Health Literacy
Mark V. Williams, MD, FACP
Professor of Medicine
Director, Hospital Medicine Unit
Emory University School of Medicine
Executive Medical Director, EHCA
Editor-in-Chief, Journal of Hospital Medicine
Past President, Society of Hospital Medicine
Disease Management Complexity
 Medications – 30 years ago vs. today
 LOS in the hospital
- 30 years ago vs. today
 Self-assessment of disease severity
- Glucometer, peak flow meter,
bp monitoring, weight
 Self-Treatment
- dosing, inhalers, diet, exercise,
polypharmacy
 Mistakes
Literacy
“ An individual’s ability to read, write, and speak
in English, and compute and solve problems at
levels of proficiency necessary to function on
the job and in society, to achieve one’s goals,
and develop one’s knowledge and potential.”
National Literacy Act of 1991
LOW
LITERATE
MARGINALLY
LITERATE
LITERATE
1993 National Adult Literacy Survey
17%
32%
Level 4
Level 3
Level 1
Level 2
27%
Level 5 - 3%
21%
Health Literacy
• Pill bottles
• Appointment slips
• Informed consents
• Discharge
instructions
•
Health education
materials
•
Insurance
applications
Medication
Take as directed
Dr. Literate
The ability to read, understand and act
on health care information.
TOFHLA
Test Of Functional Health Literacy in Adults
•
•
LOW
LITERATE
MARGINALLY
LITERATE
•
•
LITERATE
Uses actual materials from hospital setting.
LOW or INADEQUATE (< 60)
– often misread dosing instructions and
appointment slips.
MARGINAL (60-74)
– struggle with prescription instructions.
ADEQUATE (≥ 75)
– handle most health care tasks.
– struggle with informed consents.
Many Patients Can’t Read
Health-related Materials
Marginal
Inadequate
100
80
%
60
40
20
0
Atlanta
LA-English
LASpanish
Inadequate Health Literacy
Increases with Age
100
18-30
31-45
46-60
84%
73%
80
60
> 60
51%
%
40
20
0
Atlanta
LA- English
LA-Spanish
What do these people
have in common?
•
•
•
•
Richard Branson
Virgin Airways/Records
Charles Schwab
Discount Broker
John Chambers
CEO of Cisco
Craig McCaw
Cellular Industry
And the answer is not that they are billionaires!
One Third of Enrollees Had
Low Literacy
60
Marginal
Inadequate
50
40
%
30
20
10
0
English
Spanish
Total
Low Literacy
Increases with Age
60
Inadequate
50
Marginal
40
%
30
20
10
0
65-69
70-74
75-79
80-84
>=85
Less Educated have
Poorer Health Literacy
60
Inadequate
50
Marginal
40
%
30
20
10
0
0 to 8
9 to 11
12
> 12
READING ERRORS for Medicare
Enrollees with Inadequate Literacy
•
•
•
•
•
•
Take medicine every 6 hours
48%
Interpret blood sugar value
68%
Identify next appointment
27%
Take medicine on empty stomach
54%
Upper GI instructions (4th grade)
76%
Medicaid Rights (10th grade)
100%
Relevance
•
•
Prevalence of inadequate health literacy
Current health system does not
acknowledge the problem
– Use of written word to communicate
– Navigation
– Completing forms
•
Barrier to health care
Low Literate Patients
Less Likely to Know Diagnosis
100
Literate
Marginal
Low
80
% Know
Diagnosis
60
40
20
0
English
Spanish
Low Literate Patients Less Likely to Know
Name and Purpose of Medications
100
Literate
Marginal
Low
80
%
60
Correct
40
20
0
Name
Purpose
Patients with Hypertension Less Likely
to Know Correct Health Behaviors
Know exercise
 blood pressure
Know weight loss
 blood pressure
Low Literate
0
20
40
60
Marginal
Literate
Percent
80
100
Poor Reading Skills Correlate with
Less Knowledge of Asthma
Know must stay
away from allergens.*
Know need to see MD
even when not having
an asthma attack.*
0
* p = 0.001
20
40
60
% Correct
80
100
Low Literate
Marginal
Literate
Poor Reading Skills Correlate with
Less Knowledge of Asthma
Know asthma meds
have side effects.
p = 0.02
Know technique
affects dose
delivered via MDI.
p < 0.001
0
20
40
60
% Correct
80
100
Low Literate
Marginal
Literate
Low Literate Asthma Patients
have Poorer MDI Skills*
4
3
Mean MDI
Score
0-4
2
1.5
1
1.7
1
0
Low
Marginal
Literate
* p = 0.0001
Low Literate Diabetic Patients have
Less Knowledge of Their Illness
Know normal
sugar range
Know uncontrolled
diabetes damages
kidneys / nerves
Low Literate
Marginal
0
20
40
60
Literate
Percent
80
100
Provider – Patient
Communication Challenges
• 40-80% of medical information
is immediately forgotten.
• Almost half of information is
remembered incorrectly.
• The more information given,
the more information forgotten
Health Literacy
and Diabetes Outcomes
•
Cross sectional observational study of
408 English- and Spanish-speaking
primary care patients with Type 2 diabetes
•
Inadequate health literacy associated with
– Worse glycemic control
– Higher rates of retinopathy
– Health literacy accounted for up to 0.72
percentage points of HbA1c
Schillinger, JAMA 2002;288:475-482
Health Literacy and
Diabetes Outcomes
Outcome
Adequate
Inadequate
Tight glycemic control
33%
20%
Poor glycemic control
20%
30%
Report Retinopathy
19%
36%
Schillinger, JAMA 2002;288:475-482
Odds of Self-reported
Diabetes complications
Inadequate vs. Adequate Health Literacy
Complication
OR (95% CI)
p value
Retinopathy (documented)
2.68 (1.6 - 4.6)
.001
Nephropathy
1.71 (0.8 - 3.9)
.20
Lower ext. Amputation
2.48 (0.7 - 8.3)
.14
Cerebrovascular Dz
2.71 (1.1 - 7.0)
.04
Ischemic heart disease
1.73 (0.8 - 3.6)
.15
Schillinger, JAMA 2002;288:475-482
Prostate Cancer
 Patients with low literacy 69% more likely to
have late stage diagnosis at presentation.
 Low literacy more significant predictor of
late stage diagnosis than race or age.
Bennet, J Clin Oncol 1998
Compliance with Anti-HIV Meds
Patients with low literacy
are 4 times more likely
to be non-compliant
Kalichman S, et al. JGIM 1999
Colorectal Cancer Screening
Terms not understood:
 Colon
 Bowel
 Rectum
 Screening / Blood in Stool
 Polyp / Tumor
 Growth / Lesion
Davis T, et al. Cancer Investigation 2000
Preventive Health Care
•
Inadequate health literacy associated with
lower self-reported preventive service use
Influenza Vaccine
OR = 1.4
Pneumococcal Vaccine
OR = 1.3
Mammogram
OR = 1.4
Pap smear
OR = 1.7
Patients with Low Literacy
More Likely to Report Poor Health
50
43
40
34
% Poor
Health
30
20
20
10
0
Literate
Marginal
Low Literate
52% Increase in Odds of Hospitalization
for Patients with Low Literacy*
2
1.52
1.5
Odds
Ratio
1
1
0.5
0
Literate
Low Literate
*Adjusted for age, gender, socioeconomic status,
health status, and regular source of care.
Why Excess Hospitalizations?
• Less knowledge of self-care?
• Worse compliance with treatment?
• Worse general health behaviors?
• Less ability to negotiate the
health care system?
RAND Study
•
•
•
Education plays a major role in general health
Patients with chronic diseases
– Better able to follow complex medical regimens if they
have a college degree
– “proven experience in dealing with detailed and
complex chores that have to be done constantly”
Less educated benefited most from
intensive treatment programs
– Frequent physician visits; telephone reminders
– Physicians should “adjust the intensity of their care
based on the educational background of their patients.”
AHRQ Evidence Report 2004*
Literacy & Health Outcomes
Low literacy LINKED to:
• Poor understanding of information
• Medication errors
• Poor health
• Limited health access
• Substandard medical care
• Adverse health outcomes
• Disparities
Analysis of Literature 1980-2003
Costs of Low Health Literacy
• $50 billion annually?
– National Academy on an Aging Society
• Poorer quality medical care
• Malpractice suits
– lack of “informed” consent
Shame and Low Literacy
•
•
•
•
40% admit shame
Patients don’t tell anyone
– 2/3 have not told their spouses
– 1/2 have not told their children
– 19% have never told anyone
90% believe it helpful for doctors to know
31% opposed to documentation on hospital card
“Physicians who act as literacy police to identify patients with
limited literacy skills, will only chase patients out of their office.”
Low Literacy is Overlooked
Patients don’t fit the stereotype
Many people with inadequate literacy
 Are born in USA (75%)
 Are white (50%)
 Hold full or part -time job (40%)
 Finished high school (25%)
Low Literacy is Overlooked
Patients don’t volunteer it:
 Many patients do not recognize their
inadequate literacy
 Many are ashamed of their reading problem
and hide it
 Not willing to have their reading ability
measured or recorded in medical record
Low Literacy is Overlooked
Clinicians don’t ask about it:
 Unaware the problem exists
 Don’t know how to ask
 Don’t know how to respond
 Don’t want to open a Pandora’s box
Time for a Different Approach
• Recognize shifts in medical care
– acute to chronic care
– hospital to outpatient care
– increased learning demands
•
Recognize limitations of current approach
for dealing with inadequate literacy
– most people learn better with audio or
visual aids, regardless of reading level
6 Simple Steps
1) Slow down
2) Use living room language
3) Show, draw pictures
4) Limit information; repeat instructions
5) Use a “teach back” or “show me”
approach to confirm understanding
6) Be respectful, caring, sensitive
Do you understand?
Do you have any questions?
Potential Strategies
Suggested by other physicians
 Bring family member/friend; bring all meds
 Offer help w/forms
 Limit instruction
 Repeat concepts more than once
 Ask pt to repeat, “teach back”
 Write it down in simple language
 Follow up w/call
A New Paradigm
•
•
Determine patients’ learning capabilities
•
Use audiovisual aids as adjuncts or
primary learning materials
•
Comprehension testing for key points
Systematic, programmed learning
– Show me or Teach back
•
GOAL: PATIENT EMPOWERMENT
“Teach back” works
•
“Asking that patients recall and restate what they
have been told” is one of 11 top patient safety
practices based on strength of scientific evidence.
(AHRQ, 2001 Report on Making Health Care Safer)
•
Physicians’ application of interactive communication
to assess recall or comprehension was associated
with better glucose control for diabetic patients.
(Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”)
Disease Management & Low Literacy
• Low literate patients with diabetes
benefit most from targeted interventions
• Lower HbA1c (OR = 4.6)
• No difference among literate patients
• No difference in control of bp
AMA Foundation’s Health Literacy
Initiative provides tools:
•
•
•
•
•
•
•
•
Video and “Manual for Clinicians”
Power Point slides with facilitator notes
Participant Guides
Faculty Guide
Evaluation questionnaires
Feedback and networking
Small grants
www.amafoundation.org
More Effective Term for Health Literacy:
Clear Health Communication
• “Health literacy”
–Not well known among providers and patients
–Seen as negative among all stakeholders
• Clear Health Communication
–Research indicates:
• Simple and easy to understand
• Communicates that better health is achieved through
a more effective exchange of information
Ask Me 3
1) What is my main problem?
2) What do I need to do?
3) Why is it important for me to do this?
Partnership for Clear
Health Communication: Ask Me 3
• Purpose – Improve
•
•
•
•
communication between
patient and provider
What – 3 questions
patients can ask
their provider to improve
understanding
Who – Targeting
patients and providers
When – Launched at
the Day of Understanding.
Communicated all year
How Executed – Delivered by
Partnership members at
medical meetings, local
markets, etc.
Pictograms*
Spoken instructions
14%
Spoken + Pictogram
85%
After 4 weeks
71%
Peer Educators
Dr. Gil Friedel
*Houts, Pt Ed & Counseling, 2001