Addressing Health Literacy and Health Communication in Diabetes and Obesity

1. Addressing Health Literacy and Health Communication in Diabetes and Obesity Russell L. Rothman MD MPP Associate Professor, Internal Medicine & Pediatrics Director, Center for Health Services Research Chief, Internal Medicine/Pediatrics Section Co-Director, Community Engaged Research, VICTR Associate Director, Center for Diabetes Translational Research Vanderbilt University Medical Center

2. Presenter Disclosure Disclosed no conflict of interest.

3. Why inadequate diabetes care? Community Cultural beliefs Access to Care Access to Diet Access to Exercise Environmental Factors System Insurance/Financing Focus on Acute Care Lack of EMR Bureaucracy Quality Patient Physiology/genetics SES factors Knowledge/Attitudes/Beliefs Behaviors/ Adherence Health Literacy Provider Knowledge Attitudes/Beliefs Behaviors Incentives Health Communication Skills

4. Increasing Concern about Literacy and Numeracy Skills

5. Literacy Cultural and Conceptual Knowledge Listening Speaking Writing Reading Numeracy Oral Literacy Print Literacy Literacy is a Complex Skill IOM, Health Literacy, 2004

6. Poor Health Literacy is Common • Health literacy: “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” • Over 90 million Adult Americans have poor literacy skills and over 110 million have poor quantitative skills • Difficulty navigating health system, understanding materials and recommendations, performing self-care, etc.

7. Numeracy is an Important Component • “The ability to understand and use numbers and math skills in daily life” • Calculations, deduction/logic, interpretation of graphs/labels, time, probability, etc. • Highly correlated with literacy, but not perfect Calvin and Hobbs, Bill Watterson, Universal Press Syndicate, Released on: Friday, Oct 10th 1986. Rothman et al, J Health Comm, 2009

8. Why is literacy important in health care and research? • Patients with low literacy have: • Trouble reading prescriptions, following medical instructions • Trouble understanding educational materials • Trouble interpreting and applying numbers to health situations • Trouble consenting to research or procedures • Difficulty answering survey items or other measures • Difficulty following research protocols

9. Why is numeracy important in health care? • Patients with low numeracy may have trouble: • Understanding dosages of medications • Understanding the timing of when to take medications or have them refilled • Interpreting nutritional information • Understanding volume status • Interpreting blood sugars, adjusting insulin • Understanding risks and probability

10. What it is like for patients…

11. Many Outcomes Associated with Literacy Health Outcomes/Services • General health status • Hospitalization • Mortality • Emergency department use • Depression • Diabetes control • HIV control • Prostate Cancer Stage • BMI • Mammography • Pap smear, STD Screening • Immunizations • Cost Behaviors • Breastfeeding • Behavioral problems • Adherence to medication • Smoking, Substance abuse Knowledge • Food label and portion size understanding • Birth control knowledge • Emergency department instructions • Asthma knowledge • Hypertension knowledge DeWalt, JGIM 2004 McCormack, Annals of Internal Medicine 2011

12. Literacy/Numeracy & Diabetes • Literacy skills needed: • Knowledge of disease prevention and disease • Understanding of educational materials • Performance of self-management tasks • Interaction with medical system • Numeracy skills needed: • Understanding of risk and probability • Understanding weight status • Understanding medications • Understanding nutrition information • Understanding exercise • Interpreting glucose and other measures

13. Literacy and Diabetes Outcomes Schillinger, JAMA, 2002

14. Numeracy and Food Labels

15. Study Design • Design: Cross sectional survey • Setting: Primary care clinic • Instruments: • Demographics • Food Label Usage and Attitudes • Assessed literacy with REALM • Assessed numeracy with WRAT3 • 26 item food label survey Rothman et al, AM J Prev Med, November 2006

16. Demographics

17. Literacy, Numeracy, Food Labels

18. Calculating Fiber Intake • How many grams of dietary fiber are in 5 candies? • Correct Response: 1 gram • Percent Correct 66 %

19. Nutrition Score by Characteristics

20. Nutrition Score Correlations • Higher performance on the food label survey was significantly correlated with: • Higher education (r=0.44) • Higher income (r=0.56) • Higher literacy (r=0.52) • Higher numeracy (r=0.67)

21. Conclusions • Patient comprehension of food labels was fair. • Comprehension was worse when patient needed to apply serving sizes, or perform multi-step math. • Comprehension was worse for patients who were obese or had chronic illness • Comprehension was highly correlated with math and literacy skills

22. Literacy, Numeracy, Food Labels

23. Portion Size Study 20 Years Ago Today • Enrolled 164 pts • Asked to serve “single serving” of 4 items, and then told to serve actual amount (in oz or grams) • 2/3 had inaccurate estimation of portion sizes • Poor estimation linked with literacy and numeracy 500 calories 1,025 calories 333 calories 590 calories 85 Calories 250 Calories Huizinga et al, Am J of Prev Med, 2009

24. Numeracy and Diabetes

25. Diabetes and Numeracy Study • Design: Cross sectional survey • Setting: Endocrine and Primary Care Clinics • Instruments: • Demographics • A1C and Meter Downloads • Assessed literacy with REALM • Assessed math skills with WRAT3 • Diabetes Knowledge (DKT), Self Care (SSCA) • Assess diabetes numeracy with DNT Cavanaugh et al, Annals of Internal Medicine, 2009

26. Demographics

27. Overall DNT Results • Mean score 61% (SD 25%) • Range 5%-100% • Internal Reliability: 0.95 • Trouble Spots • Interpreting serving sizes • Fractions or decimals • Applying multi-step regimens (ex. sliding scale and carb-ratios) • Applying titration instructions

28. 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%

29. Monitoring • Your target blood sugar is between 60 and 120. Please circle the values below that are in the target range (circle all that apply): 55 145 118 Correct Response: Circle 118 only Percent Correct: 74%

30. 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%

31. 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? 43. ANSWER _________ units Percent Correct: 37% (accept 5-6units)

32. 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) and lower: • A1C (r= -0.08, p =0.11) • In multivariate analysis, each 10 point increase in DNT score was correlated with a 0.1 point decrease in A1C (p<0.05).

33. Conclusions • Performance on DNT was fair/poor • Disconnect between what is taught and what patients can do. • Performance on DNT was correlated with literacy and math skills. • Performance on DNT was also correlated with A1C, when adjusted for other covariates.

34. Communicating: What can you do? • Use low literacy and picture based materials • Individualize education • Teach concepts in a simplified manner • Use teach back technique • Address cultural issues • Shared goal setting

35. Sample Low Literacy Materials

36. Teaching Concepts • Limit advice to key concepts. Focus on behaviors and actions • Focus on one concept at a time; partition information • Use concrete terms and examples • Make info culturally relevant and personal • Avoid Jargon! • Practice patient centered communication and shared goal setting

37. 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

38. Cultural Challenges Language Use Language Appropriate Handouts Use a translator! Family Structure Multiple caregivers Health Beliefs Dissonance from the “biomedical model” Campinha-Bacote, 2003

39. Shared Goal Setting • Let patient or 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) • Assess their confidence in achieving the goal • 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!

40. Literacy Interventions

41. Initial Diabetes Intervention 6 Month Follow-Up 1 Year Follow-Up Baseline 105 Control 99 Control 95 Control 217 Patients with T2DM Initial Pharmacist Session R 112 Interv. 105 Interv. 98 Interv.

42. Intervention • Diabetes Education • Evidence-based medication algorithms • Database to track and manage patient outcomes • Diabetes Care Coordinator • Addressed literacy by using: • Individualized verbal education • Low literacy material • Teaching concepts in a simplified manner • “Teach back” techniques to confirm learning

43. Significant Clinical Improvements at 12 months Rothman AM J Med, 2005

44. Literacy was an Important Factor High Literacy Patients Low Literacy Patients

45. Diabetes and Numeracy RCT

46. DLNET Toolkit Text at 5th grade reading level Color coding Pictures for key concepts Step-by-step instructions Simplified medication instructions Practice skills worksheets 46 Wolff K et al. The Diab Educ 2009

47. Study Demonstrates Value of Addressing Health Literacy *P = 0.03 *Adjusting for age, gender, race, type of diabetes, income level, site of intervention and baseline DNT score and Hba1c levels 47 Cavanaugh KL et al. Diabetes Care 2009

48. Diabetes Nutrition Education Study (DINES)

49. Carb Counting vs Plate Method 49

50. Results Demonstrate Value of Simpler Diabetes Education