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Wols nwod nehw gniklat ot stneitap. The Clinical Impact of Poor Health Literacy on Clinical CareRobert C. Moravec, MD2006 . Wols nwod nehw gniklat ot stneitap. Slow down when talking to patients. . True or False?. Most people with a literacy problem are poor, immigrants, or minorities.Peop
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1. Health Literacy: Help Your Patients Understand Presented by:
American Medical Association Foundation & American Medical Association NOTE TO FACILITATOR: Special directions or ideas for the facilitator, like these, are in italics. The non-italicized notes are examples of things to say about the slide. As a facilitator, you should be familiar with the notes for each slide. However, the notes are not meant to be read word for word. Practice out loud in your own words until you are comfortable. We encourage you to add your own stories and experiences. Please follow the suggested times as closely as possible.
(0:00)
Welcome everyone to the session. Introduce yourself and other faculty, as appropriate.
Check that each person has a Participant Guide and explain that they will use it during the workshop as a reference.
Check that each person has a copy of the Power Point slides (3 per page) and explain they can use it to take notes.
Explain: This workshop is part of a series developed by the AMA Foundation to increase clinician awareness of health literacy issues.
Module 3: (Total Time = 60 min.) (For facilitator information only.)
0:00 Introduction
.Slides 1-6 (4 min.)
0:04 NALS
.Slides 7-9 (4 min.)
0:08 Activity
..Slides 10-12 (3 min.)
0:11 Implications
.Slides 13-26 (10 min.)
0:21 Video
..Slide 27 (23 min.)
0:44 Video Discussion
.Slide 28 (5 min.)
0:49 Barriers
.Slides 29-30 (5 min.)
0:54 Guiding Priniciples/Strategies/What other docs have tried
.Slides 31-34 (3 min.)
0:57 Resources/Evaluations
.Slides 35-37 (3 min.)
0:60 End
NOTE TO FACILITATOR: Special directions or ideas for the facilitator, like these, are in italics. The non-italicized notes are examples of things to say about the slide. As a facilitator, you should be familiar with the notes for each slide. However, the notes are not meant to be read word for word. Practice out loud in your own words until you are comfortable. We encourage you to add your own stories and experiences. Please follow the suggested times as closely as possible.
(0:00)
Welcome everyone to the session. Introduce yourself and other faculty, as appropriate.
Check that each person has a Participant Guide and explain that they will use it during the workshop as a reference.
Check that each person has a copy of the Power Point slides (3 per page) and explain they can use it to take notes.
Explain: This workshop is part of a series developed by the AMA Foundation to increase clinician awareness of health literacy issues.
Module 3: (Total Time = 60 min.) (For facilitator information only.)
0:00 Introduction
.Slides 1-6 (4 min.)
0:04 NALS
.Slides 7-9 (4 min.)
0:08 Activity
..Slides 10-12 (3 min.)
0:11 Implications
.Slides 13-26 (10 min.)
0:21 Video
..Slide 27 (23 min.)
0:44 Video Discussion
.Slide 28 (5 min.)
0:49 Barriers
.Slides 29-30 (5 min.)
0:54 Guiding Priniciples/Strategies/What other docs have tried
.Slides 31-34 (3 min.)
0:57 Resources/Evaluations
.Slides 35-37 (3 min.)
0:60 End
2. Wols nwod nehw gniklat ot stneitap The Clinical Impact of Poor Health Literacy on Clinical Care
Robert C. Moravec, MD
2006
3. Wols nwod nehw gniklat ot stneitap
Slow down when talking to patients
4. True or False? Most people with a literacy problem are poor, immigrants, or minorities.
People will tell you if they have a problem reading.
The number of years of schooling is a good general guide to determine literacy level.
Purpose: To grab participants attention and challenge their thinking
..
Please turn to the first page of your Participant Guide and answer the following questions:
(read through each question)
Please also estimate the percentage of patients in your current practice who have a health literacy problem.
Transition: We arent going to discuss these now. As we go through the module listen for information that can help you determine the answers. (The answers are also in the back of your guide.) If you have questions, we can discuss them at the end of the module
.
Purpose: To grab participants attention and challenge their thinking
..
Please turn to the first page of your Participant Guide and answer the following questions:
(read through each question)
Please also estimate the percentage of patients in your current practice who have a health literacy problem.
Transition: We arent going to discuss these now. As we go through the module listen for information that can help you determine the answers. (The answers are also in the back of your guide.) If you have questions, we can discuss them at the end of the module
.
5. Up to ˝ of US population may be at risk for
Medical misunderstandings
Mistakes
Excess hospitalizations
Poor health outcomes
Purpose: To describe the seriousness of the problem.
We are here because there is a serious and growing problem that is affecting our ability to deliver care
..low levels of health literacy. In fact,
.
1/2 of the US population may be at risk for:
Misunderstanding health care instruction, prescription bottles, appointment slips
Mistakes taking medications incorrectly or preparing for diagnostic tests
Excess hospitalizations due to inability to self-manage chronic disease
Poor health outcomes such as higher HbA1c (poor blood sugar control) among patients with diabetes
Transition: Why are so many at risk?
.
Purpose: To describe the seriousness of the problem.
We are here because there is a serious and growing problem that is affecting our ability to deliver care
..low levels of health literacy. In fact,
.
1/2 of the US population may be at risk for:
Misunderstanding health care instruction, prescription bottles, appointment slips
Mistakes taking medications incorrectly or preparing for diagnostic tests
Excess hospitalizations due to inability to self-manage chronic disease
Poor health outcomes such as higher HbA1c (poor blood sugar control) among patients with diabetes
Transition: Why are so many at risk?
.
6. Why are they at risk? Reliance on the written word for patient instruction
Increasingly complex health system
More medications
More tests and procedures
Growing self-care requirements
Puspose: To explain key factors that contribute to the problem.
They are at risk for two key reasons:
Despite a high level of inadequate and marginal literacy skills among patients, the health care system is almost entirely reliant on the written word for communication, including patient instructions and navigation around health care facilities.
This is compounded by the fact that our health care system is placing increasing demands on patients to manage their own care, making it more and more necessary for them to have advanced health literacy skills.
Transition: So what can we do?
Puspose: To explain key factors that contribute to the problem.
They are at risk for two key reasons:
Despite a high level of inadequate and marginal literacy skills among patients, the health care system is almost entirely reliant on the written word for communication, including patient instructions and navigation around health care facilities.
This is compounded by the fact that our health care system is placing increasing demands on patients to manage their own care, making it more and more necessary for them to have advanced health literacy skills.
Transition: So what can we do?
7. Definitions: General Literacy:
An individuals 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 ones goals, and develop ones knowledge and potential.
National Literacy Act of 1991
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.
Healthy People 2010 Purpose: To explain the difference between general literacy and health literacy and involve participants in thinking about their own situations.
This slide builds.
The main focus here is on health literacy, but some of the important research that we will share with you is on general literacy.
General Literacy: Note that there are verbal and numerical components to literacy.
Health Literacy: Patients must be able to make appropriate health care decisions and follow instructions for treatment if they are to effectively interact with their health care system.
Transition: Weve mentioned that ˝ of the population is at risk for low health literacy. How do we know this?
.
Purpose: To explain the difference between general literacy and health literacy and involve participants in thinking about their own situations.
This slide builds.
The main focus here is on health literacy, but some of the important research that we will share with you is on general literacy.
General Literacy: Note that there are verbal and numerical components to literacy.
Health Literacy: Patients must be able to make appropriate health care decisions and follow instructions for treatment if they are to effectively interact with their health care system.
Transition: Weve mentioned that ˝ of the population is at risk for low health literacy. How do we know this?
.
8. National Adult Literacy Survey n = 26,000
Most accurate portrait of literacy in U.S.
Scored on 5 levels
Result: 48% of US population have inadequate or marginal literacy skills (0:04)
Purpose: To describe the study that showed that ˝ of the population is at risk.
The National Adult Literacy Survey was conducted in 1992 and published in 1993.
This study was conducted by the Department of Education.
26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US.
The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy)
Based on this study we know that almost 50% of the US population falls in the first two levels, inadequate or marginal literacy.
There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which is included in the AMA Foundation Health Literacy: Help Your Patients Understand kit.
Transition: The full results for the 5 levels are represented in the following chart
..
(0:04)
Purpose: To describe the study that showed that ˝ of the population is at risk.
The National Adult Literacy Survey was conducted in 1992 and published in 1993.
This study was conducted by the Department of Education.
26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US.
The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy)
Based on this study we know that almost 50% of the US population falls in the first two levels, inadequate or marginal literacy.
There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which is included in the AMA Foundation Health Literacy: Help Your Patients Understand kit.
Transition: The full results for the 5 levels are represented in the following chart
..
9. 1993 National Adult Literacy Survey Purpose: To describe the 5 levels in NALS. (There are 2 additional slides in the Appendix on NALS Level 1 and Level 2.)
Level 1:
The red section of the diagram represents the lowest level, those that have inadequate literacy. Although they can perform some reading and writing tasks, their limited literacy skills prevent full functioning in todays society. Level 1 represents 21% of the population.
Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the gist of the content of the article.
They usually (with 80% reliability) can sign their name and total a bank deposit entry
They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form.
Level 2:
The yellow section of the diagram represents those with marginal literacy skills. Individuals in this level have somewhat more advanced skills than those in Level 1, but they are still substantially limited in their ability to read and understand text. Level 2 represents 27% of the population.
Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. They also struggle with writing a simple letter explaining an error on a bill.
What is the impact? All health care directions are words and numbers. Take one of our oldest directions Take one teaspoon four times a day. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 3 1/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once?
Another example: Take 2/3 of your insulin dosage before surgery. We should be translating this into the exact amount
.e.g. if they normally take 15 units, they should take only 10 units before surgery.
Together, Level 1 and Level 2 include 48% of the population, almost half of the US adult population.
Levels 3, 4 and 5:
In contrast, persons at NALS levels 3, 4 and 5 have sufficient literacy skills to permit full functioning in society
Additional information for discussion if time permits:
Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school.
There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with functionally illiterate people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently.
Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy
..
Purpose: To describe the 5 levels in NALS. (There are 2 additional slides in the Appendix on NALS Level 1 and Level 2.)
Level 1:
The red section of the diagram represents the lowest level, those that have inadequate literacy. Although they can perform some reading and writing tasks, their limited literacy skills prevent full functioning in todays society. Level 1 represents 21% of the population.
Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the gist of the content of the article.
They usually (with 80% reliability) can sign their name and total a bank deposit entry
They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form.
Level 2:
The yellow section of the diagram represents those with marginal literacy skills. Individuals in this level have somewhat more advanced skills than those in Level 1, but they are still substantially limited in their ability to read and understand text. Level 2 represents 27% of the population.
Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. They also struggle with writing a simple letter explaining an error on a bill.
What is the impact? All health care directions are words and numbers. Take one of our oldest directions Take one teaspoon four times a day. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 3 1/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once?
Another example: Take 2/3 of your insulin dosage before surgery. We should be translating this into the exact amount
.e.g. if they normally take 15 units, they should take only 10 units before surgery.
Together, Level 1 and Level 2 include 48% of the population, almost half of the US adult population.
Levels 3, 4 and 5:
In contrast, persons at NALS levels 3, 4 and 5 have sufficient literacy skills to permit full functioning in society
Additional information for discussion if time permits:
Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school.
There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with functionally illiterate people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently.
Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy
..
10. NALS Level 1 Inadequate Literacy (21%) Able to:
Sign name
Find a country in an article
Total a bank deposit entry
Cannot consistently:
Understand the gist of an article.
Use a bus schedule
Enter information on a SS application Purpose: To provide more specific information about Level 1.
This level person would have inadequate literacy to function in society.
Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the gist of the content of the article.
They usually (with 80% reliability) can sign their name and total a bank deposit entry
They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form.
Additional information for discussion if time permits:
Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school.
There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with functionally illiterate people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently.
Purpose: To provide more specific information about Level 1.
This level person would have inadequate literacy to function in society.
Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the gist of the content of the article.
They usually (with 80% reliability) can sign their name and total a bank deposit entry
They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form.
Additional information for discussion if time permits:
Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school.
There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with functionally illiterate people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently.
11. NALS Level 2 Marginal Literacy (27%) Able to:
Find intersection on street map
Locate information in newspaper article
Determine difference in price on tickets
Cannot consistently:
Use a bus schedule
Identify information from a bar graph
Write a brief letter of complaint Purpose: To provide specific information about Level 2.
Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs.
Level 2 includes tasks such as getting the information from the newspaper article, finding the intersection on the map. Concepts with words and numbers such as figuring out the bus schedule or the bar graph or even writing a simple letter explaining an error on a bill.
All health care directions are words and numbers. Take one of our oldest directions Take one teaspoon four times a day. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 31/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once?
Another example: Take 2/3 of your insulin dosage before surgery. We should be translating this into the exact amount
.e.g. if they normally take 15 units, they should take only 10 units before surgery.
Purpose: To provide specific information about Level 2.
Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs.
Level 2 includes tasks such as getting the information from the newspaper article, finding the intersection on the map. Concepts with words and numbers such as figuring out the bus schedule or the bar graph or even writing a simple letter explaining an error on a bill.
All health care directions are words and numbers. Take one of our oldest directions Take one teaspoon four times a day. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 31/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once?
Another example: Take 2/3 of your insulin dosage before surgery. We should be translating this into the exact amount
.e.g. if they normally take 15 units, they should take only 10 units before surgery.
12. 2003 National Assessment of Adult Literacy Average quantitative literacy scores of adult increased 8 points between 1992 and 2003.
Average prose and document literacy did not differ significantly
Various race groups varied in the overall scores
13. Overview of Literacy Levels Below Basic No more that the most simple and concrete literacy skills
Basic Perform necessary and everyday literacy skills
Intermediate skills necessary to perform moderately challenging literacy activities
Proficient can perform more complex and challenging literacy activities
14. Overview of Literacy Levels 2003 Below Basic ~14% for both
Basic 29% Prose
22% Document
36% - 43% Marginal Literacy
Intermediate 44% Prose
53% Document
Proficient ~13% for both
15. 2003 National Assessment o Adult Literacy Blacks :
Prose literacy - +8 points
Document literacy +6 points
Asian / Pacific Islanders
Prose literacy +16 points
16. 2003 National Assessment o Adult Literacy Hispanics
Document literacy - 18 points
White:
Prose and document literacy no change
17. What is the impact of only Level 2 (marginal) literacy? Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. They also struggle with writing a simple letter explaining an error on a bill.
All health care directions are words and numbers.
18. What can we do to help? Understand the problem
Identify the barriers faced by both patients and clinicians
Identify and implement strategies to enhance health literacy
Advocate for system change Purpose: To identify ways in which clinicians can help address the problem.
Note about special effects: This slide is set to build. This means that you need to click to see each bullet point on the slide. The idea is to cover one point at a time and then click to advance to the next point. We suggest that you rehearse this in the Slide Show view so that you feel comfortable with it.
We need your leadership to help bring this issue forward.
In your own clinical setting, whether it be a physician practice, a clinic, a hospital or community setting, you can begin to address this issue by:
Understanding the scope and implications of the health literacy problem,
Identifying the barriers faced by both patients and clinicians, and
Identifying and implementing best practices and techniques
Being an advocate for system change to advance health literacy
..this is a safety issue, a financial issue, an access issue, a fairness issue, a communications issue, a time management issue
it ultimately affects how you care for your patients.
Transition: We have designed this workshop to help you begin this process
...
Purpose: To identify ways in which clinicians can help address the problem.
Note about special effects: This slide is set to build. This means that you need to click to see each bullet point on the slide. The idea is to cover one point at a time and then click to advance to the next point. We suggest that you rehearse this in the Slide Show view so that you feel comfortable with it.
We need your leadership to help bring this issue forward.
In your own clinical setting, whether it be a physician practice, a clinic, a hospital or community setting, you can begin to address this issue by:
Understanding the scope and implications of the health literacy problem,
Identifying the barriers faced by both patients and clinicians, and
Identifying and implementing best practices and techniques
Being an advocate for system change to advance health literacy
..this is a safety issue, a financial issue, an access issue, a fairness issue, a communications issue, a time management issue
it ultimately affects how you care for your patients.
Transition: We have designed this workshop to help you begin this process
...
19. What is it like?
The following passage simulates what a reader with low general literacy (NALS Level 1) sees on the printed page.
You have 1 minute to read.
Hint: The first word is cleaning (0:08)
Activity Purpose: To simulate what it is like to have inadequate literacy.
Note to facilitator: This exercise is designed to take 3 minutes, including the introduction, the reading and the discussion. If you finish early, move on to the next section.
Directions:
I will put a written passage on the screen for you to read. It simulates what a reader with low general literacy sees on the printed page.
Read the entire passage out loud.
You have 1 minute to read.
Hint: The words are written backwards and the first word is cleaning
Transition: We will read the entire passage as a group. So lets start
.
(0:08)
Activity Purpose: To simulate what it is like to have inadequate literacy.
Note to facilitator: This exercise is designed to take 3 minutes, including the introduction, the reading and the discussion. If you finish early, move on to the next section.
Directions:
I will put a written passage on the screen for you to read. It simulates what a reader with low general literacy sees on the printed page.
Read the entire passage out loud.
You have 1 minute to read.
Hint: The words are written backwards and the first word is cleaning
Transition: We will read the entire passage as a group. So lets start
.
20. GNINAELC Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-red edixo selcitrap. Esu a nottoc baws denetsiom htiw lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio. Directions to facilitator:
It may be hard to get the group reading out loud, So start reading with them, Cleaning
To (pause) assure (pause)
.Keep them going through the entire passage.
You may have to read a word out loud as they falter. Some will start to read it faster and you can comment, Aha, someone is getting on to it faster, they are becoming a good reader while the rest of us are struggling
They may have particular trouble deciphering capstan and also brown-red oxide is there as a typo - you can help them over those spots...
Get them through the entire passage - there should be a lot of laughter - and then go on to the next slide
Directions to facilitator:
It may be hard to get the group reading out loud, So start reading with them, Cleaning
To (pause) assure (pause)
.Keep them going through the entire passage.
You may have to read a word out loud as they falter. Some will start to read it faster and you can comment, Aha, someone is getting on to it faster, they are becoming a good reader while the rest of us are struggling
They may have particular trouble deciphering capstan and also brown-red oxide is there as a typo - you can help them over those spots...
Get them through the entire passage - there should be a lot of laughter - and then go on to the next slide
21. What is it like?
How do you clean the capstan? Note to facilitator: This slide builds.
First ask for general reactions of what it was like to read this information.
Ask, What was it like to read this?, How did it make you feel? (tired?, frustrated?, etc.), How would you describe the frustration you felt?, How did you feel when you figured it out? , How did it make you feel if someone near you was reading faster?
Note: Ultimately you can read the passage, but it takes time. A person with low literacy may not perceive that they have a problem because, after all, they could read it and sound out and recognize every word. But the effort is great. So people say they can read, but are slow readers. They dont like to read. And may have to read it several times over to get the meaning.
Then click and show the question, How do you clean the capstan?
Ask, Can you answer this question?, Why are you having trouble answering the question?
Notes to facilitator: Use the discussion to bring out these key points
..
Reading does not equal understanding!!
Comprehension and retention are problems because all your energy is going into decoding each word by itself. A person with low literacy is likely to miss a lot of meaning.
Transition: Hopefully this activity has helped you to understand what having low literacy skills is like
Note to facilitator: This slide builds.
First ask for general reactions of what it was like to read this information.
Ask, What was it like to read this?, How did it make you feel? (tired?, frustrated?, etc.), How would you describe the frustration you felt?, How did you feel when you figured it out? , How did it make you feel if someone near you was reading faster?
Note: Ultimately you can read the passage, but it takes time. A person with low literacy may not perceive that they have a problem because, after all, they could read it and sound out and recognize every word. But the effort is great. So people say they can read, but are slow readers. They dont like to read. And may have to read it several times over to get the meaning.
Then click and show the question, How do you clean the capstan?
Ask, Can you answer this question?, Why are you having trouble answering the question?
Notes to facilitator: Use the discussion to bring out these key points
..
Reading does not equal understanding!!
Comprehension and retention are problems because all your energy is going into decoding each word by itself. A person with low literacy is likely to miss a lot of meaning.
Transition: Hopefully this activity has helped you to understand what having low literacy skills is like
22. Low health literacy = problems with
Medications
Appointment slips
Informed consents
Discharge instructions
Health education materials
Insurance applications (0:11)
Purpose: To identify problems that result from inadequate health literacy.
As you can imagine, a constellation of reading and numerical skills are required to function in the health care environment.
This includes:
Reading prescription bottles
Figuring out appointment slips (one study found that 26% of patients could not read their appointment slips).
Understanding informed consents (Informed consent language is usually at the 12th-17th grade level. The average American reads at an 8th grade level.)
Understanding discharge instructions
Following diagnostic test instructions
Reading health education materials (Most are written at 12th grade or above. It is very difficult to simplify complex ideas. See the manual for more information.)
Completing health insurance applications
Transition: And these problems are compounded in a health care system that has changed dramatically over the last 35 years
.
(0:11)
Purpose: To identify problems that result from inadequate health literacy.
As you can imagine, a constellation of reading and numerical skills are required to function in the health care environment.
This includes:
Reading prescription bottles
Figuring out appointment slips (one study found that 26% of patients could not read their appointment slips).
Understanding informed consents (Informed consent language is usually at the 12th-17th grade level. The average American reads at an 8th grade level.)
Understanding discharge instructions
Following diagnostic test instructions
Reading health education materials (Most are written at 12th grade or above. It is very difficult to simplify complex ideas. See the manual for more information.)
Completing health insurance applications
Transition: And these problems are compounded in a health care system that has changed dramatically over the last 35 years
.
23. Changes in the health care system
4 - 6 weeks bed rest
in hospital
650
3 weeks in hospital
2 hours a day of diabetic education classes
2-4 days in hospital
(M&R Guidelines)
10,000 +
outpatient
0-3 hours diabetic
education classes
written materials
internet
telemedicine Purpose: To describe changes in our health care system that exacerbate the problem of low health literacy.
Our health system has evolved over the last 35 years to a place where it demands that patients carry out their own complex medical care.
Note to facilitator: Choose one or two examples from the information below to paint a picture of the differences in health care today versus 35 years ago. It is not necessary to cover all the information.
35 years ago a patient with a heart attack was immediately hospitalized for 6 weeks, flat in bed for several weeks and not even let up to go to the commode! If they survived, by the time they left the hospital, they knew everything they needed to know about how to care for themselves, the drugs they were on (we only had 3 or 4 available), the side effects, etc. Nowadays the same patient will be in and out of the hospital in 2-4 days, on 7 or 8 different drugs at every hour of the day or night, long lists of instructions, life style changes, diet changes (not only low fat, but avoiding such things as a grapefruit because it interacts with the drugs they are on), many different physician appointments, tests, etc. And they are still in shock, having come face to face with their own mortality!
35 years ago there were only 650 drugs, so that a primary care physician could know all of them. Today there are over 10,000 drugs, so no one individual can be familiar with all!
In terms of patient education, 35 years ago a new diabetic patient would be hospitalized for 3 weeks. In addition to all the tests and insulin adjustments, they had 2 hours of patient education per day. (weekdays only, nothing happened on Sat. or Sun). So before they left the hospital, they had had 15 classes or 30 hours of instruction. Because patients came and left during the 3 weeks there was lots of repetition. Nowadays, new diabetics are treated outpatient, signed up for the next diabetes lectures perhaps next month perhaps only 1-3 hours worth perhaps have a one-on-one 30 minutes with a dietician and primarily need to read through several brochures and teach themselves.
Todays health care system puts a tremendous burden on the patient to teach themselves what they need to care for themselves. We give them written and verbal instructions and expect them to understand and know how to translate that information into the routine of their everyday lives. The questions are Are our expectations unrealistic? and How many can actually do this with the information we provide?
Transition: There are many factors that contribute to low health literacy
Purpose: To describe changes in our health care system that exacerbate the problem of low health literacy.
Our health system has evolved over the last 35 years to a place where it demands that patients carry out their own complex medical care.
Note to facilitator: Choose one or two examples from the information below to paint a picture of the differences in health care today versus 35 years ago. It is not necessary to cover all the information.
35 years ago a patient with a heart attack was immediately hospitalized for 6 weeks, flat in bed for several weeks and not even let up to go to the commode! If they survived, by the time they left the hospital, they knew everything they needed to know about how to care for themselves, the drugs they were on (we only had 3 or 4 available), the side effects, etc. Nowadays the same patient will be in and out of the hospital in 2-4 days, on 7 or 8 different drugs at every hour of the day or night, long lists of instructions, life style changes, diet changes (not only low fat, but avoiding such things as a grapefruit because it interacts with the drugs they are on), many different physician appointments, tests, etc. And they are still in shock, having come face to face with their own mortality!
35 years ago there were only 650 drugs, so that a primary care physician could know all of them. Today there are over 10,000 drugs, so no one individual can be familiar with all!
In terms of patient education, 35 years ago a new diabetic patient would be hospitalized for 3 weeks. In addition to all the tests and insulin adjustments, they had 2 hours of patient education per day. (weekdays only, nothing happened on Sat. or Sun). So before they left the hospital, they had had 15 classes or 30 hours of instruction. Because patients came and left during the 3 weeks there was lots of repetition. Nowadays, new diabetics are treated outpatient, signed up for the next diabetes lectures perhaps next month perhaps only 1-3 hours worth perhaps have a one-on-one 30 minutes with a dietician and primarily need to read through several brochures and teach themselves.
Todays health care system puts a tremendous burden on the patient to teach themselves what they need to care for themselves. We give them written and verbal instructions and expect them to understand and know how to translate that information into the routine of their everyday lives. The questions are Are our expectations unrealistic? and How many can actually do this with the information we provide?
Transition: There are many factors that contribute to low health literacy
24. Factors that contribute to health literacy: General literacy
Experience with health system
Complexity of information
Cultural and language factors
How information is communicated
Aging
Purpose: To identify the variety of factors that contribute to health literacy.
This slide builds.
General literacy, the ability to read, write and understand written material, is a major factor in determining the level of someones health literacy.
But other factors, can also have an impact:
Experience with the health system
Complexity of the information presented
Cultural and language factors that may influence information processing and decision-making
How the information is communicated
Aging Studies have shown that health literacy tends to decrease with age
Transition: So how extensive is the problem of low health literacy?
Note to facilitator: If you are conducting this session in a longer format (1 hour or more) you may want to have a discussion here. Ask, Are there other factors you can think of?
(Examples of answers might include: knowledge of health-related subjects, the stress level at the time information is communicated, concurrent illness, support or information available, ability to ask questions, competing information (internet), distrust, etc.)
Transition: So what does research tell us?
..Purpose: To identify the variety of factors that contribute to health literacy.
This slide builds.
General literacy, the ability to read, write and understand written material, is a major factor in determining the level of someones health literacy.
But other factors, can also have an impact:
Experience with the health system
Complexity of the information presented
Cultural and language factors that may influence information processing and decision-making
How the information is communicated
Aging Studies have shown that health literacy tends to decrease with age
Transition: So how extensive is the problem of low health literacy?
Note to facilitator: If you are conducting this session in a longer format (1 hour or more) you may want to have a discussion here. Ask, Are there other factors you can think of?
(Examples of answers might include: knowledge of health-related subjects, the stress level at the time information is communicated, concurrent illness, support or information available, ability to ask questions, competing information (internet), distrust, etc.)
Transition: So what does research tell us?
..
25. One-third of patients at 2 public hospitals had inadequate health literacy: In this graph, the red represents patients with inadequate literacy and the yellow represents patients with marginal literacy.
INADEQUATE: Atlanta: 33%, LA-English-speaking: 13%, LA-Spanish-speaking tested in Spanish: 42%
These patients often misread dosing instructions and appointment slips. 95% could not comprehend the standard informed consent document at the Atlanta hospital.
MARGINAL: Atlanta: 12%, LA-English-speaking: 9%, LA-Spanish-speaking tested in Spanish: 20%
OVERALL: Inadequate combined with marginal literacy
..
47% Atlanta, 22% LA-English speaking, 62% LA-Spanish-speaking tested in Spanish
Transition: Health reading tasks can prove daunting for some patients
.
Reference: Williams, MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274: 1677-1682.In this graph, the red represents patients with inadequate literacy and the yellow represents patients with marginal literacy.
INADEQUATE: Atlanta: 33%, LA-English-speaking: 13%, LA-Spanish-speaking tested in Spanish: 42%
These patients often misread dosing instructions and appointment slips. 95% could not comprehend the standard informed consent document at the Atlanta hospital.
MARGINAL: Atlanta: 12%, LA-English-speaking: 9%, LA-Spanish-speaking tested in Spanish: 20%
OVERALL: Inadequate combined with marginal literacy
..
47% Atlanta, 22% LA-English speaking, 62% LA-Spanish-speaking tested in Spanish
Transition: Health reading tasks can prove daunting for some patients
.
Reference: Williams, MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274: 1677-1682.
26. Many patients struggle with health reading tasks
. Take medicine every 6 hours 22%
Take medicine on empty stomach 42%
Upper GI instructions (4th grade) 21%
Medicaid Rights (10th grade) 46% For example, many are unable to answer correctly very simple questions about health instruction.
For example, in one study 42% did not answer this question correctly
.
This is a medicine you take on an empty stomach. This means 1 hour before or two hours after meals. You usually have lunch at noon. When would you take the medicine?
Transition: We mentioned before that one of the factors for low health literacy seems to be age
.
Reference: Williams, MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274: 1677-1682. For example, many are unable to answer correctly very simple questions about health instruction.
For example, in one study 42% did not answer this question correctly
.
This is a medicine you take on an empty stomach. This means 1 hour before or two hours after meals. You usually have lunch at noon. When would you take the medicine?
Transition: We mentioned before that one of the factors for low health literacy seems to be age
.
Reference: Williams, MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274: 1677-1682.
27. Inadequate health literacy increases with age
The prevalence of inadequate health literacy steadily increases with age.
Of note, patients were screened for dementia in this study and those with any signs of dementia excluded.
We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a use it or lose it phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV.
While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy.
Transition: There has been a substantial amount of research on literacy in the last decade
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.
The prevalence of inadequate health literacy steadily increases with age.
Of note, patients were screened for dementia in this study and those with any signs of dementia excluded.
We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a use it or lose it phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV.
While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy.
Transition: There has been a substantial amount of research on literacy in the last decade
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.
28. What do we know from a decade of research? Low health literacy leads to:
Lower health knowledge and less healthy behaviors. (0:50)
Purpose: To provide an overview of research on the implications of low health literacy and strategies to address low health literacy.
Note: This slide builds.
Weve learned a lot over the last decade about the implications of low health literacy. You will find more on this body of research in your Manual for Clinicians (or summarized in your Participant Guide).
Data from numerous studies shows that low health literacy leads to:
Lower health knowledge and less healthy behaviors.
Poorer health outcomes
Greater costs
There is also research on communication techniques that enhance health literacy.
Transition: Literacy level is also a good predictor of health status
.
References:
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.
Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015.
Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64.
Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30.
Schillinger D, et al. Closing the Loop. Arch Intern Med. 2003; 163:
AHRQ, 2001 Report on Making Health Care Safer.
(0:50)
Purpose: To provide an overview of research on the implications of low health literacy and strategies to address low health literacy.
Note: This slide builds.
Weve learned a lot over the last decade about the implications of low health literacy. You will find more on this body of research in your Manual for Clinicians (or summarized in your Participant Guide).
Data from numerous studies shows that low health literacy leads to:
Lower health knowledge and less healthy behaviors.
Poorer health outcomes
Greater costs
There is also research on communication techniques that enhance health literacy.
Transition: Literacy level is also a good predictor of health status
.
References:
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.
Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015.
Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64.
Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30.
Schillinger D, et al. Closing the Loop. Arch Intern Med. 2003; 163:
AHRQ, 2001 Report on Making Health Care Safer.
29. Less healthy behaviors for patients with low literacy
. More exposure to violence
Pregnant women more likely to smoke
Less breastfeeding
Less likely to be get flu vaccine or pneumovax Less healthy behaviors for low literacy patients included things like
.. (read the above points)
Transition: There are also less healthy behaviors for children and adolescents with low literacy
..
References:
Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78:1912-20;
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998;158:166-172;
Davis TC, Byrd RS, Arnold CL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescents in a summer sports program. J Adolesc Health. 1999; 24:403-11;
Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001; 32:313-20.
Less healthy behaviors for low literacy patients included things like
.. (read the above points)
Transition: There are also less healthy behaviors for children and adolescents with low literacy
..
References:
Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78:1912-20;
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998;158:166-172;
Davis TC, Byrd RS, Arnold CL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescents in a summer sports program. J Adolesc Health. 1999; 24:403-11;
Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001; 32:313-20.
30. Low literate diabetic patients less likely to know correct management
. In one study of diabetic patients, those with low literacy were less likely to know correct management of hypoglycemic symptoms.
Patients who attended diabetes education classes were tested with the TOHFLA to determine their health literacy level before starting the classes, and then tested on knowledge after the class. While 95% of those with adequate literacy (green) knew the symptoms of hypoglecemia, only 48% of those with inadequate literacy (red) sitting side by side in the classes, got this key message.
What is of equally great concern, is that when it comes to knowing what to do about this life-threatening major adverse drug event, only 75% of those with adequate literacy knew what to do. So even in the best of circumstances, we dont know how to get crucial messages understood. We need to learn a great deal more about how to make our health care communication more effective.
Transition: It is not surprising that diabetic patients with low literacy have poorer health outcomes
.
Reference: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.In one study of diabetic patients, those with low literacy were less likely to know correct management of hypoglycemic symptoms.
Patients who attended diabetes education classes were tested with the TOHFLA to determine their health literacy level before starting the classes, and then tested on knowledge after the class. While 95% of those with adequate literacy (green) knew the symptoms of hypoglecemia, only 48% of those with inadequate literacy (red) sitting side by side in the classes, got this key message.
What is of equally great concern, is that when it comes to knowing what to do about this life-threatening major adverse drug event, only 75% of those with adequate literacy knew what to do. So even in the best of circumstances, we dont know how to get crucial messages understood. We need to learn a great deal more about how to make our health care communication more effective.
Transition: It is not surprising that diabetic patients with low literacy have poorer health outcomes
.
Reference: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.
31. Poor health outcomes for diabetic patients
Diabetic patients with low health literacy have poorer glycemic control than patients with adequate literacy.
(Schillinger D, et al. JAMA. 2002.)
Diabetic children (ages 5-17) had poorer glycemic control if their parents had lower literacy skills.
(Ross LA, et al. Diabetic Med. 2001.)
Read these examples.
Transition: These examples provide strong scientific evidence that low literacy leads to poorer health outcomes
.
References:
Schillinger D, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-82.
Ross LA, Frier BM, Kelnar CJ, Deary IJ. Child and parental mental ability and glycemic control in children with Type 1 diabetes. Diabetic Med. 2001;18:364-9.
Read these examples.
Transition: These examples provide strong scientific evidence that low literacy leads to poorer health outcomes
.
References:
Schillinger D, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-82.
Ross LA, Frier BM, Kelnar CJ, Deary IJ. Child and parental mental ability and glycemic control in children with Type 1 diabetes. Diabetic Med. 2001;18:364-9.
32. Patients with low literacy have poorer health outcomes: 69% more likely to have late stage diagnosis of prostate CA at presentation. (Bennet, J Clin Oncol 1998)
4 times more likely to be non-compliant with Anti-HIV meds. (Kalichman S, et al. JGIM 1999) Read these examples.
(Non-compliance with anti HIV meds could mean that the patient did not understand how to take the meds.)
Transition: And low literacy contributes to more hospitalizations
.
References:
Bennet CL, Ferreira NR, Davis TC, et al. Relationship between literacy, race, and stage of presentation among low income patients with prostate cancer. J Clin Oncol. 1998; 16: 3101-4.
Kalichman S, et al. Adherence to combination antiretroviral therapies in HIV patients of low literacy. JGIM. 1999; 14: 267-73.
Read these examples.
(Non-compliance with anti HIV meds could mean that the patient did not understand how to take the meds.)
Transition: And low literacy contributes to more hospitalizations
.
References:
Bennet CL, Ferreira NR, Davis TC, et al. Relationship between literacy, race, and stage of presentation among low income patients with prostate cancer. J Clin Oncol. 1998; 16: 3101-4.
Kalichman S, et al. Adherence to combination antiretroviral therapies in HIV patients of low literacy. JGIM. 1999; 14: 267-73.
33. Patients with low literacy more likely to be hospitalized In a study that followed more than 1000 patients at a public hospital for 2 years, patients with inadequate health literacy were twice as likely to be hospitalized.
Even after controlling for age, gender, socioeconomic status, health status, and regular source of care, inadequate health literacy was associated with a 52% increased odds of hospitalization.
Transition: And all of this adds up to BIG COSTS!!!
Reference:
Baker DW, Parker RM, Williams MV. Health literacy and the risk of hospital admission. JGIM. 1998; 13: 791-8.In a study that followed more than 1000 patients at a public hospital for 2 years, patients with inadequate health literacy were twice as likely to be hospitalized.
Even after controlling for age, gender, socioeconomic status, health status, and regular source of care, inadequate health literacy was associated with a 52% increased odds of hospitalization.
Transition: And all of this adds up to BIG COSTS!!!
Reference:
Baker DW, Parker RM, Williams MV. Health literacy and the risk of hospital admission. JGIM. 1998; 13: 791-8.
34. Poor reading skills correlate with less knowledge of asthma The Graph shows the % of patients in each category of reading skills that answered correctly. The knowledge questions were in the format of True or False questions.
If someone takes asthma medicine every day, they do not have to stay away from things that they are allergic to.
While 91% of literate patients were aware they needed to stay away from things they are allergic to, only 50% of those with the poorest reading skills knew this.
Someone with asthma only needs to see a doctor about asthma when he or she is having an attack.
While 95% of literate patients were aware they needed to see the doctor even when not having an asthma attack, only 36% of those with the poorest reading skills knew this. This lack of awareness of the importance of preventive or maintenance care, may be an important contributor to poor asthma control and high use of emergency rooms and hospitalization.
Reference:
Williams MV, Baker DW, Honig LG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114; 1008-15.The Graph shows the % of patients in each category of reading skills that answered correctly. The knowledge questions were in the format of True or False questions.
If someone takes asthma medicine every day, they do not have to stay away from things that they are allergic to.
While 91% of literate patients were aware they needed to stay away from things they are allergic to, only 50% of those with the poorest reading skills knew this.
Someone with asthma only needs to see a doctor about asthma when he or she is having an attack.
While 95% of literate patients were aware they needed to see the doctor even when not having an asthma attack, only 36% of those with the poorest reading skills knew this. This lack of awareness of the importance of preventive or maintenance care, may be an important contributor to poor asthma control and high use of emergency rooms and hospitalization.
Reference:
Williams MV, Baker DW, Honig LG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114; 1008-15.
35. One-third of SeniorCare enrollees had inadequate literacy
In a study of more than 3000 managed care Medicare enrollees, inadequate or marginal health literacy was common.
Of note: English speaking patients were assessed in English, Spanish-speaking were assessed in Spanish.
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.In a study of more than 3000 managed care Medicare enrollees, inadequate or marginal health literacy was common.
Of note: English speaking patients were assessed in English, Spanish-speaking were assessed in Spanish.
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.
36. Reading errors for SeniorCare 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% Many managed care Medicare recipients with inadequate literacy have problems with common medical tasks.
This shows the % of enrollees who struggled with each task.
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.
Many managed care Medicare recipients with inadequate literacy have problems with common medical tasks.
This shows the % of enrollees who struggled with each task.
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.
37. Health knowledge deficits for patients with low literacy
Patients with asthma less likely to know how to use an inhaler
Patients with diabetes less likely to know symptoms of hypoglycemia
Patients with hypertension less likely to know that weight loss and exercise lower blood pressure
Mothers less likely to know how to read a thermometer.
Knowledge deficits for low literacy patients included things like
.. (read the above points)
References:
Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78:1912-20;
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998;158:166-172;
Davis TC, Byrd RS, Arnold CL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescents in a summer sports program. J Adolesc Health. 1999; 24:403-11;
Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001; 32:313-20.
Knowledge deficits for low literacy patients included things like
.. (read the above points)
References:
Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78:1912-20;
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998;158:166-172;
Davis TC, Byrd RS, Arnold CL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescents in a summer sports program. J Adolesc Health. 1999; 24:403-11;
Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001; 32:313-20.
38. Mothers with low literacy Greater risk of depression
Less knowledge about adverse effects of smoking
Less breast-feeding
Less able to read a thermometer Less healthy behaviors for mothers with low literacy include
.. (read the above points)
References:
Zaslow MJ, Hair Ec, Dion MR, et al. Maternal depressive symptoms and low literacy as potential barriers to employment in a sample of families receiving welfare: are there two-generational implications? Women Health . 201;32:211-51 Mothers with lower literacy had greater incidence of depression but there was no relationship detected between maternal literacy and depression or antisocial behavior among their children.
Arnold CL, Davis TC, Berkel HJ et al. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prevent Med. 2001;32:313-20.
Kaufman H, Skipper B, Small L, et al. Effect of literacy on breast-feeding outcomes. Southern Med J. 2001;94:293-6.
Fredrickson DD, Washigton RL, Pham N e tal, Reading grade levels and health behaviors of parents at child clinics. Kansas Med . 1995;96:127-9.
Less healthy behaviors for mothers with low literacy include
.. (read the above points)
References:
Zaslow MJ, Hair Ec, Dion MR, et al. Maternal depressive symptoms and low literacy as potential barriers to employment in a sample of families receiving welfare: are there two-generational implications? Women Health . 201;32:211-51 Mothers with lower literacy had greater incidence of depression but there was no relationship detected between maternal literacy and depression or antisocial behavior among their children.
Arnold CL, Davis TC, Berkel HJ et al. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prevent Med. 2001;32:313-20.
Kaufman H, Skipper B, Small L, et al. Effect of literacy on breast-feeding outcomes. Southern Med J. 2001;94:293-6.
Fredrickson DD, Washigton RL, Pham N e tal, Reading grade levels and health behaviors of parents at child clinics. Kansas Med . 1995;96:127-9.
39. Research also shows that:
Literacy is a predictor of health status
It is a stronger predictor than age, income, employment status, education level, or racial and ethnic group Research has also shown that literacy is a predictor of health status; a stronger predictor than age, income, employment, education or ethnic group. In other words, not having good literacy skills is bad for your health!
Again, the research we are referring to here is discussed in more detail in your printed manual.
References:
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.
Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015.
Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64.
Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30.
Research has also shown that literacy is a predictor of health status; a stronger predictor than age, income, employment, education or ethnic group. In other words, not having good literacy skills is bad for your health!
Again, the research we are referring to here is discussed in more detail in your printed manual.
References:
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.
Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015.
Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64.
Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30.
40. Estimated $50+* billion annual costs of poor health literacy
We all pay!
39% paid by Medicare through FICA taxes on workers
17% paid by employers
16% paid by patients out-of-pocket
14% paid by Medicaid
The remaining 14% comes from other public and private sources.
THE COST = $50 BILLION or more PER YEAR (based on 1998 dollars), attributable to low literacy alone.
Primary source of higher health care expenditures for persons with low health literacy is longer hospital stays.
Other factors include medication errors, excess hospitalizations, more use of the emergency department and higher level of illness.
Who pays for all this? We all do.
Transition: So now lets see what some real patients and physicians have to say about this problem
Reference:
Friedland, RB. Understanding Health Literacy: New Estimates of the Cost of Inadequate Health Literacy. Washington, D.C.: National Academy of Aging Society, 1998.
THE COST = $50 BILLION or more PER YEAR (based on 1998 dollars), attributable to low literacy alone.
Primary source of higher health care expenditures for persons with low health literacy is longer hospital stays.
Other factors include medication errors, excess hospitalizations, more use of the emergency department and higher level of illness.
Who pays for all this? We all do.
Transition: So now lets see what some real patients and physicians have to say about this problem
Reference:
Friedland, RB. Understanding Health Literacy: New Estimates of the Cost of Inadequate Health Literacy. Washington, D.C.: National Academy of Aging Society, 1998.
41. Video: The patients voice...
This video was made by the AMA in 2003
You will see real patients and real physicians talking about literacy issues
(0:21)
Purpose: To present the problem through the eyes of real patients.
In this video you will see real patients and physicians talking about health literacy issues and their own experiences.
Many of them will remind you of your own patients and situations you have faced. One thing is clear: These patients cannot easily be categorized or identified! (You cant tell by looking.)
Some practical strategies for how to deal with low health literacy will also be demonstrated.
If you would like to take notes, you can use your Participant Guide.
Play the video. (It is 23 minutes long.) (0:21)
Purpose: To present the problem through the eyes of real patients.
In this video you will see real patients and physicians talking about health literacy issues and their own experiences.
Many of them will remind you of your own patients and situations you have faced. One thing is clear: These patients cannot easily be categorized or identified! (You cant tell by looking.)
Some practical strategies for how to deal with low health literacy will also be demonstrated.
If you would like to take notes, you can use your Participant Guide.
Play the video. (It is 23 minutes long.)
42. The shame of low literacy The patients voice
. Mrs. Walker: It paralyzes your every thought.
Mr. Bowman: This is your greatest fear.
Mrs. Grigar: I hide it
.it drains you.
Mr. Bell: I blame them, they dont respect me.
(0:03)
Note to facilitator: This slide builds. You can show each quote by clicking to advance.
In the video we saw a number of patients who had low health literacy talk about their fears and concerns:
You may remember Mrs. Walker, who talked about her fear of being discovered and how It paralyzes your every thought.
Or Mr. Bowman, who said that [Being discovered] is your greatest fear.
Or Mrs. Grigar, who talked about how trying to hide it drains you.
Or finally, Mr. Bell, who has walked out of the office saying that I blame them, they dont respect me as a defense mechanism so that he wont be discovered.
Ask, Have you encountered similar patients in your practice? Or share a personal story to illustrate the point.
Note to facilitator: If it has been some time since participants have viewed the video, you may want to consider replaying the short 3-minute section of patients talking about a shame-free environment.
Transition: Most patients with limited literacy skills have probably never told anyone in the healthcare system
.
(0:03)
Note to facilitator: This slide builds. You can show each quote by clicking to advance.
In the video we saw a number of patients who had low health literacy talk about their fears and concerns:
You may remember Mrs. Walker, who talked about her fear of being discovered and how It paralyzes your every thought.
Or Mr. Bowman, who said that [Being discovered] is your greatest fear.
Or Mrs. Grigar, who talked about how trying to hide it drains you.
Or finally, Mr. Bell, who has walked out of the office saying that I blame them, they dont respect me as a defense mechanism so that he wont be discovered.
Ask, Have you encountered similar patients in your practice? Or share a personal story to illustrate the point.
Note to facilitator: If it has been some time since participants have viewed the video, you may want to consider replaying the short 3-minute section of patients talking about a shame-free environment.
Transition: Most patients with limited literacy skills have probably never told anyone in the healthcare system
.
43. Strategies to enhance health literacy
Enhance assessment techniques
Create a shame-free environment
Improve interpersonal communication with patients
Create and use patient-friendly written materials
Where are we in the workshop?
In the previous module (Module 1 - Overview) we identified these 4 strategies for enhancing the health literacy of patients.
(In Module 3 we will address the last two strategies.)
Transition: In this module (Module 2), we will focus on the first two strategies in more detail.
Where are we in the workshop?
In the previous module (Module 1 - Overview) we identified these 4 strategies for enhancing the health literacy of patients.
(In Module 3 we will address the last two strategies.)
Transition: In this module (Module 2), we will focus on the first two strategies in more detail.
44. Patients wont tell you. % of patients who have never told about their illiteracy:
Supervisor 91%
Children 53%
Spouse 68%
Anyone 19%
What do you think the % is for their physician?
Parikh N, et al. Patient Educ Couns, 1996. Most patients with limited literacy skills have probably never told anyone in the healthcare system.
According to one study, 91% had never told their supervisor, 53% had never told their children, and 68% had never even told their spouses!
Transition: Ask, Based on this information, what are some of the emotions you think these patients might experience?
Reference: Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996; 27:33-9.
Most patients with limited literacy skills have probably never told anyone in the healthcare system.
According to one study, 91% had never told their supervisor, 53% had never told their children, and 68% had never even told their spouses!
Transition: Ask, Based on this information, what are some of the emotions you think these patients might experience?
Reference: Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996; 27:33-9.
45. In a doctors office, patients may feel
.. Fearful
Anxious
Angry
Stupid
Embarrassed
Ashamed
Suspicious, on guard
Other emotions?
Note to facilitator: This slide builds. Before you show the points on the screen, ask the audience for their ideas.
Ask, How do you think someone with limited reading ability might feel?
Other possible answers might include: Exhausted, numb, withdrawn.
Ask, If these were your patients, would you be likely to consider any of them difficult patients? Which ones and why? (Get a few ideas from the audience. The most likely patient to be mentioned may be Mr. Bell since his reaction was one of anger directed at the staff.)
Transition: So given all this, what can we do? Assessment is one of the tools we have to address this issue
.Note to facilitator: This slide builds. Before you show the points on the screen, ask the audience for their ideas.
Ask, How do you think someone with limited reading ability might feel?
Other possible answers might include: Exhausted, numb, withdrawn.
Ask, If these were your patients, would you be likely to consider any of them difficult patients? Which ones and why? (Get a few ideas from the audience. The most likely patient to be mentioned may be Mr. Bell since his reaction was one of anger directed at the staff.)
Transition: So given all this, what can we do? Assessment is one of the tools we have to address this issue
.
46. Red Flags: Patients may seek to protect themselves by
. Seeking help only when illness is advanced
Walking out of the waiting room
Making excuses
Pretending they can read
Becoming angry, demanding
Clowning around, using humor
Being quiet, passive
Detour, letting doctor miss the concern
Note to facilitator: This slide builds.
In a medical setting patients may protect themselves by exhibiting these behaviors
.(read through list, provide examples)
These coping mechanisms may protect the patient from being discovered, but they are likely to have a negative impact on the health care the patient receives.
Transition: Patients may also say things that could indicate a potential problem
.. Note to facilitator: This slide builds.
In a medical setting patients may protect themselves by exhibiting these behaviors
.(read through list, provide examples)
These coping mechanisms may protect the patient from being discovered, but they are likely to have a negative impact on the health care the patient receives.
Transition: Patients may also say things that could indicate a potential problem
..
47. Use the social history to ask: Ask about education, reading, learning styles be non-judgmental.
Use this discussion to open a space for the patient to talk about literacy issues. (0:10)
Using the social history is a safe, nonjudgmental approach because it is one of many questions asked. We saw a good example in the video.
After asking about occupation and education, the clinician added a question that would help the patient open up and discuss the issue if they so desired. She asked: How happy are you with the way you read?
Transition: Each individual will need to determine how to ask about this topic in a way that is comfortable for them and does not appear to be judgmental to the patient. Lets look at some examples
(0:10)
Using the social history is a safe, nonjudgmental approach because it is one of many questions asked. We saw a good example in the video.
After asking about occupation and education, the clinician added a question that would help the patient open up and discuss the issue if they so desired. She asked: How happy are you with the way you read?
Transition: Each individual will need to determine how to ask about this topic in a way that is comfortable for them and does not appear to be judgmental to the patient. Lets look at some examples
48. Shame-free communication means.. Be curious, listen
Ask before you advise
Give the patient time to respond
Take the patients concern seriously
Discuss how you can best help the patient care for themselves
Ask patients how they want information communicated to them
Be positive, hopeful, empowering
Take a minute to look over these points
.(give them about 10 seconds to look at the slide).
These points sound very basic but it is not always easy to follow them.
For example, taking the time to listen to the patients concerns is something that can easily be overlooked in the rush of day-to-day appointments.
The average patient actually talks for 90 seconds or less, when asked.
Reference: Langewitz W, Benz M, Keller A, Kiss A, Ruttimanns, Wossmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325: 682-3.
Slowing down and giving the patient enough time to respond is very important to creating shame-free communication.
It is also important to ask patients how they want information communicated
..Example: How would you like to learn about mammograms?
Transition: Weve talked about red flags and using the social history to create a safe space to discuss a literacy problem. Now lets look at how medication reviews can be used to identify and address problems
Take a minute to look over these points
.(give them about 10 seconds to look at the slide).
These points sound very basic but it is not always easy to follow them.
For example, taking the time to listen to the patients concerns is something that can easily be overlooked in the rush of day-to-day appointments.
The average patient actually talks for 90 seconds or less, when asked.
Reference: Langewitz W, Benz M, Keller A, Kiss A, Ruttimanns, Wossmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325: 682-3.
Slowing down and giving the patient enough time to respond is very important to creating shame-free communication.
It is also important to ask patients how they want information communicated
..Example: How would you like to learn about mammograms?
Transition: Weve talked about red flags and using the social history to create a safe space to discuss a literacy problem. Now lets look at how medication reviews can be used to identify and address problems
49. Use a medication review to identify problems: Ask patients to bring in all their medications
Ask them to name and explain the purpose of each one
Discuss exactly how and when they take each one
Use this discussion to identify areas of confusion and to answer questions At the time the appointment is made, ask the patient to bring in all medications (prescription and over-the-counter medications, nutritional and herbal supplements, etc.).
When the patient comes to the office, the physician, nurse or medical assistant can conduct the medication review by asking the patient to name each medication and explain its purpose and how it is taken.
Here are some things to look for:
Does the patient identify the medication by reading the label or by opening the bottle and looking at or pouring the pills into their hand? (If they look at the pills it may be a sign of low literacy skills.)
How easily can the patient answer specific questions about how they take the medication?
Example: When was the last time you took this medicine and when was the time before that?
Do they become confused when asked questions about the medication?
Use this discussion about the medications to address any areas of confusion.
Transition: We think this is potentially such a useful technique that we want to give you a chance to plan for conducting a medication review
.
At the time the appointment is made, ask the patient to bring in all medications (prescription and over-the-counter medications, nutritional and herbal supplements, etc.).
When the patient comes to the office, the physician, nurse or medical assistant can conduct the medication review by asking the patient to name each medication and explain its purpose and how it is taken.
Here are some things to look for:
Does the patient identify the medication by reading the label or by opening the bottle and looking at or pouring the pills into their hand? (If they look at the pills it may be a sign of low literacy skills.)
How easily can the patient answer specific questions about how they take the medication?
Example: When was the last time you took this medicine and when was the time before that?
Do they become confused when asked questions about the medication?
Use this discussion about the medications to address any areas of confusion.
Transition: We think this is potentially such a useful technique that we want to give you a chance to plan for conducting a medication review
.
50. All staff need to be involved in
.. Understanding the scope of the problem
Identifying patient barriers to care
Creating strategies to address the barriers
Implementing and assessing the effectiveness of these strategies
Conducting on-going follow-up and evaluation
(0:45)
Note to facilitator: This slide builds.
To create effective change, involvement of all staff is critical to your success. Staff need to be involved in:
Understanding the scope of the problem
Identifying patient barriers to care
Creating strategies to address the barriers
Implementing and assessing the effectiveness of these strategies
Conducting on-going follow-up and evaluation
Transition: A general roadmap for involving staff would include
(0:45)
Note to facilitator: This slide builds.
To create effective change, involvement of all staff is critical to your success. Staff need to be involved in:
Understanding the scope of the problem
Identifying patient barriers to care
Creating strategies to address the barriers
Implementing and assessing the effectiveness of these strategies
Conducting on-going follow-up and evaluation
Transition: A general roadmap for involving staff would include
51. Failure to communicate Doctor: Your foot infection is so severe that we will not be able to treat it locally.
Patient: I hope I dont have to travel far, doctor. Im afraid of flying. Note: This slide builds.
Has something like this ever happened to you?
Feel free to add other stories from your own experience
.such as Nurse, I think we are ready to move this patient to the floor. (The patient is thinking literally that they must lie on the floor.)
These examples also demonstrate that even non-medical words can be misunderstood and misinterpreted.Note: This slide builds.
Has something like this ever happened to you?
Feel free to add other stories from your own experience
.such as Nurse, I think we are ready to move this patient to the floor. (The patient is thinking literally that they must lie on the floor.)
These examples also demonstrate that even non-medical words can be misunderstood and misinterpreted.
52. Practice: Plain, non-medical language Anti-inflammatory
Benign
Contraception
Hypertension
Oral
Echocardiogram (0:09) Purpose: To practice using plain, non-medical language.
Note to facilitator: This slide builds. Go through one term at a time and ask for ideas on translating to plain language. Get 2 or 3 ideas for each term and keep moving. Dont get bogged down. This exercise should only take 2 minutes. If you are short on time, choose only 2 or 3 and move on to the next slide.
Refer participants to their Participant Guide, Practice: Plain, non-medical language, if they would like to take notes.
For each word, ask What could you say instead?
Possible answers:
Anti-inflammatory
..lessens swelling and irritation
Benign
..not cancer
Contraception
birth control
Hypertension
..high blood pressure
Oral
.by mouth
Echocardiogram
..pictures of the heart
Transition: And now, Step 3: Focus on key messages
.
(0:09) Purpose: To practice using plain, non-medical language.
Note to facilitator: This slide builds. Go through one term at a time and ask for ideas on translating to plain language. Get 2 or 3 ideas for each term and keep moving. Dont get bogged down. This exercise should only take 2 minutes. If you are short on time, choose only 2 or 3 and move on to the next slide.
Refer participants to their Participant Guide, Practice: Plain, non-medical language, if they would like to take notes.
For each word, ask What could you say instead?
Possible answers:
Anti-inflammatory
..lessens swelling and irritation
Benign
..not cancer
Contraception
birth control
Hypertension
..high blood pressure
Oral
.by mouth
Echocardiogram
..pictures of the heart
Transition: And now, Step 3: Focus on key messages
.
53. 2. Explain things clearly using plain language. Slow down the pace of your speech
Use analogies
Arthritis is like a creaky hinge on a door.
Use plain, non-medical language
Pain killer instead of analgesic
(0:08) Purpose: To describe the components of Step 2 and give examples.
Note: This slide builds.
Slow down the pace of your speech.
Try to be conscious of how fast you are talking. We often talk much faster than we think we do. Try to pace yourself like a radio announcer.
Use analogies.
Use analogies that will translate the medical concept into something that the patient can more easily relate to, such as what they do for a living. This kind of conversational language creates more opportunities for dialogue.
Example: Arthritis is like a creaky hinge on a door.
Example: Your arteries are like plumbing and they are clogged up.
Use plain, non-medical language.
We should always seek to use plain, non-medical language when speaking to patients. Words that clinicians use in their day-to-day conversations with colleagues, including the most basic medical terms, may be unfamiliar to the majority of non-medically trained persons.
Example: Pain killer versus analgesic
Transition: Here are some medical terms to practice with
..(0:08) Purpose: To describe the components of Step 2 and give examples.
Note: This slide builds.
Slow down the pace of your speech.
Try to be conscious of how fast you are talking. We often talk much faster than we think we do. Try to pace yourself like a radio announcer.
Use analogies.
Use analogies that will translate the medical concept into something that the patient can more easily relate to, such as what they do for a living. This kind of conversational language creates more opportunities for dialogue.
Example: Arthritis is like a creaky hinge on a door.
Example: Your arteries are like plumbing and they are clogged up.
Use plain, non-medical language.
We should always seek to use plain, non-medical language when speaking to patients. Words that clinicians use in their day-to-day conversations with colleagues, including the most basic medical terms, may be unfamiliar to the majority of non-medically trained persons.
Example: Pain killer versus analgesic
Transition: Here are some medical terms to practice with
..
54. 3. Focus on key messages and repeat. Limit information by focusing on 1-3 key messages per visit
Review each point and repeat several times
Have other staff reinforce key messages.
(0:11) Purpose: To describe the components of Step 3.
Note: This slide builds.
Limit information to 1-3 key messages.
The principle behind this approach is that advice is remembered better, and patients are more likely to act on it, when the advice is given in small pieces and is relevant to the patients current needs or situation.
Reference 40: Vogel DR, Dickson GW, Lehman JA. Driving the audience action response. In: Petterson R. Visuals for Information: Research and Practice. Englewood Cliffs, NJ: Education Technology Publications, 1989.)
Repeat messages several times.
These key messages should be repeated several times during the visit and summarized/reviewed at the end because people learn more effectively when they hear things more than once.
Have staff reinforce key messages.
Working with your staff to reinforce the key messages is also very effective. Ideally, the information will be reviewed and repeated by multiple members of the health care team, perhaps a physician, nurse, pharmacist, dietician, and others.
Repetition can also be achieved through handouts which reinforce key points. Consider reading the handouts to patients to emphasize the importance of the information. If the handout is too long to read, it may be too complex.
Transition: Lets look at a specific situation and determine key messages
(0:11) Purpose: To describe the components of Step 3.
Note: This slide builds.
Limit information to 1-3 key messages.
The principle behind this approach is that advice is remembered better, and patients are more likely to act on it, when the advice is given in small pieces and is relevant to the patients current needs or situation.
Reference 40: Vogel DR, Dickson GW, Lehman JA. Driving the audience action response. In: Petterson R. Visuals for Information: Research and Practice. Englewood Cliffs, NJ: Education Technology Publications, 1989.)
Repeat messages several times.
These key messages should be repeated several times during the visit and summarized/reviewed at the end because people learn more effectively when they hear things more than once.
Have staff reinforce key messages.
Working with your staff to reinforce the key messages is also very effective. Ideally, the information will be reviewed and repeated by multiple members of the health care team, perhaps a physician, nurse, pharmacist, dietician, and others.
Repetition can also be achieved through handouts which reinforce key points. Consider reading the handouts to patients to emphasize the importance of the information. If the handout is too long to read, it may be too complex.
Transition: Lets look at a specific situation and determine key messages
55. 4. Use teach back or show me techniques. Ask patient to demonstrate understanding
What will you tell your spouse about your condition?
I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.
Do not ask,
Do you understand? .
(0:24) Purpose: To explain why teach backs are important and discuss ways to ask for a teach back. (Also see Frequently Asked Questions for research on teach backs.)
Note: This slide builds.
Ask patient to demonstrate understanding.
The teach back allows you to check for understanding and, if necessary, re-teach the information.
This technique creates the opportunity for dialogue in which the physician provides information, then encourages the patient to respond and confirm understanding before adding any new information.
We must ask the patient to explain or demonstrate understanding in a way that is not demeaning.
Example: What will you tell your spouse about your condition?
It is important not to appear rushed, annoyed, or bored during these efforts your affect must agree with your words.
Do not ask, Do you understand?.
Never ask this
.You are likely to get a yes whether or not they understand. This technique is not considered effective.
Research also indicates that teach backs work.
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 glycemic control for diabetic patients. (Schilinger D. Closing the Loop. Arch Intern Med. 2003; 163)
Discussion: (3 min.) (Facilitator: Also refer participants to the Participant Guide, How to ask for a teach back.)
Ask, How many of you already do this on a regular basis? What have you found to be the advantages of this technique? How would you advise clinicians who might be reticent about using this technique?
Ask, What are some other ways you can ask for a teach back?
Take a few ideas. Make sure that they do not sound demeaning. If there is a potential problem with an idea, ask the group, How would you feel if you were asked this question?
Video example: You have a lot of friends with arthritis. What would you tell them about your condition?
Sample answer: Tell me what you will do and how you will do it when you get home.
Sample answer: Ive given you a lot of information. We should probably recap what we have discussed. Why dont you start.
Transition: The 5th and last step is: Use patient-friendly written materials to enhance interaction
..
(0:24) Purpose: To explain why teach backs are important and discuss ways to ask for a teach back. (Also see Frequently Asked Questions for research on teach backs.)
Note: This slide builds.
Ask patient to demonstrate understanding.
The teach back allows you to check for understanding and, if necessary, re-teach the information.
This technique creates the opportunity for dialogue in which the physician provides information, then encourages the patient to respond and confirm understanding before adding any new information.
We must ask the patient to explain or demonstrate understanding in a way that is not demeaning.
Example: What will you tell your spouse about your condition?
It is important not to appear rushed, annoyed, or bored during these efforts your affect must agree with your words.
Do not ask, Do you understand?.
Never ask this
.You are likely to get a yes whether or not they understand. This technique is not considered effective.
Research also indicates that teach backs work.
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 glycemic control for diabetic patients. (Schilinger D. Closing the Loop. Arch Intern Med. 2003; 163)
Discussion: (3 min.) (Facilitator: Also refer participants to the Participant Guide, How to ask for a teach back.)
Ask, How many of you already do this on a regular basis? What have you found to be the advantages of this technique? How would you advise clinicians who might be reticent about using this technique?
Ask, What are some other ways you can ask for a teach back?
Take a few ideas. Make sure that they do not sound demeaning. If there is a potential problem with an idea, ask the group, How would you feel if you were asked this question?
Video example: You have a lot of friends with arthritis. What would you tell them about your condition?
Sample answer: Tell me what you will do and how you will do it when you get home.
Sample answer: Ive given you a lot of information. We should probably recap what we have discussed. Why dont you start.
Transition: The 5th and last step is: Use patient-friendly written materials to enhance interaction
..
56. 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 glycemic control for diabetic patients. (Schilinger D. Arch Intern Med. 2003; 163) Recent research indicates that checking for understanding by using a teach back technique in interactions with patients is effective. (More on this in Module 3.)
Transition: And we have numerous anecdotal reports from which to gain ideas
References:
AHRQ, 2001 Report on Making Health Care Safer.
Schillinger D. Closing the Loop. Arch Intern Med. 2003; 163:
Recent research indicates that checking for understanding by using a teach back technique in interactions with patients is effective. (More on this in Module 3.)
Transition: And we have numerous anecdotal reports from which to gain ideas
References:
AHRQ, 2001 Report on Making Health Care Safer.
Schillinger D. Closing the Loop. Arch Intern Med. 2003; 163:
57. 5. Use patient-friendly educational materials to enhance interaction. Show or draw simple pictures
Focus only on key points
Emphasize what the patient should do
Minimize information about anatomy and physiology
Be sensitive to cultural preferences. (0:28) Purpose: To describe the components of Step 5.
Note: This slide builds.
Evidence indicates that all patients not just those with limited literacy skills prefer easy-to-read materials to more complex or comprehensive materials:
Show or draw simple pictures.
Youve heard the statement, A picture is worth a thousand words. Many people are visual learners or learn more effectively with the combination of hearing and seeing. Dont underestimate this in your patient teaching.
The most effective pictures or models are simple.
Focus only on key points.
We have spent a considerable amount of time in this module addressing the issue of limiting content to key messages things the patient needs to know and put in to action.
The technique is the same whether we are talking about verbal or written communication. Remember the example you worked on for Strep Throat? You boiled down that long explanation into 3 key points that said everything that the patient should do.
Emphasize what the patient should do.
Think in terms of the actions the patient needs to take. Write in active voice to describe these actions.
Minimize information about anatomy and physiology.
Be sensitive to cultural preferences.
A good way to know if the materials will work with your audience is to conduct user tests before you finalize them.
This is another way of saying that you dont need to provide a large amount of background
only the key points.
Facilitator: Be prepared to deal with a question such as What if the patient wants more information? Possible answer: First you should provide the basic structure using the key messages. Then you can build on that.
Transition: Some other helpful guidelines for written materials include
.(0:28) Purpose: To describe the components of Step 5.
Note: This slide builds.
Evidence indicates that all patients not just those with limited literacy skills prefer easy-to-read materials to more complex or comprehensive materials:
Show or draw simple pictures.
Youve heard the statement, A picture is worth a thousand words. Many people are visual learners or learn more effectively with the combination of hearing and seeing. Dont underestimate this in your patient teaching.
The most effective pictures or models are simple.
Focus only on key points.
We have spent a considerable amount of time in this module addressing the issue of limiting content to key messages things the patient needs to know and put in to action.
The technique is the same whether we are talking about verbal or written communication. Remember the example you worked on for Strep Throat? You boiled down that long explanation into 3 key points that said everything that the patient should do.
Emphasize what the patient should do.
Think in terms of the actions the patient needs to take. Write in active voice to describe these actions.
Minimize information about anatomy and physiology.
Be sensitive to cultural preferences.
A good way to know if the materials will work with your audience is to conduct user tests before you finalize them.
This is another way of saying that you dont need to provide a large amount of background
only the key points.
Facilitator: Be prepared to deal with a question such as What if the patient wants more information? Possible answer: First you should provide the basic structure using the key messages. Then you can build on that.
Transition: Some other helpful guidelines for written materials include
.
58. Guidelines for creating patient-friendly written materials: Simple words (1-2 syllables)
Short sentences (4-6 words)
Short paragraphs (2-3 sentences)
No medical jargon
Headings and bullets
Lots of white space. (0:31)
Purpose: To cover guidelines for written materials and potentially review examples in Participant Guide.
Note: This slide builds.
Use simple words, short sentences and short paragraphs
This point is all about readability. Written materials should ideally be created for readability at the 5th or 6th grade level, thus assuring readability for the majority of adults. Text constructed at the 5th or 6th grade level typically is constructed of short words, all or most of which are one or two syllables long. Sentences should be as short as possible. Paragraphs should contain no more than two or three sentences.
In the Strep Throat exercise, you saw that it was possible to construct text at this basic level.
No medical jargon
And dont forget to use plain, non-medical language and be relentless about this!
Use headings and bullets to increase retention:
Written material is often difficult to read when it contains text that is dense, in small font, or presented in long uninterrupted paragraphs
Think about chunking the content into key points under headings and bulleting key points.
Use uncluttered layout with lots of white space
If you use short paragraphs and headings and bullet points, you will automatically increase the amount of white space on the page.
Following these simple guidelines will really help you to produce readable, effective patient education handouts. There are some examples of effective patient education materials in your Participant Guide. (Facilitator: If you have time you can walk them through the examples. Otherwise, suggest that they look at the examples on their own.)
Transition: Before we do our last activity in which you will apply all 5 steps, lets briefly review what we have covered so far
(0:31)
Purpose: To cover guidelines for written materials and potentially review examples in Participant Guide.
Note: This slide builds.
Use simple words, short sentences and short paragraphs
This point is all about readability. Written materials should ideally be created for readability at the 5th or 6th grade level, thus assuring readability for the majority of adults. Text constructed at the 5th or 6th grade level typically is constructed of short words, all or most of which are one or two syllables long. Sentences should be as short as possible. Paragraphs should contain no more than two or three sentences.
In the Strep Throat exercise, you saw that it was possible to construct text at this basic level.
No medical jargon
And dont forget to use plain, non-medical language and be relentless about this!
Use headings and bullets to increase retention:
Written material is often difficult to read when it contains text that is dense, in small font, or presented in long uninterrupted paragraphs
Think about chunking the content into key points under headings and bulleting key points.
Use uncluttered layout with lots of white space
If you use short paragraphs and headings and bullet points, you will automatically increase the amount of white space on the page.
Following these simple guidelines will really help you to produce readable, effective patient education handouts. There are some examples of effective patient education materials in your Participant Guide. (Facilitator: If you have time you can walk them through the examples. Otherwise, suggest that they look at the examples on their own.)
Transition: Before we do our last activity in which you will apply all 5 steps, lets briefly review what we have covered so far
59. What are the barriers to patients?
Barriers to Access
Barriers to Diagnosis
Barriers to Treatment (0:49) Purpose: To have participants think about their own situation and generate a list of barriers for their patients.
In the video we saw examples of barriers to patients. Ask, What are some examples?
You may take notes in your Participant Guide.
Note to facilitator: If the participants do not have any ideas, use some of the following examples:
Access: Insurance Forms, Intake Forms - ER easiest, Medical History Questionnaires, Informed Consents
Think of Mr. Bell - your heart pounds when facing the nightmare of a form to fill out that he cannot read.. Think of Mr. Bowman, who ends up in an emergency room because he cant fill out the form and is too embarrassed to ask for help. Emergency rooms are easier on these patients, because someone else asks the questions and fills out the forms!
Diagnosis: Patient provides mistaken information, Patient misunderstands physicians questions, Physician misunderstands patient
Mr. Day doesnt think he has hypertension. Mrs. Irwin says one of her medications is Lithium when it is really Lipitor. If the doctor didnt have the actual bottle to read the label and just took her name for the medicine, he could assume she had a diagnosis of manic depression rather than hyperlipidemia.
Ask, What barriers do you have in your patient-care environment?
Treatment: Misunderstandings of treatment directions may lead to serious mistakes or non-compliance
Mrs.Tilsey understands what she needs to do, but because she only recognizes the drugs by a few letters, and since she cannot read the names, she can mix up similar looking drugs and end up taking two tranquillizers instead of 1 tranquillizer and 1 Accolite
Gather ideas from participants and use the next slide or a flipchart to record them.
Before you leave today, pick one of the barriers that your patients are faced with, and decide on something you will do to remove the barrier.
Transition: We have learned a lot over the last decade about health literacy. And we are trying to address the problem in a variety of ways. To close this overview module we would like to suggest some guiding principles as you go forward in your own practice/setting
(0:49) Purpose: To have participants think about their own situation and generate a list of barriers for their patients.
In the video we saw examples of barriers to patients. Ask, What are some examples?
You may take notes in your Participant Guide.
Note to facilitator: If the participants do not have any ideas, use some of the following examples:
Access: Insurance Forms, Intake Forms - ER easiest, Medical History Questionnaires, Informed Consents
Think of Mr. Bell - your heart pounds when facing the nightmare of a form to fill out that he cannot read.. Think of Mr. Bowman, who ends up in an emergency room because he cant fill out the form and is too embarrassed to ask for help. Emergency rooms are easier on these patients, because someone else asks the questions and fills out the forms!
Diagnosis: Patient provides mistaken information, Patient misunderstands physicians questions, Physician misunderstands patient
Mr. Day doesnt think he has hypertension. Mrs. Irwin says one of her medications is Lithium when it is really Lipitor. If the doctor didnt have the actual bottle to read the label and just took her name for the medicine, he could assume she had a diagnosis of manic depression rather than hyperlipidemia.
Ask, What barriers do you have in your patient-care environment?
Treatment: Misunderstandings of treatment directions may lead to serious mistakes or non-compliance
Mrs.Tilsey understands what she needs to do, but because she only recognizes the drugs by a few letters, and since she cannot read the names, she can mix up similar looking drugs and end up taking two tranquillizers instead of 1 tranquillizer and 1 Accolite
Gather ideas from participants and use the next slide or a flipchart to record them.
Before you leave today, pick one of the barriers that your patients are faced with, and decide on something you will do to remove the barrier.
Transition: We have learned a lot over the last decade about health literacy. And we are trying to address the problem in a variety of ways. To close this overview module we would like to suggest some guiding principles as you go forward in your own practice/setting
60. (0:54)
Provide easy-to-understand information for ALL patients.
Ensure the environment is patient-friendly and shame-free for ALL patients.
All patients, not just those with low health literacy, will benefit from these guidelines.
Transition: Keeping these guiding principles in mind, we will examine and practice some of the best practices and techniques demonstrated in the video in the subsequent modules of the workshop
(0:54)
Provide easy-to-understand information for ALL patients.
Ensure the environment is patient-friendly and shame-free for ALL patients.
All patients, not just those with low health literacy, will benefit from these guidelines.
Transition: Keeping these guiding principles in mind, we will examine and practice some of the best practices and techniques demonstrated in the video in the subsequent modules of the workshop
61. What have other docs tried? Medication reviews helped to identify and address health literacy problems
Maps on the back of appointment letters cut down on no shows
Maps on the back of requisition slips increased completed lab work
Organized, simplified pre-op instructions, both written and verbal, cut surgical same-day cancellations from 5% to 0.8%
This slide builds.
Anecdotal reports from 2 years of AMA Foundation health literacy awareness initiative include:
Of 25 patients I saw today, 9 had health literacy problems - identified through medication review.
We put maps on the back of mailed appointment letters and cut down our no shows
Maps on the back of requisition slips increased completed lab work.
Organized, simplified pre-op instructions, both written and verbal, have cut surgical same-day cancellations (due to poor pre-op preparation such as eating instead of being NPO, no bowel preparation, etc.) from 5% to 0.8%!
(More on these in Module 2.)
Transition: This brings us to the end of Module 1. We hope that this last hour has motivated you to learn more about this important topic. Thank you for your participation!
This slide builds.
Anecdotal reports from 2 years of AMA Foundation health literacy awareness initiative include:
Of 25 patients I saw today, 9 had health literacy problems - identified through medication review.
We put maps on the back of mailed appointment letters and cut down our no shows
Maps on the back of requisition slips increased completed lab work.
Organized, simplified pre-op instructions, both written and verbal, have cut surgical same-day cancellations (due to poor pre-op preparation such as eating instead of being NPO, no bowel preparation, etc.) from 5% to 0.8%!
(More on these in Module 2.)
Transition: This brings us to the end of Module 1. We hope that this last hour has motivated you to learn more about this important topic. Thank you for your participation!
62. What is HealthEast doing?
This slide builds.
Anecdotal reports from 2 years of AMA Foundation health literacy awareness initiative include:
Of 25 patients I saw today, 9 had health literacy problems - identified through medication review.
We put maps on the back of mailed appointment letters and cut down our no shows
Maps on the back of requisition slips increased completed lab work.
Organized, simplified pre-op instructions, both written and verbal, have cut surgical same-day cancellations (due to poor pre-op preparation such as eating instead of being NPO, no bowel preparation, etc.) from 5% to 0.8%!
(More on these in Module 2.)
Transition: This brings us to the end of Module 1. We hope that this last hour has motivated you to learn more about this important topic. Thank you for your participation!
This slide builds.
Anecdotal reports from 2 years of AMA Foundation health literacy awareness initiative include:
Of 25 patients I saw today, 9 had health literacy problems - identified through medication review.
We put maps on the back of mailed appointment letters and cut down our no shows
Maps on the back of requisition slips increased completed lab work.
Organized, simplified pre-op instructions, both written and verbal, have cut surgical same-day cancellations (due to poor pre-op preparation such as eating instead of being NPO, no bowel preparation, etc.) from 5% to 0.8%!
(More on these in Module 2.)
Transition: This brings us to the end of Module 1. We hope that this last hour has motivated you to learn more about this important topic. Thank you for your participation!
63. Review: Five steps to enhance your interactions with patients 1. Conduct patient-centered visits
2. Explain things clearly in plain language
3. Focus on key messages and repeat
4. Use a teach back or show me technique to check for understanding
5. Use patient-friendly educational materials to enhance interaction. (0:33) Purpose: To quickly review the 5 steps and set the stage for the last activity.
We have covered these 5 steps for enhancing patient interaction. (Go through very quickly or just have the participants read the slide. You should not spend more than 30 seconds on this slide.)
Transition: Now we have an activity that will give you a chance to practice putting all of this together. But before we start the activity, do you have any questions?(0:33) Purpose: To quickly review the 5 steps and set the stage for the last activity.
We have covered these 5 steps for enhancing patient interaction. (Go through very quickly or just have the participants read the slide. You should not spend more than 30 seconds on this slide.)
Transition: Now we have an activity that will give you a chance to practice putting all of this together. But before we start the activity, do you have any questions?
64. Summary: Specific strategies to enhance health literacy
Create a shame-free environment
Enhance assessment strategies
Improve interpersonal communication with patients
Create and use patient-friendly materials
Note: This slide builds.
As we saw on the video, these are the key strategies that will help you enhance the health literacy of your patients:
Creating a shame-free environment (Module 2)
Improving assessment strategies (Module 2)
Improving interpersonal communication with patients (Module 3)
Creating and using patient-friendly written materials (Module 3)
In the next sections of the workshop we will focus more specifically on each of these areas.
Transition: We already know there are some things we can do to help remove barriers for patients
Note: This slide builds.
As we saw on the video, these are the key strategies that will help you enhance the health literacy of your patients:
Creating a shame-free environment (Module 2)
Improving assessment strategies (Module 2)
Improving interpersonal communication with patients (Module 3)
Creating and using patient-friendly written materials (Module 3)
In the next sections of the workshop we will focus more specifically on each of these areas.
Transition: We already know there are some things we can do to help remove barriers for patients
