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Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

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Page 1: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University
Page 2: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Can you read this?Can you read this?

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

Page 3: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

How many adult Americans have difficulty How many adult Americans have difficulty reading and understanding health reading and understanding health

information?information?

A. 9 million

B. 90 million

C.50 million

D.Fewer than 1 million

Page 4: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Definition of Health LiteracyDefinition of Health Literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

It involves the ability to use and interpret text, documents and numbers effectively

Page 5: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

The Scope of Low Health LiteracyThe Scope of Low Health Literacy

In 2003, the National Assessment of Adult Literacy (NAAL)

90 million Americans (39% of adults) have limited health literacy

One in five adults read at the 5th grade level or below.

Average American reads at the 8th to 9th grade level

More than 66% of US adults age 60 and over have inadequate or marginal literacy skills

Page 6: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Examples of Health Literacy TasksExamples of Health Literacy Tasks

Proficient Skills: 13%

`Calculate employee’s share of health insurance cost for year using a table on monthly cost

Intermediate Skills: 53%

Determine timing, administration and interactions based on info from drug label

Basic Skills: 22%

Give 2 reasons why a person with no symptoms should be screened based on a clearly written pamphlet

Below basic skills: 14%

Circle date of medical appointment on hospital appointment slip

Page 7: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Who is at risk for low health literacy?Who is at risk for low health literacy?

A. Elderly

B. Ethnic Minorities

C. Those with low income and education levels

D. Those with high income and education

E. A, B, and C

F. All of the above

Page 8: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Highest Risk for Limited Health Highest Risk for Limited Health LiteracyLiteracy

Elderly

Low income

Unemployed

Did not finish high school

Minority ethnic group (Hispanic, African American)

Recent immigrant to US who does not speak english

Born in US but English is 2nd language

Page 9: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Health System Problems Encountered by Health System Problems Encountered by Persons with Limited Literacy SkillsPersons with Limited Literacy Skills

26% Did not understand when their next appointment was scheduled

42% Did not understand instructions: “take medication on an empty stomach”

78% Misinterpret warnings on prescription labels

86% Could not understand rights and responsibilities section of a medicaid application

Page 10: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Impact of Low Health LiteracyImpact of Low Health Literacy

Individuals have less knowledge about their health problems

Make more medication or treatment errors

Fail to seek preventive care

More hospitalizations

Higher health care costs

Less able to “comply” with treatments

Poorer health status

Page 11: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Shame and Health Literacy: the Shame and Health Literacy: the unspoken connectionunspoken connection

Adequate Health Literacy

49% Feel bad/never tell

60% Feel ashamed

94% Hide problem

Low Health Literacy

51% Feel bad/never tell

60% Feel ashamed

78% Hide problem

"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counseling. 1996. 27: 33-39

Page 12: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Who knows you have trouble Who knows you have trouble reading?reading?

Never told:

Spouse

Children

Relatives

Co- workers

Friends

No one

53%

57%

86%

62%

67%

19%

"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counselling.

1996. 27: 33-39

Page 13: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Physician Assessment of Health Physician Assessment of Health LiteracyLiteracy

Physicians often under recognize limited health literacy

Most physicians’ attempt to measure literacy level by their patients highest grade of education

Rely on their patients’ own assessment of their reading skills

Overestimate their patients ability to understand medical information

Often provide information to patients in a level of complexity that patients do not understand

Page 14: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

What can we do?What can we do?

Recognize signs of limited health literacy

Screen for health literacy

Learn clear communication techniques

Educate patients on Ask-Me-3

Page 15: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Ms Kelly GreenMs Kelly Green

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

"

Page 16: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Office VisitOffice Visit

Page 17: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University
Page 18: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Signs (Clues) of Low Health LiteracySigns (Clues) of Low Health LiteracyBehaviors

Forms incomplete or inaccurately completed

Frequently missed appointments

“Noncompliance” with medication regimens

Lack of follow-up with lab tests, imaging or referrals

Responses to written information

“I forgot my glasses. I’ll read this when I get home.”

“I forgot my glasses. Can you read this to me?”

“Let me bring this home so I can discuss it with my children”

Responses to questions about medications

Unable to name medications

Unable to explain what the meds are for

Unable to explain timing of medication administration

Page 19: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

If you suspect Ms. Green’s health If you suspect Ms. Green’s health literacy is limited what screening tests literacy is limited what screening tests

could you perform?could you perform?

Page 20: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Quick Screening Tests for Health Quick Screening Tests for Health LiteracyLiteracy

Single question screens

Assessment instruments

REALM-R: Rapid Estimate of Adult Literacy in Medicine-Revised

NVS: The Newest Vital Sign

Page 21: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Single Question ScreensSingle Question Screens

“How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”

Never Rarely Sometimes Often Always

“How confident are you filling out medical forms by yourself?”

Extremely Quite a bit Somewhat A little bit Not at all

Both been validated in English

The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Prac. 2006;7:21.

Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874-877

Page 22: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

REALM-RREALM-R

Word recognition test consisting of 11 medical terms

1st 3 words are not scored (fat, flu, pill): left to decrease test anxiety and enhance patient confidence

Administration time: <2 minutes

Only available in English

Score of 6 or less considered to be at risk for limited health literacy

Forms and instructions available at www.adultmeducation.com

A Shortened Instrument for Literacy Screening. JGIM 2003; 18:1036-1038

Page 23: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University
Page 24: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

The Newest Vital SignThe Newest Vital Sign

Read and analyze a nutrition label of ice cream

6 questions

Administration time 3 to 5 minutes

Scores:

0-1 Limited literacy

2-3 Possible limited literacy

4-6 Adequate literacy

Page 25: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

The Newest Vital Sign: Ms Kelly The Newest Vital Sign: Ms Kelly GreenGreen

Page 26: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Lets try it out:Lets try it out:

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

Page 27: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University
Page 28: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

NVS: AnswersNVS: Answers

1. 1000 calories

2. Any of the following correct:

1. 1 cup

2. ½ the container

3. 2 servings

3. 33 grams

4. 10%

5. No

6. Because it has peanut oil

Page 29: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Will patients agree to have their literacy Will patients agree to have their literacy skills assessed in clinical practice?skills assessed in clinical practice?

Controlled trial

20 different practices in South Florida

Intervention group: routine literacy assessment with NVS during check in (289)

Control group: No screening (303)

Surveyed at end of visit with Art of Medicine Survey Questionnaire (AMSQ)- validated patient satisfaction survey

Will patients agree to have their literacy skills assessed in clinical practice? Health Ed Res

2008;23(4): 603-611

Page 30: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

ResultsResults

Intervention Group

289 asked to undergo screening

284 agreed (98.3%)

46.1% limited health literacy on NVS screen

271 completed AMSQ

Control Group

303 completed AMSQ

No difference between groups on patient satisfaction

Will patients agree to have their literacy skills assess in clinical practice? Health Ed Res

2008;23(4): 603-611

Page 31: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

How can we communicate with our How can we communicate with our patient better?patient better?

Ms. Green scored a 3

on the Newest

Vital Sign

Page 32: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

CommunicationCommunication

What do patients want?

Clear and simple information

Want to know what they need to do

What health providers provide…

Medical words and complicated explanations

Too much information

Information that is often irrelevant to what patients need to do

Page 33: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

How can you help your patients How can you help your patients understand?understand?

Page 34: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Steps to Improving Communication and Steps to Improving Communication and UnderstandingUnderstanding

Recognize the problem

Eliminate barriers for communication

Confirm that patients understand what they need to understand: teach back

Find a way that works for your patient to understand and remember

Ask me 3

Literature

Written instructions

Page 35: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Open and Shame Free EnvironmentOpen and Shame Free Environment

Adopt an “attitude of helpfulness”

Convey safe and nonjudgmental environment

Plain signage

Be on alert to clues

Page 36: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Eliminate BarriersEliminate Barriers

Hearing and visual impairments

Medical interpreters/ translators

Should be qualified

Visual aids for low literacy

Multi-Media

Interactive Computer programs/TV

Video/audiotape

Body language

Page 37: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Speak in plain languageSpeak in plain language

Use clear and easy to follow language Be specific and use examples Beware of words with multiple

meanings (stool, gait, dressing) and clarify when using

Avoid complicated words and over use of medical jargon

Avoid acronyms and new words (CT scan, RUQ U/S, HDL)

Give them a health context for numbers Encourage questions and take a pause

Page 38: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Taboo: Taboo: A game of “speaking in A game of “speaking in plain language”plain language”

Rules of the game

One person gets a card with a medical term “target word” on it

You need to describe the target word without using the taboo words listed on the card to your group

You can use taboo words if it is immediately defined in layman’s terms

You have 2 minutes to do this

Page 39: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Common medical words that patients with Common medical words that patients with limited literacy may not understandlimited literacy may not understand

Blood in stool

Bowel

Colon

Growth

Lesion

Polyp

Rectum

Screening

Tumor

The role of inadequate health literacy skills in colorectal cancer screening." Cancer Invest.

2001:19:193-2000

Page 40: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

What percentage of patients “forget” what What percentage of patients “forget” what the Doctor told them as soon as they leave the Doctor told them as soon as they leave the office?the office?

A. 80%

B. 50%

C. 10%

D. <10%

Page 41: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Implications for “Not Implications for “Not Understanding” the PhysicianUnderstanding” the Physician

Up to 80% of patients forget what the doctor tells them

50% of what they remember is recalled incorrectly

30% US patients leave their MD’s office with unanswered questions

2 out of 5 do not follow advice because it is too difficult or because they disagree with it

"Patients' memory for medical information," Journal of Royal Society of Medicine2003:96:219-222“Diverse Communities. Common Concerns: Assessing Health care Quality for Minority Americans. The Commonwealth Fund. March 2002.

Page 42: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Convey the important points to Convey the important points to remember!remember!

Page 43: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Verify they understandVerify they understand

Teach Back

Encourage Questions

Ask-Me-3

Page 44: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Verify they understand:Verify they understand:Teach Back ApproachTeach Back Approach

Do not ask a patient, “Do you understand?”

Ask a patient to explain or demonstrate how they will undertake a recommended treatment or intervention.

“I want to be sure that I did a good job explaining your blood pressure medications, because this can be confusing. Can you tell me what changes we decided to make and how you will now take the medication?” Or “Can you explain what I just told you to make sure I covered everything?”

If patient cannot explain correctly, assume that you have not provided adequate teaching. Re-teach the information using alternate approaches.

Page 45: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Teach Back Approach:Teach Back Approach:

Page 46: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Encouraging patients to ask more Encouraging patients to ask more questions during the exam will increase questions during the exam will increase the length of their visit?the length of their visit?

A. True

B. False

British Medical Journal,sept 2002. vol. 325:682-683

Page 47: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Teach your patient to be proactive: Teach your patient to be proactive: What’s Ask-Me-3?What’s Ask-Me-3?

New patient education program designed to promote communication between patient and Health Care Provider to improve health outcomes

Quick and effective tool

Can foster clear communication between provider and patient

Studies have shown that patients who understand health instructions make fewer mistakes taking medication or preparing for a procedure

Study also showed a higher level of satisfaction from patients and a feeling of improved communication using Ask-Me-3 compared to a control group

For downloadable free materials, posters and brochures: www.npsf.org/askme3

www.AskMe3.org

Page 48: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Ask me 3Ask me 3

What is my main problem?

What do I need to do? Why is it

important for me to do this?

Diagnosis

Treatment

Context

Page 49: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Provide Patients with Written Provide Patients with Written Instructions Instructions

Do not abbreviate!

SOB is not a flattering term in layman’s language!

BID does not necessarily mean twice a day.

Add pictures to communicate your points

1/5 adults read at a level below 5th grade; simplify to a lower grade level

Materials should be written in fifth to eighth grade level

Define complicated terms/ limit syllables

Page 50: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Ms. GreenMs. Green

Page 51: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Health Literacy and Psychosocial Health Literacy and Psychosocial issuesissues

Depression/Anxiety

Caregiver stress

Dementia

Limited Health Literacy is a psychosocial issue

Page 52: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Health Literacy and Psychosocial Health Literacy and Psychosocial issues: Literature searchissues: Literature search

Literacy Education as Treatment for Depression in patients with limited literacy and Depression

J GEN INTERN MED 2006; 21:823–828.

Understanding the impact of family caregiver cancer literacy on patient health outcomes

Patient Education and Counseling 2008

Relationship of Empathy to Appraisal, Depression, Life Satisfaction, and Physical Health in Informal Caregivers of Older Adults

Research in Nursing & Health, 2001, 24, 44±56

Page 53: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Health Literacy and Psychosocial Health Literacy and Psychosocial issues: Literature searchissues: Literature search

Does a higher Education level protect against anxiety and depression? The HUNT study

Social Science and Medicine 2008

Health Literacy and Cognitive Performance in Older Adults

JAGS 2009 Vol 57:1475-1480

Page 54: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Conclusion: Steps to improving Conclusion: Steps to improving understandingunderstanding

Recognize the problem

Screen patients and caregivers when appropriate

Use communication techniques to foster understanding

Plain language

Teach-Back

Visual Cues

Encourage patients to be pro-active (Ask-Me-3)

Give patient-friendly written instructions or patient education handouts

Page 55: Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD State University

Thank you for your attention!Thank you for your attention!