Current Concepts in Health Literacy

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Current Concepts in Health Literacy

• Michael Paasche-Orlow, MD, MA, MPH
• Boston University School of Medicine
• mpo_at_bu.edu

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• Mnay fo yuor pinetats hvae tbuorle wtih the
  slef-crae tksas tehy need ni oderr to saty
  hlaehty.

Waht are you gnoig ot od Aubot ti?
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Definition - Literacy
The ability to use printed and written
information to function in society, to achieve
ones goals, and to develop ones knowledge and
potential. Not Illiteracy National Assessment
of Adult Literacy (NAAL), 2003 National Adult
Literacy Survey (NALS), 1992 Over 18,000 adults
representing the entire U.S. household
population National Center for Health Statistics,
Department of Education
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Different Types of Information

• Prose
• to search, comprehend, use continuous texts
• health information materials, NPP, PBOR, ICF
• Document
• to search, comprehend, use non-continuous texts
• drug/food labels, appointment slips, enrollment
  forms
• Quantitative
• to identify and perform computations, using
  numbers or numerical concepts
• calculating dose, costs (Medicare Part D), risk

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Prevalence of Limited Literacy

• National Assessment of Adult Literacy (NAAL,
  2003)
• Over 90 million with inadequate functional
  literacy
• Below Basic or Basic level of literacy
• More common among those with limited education,
  elderly, minorities, immigrants, low SES, people
  with chronic diseases

From http//nces.ed.gov/naal/
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Limited Literacy Below Basic

• People in Below Basic do not have the skills to
  perform simple literacy activities such as
• reading and understanding short, commonplace
  prose
• news papers
• reading and understanding simple documents
• voter registration, drivers license, social
  security
• locating easily identifiable quantitative
  information and using it to solve simple,
  one-step arithmetic operations
• checkbook, bill, tip

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Literacy and Education
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Literacy and Race/Ethnicity
Black
24
43
31
2
7
25
51
17
White
Hispanic
44
30
23
4
Asian/ PI
14
32
42
12
AI/ AN
19
29
41
10
0
20
40
60
80
100
Below Basic
Basic
Intermediate
Proficient
NAAL 2003
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Adult Literacy Estimates (Based on 1990 U.S.
Census Data)
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Definition Health Literacy

• The ability to understand and use health-related
  printed information in daily activities at home,
  at work, and in the community to achieve one's
  goals and to develop one's knowledge and
  potential.
• National Assessment of Adult Literacy (NAAL),
  2003 National Center for Health Statistics
• Department of Education

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Definition 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. Healthy People
2010 IOM AMA ACPF JACHO HRSA NIH RO1,
R21, RO3
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Prevalence of Limited Health Literacy

• Prevalence across 85 medical studies
• 26 inadequate health literacy
• 20 marginal health literacy
• Multiple instruments
• TOFHLA
• Prose, Quantitative
• REALM
• Word Pronunciation

Paasche-Orlow, JGIM 2005
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Health Literacy - Associations

• Hospitalization
• Emergency department use
• Early Re-hospitalization
• General health status
• Prostate cancer stage
• Depression
• Diabetes control
• Asthma Acute Care Utilization
• HIV control
• Mammography
• Pap smear
• Pneumococcal immunization
• Influenza immunization
• STD screening

• Substance abuse
• Breastfeeding
• Adherence to medication
• Smoking
• Asthma Inhaler skill
• Birth control knowledge
• Cervical cancer screening
• Emergency department info.
• Asthma knowledge
• Hypertension knowledge
• Consent knowledge
• Cost
• Mortality

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Examples Inadequate Literacy

• Correct
• Identify next appointment 73
• Take medicine every 6 hours 52
• Take medicine on empty stomach 46
• Interpret blood sugar value 32
• Upper GI instructions (4th grade) 24
• Medicaid Rights (10th grade) 0

Gazmararian, JAMA 1999
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Health Outcomes Mortality

• Prudential Health Study
• 3260 Medicare managed-care enrollees in 4 metro
  areas, 1997
• S-TOFHLA
• Mortality from the NDI, 2003
• Crude mortality rates
• inadequate (n 800) 39.4
• marginal (n 366) 28.7
• adequate (n 2094) 18.9
• After adjusting for demographics, SES, and
  baseline health, the hazard ratios for all-cause
  mortality compared adequate health literacy
• inadequate 1.52 (95 CI 1.26-1.83)
• marginal 1.13 (95 CI 0.90-1.41)
• Years of school completed was only weakly
  associated with mortality in bivariate analyses
  and was not significant in multivariate models

Baker, D. W. et al. Arch Intern Med
20071671503-1509.
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Health Outcomes Mortality

• Health, Aging, and Body Composition study
• 2,512 community-dwelling elders without baseline
  functional difficulties or dementia from Memphis
  and Pittsburgh, 1999
• Rapid Estimate of Adult Literacy in Medicine
  (limited vs adequate)
• Mortality from SSDI, 2004
• Mean age was 75.6 years, 48 were male, 38 were
  black
• Crude mortality rates
• Limited Literacy (n595) 19.7
• Adequate literacy (n1,917) 10.6
• After adjusting for demographics and
  socioeconomic status, co-morbid conditions,
  self-rated health status, health-related
  behaviors, health care access measures, and
  psychosocial status, the hazard ratio for
  all-cause mortality compared adequate health
  literacy
• Limited Literacy HR 1.75 (95 CI, 1.27 to 2.41)

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Implications (ad interim)

• High Prevalence
• Many Health Ramifications
• Disparities

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What Now?

• ? Shift the paradigm
• ? Simplify
• ? Standardize
• ? Rededicate Ourselves to Patient
  Education and Activation
• ? Experiment

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? Shift the paradigm Not Patient Skills --
Context

• Traditional focus is the Low-Literate Patient
• Screening vs universal approach
• All Literacy is defined contextually
• Overly Complex System
• The current system assumes literacy
• Flip the default
• At what prevalence does this seem acceptable?
• All ways (to date) of simplifying health care
  improve satisfaction, comprehension, and
  retention for all subjects (not just low literate)

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Inhaler Technique
Proportion () correctly performing each
component of MDI technique Inadequate health
literacy white bars 1 shaking the inhaler 2
exhaling before actuation 3 closing lips around
mouthpiece 4 pressing down once 5 taking a
full/deep breath without triggering whistle 6
holding breath 5 s.
Paasche-Orlow, Am J Respir Crit Care Med. 2005
Oct 15172(8)980-6.
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A Tide That Raises All Ships
Better MDI technique score ( with 4/6 correctly
done) and mastery of discharge medication regimen
( exhibiting 4/4 questions correctly answered
for all three medications in the standardized
regimen) by literacy category at discharge study
visit and at 2 wk. Inadequate health literacy
white bars
Paasche-Orlow, Am J Respir Crit Care Med. 2005
Oct 15172(8)980-6.
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? Simplify

• Communication
• 4 unclarified jargon terms/encounter
• Castro Am J Health Behav. 200731(Suppl
  1)S85-S95
• All Patient Facing materials

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Consent to Treatment

• I/we voluntarily authorize the rendering of such
  care, including diagnostic procedures and medical
  treatment, by authorized agents and employees of
  the University of Kentucky, its medical staff and
  their designees, as may in their professional
  judgement be deemed necessary or beneficial, and
  may include testing for HIV (the virus that
  causes AIDS( and other blood borne diseases. I/we
  acknowledge that no guarantees have been made as
  to the effect of such examination or treatment on
  my condition or the condition of the person for
  whom I am duly authorized to sign. I/we
  understand that I/we have the right to make
  decisions concerning my health care or the health
  care of the person for whom I am duly authorized
  to make decisions, including the right to refuse
  medical and surgical procedures.
• This consent to treatment may be revoked at any
  time, except to the extent that action has
  already been taken, by the patient/duly
  authorized agent.

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YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH
INFORMATION

• To revoke your authorization to use or disclose
  PHI at any time except, unless your authorization
  was obtained as a condition of obtaining
  insurance coverage, and except to the extent your
  PHI has already been disclosed pursuant to your
  authorization. Your revocation request must be
  made in writing to the Medical Records unit of
  the facility where you originally filed your
  authorization.

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Informed Consent Form Readability Standards vs.
Actual Readability A Survey of U.S. Medical
School Institutional Review Boards

• Relevant data were extractable from 114/123 (93)
  medical school websites examined.
• Paasche-Orlow, NEJM 2003

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Readability Standards

• Grade Level Standards in 61/114 (54)
• Range 5th-10th (mode 8th) grade.

• Descriptive guidelines in 47/114 (41)
• in simple lay language

• No language guidelines in 6/114 (5)

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Examples Voluntary Nature of Participation
You dont have to be in this research study. You
can agree to be in the study now and change your
mind later. Your decision will not affect your
regular care.  
(4th)
You voluntarily consent to participate in this
research investigation. You may refuse to
participate in this investigation or withdraw
your consent and discontinue participation in
this study without penalty and without affecting
your future care or your ability to receive
alternative medical treatment at the University.
(College)
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Examples Benefits (When there are none)
There is no benefit to you from being in the
study. Taking part in this study may help
patients in the future.
(4th)
There may be no direct benefit to me, however,
information from this study may benefit other
patients with similar medical problems in the
future.
(12th)
The research physician treats all subjects under
a specific protocol to obtain generalizable
knowledge and on the premise that you may or may
not benefit from your participation in the study.
(College)
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Observed Readability of Template

• Mean Flesch-Kincaid grade level was 10.6 (95CI
  10.3 to 10.8).
• Presence of a specified grade level standard did
  not influence Flesch-Kincaid grade level (10.7
  vs. 10.5, P0.10).
• In schools with specified grade level standards
• Mean of 2.8 (2.4 to 3.2) grade levels higher,
  Plt0.001.
• 5/61, 8 (95 CI 3 to 18) met their own standard

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IRB Readability Conclusions

• IRBs do not meet their own readability
  standards.
• Actual reading level were not influenced by
  readability standards, level of research
  activity, or local estimates of low literacy.
• Recent OHRP oversight was associated with
  better readability.
• The language presented by IRBs, even in schools
  which underwent OHRP oversight remains beyond
  the ken of the majority of American adults.

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? Standardize

• Medication Label
• Warning Icons
• General Instructions
• Public Health Messaging

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? Rededicate Ourselves to Patient Education and
Activation

• Teach About Patient Education
• Value Patient Education
• Culturally
• Time
• Team Model
• Align Incentives
• P4P
• Shift default assumption
• Currently pt needs to ask questions
• Proactively confirm pt comprehension
• Patient Safety
• Consider your practice settings

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Closing the Loop
Schillinger, Arch Intern Med. 2003 Jan
13163(1)83-90.
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? Experiment

• RED
• RED-Lit
• VIDEO
• ElderWalk
• AHRQ IC Toolkit

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RED Take-off Checklist

• Ten discrete, mutually reinforcing, components
• Reconcile Discharge Plans w/ Nat Guidelines
• Medication Reconciliation
• Outstanding Tests and Studies
• Post Discharge Services
• Physician Appointments
• What to do if a problem arises
• Assess understanding
• Patient Education
• Telephone re-enforcement
• Discharge Plan

Adopted by National Quality Forum as one of 30
"Safe Practices" (SP-11)
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Enrollment Criteria

• Admitted to Boston Medical Center
• gt 18 years old
• English speaking
• Not on precautions
• Does not live in an institutionalized setting
• Has telephone
• Able to consent
• Not previously enrolled

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How successfully were the methods implemented?
Randomization Excellent Time with Subject
53 minutes PharmD TC at 2-4
days 75 AHCPDC summaries sent to
PCP 98 PCP appt made at DC RED
93 Control33 Telephone Call
at 30 days 83
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Readiness for Discharge and Health Literacy
The RED closes the gap between literacy groups
(less than high school reading level vs. high
school and above) in preparedness and
satisfaction questions
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Summary

• ? Shift the paradigm
• - dont assume literacy
• ? low lit default
• - dont wait for the questions
• ? confirm comprehension
• ? Simplify
• ? Standardize
• ? Rededicate Yourself to Pt Ed Activation
• ? Experiment! (causal model)

Paasche-Orlow, AJHB Sept HL Supplement