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HEALTH LITERACY AND HIV/AIDS OVERVIEW
Melanie Steilen, RN, BSN, ACRN
Patricia Abshier, PhD (ABD), MSPH, MSW
CAI
Last updated July 2012
Disclosure
The following people have no relevant financial, professional or personal relationships to disclose:
Faculty:Patricia Abshier, PhD (ABD), MSPH, MSWMelanie Steilen, RN, BSN, ACRN
Objectives
Participants will be able to Define Health Literacy Discuss the impact of Health Literacy on
HIV Care Discuss methods for addressing health
literacy with clients/patients Demonstrate the use of the Newest Vital
Sign and the REALM-R for formal assessment
Basic information about a colonoscopy, as perceived by a patient with limited literacy skills
Health Literacy Is…
“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 Includes the ability to perform essential health care tasks:
•Understand appointment slips•Follow instructions on medication labels•Obtain information about an illness•Participate in discussions of informed consent•Enroll in health insurance plan
Health Care and Health Literacy
Most patient instructions are written Verbal instructions
Often complex Delivered rapidly Easy to forget in stressful situation
Increasingly complex health system More medications More tests and procedures Greater self-care requirements Participatory/informed decision-making
Impact of Health Literacy
Health Outcomes/Health Services General health status Hospitalization Emergency department
use Depression Diabetes control HIV control
Adherence / Compliance Retention
Immunization STD
Behaviors Only Substance abuse Behavioral problems Adherence to
medication* Smoking*
Knowledge Only Birth control knowledge Emergency department
instructions Asthma knowledge Hypertension
knowledge
DeWalt, JGIM 2004
Comprehension of Medicare
Gazmararian, JAMA 1999
Health Literacy and Medication
Health Literacy and Medication
One capsule twice daily
One tablet by mouth twice a day for 3 days
One tablet two times a day
One tablet by mouth twice a day
Tomar 1tab XLA boca vezdia X7 dias luego do XLA boca X7 dias
Take one by mouth 3? Times a day
Take as directed
HIV/AIDS Related Findings
Persons of low literacy were more likely to miss treatment doses because of confusion, depression, and desire to cleanse their body than were participants with higher health literacy.
Poor health literacy creates barriers to fully understanding one’s health, illness, and treatments. Misperceptions of treatment in the case of HIV infection creates danger for potentially transmitting treatment-resistant strains of HIV.
The Prevalence of Limited Health Literacy
N=31,129 subjects from 85 Studies
HIV/AIDS Related Findings
Health Literacy Indicator Percent of Clients
Read below a 9th grade level 48%
Can't name their medications 33%
Don’t know how to take their medications of those below 9th grade
level66%
Don't know meaning of viral load or CD4 count of those below 9th grade level
75%
N = 157 HIV Positive (Shreveport, LA)
HIV/AIDS Related Findings
204 patients receiving care in Shreveport, Louisiana and Chicago, Illinois. One-third of patients had limited
literacy skills. These patients were less able to describe CD4
count, viral load and to correctly identify medications in their regimen.
Limited literacy was an independent predictor of poor understanding of CD4 count, correct medication identification.
HIV/AIDS Related Findings
A significant interaction was found between number of HIV medications and literacy level. Among patients taking only 1–2 HIV medications, 100% of higher literate patients were able to identify their medications, compared to none of the lower literate patients prescribed three or more HIV medications. (Note: Need to look at how many medications in
general not just HAART)
Patients with limited literacy skills may lack essential knowledge related to their HIV treatment.
Recommended Strategies to Improve Communication
Explain things clearly in plain language Use a “teach back” or “show me”
technique to check understanding Effectively solicit questions – DON’T ASK
“Do you have any questions?” Focus on key messages and repeat Use patient-friendly educational
materials to enhance interaction
*AMA Foundation
Recommended Strategies to Improve Communication Slow down the pace of your speech Use plain, non-medical language
“Pain killer” instead of “analgesic” Use patient’s own terms Define new terms Be specific
What does taking medicine “on an empty stomach” really mean?
Avoid concept words “Hamburger” instead of “red meat”
Use analogies “Arthritis is like a creaky hinge on a door.”
Recommended Strategies to improve Communication
Angina Atherosclerosis Benign Carcinoma Immunization Hypertension “Negative” test Take one tablet twice
daily for seven days
Chest pain Clogged blood
vessels Not cancer Cancer Shot, vaccine High blood pressure Normal test Take 1 pill at 8am &
another pill at 8pm for 7 days
What could we say instead of… How about….
Case Study 1 - John
John is a 65-year-old White man who has sex with men and who presents with anal lesions and rectal bleeding. John’s CD4+ T cell count is for the 3rd month below 200 cells/mm3. His viral load is at 2500 copies/mL. An anal Pap smear is performed and shows squamous intraepithelial lesions.
John’s physician assistant, Ms. Gonzalez, plans to refer him for an anoscopy and biopsy. While filling out the necessary paperwork for this procedure, the desk clerk notices that John is having problems completing the forms and leaves several sections blank. The clerk reports this back to Ms. Gonzalez.
Case Study 1 - John
Ms. Gonzalez must now speak to John about his low CD4+ T cell count and the possible diagnosis of cancer as well. She starts to counsel John and hands him a brochure that gives more details about AIDS and the importance of self care. John is hesitant about taking the brochure, but places it in his pocket and says that he will read it later. John says he prefers to talk directly to Ms. Gonzalez rather than read a brochure.
Addressing Health Literacy in HIV Care and Treatment : A Collection of Case Studies, AETC Multicultural Care Workgroup Jan 2007
Case Study #1 – John Continued
How can Ms. Gonzalez assess John’s health literacy level? Does the fact that he put the brochure away give any clues?
If John has low health literacy, what would be the added challenge to his HIV care and treatment?
How can a provider explain what low CD4+ T cell count means? How can the provider determine John’s adherence to medications?
How can a provider explain the treatment/prevention/risk reduction regimen for HIV infection?
Should members of the office staff be involved in the referral process for biopsy and testing? If so, how?
How to Test Health Literacy Medication review
Ask patient to name and explain purpose of one or two meds
Screening questions “How often do you have someone help
you read hospital materials?” Formal assessment
Rapid Estimate of Adult Literacy in Medicine (REALM-R)
New Vital Sign (NVS) Test of Functional Health Literacy in
Adults (TOFHLA)
Case Study #2 - Theresa
Theresa, a 22-year-old African American female, presents to her primary care physician (Dr. Beal) for enlarged lymph nodes. She reports swelling in her neck for the past two weeks and believes she is experiencing some continuing effects from a “really bad” case of the flu she had two weeks ago. She reports that she is extremely tired, has frequent headaches, and has also had a rash.
Addressing Health Literacy in HIV Care and Treatment : A Collection of Case Studies, AETC Multicultural Care Workgroup Jan 2007
Case Study #2 - Theresa
The physical exam reveals that Theresa’s inguinal lymph nodes are also swollen. Dr. Beal tells Theresa that her symptoms could be related to a number of things and asks about her last HIV test. She denies a history of ever having an HIV test, adding, “My throat hurts, not my blood, plus I have not lost any weight and I’m obviously not a gay man.” She says she has been with the same male sexual partner for the past four years. She and her partner rarely use condoms because she uses Depo Provera® injections for pregnancy prevention. She does recall that her partner complained of similar symptoms three months ago but he “got better” after one week. She also says that her boyfriend looks healthy and is not gay.
Case Study #2 - Theresa
Discuss the health literacy implications of her statement: “My throat hurts, not my blood, plus I have not lost any weight and I’m obviously not a gay man.”
How can Dr. Beal explain the early signs/symptoms of
HIV as well as discuss the risk factors? Should Dr. Beal encourage Theresa to have an HIV
test? Why or Why not? What tactics could be used to initiate the discussion?
Based on the case study discussion, what strategies
to address health literacy might you include in an action plan for Theresa’s care?
Newest Vital Sign
The Newest Vital Sign is based on a nutrition label from an ice cream container. Patients are given the label and then asked 6 questions about how they would interpret and act on the information contained on the label.
The questions are read to the individual by the provider, the provider has a score sheet.
For more detail and instructions refer to handout.
Newest Vital Sign
Administering the Newest Vital Sign Activity
Find a partner One client One clinician
Administer the tool
Process use of the Newest Vital Sign
REALM-R
The REALM - R is a medical-word recognition and pronunciation test.
2 min to administer
For more detail and instructions refer to handout.
REALM-R Scoring Score Grade range
Zero = 3rd grade and below will not be able to read most low-literacy
materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes.
1-3 = 4th to 6th grade will need low-literacy materials, may not be able to
read prescription labels. 4-6 = 7th to 8th grade
will struggle with most patient education materials; will not be offended by low-literacy materials.
7 = High school will be able to read most patient education materials.
Administering the REALM-R
Activity Find a partner
One client One clinician
Administer the tool
Process use of the Realm-R