Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care

1. Doctor-Patient Relationships: Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University of New York, Stony Brook Department of Medicine, Division of Geriatrics

2. Can you read this? Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.

3. How many adult Americans have difficulty reading and understanding health information? • 9 million • 90 million • 50 million • Fewer than 1 million

4. Definition of Health Literacy The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. It involves the ability to use and interpret text, documents and numbers effectively

5. The Scope of Low Health Literacy • In 2003, the National Assessment of Adult Literacy (NAAL) • 90 million Americans (39% of adults) have limited health literacy • One in five adults read at the 5th grade level or below. • Average American reads at the 8th to 9th grade level • More than 66% of US adults age 60 and over have inadequate or marginal literacy skills

6. Examples of Health Literacy Tasks • Proficient Skills: 13% • `Calculate employee’s share of health insurance cost for year using a table on monthly cost • Intermediate Skills: 53% • Determine timing, administration and interactions based on info from drug label • Basic Skills: 22% • Give 2 reasons why a person with no symptoms should be screened based on a clearly written pamphlet • Below basic skills: 14% • Circle date of medical appointment on hospital appointment slip

7. Who is at risk for low health literacy? • Elderly • Ethnic Minorities • Those with low income and education levels • Those with high income and education • A, B, and C • All of the above

8. Highest Risk for Limited Health Literacy • Elderly • Low income • Unemployed • Did not finish high school • Minority ethnic group (Hispanic, African American) • Recent immigrant to US who does not speak english • Born in US but English is 2nd language

9. Health System Problems Encountered by Persons with Limited Literacy Skills • 26% Did not understand when their next appointment was scheduled • 42% Did not understand instructions: “take medication on an empty stomach” • 78% Misinterpret warnings on prescription labels • 86% Could not understand rights and responsibilities section of a medicaid application

10. Impact of Low Health Literacy • Individuals have less knowledge about their health problems • Make more medication or treatment errors • Fail to seek preventive care • More hospitalizations • Higher health care costs • Less able to “comply” with treatments • Poorer health status

11. Shame and Health Literacy: the unspoken connection Adequate Health Literacy Low Health Literacy 51% Feel bad/never tell 60% Feel ashamed 78% Hide problem • 49% Feel bad/never tell • 60% Feel ashamed • 94% Hide problem "Shame and Health Literacy: The Unspoken Connection." Patient Education and Counseling. 1996. 27: 33-39

12. Who knows you have trouble reading? Never told: 53% 57% 86% 62% 67% 19% • Spouse • Children • Relatives • Co- workers • Friends • No one "Shame and Health Literacy: The Unspoken Connection." Patient Education and Counselling. 1996. 27: 33-39

13. Physician Assessment of Health Literacy • Physicians often under recognize limited health literacy • Most physicians’ attempt to measure literacy level by their patients highest grade of education • Rely on their patients’ own assessment of their reading skills • Overestimate their patients ability to understand medical information • Often provide information to patients in a level of complexity that patients do not understand

14. What can we do? • Recognize signs of limited health literacy • Screen for health literacy • Learn clear communication techniques • Educate patients on Ask-Me-3

15. Ms Kelly Green Ms Kelly Green is a 54 year old caregiver to her mother who is bringing her to your office for a follow up visit. Her mom has history of dementia, hypertension, hypothyroidism and arthritis. She was just discharged from the hospital for Uncontrolled Hypertension. "

16. Office Visit

17. Did Ms. Green give any clues that she may have limited health literacy?

18. Signs (Clues) of Low Health Literacy Behaviors • Forms incomplete or inaccurately completed • Frequently missed appointments • “Noncompliance” with medication regimens • Lack of follow-up with lab tests, imaging or referrals Responses to written information • “I forgot my glasses. I’ll read this when I get home.” • “I forgot my glasses. Can you read this to me?” • “Let me bring this home so I can discuss it with my children” Responses to questions about medications • Unable to name medications • Unable to explain what the meds are for • Unable to explain timing of medication administration

19. If you suspect Ms. Green’s health literacy is limited what screening tests could you perform?

20. Quick Screening Tests for Health Literacy • Single question screens • Assessment instruments • REALM-R: Rapid Estimate of Adult Literacy in Medicine-Revised • NVS: The Newest Vital Sign

21. Single Question Screens • “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Never Rarely Sometimes Often Always • “How confident are you filling out medical forms by yourself?” Extremely Quite a bit Somewhat A little bit Not at all • Both been validated in English The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Prac. 2006;7:21. Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874-877

22. REALM-R • Word recognition test consisting of 11 medical terms • 1st 3 words are not scored (fat, flu, pill): left to decrease test anxiety and enhance patient confidence • Administration time: <2 minutes • Only available in English • Score of 6 or less considered to be at risk for limited health literacy • Forms and instructions available at www.adultmeducation.com A Shortened Instrument for Literacy Screening. JGIM 2003; 18:1036-1038

24. The Newest Vital Sign • Read and analyze a nutrition label of ice cream • 6 questions • Administration time 3 to 5 minutes • Scores: • 0-1 Limited literacy • 2-3 Possible limited literacy • 4-6 Adequate literacy

25. The Newest Vital Sign: Ms Kelly Green

26. Lets try it out: “I am asking everyone visiting the clinic to help us learn how well they can understand the medical information that doctors give them. Would you be willing to help us by looking at some health information and then answers a few questions about that information. Your answers will help the doctors learn how to provide medical information in ways that patients will understand. It will only take about 3 minutes.”

28. NVS: Answers • 1000 calories • Any of the following correct: • 1 cup • ½ the container • 2 servings • 33 grams • 10% • No • Because it has peanut oil

29. Will patients agree to have their literacy skills assessed in clinical practice? • Controlled trial • 20 different practices in South Florida • Intervention group: routine literacy assessment with NVS during check in (289) • Control group: No screening (303) • Surveyed at end of visit with Art of Medicine Survey Questionnaire (AMSQ)- validated patient satisfaction survey Will patients agree to have their literacy skills assessed in clinical practice? Health Ed Res 2008;23(4): 603-611

30. Results • Intervention Group • 289 asked to undergo screening • 284 agreed (98.3%) • 46.1% limited health literacy on NVS screen • 271 completed AMSQ • Control Group • 303 completed AMSQ • No difference between groups on patient satisfaction Will patients agree to have their literacy skills assess in clinical practice? Health Ed Res 2008;23(4): 603-611

31. How can we communicate with our patient better? • Ms. Green scored a 3 on the Newest Vital Sign

32. Communication What do patients want? What health providers provide… Medical words and complicated explanations Too much information Information that is often irrelevant to what patients need to do • Clear and simple information • Want to know what they need to do

33. How can you help your patients understand?

34. Steps to Improving Communication and Understanding • Recognize the problem • Eliminate barriers for communication • Confirm that patients understand what they need to understand: teach back • Find a way that works for your patient to understand and remember • Ask me 3 • Literature • Written instructions

35. Open and Shame Free Environment • Adopt an “attitude of helpfulness” • Convey safe and nonjudgmental environment • Plain signage • Be on alert to clues

36. Eliminate Barriers • Hearing and visual impairments • Medical interpreters/ translators • Should be qualified • Visual aids for low literacy • Multi-Media • Interactive Computer programs/TV • Video/audiotape • Body language

37. Speak in plain language • Use clear and easy to follow language • Be specific and use examples • Beware of words with multiple meanings (stool, gait, dressing) and clarify when using • Avoid complicated words and over use of medical jargon • Avoid acronyms and new words (CT scan, RUQ U/S, HDL) • Give them a health context for numbers • Encourage questions and take a pause

38. Taboo: A game of “speaking in plain language” Rules of the game One person gets a card with a medical term “target word” on it You need to describe the target word without using the taboo words listed on the card to your group You can use taboo words if it is immediately defined in layman’s terms You have 2 minutes to do this

39. Common medical words that patients with limited literacy may not understand • Blood in stool • Bowel • Colon • Growth • Lesion • Polyp • Rectum • Screening • Tumor The role of inadequate health literacy skills in colorectal cancer screening." Cancer Invest. 2001:19:193-2000

40. What percentage of patients “forget” what the Doctor told them as soon as they leave the office? • 80% • 50% • 10% • <10%

41. Implications for “Not Understanding” the Physician • Up to 80% of patients forget what the doctor tells them • 50% of what they remember is recalled incorrectly • 30% US patients leave their MD’s office with unanswered questions • 2 out of 5 do not follow advice because it is too difficult or because they disagree with it "Patients' memory for medical information," Journal of Royal Society of Medicine2003:96:219-222 “Diverse Communities. Common Concerns: Assessing Health care Quality for Minority Americans. The Commonwealth Fund. March 2002.

42. Convey the important points to remember!

43. Verify they understand • Teach Back • Encourage Questions • Ask-Me-3

44. Verify they understand:Teach Back Approach • Do not ask a patient, “Do you understand?” • Ask a patient to explain or demonstrate how they will undertake a recommended treatment or intervention. • “I want to be sure that I did a good job explaining your blood pressure medications, because this can be confusing. Can you tell me what changes we decided to make and how you will now take the medication?” Or “Can you explain what I just told you to make sure I covered everything?” • If patient cannot explain correctly, assume that you have not provided adequate teaching. Re-teach the information using alternate approaches.

45. Teach Back Approach:

46. Encouraging patients to ask more questions during the exam will increase the length of their visit? • True • False British Medical Journal,sept 2002. vol. 325:682-683

47. Teach your patient to be proactive: What’s Ask-Me-3? • New patient education program designed to promote communication between patient and Health Care Provider to improve health outcomes • Quick and effective tool • Can foster clear communication between provider and patient • Studies have shown that patients who understand health instructions make fewer mistakes taking medication or preparing for a procedure • Study also showed a higher level of satisfaction from patients and a feeling of improved communication using Ask-Me-3 compared to a control group • For downloadable free materials, posters and brochures: www.npsf.org/askme3 www.AskMe3.org

48. Ask me 3 What is my main problem? What do I need to do? Why is it important for me to do this? Diagnosis Treatment Context

49. Provide Patients with Written Instructions • Do not abbreviate! • SOB is not a flattering term in layman’s language! • BID does not necessarily mean twice a day. • Add pictures to communicate your points • 1/5 adults read at a level below 5th grade; simplify to a lower grade level • Materials should be written in fifth to eighth grade level • Define complicated terms/ limit syllables

50. Ms. Green