Addressing Health Literacy & Health Communication to Improve Blood Pressure Management

1. Addressing Health Literacy & Health Communication to Improve Blood Pressure Management Russell L. Rothman MD MPP April 10, 2010 Associate Professor, Internal Medicine & Pediatrics Director, Program on Effective Health Communication Chief, Internal Medicine & Pediatrics Section Vanderbilt University Medical Center

2. UNC Michael Pignone MD MPH Darren DeWalt MD MPH Eliana Perrin MD MPH Morris Weinberger PhD John Buse MD PhD CDE Robb Malone PharmD CDE Betsy Bryant PharmD CDE Victoria Hawke Britton Crigler BS James Joyner BA LSU Terry Davis PhD Vanderbilt Tom Elasy MD MPH Robert Dittus MD MPH Kerri Cavanaugh MD MPH Mimi Huizinga MD MPH Dianne Davis RD CDE Becky Gregory RD CDE Ken Wallston PhD Ayumi Shintani PhD Tebeb Gebretsadik MPH Lynn Fuchs PhD Marlon Fielder BS, Rachel Garton BS, Erica Russell BA Jessica Sparks, Ryan Housam, Hilary Weiss Disha Kumar, Thomas Spain, Sara Deery Vanderbilt DRTC Meharry Richard White MD Acknowledgements • Previous Funding Support: RWJ Clinic Scholars Program, UNC Department of Medicine, Vanderbilt Diabetes Center, Vanderbilt DRTC, Vanderbilt Center for Health Services Research, Pfizer Clear Health Communication Initiative, ADA( Novo Nordisk) • Current Funding Support: NIDDK (K23, R03), Project Diabetes (Tenn), AADE, NICHD (R01)

3. Outline of Talk • Adequacy of current BP care • What is health literacy and numeracy? • Scope of problem • How to diagnose low literacy • What can you do to address literacy and improve your health communication? • Interventions for low literacy and numeracy

4. HTN Management Hajar, JAMA 2003

5. Quality of HTN management in the U.S. EA McGlynn, N Engl J Med 2003;348:2635-45.

6. Quality of CV Care in TN Dashboard on Health Care Quality Compared to All States AHRQ National Healthcare Quality Report, 2008 (http://statesnapshots.ahrq.gov/snaps08/clinicalarea.jsp?menuId=19&state=TN&level=16)

7. Why inadequate care? Community System • Cultural beliefs • Access to Care • Access to Diet • Access to Exercise • Environmental Factors • Insurance • Focus on Acute Care • Lack of EMR • Bureaucracy Provider Patient Knowledge Attitudes/Beliefs Behaviors/ Adherence/ Cost Health Literacy Knowledge Attitudes/Beliefs Behaviors Health Communication Skills

8. Concern about Literacy and Numeracy Skills

9. What is Literacy? • Literacy: “ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop ones knowledge and potential” • Health Literacy: “The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”

10. Literacy Cultural and Conceptual Knowledge Listening Speaking Writing Reading Numeracy Oral Literacy Print Literacy Components of Literacy IOM, Health Literacy, 2004

11. Numeracy • A component of overall literacy • “The ability to understand and use numbers and math skills in daily life” • Includes: calculations, interpretation of graphs/labels, time, probability, ability to deduce when and what math is needed for a given situation.

12. Numeracy vs Literacy • Highly correlated with literacy, but not perfect Calvin and Hobbs, Bill Watterson, Universal Press Syndicate, Released on: Friday, Oct 10th 1986.

13. Who has poor literacy/numeracy ? • NALS (1992) and NAAL (2003) • 40-44 million Americas are functionally illiterate • 50 million have marginal literacy & numeracy skills • Average American reads at 8th-9th grade level • Quantitative skills are often worse • Worse literacy skills among minorities, and the elderly

14. Why is literacy/numeracy important in chronic illness care? • Literacy skills needed in chronic care: • Knowledge of disease • Understand educational materials • Performance of self-management tasks • Interact with medical system • Numeracy skills needed: • Nutrition, food labels, portion sizes • Glucose monitoring, carbohydrate counting, Insulin • Understand dose and timing of medications • Interpret weights, fluid status

15. What is it really like for patients? • Video #1 and discussion (Clip_1)

16. Audience Response Question

17. Outcomes Associated with Literacy Behaviors Only Substance abuse Breastfeeding Behavioral problems Adherence to medication Smoking Knowledge Only Birth control knowledge Cervical cancer screening Emergency department instructions Asthma knowledge Hypertension knowledge • Health Outcomes/Health Services • General health status • Hospitalization • Emergency department use • Prostate cancer stage • Depression • Diabetes control • HIV control • Mammography • Pap smear • Pneumococcal immunization • Influenza immunization • STD screening • Cost DeWalt, JGIM 2004

18. Literacy and Diabetes Outcomes Schillinger, JAMA, 2002

19. Looking Closer at Literacy and Numeracy

20. Understanding Medications

21. What Does this Picture Mean? • “Someone swallowed a nickel” • “ Indigestion” • “Bladder” • “Looks like a ghost- Casper” *Wolf M, Davis T. Am J Health System Pharm. 2006 * Davis T, Wolf M. JGIM. 2006

22. Does Adding the Words Help? • “Chew pill and crush before swallowing” • “Chew it up so it will dissolve, don’t swallow whole or you might choke” • “Just for your stomach” 46 % of patients with low literacy understood these instructions

23. What Does This Picture Mean? • “Somebody is dizzy” • “Don’t touch this stuff” • “Take anywhere” • “Chills or shaking” • “Having an experience with God”

24. Adults Struggle With Decoding • “Use extreme caution in how you take it” • “Medicine will make you feel dizzy” • “Take only if you need it” 8% of patients with low literacy understood this instruction

25. “How would you take this medicine?” • 395 primary care patients in 3 states • 46% did not understand instructions ≥ 1 labels • 38% with adequate literacy missed at least 1 label * Davis, Wolf, Bass, Parker. Ann Intern Med. 19 Dec, 2006

26. John Smith Dr. Red Take two tablets by mouth twice daily. Benazepril 20mg 1 refill Medication and Numeracy “Show Me How Many Pills You Would Take in 1 Day” 71 35 * Davis, et al. Ann Intern Med. 2006

27. More Precise Labels Aid ComprehensionInstructions that require interpretation are poorly understood *p<0.001, ‡ p<0.01 * Davis T. J Gen Int Med, 2008

28. Example • Video #2 (Clip_2)

29. Labels are often not clear. Mistakes are more common the more medications a patient takes. Ability to read the Rx label does not guarantee ability to understand and act on the instructions. Conclusions

30. Diabetes and Numeracy Study • Cross sectional survey in Endocrine and Primary Care Clinics Huizinga et al, BMC Health Services Res, 2008 Cavanaugh et al, Annals of Internal Medicine, 2008

31. Diabetes Numeracy Test Results • Mean score on Diabetes Numeracy Test: 61% (range 5%-100%) • Trouble Spots • Interpreting serving sizes • Fractions or decimals • Applying multi-step regimens (ex. sliding scale and carb-ratios) • Applying titration instructions

32. Serving Size • If you ate the entire bag of chips, how many total grams of carbohydrate would you eat? Correct Response: 63 gms Correct: 44%

33. Insulin Correction Scale (I) • You are told to follow the sliding scale shown here. The sliding scale indicates the amount of insulin you take based upon your blood sugar levels: • Percent Correct:85%

34. Insulin Correction Scale (II) After seeing the Doctor, you are given the following instruction to lower a high blood sugar level before a meal: “Starting with a blood sugar of 120, take 1 unit of Humalog insulin for each 50 points of blood sugar.” How much insulin should you take for a blood sugar of 375? ANSWER _________ units Percent Correct: 37% (accept 5-6 units)

35. DNT and other measures • Higher DNT scores are sig. correlated with higher: • education (r=0.51) • literacy (r=0.50) • math skills (r=0.64) • diabetes knowledge (r=0.78) • Frequency of glucose monitoring (r=0.21) • Self-efficacy (r=0.15) • And modestly correlated with lower: • A1C (r=-0.11 in adjusted analysis)

36. Challenges for Patients • Video #3 and discussion (Clip_3)

37. Audience Response Question

38. Identifying Patients with Low Literacy

39. Assessing Literacy Status • Not Reliable • Asking directly • Asking educational status • Quick Techniques • Pill bottle • Signing name • Red Flags (Missed Appts, noncompliance, etc) • Validated Techniques • REALM • TOFHLA • The Newest Vital Sign • WRAT, SORT, PIAT

40. Communicating: What can you do? • Use low literacy and picture based materials • Individualized education • Teach concepts in a simplified manner • Use teach back technique

41. Low literacy Information • Most patient information is written at or above the 10th grade levels • Low literacy materials can improve patient knowledge and outcomes. • When making materials: • Avoid pathophysiology and jargon and focus on key concepts/actions. • Use figures to simplify text • Increase white space • Try to write for the 4th-6th grade level • Use SMOG, FRY, Flesh-Kincaid Methods to assess your materials

42. Resources for Low Literacy Material • Writing your own: • http://www.pfizerhealthliteracy.com/ • http://www.ama-assn.org/ama/pub/category/8115.html • http://www.chcs.org/resource/hl.html • http://www.usability.gov/ • Available Materials: • http://www.fda.gov/opacom/lowlit/englow.html • http://www.nlm.nih.gov/medlineplus/healthtopics.html (click on easy to read) • www.niddk.nih.gov/health/eztoread.htm#dia • http://diabetes.niddk.nih.gov/dm/a-z.asp

43. Educational Materials

44. Educational Materials

45. Clarifying Prescriptions http://picturerxcard.com/

46. Teaching Concepts • Limit advice to key concepts. Focus on behaviors and actions • Simplify concepts • Focus on one concept at a time; partition information • Use concrete terms and examples • Make info culturally relevant and personal • Avoid Jargon!

47. Clinician Assesses Patient recall and Comprehension New Concept: Health Information, Advice, or Change in Management Clinician Explains New Concept Patient Recalls and Comprehends Clinician Clarifies and Tailors Explanation Adherence Clinician Reassesses Patient Recall and Comprehension Teachback technique Schillinger, Arch Int Med, 2003

48. Shared Goal Setting • Let family initiate • Practice “reflective” listening” • Provide affirmation of positive behaviors • Show empathy for challenges • Choose goal that is realistic and attainable • Can offer a few choices and settle on goals together • Roll with resistance (don’t challenge patients who resist change; instead ask them to come up with solutions) • Make sure patient is committed/ready to change • Be concrete • Set a time for accomplishing goal • Let them know it is up to them to make change! • Promote a “you can do it” approach!

49. Shared Goal Setting

50. Cultural Challenges forCommunication • Language • Patients with Limited English proficiency • Use professional interpreters or language line. Speak to the patient! • Use of language appropriate materials • Family Structure • Consider role of spouses and other social support • Health Beliefs • Dissonance from the “biomedical model”