1. Health Literacy in Clinical Practice Kimberly Zoberi, MD Kelly Everard, PhD Laura Frankenstein, MD Department of Community and Family Medicine Saint Louis University

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3. What was it like? How do you clean the capstan?

4. Health Literacy Workshop AMA Foundation Dr. Claudette Dalton –Assistant Dean, Community Based Medical Education –University of Virginia School of Medicine How does this play out in Family Medicine?

5. Some of YOUR patients are having trouble with health literacy.

6. Health Literacy The degree to which individuals have the capacity to obtain, process and understand basic health information and services need to make appropriate health decisions. (HHS 2000 and Institute of Medicine 2004)

7. 2003 NAAL Survey

8. Overview of the literacy levels Below basic (14%): from nonliterate to able to locate easily identifiable information. Able to do very simple, familiar computations. Example: Identify what you can drink before a medical test, based on a set of short instructions

9. 2003 NAAL Survey Basic (22%): reads and understands information in simple contexts. Locates quantitative information, can infer simple computations. Example: After reading a clearly written pamphlet, give two reasons a person should be tested for a disease.

10. 2003 NAAL Survey Intermediate (53%): reads moderately dense text, summarizes, simple inferences about meaning, locates less familiar quantitative information, solves problems when arithmetic is not specified or easily inferred. Example: Determine a healthy weight range for a person, based on a BMI graph.

11. 2003 NAAL Survey Proficient (12%): Reads lengthy, complex, abstract prose. Integrates, synthesizes and analyzes multiple pieces of information. Locates abstract quantitative information, solves multistep problems when computation not easily inferred. Example: Evaluate information to determine which legal document is applicable to a specific healthcare situation.

12. Implications for Health Care Reading and number skills required everywhere in the health care environment. Medication dosages, health education materials, informed consent, insurance forms, appointment slips…

13. Implications for Health Care Higher admission rates Higher number of days hospitalized Lower understanding of chronic disease Example: diabetic patients with low health literacy have poorer glycemic control and more retinopathy

14. Implications for Health Care 1 in 3 US patients leave their physician’s office with important questions unanswered 2 in 5 do not follow the physician’s advice because it is too difficult or because they disagree with it 2 in 3 report their physician did not elicit their ideas or opinions about treatment Diverse Communities, Common Concerns. The Commonwealth Fund, 2002

15. Some of YOUR patients are having trouble with health literacy… and they’re not telling you.

16. Health Literacy 40% of patients with low health literacy reported feeling ashamed. Over half of those patients had not admitted their difficulties to their spouse or children. Attempt to use coping mechanisms. Ex: Bring a family member, using visual clues, looking at pills, relying on oral explanations

17. How do we identify these patients? Self reported educational level often does NOT match reading level. Average self reported highest grade level: 11 th grade Average reading level in same group: 7 th - 8th

18. How do we identify these patients? Educational materials are grossly mismatched to average reading level. Average health education material is written at 10 th -12 th grade Average informed consent is written at 12 th -17 th grade

19. How do we identify these patients? There ARE screening tools available. –REALM –Nutrition Label Asking patients about their satisfaction with their own reading skills.

20. REALM: Rapid Estimate of Adult Literacy in Medicine List 1List 2List 3 fat _____ flu _____ pill _____ dose _____ eye _____ stress _____ fatigue _____ pelvic _____ jaundice _____ infection _____ exercise _____ behavior _____ allergic _____ menstrual _____ testicle _____ colitis _____ emergency _____ medication _____ # of (+) Responses in List 1: ________ # of (+) Responses in List 2: ________ # of (+) Responses in List 3: ________ Patient Name _________ Date of Birth _________Grade Completed _____ Date _______________ Examiner _____________Reading Level _____ Davis TC, Long SW, Jackson RH, et al: Rapid Estimate of Adult Literacy in Medicine: a shortened screening instrument. Family Medicine 25:391-395, 1993

21. Assessing Literacy: The Newest Vital Sign Nutrition Facts Serving Size 1/2 cup Servings per container 4 Amount per serving Calories 250 Fat Cal 120 %DV Total Fat 13g 20% Sat Fat 9g 40% Cholesterol 28mg 12% Sodium 55mg 2% Total Carbohydrate 30g 12% Dietary Fiber 2g Sugars 23g Protein 4g 8% * Percent Daily Values (DV) are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs. Ingredients: Cream, Skim Milk, Liquid Sugar, Water, Egg Yolks, Brown Sugar, Milk fat, Peanut Oil, Sugar, Butter, Salt, Carrageenan, Vanilla Extract. 1. If you eat the entire container, how many calories will you eat? 2. If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? 3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? 4. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? READ TO SUBJECT: Pretend that you are allergic to the following substances: Penicillin, peanuts, latex gloves, and bee stings. 5. Is it safe for you to eat this ice cream? 6. (Ask only if the patient responds “no” to question 5): Why not? Weiss, B. et al., Annals of Family Medicine 3:514-522 (2005)

22. How do we manage this situation? Use “living room” language When introducing new material, check for understanding There is a right way and a wrong way to do this! Most physicians assess patient comprehension and recall only 10-12% of the time.

23. AMA Video Health Literacy: Help Your Patients Understand American Medical Association American Medical Association Foundation

24. TABOO Game Try to describe target word without using list of “taboo” words Can use “taboo” words if they are immediately defined for the patient

25. Stress Test Catheter/Catheterization Ischemia EKG changes Pharmacologic Physiologic Perfusion

26. Sarcoidosis Inflammatory Granuloma ACE level Restrictive lung disease Infiltrative

27. Abnormal Pap ASCUS Biopsy Colposcopy Atypical Cervix Dysplasia

28. Plantar Fasciitis Calcaneus Plantar fascia Achilles tendon Gastrocnemius/Soleus muscle Steroids Inflammation

29. Congestive Heart Failure Edema Ischemia Metabolic demands Congestion Hypertension

30. Cases Students practice simple language and teach-back Patients will retain 2 or 3 main points

31. Case 1 You are prescribing Augmentin to a 5 year old girl with persistent otitis media. You need to give the patient’s mother medication instructions. The mother needs to know: 1.Frequency of dosing (1 teaspoon tid) 2.Importance of completing the antibiotic course (10 days) 3.Possible side effects (diarrhea and/or vomiting in 10-20%)

32. Case 2 Your patient is a newly diagnosed type 2 diabetic. You are discussing various aspects of diabetes. In this scenario, you will discuss diabetic retinopathy. The patient needs to know: 1.What diabetic retinopathy is 2.That good diabetic control can retard progression 3.That diabetic retinopathy can be asymptomatic in early stages 4.That regular retinal exam by an ophthalmologist

33. Case 3 Your patient has fibroid tumors in her uterus, which must be treated due to excessive bleeding. She is a good candidate for embolization therapy. In this procedure, a catheter is introduced into the femoral artery and then into the proper uterine vessel. The catheter is used to inject a sclerosing agent to just the tumor. Predictable side effects include moderate bleeding and cramping.

34. Case 3, continued The patient needs to know: 1.What the procedure entails 2.The risks and benefits of the procedure 3.Alternatives to the procedure (no treatment, hysterectomy)