View
212
Download
0
Category
Tags:
Preview:
Citation preview
1
Learning Theories and Health Literacy
PTP 783
2
1. Review learning theories
2. Discuss a framework in which learning can occur in Geriatric PT practice.
3. Discuss how health literacy impacts Geriatric PT practice.
4. Identify strategies to address assessing health literacy in verbal and written communications.
Objectives
3
Can a patient learn anything a physical therapist tells them if they are not ready to learn?
What are the barriers to learning?
4
“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
Health Literacy
5
Population >65
Non-English Speaking
Medications Prescribed
Specialists
Hospital Stay Length
Time spent with
Patients
Reimburse-ment
The Health Care System is Becoming More Complex
More Self Management in the Home
6
The complexity of the healthcare system exacerbates literacy
vulnerabilities
Payment structures
Testing
Appointments & Referrals
We Have a Problem:
7
“Every system is perfectly designed to get the results it gets”
“The definition of insanity is continuing to do the same thing over and over again and expecting a different result”
−Albert Einstein
8
“As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve.
Health care professionals do not recognize that patients do not understand the health information we are trying to communicate.
We must close the gap between what health care professionals know and what the rest of America understands.”
Dr. Richard Carmona,U.S. Surgeon General 2002-2006
9
General literacy Experience with health care system Complexity of information Cultural and language factors:
◦ ESL◦ Cultural experience
How information is communicated Aging and disease/treatment factors
Factors contributing to low health literacy
10
Fills out intake forms incompletely
Misspelling many words
Leaves the clinic before completing forms
Gets angry about forms
Identifies medication by looking at pill rather than reading the label
Informal methods to assess health literacy
Weiss BD. Health literacy: a manual for clinicians. 2003
11
n = 19,714
● Most up to date portrait of literacy in U.S.
● Scored on 4 levels
● Levels 1 and 2 cannot:
◦ Use a bus schedule or bar graph
◦ Explain the difference in two types of employee benefits
◦ Write a simple letter explaining an error on a bill
National Assessment of Adult Literacy (NAAL)*
National Center for Educational Statistics, U.S. Department of Education
12
13
14
15
Outcomes Associated with Health Literacy
Health Outcomes/Health Services
• General health status• Hospitalization• Prostate cancer stage• Depression• Asthma• Diabetes control• HIV control• Mammography• Pap smear• Pneumococcal immunization• Influenza immunization• STD screening
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
DeWalt, et al. JGIM 2004;19:1228-1239
16
90 million Americans have trouble understanding & acting on health information
Unfamiliar/complex text most difficult to read
3 billion Rx written a year
Pharmacist/physician time is limited
Elderly fill 30 Rx/year, see 8 physicians, on average
Patient SafetyMedication error: most common medical mistake
17
“How would you take this medicine?”
• 46% did not understand instructions ≥ 1 labels
• 38% with adequate literacy missed at least 1 label
395 primary care patients in 3 states
Davis TC , et al. Annals Int Med 2006, slide by T Davis
18
“Show Me How Many Pills You Would Take in 1 Day”
John Smith Dr. Red
Take two tablets by mouth twice daily.
Humibid LA 600MG1 refill
Slide by Terry Davis
71
8089
63
84
35
Davis TC , et al. Annals Int Med 2006 19
20
People with low literacy have 30-70% increased risk of hospitalization
RR = 1.29 (1.07-1.55) Medicare Managed Care
RR = 1.69 (1.13-2.53) Urban Public Hospital
Adult Hospitalization
*Adjusted for age, gender, socioeconomic status, health status, and regular source of care.
Baker et al. AJPH. 2002. 92:1278.
Baker et al. JGIM. 1998. 13:791.
21
Literacy and Mortality
Sudore et al. JGIM 2006; 21: 806-812
Health, Aging, and Body Composition Study
22
Simple Familiar Wording Understood by Most Patients
84%
(1st grade.)
Slide by Terry Davis
23
More Complex Message Limited Comprehension
59%
(10th-12th grade.
Slide by Terry Davis
24
Unfamiliar Multi-step Instructions Rarely Understood
8%
(12th-13th grade)
Slide by Terry Davis
25
Comprehension Increased with Patient Literacy Level
In multivariate analysis only literacy and age predicted comprehension.
Patients with low literacy (< 6th gd.) 3x more likely to incorrectly interpret warning labels.
<6 7-8 >9
79% 86% 88% †
35% 66% 78% *
8% 64% 82% *
8% 18% 23% *
0% 6% 15% *
* p<.0001, †
p<.05
Davis et al. JGIM 2006; 21:847–851.
% with a correct response
26
Rapid Estimate of Adult Literacy in Medicine (REALM)
Test of Functional Health Literacy in Adults (TOFHLA)
The Newest Vital Sign (NVS): ◦ recently developed and tested
Common Instruments
27
Word recognition and pronunciation
Read aloud a list of 66 medical words
Takes 2-3 minutes to administer
Highly correlated with other standard tests of reading ability (0.88-0.97)
Does not test comprehension
Not available in other languages
REALM (Rapid Estimate of Adult Literacy in Medicine)
28
fatflupilldoseeyestresssmearnervesgermsmealsdiseasecancercaffeineattackkidney
hormonesherpesseizurebowelasthmarectalincest
fatiguepelvicjaundiceinfectionexercisebehavior
prescriptionnotify
gallbladdercalories
depressionmiscarriagepregnancyarthritisnutritionmenopauseappendixabnormalsyphilis
hemorrhoidsnauseadirected
allergicmenstrualtesticlecolitis
emergencymedicationoccupationsexuallyalcoholismirritation
constipationgonorrheainflammatorydiabeteshepatitisantibioticsdiagnosispotassiumanemiaobesity
osteoporosisimpetigo
REALM
Prevention & Patient Education ProjectTerry Davis, PhDP.O. Box 33932Shreveport, LA 71130-3932
29
17 numeracy items
50 reading comprehension items
Tests ability to read and understand several health care related items
Takes 20-30 minutes to administer
Best for research purposes
Well correlated with REALM and WRAT (Wide Range Achievement Test)
Available in Spanish
TOFHLA (Test of Functional Health Literacy in Adults)
30
Doxycycline100 MGTake medication on empty stomach one hour before or two hours after a meal unless otherwise directed by your doctor.
If you eat lunch at 12:00 noon, and you want to take this medicine before lunch, what time should you take it?
Sample TOFHLA Numeracy Question
Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)
31
Your doctor has sent you to have a _________ X-ray.
a. stomachb. diabetesc. stitchesd. germs
You must have an ________ stomach when you come in.
a. asthmab. emptyc. incestd. anemia
Sample TOFHLA Reading Comprehension
Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)
32
High correlation between first two reading comprehension passages and entire assessment (including numeracy items)
Administer only the first two reading comprehension passages
Takes 5-7 minutes
Short-TOFHLA
33
REALM vs. TOFHLA
REALM TOFHLA
Word recognition Cloze method
2-3 minutes 5-7 minutes
Grade levels Inadequate/marginal/adequate
English only English and Spanish
34
Patients are given a nutrition label
6 questions are verbally administered
Assesses literacy and numeracy
Takes 3 minutes
Validated against the TOFHLA
Available in English and Spanish
The Newest Vital Sign (NVS)
Weiss et al., Ann Fam Med; 3(6) 2005
35
NVS: Example Question
If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?
Weiss et al., Ann Fam Med; 3(6) 2005
Available at Pfizer Clear Communication Initiative: http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html
36
REALM vs. NVS
REALM NVS
Word recognition Problem-solving
2-3 minutes 3 minutes
Grade levels Number correct (1-6)
English only English and Spanish
37
If just for screening, the REALM is likely the best choice
◦ Easiest to explain to patients◦ Fastest◦ Reasonably accurate
For research purposes, REALM is good, but may consider other instruments depending on goal of research
Which Instrument Should I Use?
38
Sensitive topic
Patients go to great lengths to hide problems
May offend some
Inappropriate labeling
Problems with Measuring Health Literacy
39
40
Raise awareness among providers Develop easier to read materials
◦ Including your brochures- readability assessment Improve communication skills Practice-redesign Literacy training / adult education
Interventions to Improve Health Outcomes for Patients with Low Literacy
41
Good health information is hard to come by
Most written at too high of a reading level
Few health care systems have comprehensively integrated educational materials in their overall care plans
Educational Materials
42
Teach-back method
Patient centered learning◦ What is required of them to learn
Survival skills◦ What pt. needs to know in order to get through session.◦ 3-5 things that are need to know
Ask Me 3◦ Three questions about topic
Therapeutic alliance
Repetition/reinforcement
Educational Strategies
Understanding
Clarify
Assess
Explain
43
Teach-back
44
Speaking or writing in every day language
Limit & organize the information◦ Get the message quickly and clearly ◦ Makes sense
Focus on behaviors & be realistic
Use carefully phrased words as there is a tendency to take words literally
3-5 ‘need to know’ points
Plain Language
45
Frame the message: tell them what you are going to tell them before you do.
Give specific examples and real world examples.
Use analogies for key points.
Use repetition, rephrasing and interactivity
Verify understanding with teach-back technique.
Plain language
46
Every MS Office product has this capability
Your brochures will be tested for readability
Other resources: see the BB shell
Readability
47
Chew et al in 2004:Used 16 health literacy screen questions on a 5 pt
Likert scale followed by S-TOFHLA (n=322)3 questions were effective:
1. How often do you have someone help you read hospital materials?
2. How confident are you filling out medical forms by yourself?
3. How often do you have problems learning about your medical conditions because of difficulty understanding written information?
Wallace followed up in 2006 identifying just the second question above was most accurate with detecting limited health literacy skills (83.3% sensitivity).
-more accurate than a screen of demographicS
48
Should we measure literacy and target interventions or should we institute “universal precautions”?
When low health literacy is identified, what do we do?
Is it enough to recognize that many patients have this problem?
Some Issues
49
Extras…..
50
What do you call your problem? What name does it have?
What do you think caused your problem? Why do you think it started when it did? What does your sickness do to you? How does it work? How severe is it? Will it have a short or long course? What do you fear most about your disorder? What are the chief problems that your sickness has
caused for you? What kind of treatment do you think you should
receive? What are the most important results you hope to
receive from the treatment?
Kleinman’s Tool to Elicit Health Beliefs
Dr. Arthur Kleinman, Patients and Healers in the Context of Culture.The Regents of the University of California. 1981
Recommended