1. 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

2. 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

3. National Literacy Act of 1991
“ 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

5. 1993 National Adult Literacy Survey
17%
32%
Level 4
Level 5 - 3%
Level 3
Level 1
21%
Level 2
27%

6. The ability to read, understand and act on health care information.
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.

7. TOFHLA Test Of Functional Health Literacy in Adults
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.

8. Many Patients Can’t Read Health-related Materials%

9. Inadequate Health Literacy Increases with Age
84%
73% %
51%

10. 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!

11. One Third of Enrollees Had Low Literacy%

12. Low Literacy Increases with Age%

13. Less Educated have Poorer Health Literacy%

14. 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%

15. 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

16. Low Literate Patients Less Likely to Know Diagnosis

17. Low Literate Patients Less Likely to Know Name and Purpose of Medications%
Correct

18. Patients with Hypertension Less Likely to Know Correct Health Behaviors
Know exercise
 blood pressure
Know weight loss
 blood pressure
Percent

19. 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.*
% Correct
* p = 0.001

20. 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
% Correct

21. Low Literate Asthma Patients have Poorer MDI Skills*
Mean MDI
Score
0 - 4
* p =

22. Low Literate Diabetic Patients have Less Knowledge of Their Illness
Know normal
sugar range
Know uncontrolled
diabetes damages
kidneys / nerves
Percent

23. Communication Challenges
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

24. 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:

25. Health Literacy and Diabetes Outcomes
Adequate
Inadequate
Tight glycemic control
33%
20%
Poor glycemic control
30%
Report Retinopathy
19%
36%
Schillinger, JAMA 2002;288:

26. Odds of Self-reported Diabetes complications Inadequate vs
Odds of Self-reported Diabetes complications Inadequate vs. Adequate Health Literacy
Complication
OR (95% CI)
p value
Retinopathy (documented)
2.68 ( )
.001
Nephropathy
1.71 ( )
.20
Lower ext. Amputation
2.48 ( )
.14
Cerebrovascular Dz
2.71 ( )
.04
Ischemic heart disease
1.73 ( )
.15
Schillinger, JAMA 2002;288:

27. 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

28. Compliance with Anti-HIV Meds
Patients with low literacy
are 4 times more likely
to be non-compliant
Kalichman S, et al. JGIM 1999

29. Colorectal Cancer Screening
Terms not understood:
Colon
Bowel
Rectum
Screening / Blood in Stool
Polyp / Tumor
Growth / Lesion
Davis T, et al. Cancer Investigation 2000

30. 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
Pap smear
OR = 1.7

31. Patients with Low Literacy More Likely to Report Poor Health

32. 52% Increase in Odds of Hospitalization for Patients with Low Literacy*
Ratio
*Adjusted for age, gender, socioeconomic status, health status, and regular source of care.

33. Why Excess Hospitalizations?
Less knowledge of self-care?
Worse compliance with treatment?
Worse general health behaviors?
Less ability to negotiate the  health care system?

34. 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.”

35. 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

36. Costs of Low Health Literacy
$50 billion annually?
National Academy on an Aging Society
Poorer quality medical care
Malpractice suits
lack of “informed” consent

37. 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.”

38. Low Literacy is Overlooked
(NALS-1 Readers)
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%)

39. 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

40. 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

41. 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

42. 6 Simple Steps Slow down Use living room language Show, draw pictures
Limit information; repeat instructions
Use a “teach back” or “show me” approach to confirm understanding
Be respectful, caring, sensitive

43. Do you understand? Do you have any questions?

44. 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

45. A New Paradigm Determine patients’ learning capabilities
Systematic, programmed learning
Use audiovisual aids as adjuncts or primary learning materials
Comprehension testing for key points
Show me or Teach back
GOAL: PATIENT EMPOWERMENT

46. “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”)
We know that checking for understanding by using a “teach back” technique in interactions with patients is effective.

47. Disease Management & Low Literacy
Disease management intervention:
one-to-one educational sessions including counseling and medication management
by allowing pharmacists to both initiate and titrate blood pressure– and glucose lowering medications; and
(3) strategies to address patient barriers provided by the DCC, including telephone reminders and, when needed, addressing difficulties with transportation, communication, and insurance.
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

48. 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
These are some of the resources available from the AMA Foundation Health Literacy Initiative…..
Transition: For those of you who are interested in more information, you may contact……

49. More Effective Term for Health Literacy: Clear Health Communication
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

50. Ask Me 3 What is my main problem? What do I need to do?
Why is it important for me to do this?

51. 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.

52. Pictograms* Peer Educators Dr. Gil Friedel Spoken instructions 14%
Spoken + Pictogram 85%
After 4 weeks 71%
Peer Educators
Dr. Gil Friedel
*Houts, Pt Ed & Counseling, 2001