know about Health Literacy: Health Literacy:

33%33%

Percent of physicians who make Percent of physicians who make changes in patient communications changes in patient communications after learning about health literacy: after learning about health literacy:

66%66%

Education as an Unreliable Education as an Unreliable Indicator of Literacy LevelIndicator of Literacy Level

Number of years of education not Number of years of education not equal to amount learnedequal to amount learned

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

Health People 2010 Focus Health People 2010 Focus AreasAreas

Access to Quality Health Services*Access to Quality Health Services* Arthritis, Osteoporosis, and Arthritis, Osteoporosis, and

Chronic Back ConditionsChronic Back Conditions CancerCancer Chronic Kidney DiseaseChronic Kidney Disease DiabetesDiabetes Disability and Secondary ConditionsDisability and Secondary Conditions Educational and Community-Based Educational and Community-Based

ProgramsPrograms Environmental Health*Environmental Health* Family PlanningFamily Planning Food SafetyFood Safety HEALTH COMMUNICATIONHEALTH COMMUNICATION Heart Disease and StrokeHeart Disease and Stroke HIVHIV Immunization and Infectious Immunization and Infectious

Diseases*Diseases*

Injury and Violence Prevention*Injury and Violence Prevention* Maternal, Infant, and Child HealthMaternal, Infant, and Child Health Medical Product SafetyMedical Product Safety Mental Health and Mental Mental Health and Mental

Disorders*Disorders* Nutrition and Overweight*Nutrition and Overweight* Occupational Safety and HealthOccupational Safety and Health Oral HealthOral Health Physical Activities and Fitness*Physical Activities and Fitness* Public Health InfrastructurePublic Health Infrastructure Respiratory DiseasesRespiratory Diseases Sexually Transmitted Diseases*Sexually Transmitted Diseases* Substance Abuse*Substance Abuse* Tobacco Use*Tobacco Use* Vision and HearingVision and Hearing

National Adult Literacy National Adult Literacy Survey (NALS)Survey (NALS)

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

5 Levels5 Levels

Summary of NALS LevelsSummary of NALS Levels Level 1: Level 1: Functionally IlliterateFunctionally Illiterate

– CANNOT:CANNOT: use bus schedule, find intersection on mapuse bus schedule, find intersection on map read a simple story to a childread a simple story to a child fill out social security applicationfill out social security application

Level 2: Level 2: Marginally LiterateMarginally Literate– CANNOT: CANNOT:

use bus scheduleuse bus schedule read a bar graphread a bar graph write a letter of complaintwrite a letter of complaint

Level 3 & 4: Functionally LiterateLevel 3 & 4: Functionally Literate Level 5: High-Level LiteracyLevel 5: High-Level Literacy

Results of the NALSResults of the NALS

Level 1: 22%Level 1: 22% Level 2: 27.5%Level 2: 27.5% Level 3: 31.5%Level 3: 31.5% Level 4: 16%Level 4: 16% Level 5: 3%Level 5: 3%

Increased costs of low Increased costs of low literacyliteracy

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

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

Sources of Increased CostsSources of Increased Costs Low literacy patients have:Low literacy patients have:

– more medication errorsmore medication errors– excess hospitalizationsexcess hospitalizations– longer hospital stayslonger hospital stays– more E.D. visitsmore E.D. visits– generally higher level of illnessgenerally higher level of illness

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

Limited Literacy in Limited Literacy in Healthcare SettingHealthcare Setting

Trouble understanding:Trouble understanding:

– when next appt was scheduledwhen next appt was scheduled

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

– basic disease conceptsbasic disease concepts

– how to use medical devices (asthma inhaler)how to use medical devices (asthma inhaler)

Low Literacy translates Low Literacy translates into poor health outcomesinto poor health outcomes

Health Knowledge Deficits:Health Knowledge Deficits:

– Diabetic patients less likely to know Diabetic patients less likely to know symptoms of hypoglycemiasymptoms of hypoglycemia

– Patients with low literacy are less Patients with low literacy are less likely to maintain tight control of their likely to maintain tight control of their diabetesdiabetes

Less healthy behaviors:Less healthy behaviors:

– more smoking, including during more smoking, including during pregnancypregnancy

– more exposure to violencemore exposure to violence

– less breastfeedingless breastfeeding

High Risk GroupsHigh Risk Groups– ElderlyElderly– People with limited educationPeople with limited education– Ethnic Minorities (Hispanic, AA)Ethnic Minorities (Hispanic, AA)– Recent Immigrants to the USRecent Immigrants to the US– People born in the US but English is a People born in the US but English is a

second languagesecond language– Low incomeLow income

Red FlagsRed Flags

BehaviorsBehaviors– registration forms incomplete or inaccurateregistration forms incomplete or inaccurate– frequently missed appointmentsfrequently missed appointments– noncompliance with medicationnoncompliance with medication– lack of follow-through with tests or referralslack of follow-through with tests or referrals– eyes wandering over a pageeyes wandering over a page– very slow to finishvery slow to finish– sounding out wordssounding out words– looking confusedlooking confused

ResponsesResponses

– ““I forgot my glasses”I forgot my glasses”

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

Can you expect your patient Can you expect your patient to tell you?to tell you?

Shame and StigmaShame and Stigma– 68% have never told their spouse68% have never told their spouse– 75% have never told their healthcare provider75% have never told their healthcare provider– 19% have never told anyone19% have never told anyone

may bring decoy reading materialsmay bring decoy reading materials

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

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

Overview of ImplicationsOverview of Implications

Poor Health OutcomesPoor Health Outcomes Over-utilization of health servicesOver-utilization of health services Limited effectiveness of Limited effectiveness of

treatmenttreatment Higher patient dissatisfactionHigher patient dissatisfaction Higher provider frustrationHigher provider frustration

How can you find out?How can you find out?

Do social history first in patient evaluation, Do social history first in patient evaluation, adding questions about literacy skills in a adding questions about literacy skills in a sensitive mannersensitive manner– ““How happy are you with the way you read?”How happy are you with the way you read?”– ““What do you like to read?”What do you like to read?”

Ask questions in a Ask questions in a safe and supportivesafe and supportive environment and in a neutral, nonjudgmental environment and in a neutral, nonjudgmental fashionfashion

Brown-bag medication reviewBrown-bag medication review– ““When was the last time you took one of these pills?”When was the last time you took one of these pills?”– ““When was the time before that?”When was the time before that?”– Do they read the label or look at the pill?Do they read the label or look at the pill?

Remember...Remember...

Not stupidNot stupid All social classesAll social classes Amazingly able to functionAmazingly able to function

The majority of people with low The majority of people with low literacy skills are white, native-born literacy skills are white, native-born AmericansAmericans– Health providers should not have racial/ Health providers should not have racial/

ethnic biasethnic bias

SOLUTION:SOLUTION:

What can we do?What can we do?

A.A. Make your practice patient-friendlyMake your practice patient-friendly

B.B. Communicating in an easy-to-understand Communicating in an easy-to-understand languagelanguage

C.C. Creating and using patient-friendly Creating and using patient-friendly written materialswritten materials

What can we do?What can we do?

A.A. Make your practice patient-Make your practice patient-friendlyfriendly

– Attitude of helpfulness from Attitude of helpfulness from clinicians and staffclinicians and staff

– Help with office check-in and Help with office check-in and scheduling appointmentsscheduling appointments

– Repeat important instructionsRepeat important instructions

B.B. Communicating in an easy-to-Communicating in an easy-to-understand languageunderstand language

6 Steps to improve communication with 6 Steps to improve communication with patientspatients

1.1. slow downslow down

2.2. use plain, non-medical languageuse plain, non-medical language

3.3. limit the amount of information provided, limit the amount of information provided, and repeat itand repeat it

4.4. show or draw picturesshow or draw pictures

5.5. use teach-back or show-me techniqueuse teach-back or show-me technique

6.6. create a shame-free environmentcreate a shame-free environment

Use plain, non-medical Use plain, non-medical “living room” language“living room” language

C.C. Creating and using patient-Creating and using patient-friendly written materialsfriendly written materials

1.1. Written consent forms/ patient education Written consent forms/ patient education handoutshandouts

• most forms written 10th grade to graduate most forms written 10th grade to graduate levellevel

• average US adult reads at 8th grade levelaverage US adult reads at 8th grade level

2. Principles for creating patient-2. Principles for creating patient-friendly written materialsfriendly written materials

• 5th or 6th grade level5th or 6th grade level• clear statements of instructionclear statements of instruction• avoid unnecessary background infoavoid unnecessary background info• avoid lengthy review of anatomy or avoid lengthy review of anatomy or

physiologyphysiology• short sentencesshort sentences• large textlarge text

3.3. Non-written patient education Non-written patient education materialsmaterials

• Graphic IllustrationsGraphic Illustrations-- picturespictures

-- pictographspictographs- ModelsModels

• Audiotapes and compact disksAudiotapes and compact disks

• VideotapesVideotapes

Patient EmpowermentPatient Empowerment

3 Important Questions:3 Important Questions:– What is my main problem?What is my main problem?– What do I need to do?What do I need to do?

How do I take my medicine?How do I take my medicine? When do I need to be seen again?When do I need to be seen again?

– Why is it important for me to do this?Why is it important for me to do this?

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

PowerPoint prepared by:PowerPoint prepared by: Anupama Kathiresan, Jeremiah Johnson, David NewtonAnupama Kathiresan, Jeremiah Johnson, David Newton

Medical College of GeorgiaMedical College of Georgia

Augusta, GAAugusta, GA

AMA-MSSAMA-MSSHealth Literacy Subcommittee, Anupama Kathiresan, Health Literacy Subcommittee, Anupama Kathiresan,

ChairChair

Community Service Committee, Stephen Patrick, ChairCommunity Service Committee, Stephen Patrick, Chair

www.ama-assn.org/go/msswww.ama-assn.org/go/mss