Improving Client Health Outcomes,
One Word at a Time
Your doctor tells you:
“You have a 1 in 10 chance of having
Disease A and a 1 in 20 chance of having
Disease B in the next 10 years.”
Which disease are you at
highest risk for?
Disease A
However, studies have found that people
with low health literacy were more likely to
say Disease B.
Lipkus et al, 2001 Medical Decision Making; Peters et al, 2007 Health Affairs
True or False?
A person with low health literacy skills has
a low IQ?
False
Health literacy is not about intelligence!
Doak et al, 1995 Teaching Patients with Low Literacy Skills
Immediately after leaving a doctor’s office,
patients forget 50% of the critical
information shared at that visit?
Do you know why?
Regardless of a patient’s reading ability, the
medical setting in and of itself can have a
negative impact on health literacy skills.
Davis et al, 2002 Health Literacy and Cancer Communication
Health Literacy is…….

The ability to get information, understand it,
and use it to lower risk and better health.
(University of Maryland)

To actively self manage, patients need to be
able to:
Access
Understand
Evaluate
Communicate
Apply
Vulnerable Groups
Older adults (over 65 years)
 Low income, unemployed
 Born outside of Canada
 Limited proficiency in English/French
 Low education level

* Low health literacy disproportionately
affects people with chronic disease.
Canadians’ Health Literacy Skills
Low Health Literacy
60 % of adults (16 +)
88 % of seniors (66 +)
Health Literacy in Canada: A healthy understanding, 2008
Outcomes
Reduced health related knowledge
 Poorer self management skills
 Less use of preventative care services
 Medication errors and “non-adherence”
 More use of emergency services
 Higher mortality (seniors)
 Higher health care costs

AHRQ, 2011; Canadian Council on Learning,2008
Clinical outcomes
2 x risk of Hbg A1c and Retinopathy
 1.5 x risk of late stage presentation of
cancer
 1.5 x risk of depression/anxiety
 > 1.5 x risk hospitalization
 4 x risk of maternal literacy /infant mortality

Dewalt et al JGIM, 2004
Health Literacy Impacts:
Access to
care
Health
outcomes
Patient’s
experience
Patient
Safety
Quality of
care
What affects health literacy?
Personal
Factors
Health
Literacy
System factors
Interaction of the person and the health care context
Personal factors: Life!
Physical and emotional health: pain, fatigue,
anxiety, lack of sleep
 Knowledge and cultural beliefs about
health
 Experience with the condition and the
healthcare system
 Motivation and self confidence

System factors
Providers
• Communication skills
Patient
Education
Materials
• Complexity and
design of information
Places
• Nature of the
environment
System expectations
We expect (rely on) patients and families to
be:
 Informed
 Activated
 Computer literate
 Self managing
 Partners in care
Individuals Skills vs System Demands
Average literacy skills of working adults=
grade 7/8 (lower in vulnerable
populations)
 Most health information at reading level
of ≥ Grade 10
 Research/informed consent often at a
college level
 Verbal communication- too fast in a
“foreign” language

Imbalance
Person’s
capacity
System
demands
“This is Bad Enough”
A patient’s perspective
What can we do?
Foster better conditions for self
management!
Universal precautions (Routine
Practices) in health literacy means…


We expect that every encounter is at risk
for miscommunication.
We create a shame-free environment of
care:
◦
◦
◦
◦
◦
Treat all patients equally
Anticipate communication barriers
Communicate clearly with everyone
Confirm understanding with everyone
Proactively work to minimize barriers
(Dewalt et al, 2010)
Create a Shame-Free Environment
Setting
 Instructions
 Supports
 Encourage questions
 Time to respond
 Privacy
 Body Language

Clear Language
Clear Language Myths
Myth: We’ll “dumb everything down.”
Myth: Plain language will insult adults.
Myth: Plain language creates legal risk.
Myth: Plain language is just common sense.
Clear Language: Writing and
Speaking

Familiar, everyday (non-medical) language.

Simple explanations

Friendly

Positive tone.
Acronyms
Make it Simple!









Cardiovascular
Assessment
Influenza
Ambulate
Diet
Discharge
Confidential
Discontinue
Fluids
What is clear design?
Designing print and web-based materials to
make:
◦ material look inviting and easy to read
◦ Information accessible-easy to find, read and
remember
◦ purposeful
“Clear print”, CNIB Accessibility Guidelines
Most importantly, check for
understanding!

The responsibility for communicating clearly
is ours.
“As clinicians, what we say does not matter
unless our patients are able to understand the
information we give them well enough to use
it to make good health-care decisions.
Otherwise, we didn’t reach them, and that is
the same as if we didn’t treat them.”
Regina Benjamin, US Surgeon General
Teach Back Method

One of the top patient safety practices

Not a test of the patient, but how
well we explained a concept.
National Quality Forum, 2010; Schillinger et al, 2003; Kripalani & Weiss, 2006
“Closing the loop”
Teach
Check
Schillinger et al, 2003
Clarify
Confirm
understanding
Assess understanding
Stop asking, “Do you understand?” to
assess comprehension.
Invite questions
Incorrect: “Do you have any questions?”
Correct: “What questions do you have for
me?”
Health Care Provider Response

October 2012-May 2013
-346 providers attended workshops
97% agreed or strongly agreed that their
understanding of the issue of health literacy
increased.
 97% agreed or strongly agreed that they
understood health system barriers faced by
patients.
 95% agreed or strongly agreed that they learned
how to implement improved methods of verbal
and written communication.

In Summary

Low health literacy affects health, safety as well as
the quality of care and experience.

Anyone can have difficulty understanding health
information.
Promote understanding by:
 Creating a shame-free environment
 Using clear language and design
 Using resources to reinforce learning
 Using teach back to check for comprehension
“The greatest problem with communication
is the illusion it has occurred.”
George Bernard Shaw
Thank you!
[email protected]
Visit our website for more information
www.swselfmanagement.ca