Doctor-Patient Relationships : Understanding the Importance of Health Literacy in Patient Care Jennifer Hensley, MD Catherine Nicastri, MD
State University of New York, Stony Brook Department of Medicine, Division of Geriatrics
Can you read this?
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How many adult Americans have difficulty reading and understanding health information? A. 9
million
B. 90
million
C. 50
million
D. Fewer
than 1 million
Definition 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
The 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
Examples of Health Literacy Tasks
Proficient Skills: 13%
Intermediate Skills: 53%
Determine timing, administration and interactions based on info from drug label
Basic Skills: 22%
`Calculate employee’s share of health insurance cost for year using a table on monthly cost
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
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
Highest Risk for Limited Health Literacy
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
Health System Problems Encountered by Persons 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
Impact 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
Shame and Health Literacy: the unspoken connection Adequate Health Literacy
49% Feel bad/never
Low Health Literacy
tell
51% Feel bad/never tell
60% Feel ashamed
60% Feel ashamed
94% Hide problem
78% Hide problem
"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counseling. 1996. 27: 33-39
Who knows you have trouble reading? Never told:
Spouse
53%
Children
57%
Relatives
86%
Co- workers
62%
Friends
67%
No one
19%
"Shame and Health Literacy: The Unspoken Connection." Patient Education and Counselling. 1996. 27: 33-39
Physician Assessment of Health Literacy
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
What can we do?
Recognize signs of limited health literacy
Screen for health literacy
Learn clear communication techniques
Educate patients on AskMe-3
Ms 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.
"
Office Visit
Did Ms. Green give any clues that she may have limited health literacy?
Signs (Clues) of Low Health Literacy Behaviors
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
If you suspect Ms. Green’s health literacy is limited what screening tests could you perform?
Quick Screening Tests for Health Literacy
Single question screens
Assessment instruments
REALM-R: Rapid Estimate of Adult Literacy in Medicine-Revised
NVS: The Newest Vital Sign
Single 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
Often
Always
“How confident are you filling out medical forms by yourself?” Extremely
Sometimes
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
REALM-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
