Low Health Literacy

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Low Health Literacy

• Implications for Safe Medication Use

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Changes in the Health Care System
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Understanding InstructionsDarvon 1 tablet q4h
prn
JAMA 1974 227929
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Understanding InstructionsFurosemide Take for
Fluid Retention
JAMA 1974 227929
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Understanding InstructionsTetracycline 1
capsule q6h
JAMA 1974 227929
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Patients Understanding at Discharge
Mayo Clinc Proc 200580991-4
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Do parents have numeracy skills to give medicine
to their children?

• Give 4 ccs 3 times daily for 10 days
• 700 A, 715 A, 730 A- before work?
• (shared context)
• Divide 3 into 24 or 12?
• Understand measurement
• (cc, ml, tsp, tbsp)

Tsp. volume ranges from 2-9 mL
Slide by Terry Davis, PhD
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Giving Oral Liquids Correctly
McMahon, S. et al. Pediatrics, 1997
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Can Patients Interpret Warning Labels?
Slide by Terry Davis, PhD
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Simple familiar wording understood by most
patients
84
N 253 patients at public health clinic
Slide by Terry Davis, PhD
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More complex message limited comprehension
59
Slide by Terry Davis, PhD
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Unfamiliar multi-step instructions rarely
understood
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Slide by Terry Davis, PhD
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Common Misunderstandings
Chew pill and crush before swallowing. Chew it up
so it will dissolve, dont swallow whole or you
might choke. Just for your stomach. Use extreme
caution in how you take it. Medicine will make
you feel dizzy. Take only if you need it. Dont
take medicine if youve been in the sunlight too
long. Dont leave medicine in the sun. Dont
leave medicine in sunlight but a cool place.
Slide by Terry Davis, PhD
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Interpreting Warning Labels
J Gen Intern Med 200621847-51
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Interpreting Warning Labels
J Gen Intern Med 200621847-51
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Impact of Health Literacy Ability to Identify
Medications

• Patients asked to identify their medicines from
  bottles using bottle, label, or looking at pills.
• All patients were equally likely to attempt
  identification by looking at pills as opposed to
  labels.

J Gen Intern Med 2006 21852-6
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We all feel health illiterate on 1st hearing a
new diagnosis.

• Only 50 of us can read the instructions
  brochures, ask questions, and go on the internet
  to learn more.

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Use of the internet to obtain health information
US Dept of Education, National Center for
Education Statistics
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Be suspicious when patients cant state the names
of drugs they have been taking for a long time,
make excuses for not reading the label when asked
to do so, or can recognize their medicines only
when opening the bottle and looking at the pills.
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Verbal Communication
Up to 80 of Patients Forget What Their Doctor
Tells Them As Soon As They Leave the Doctors
Office ANDNearly 50 of What They Do Remember
is Recalled Incorrectly

• Patients experience shame around the issue
• Only 14 of patients say they feel awkward
  admitting they dont understand yet 79 feel
  others dont understand
• Providers experience time challenges
• Providers interrupt patients 30 seconds after
  they start speaking if not interrupted,
  patients will speak less than two minutes

What Can We Do?
Create an Environment of TRUST
Source Health Literacy The Prescription Drug
Experience The Front Line Perspective From
Patients, Physicians and Pharmacists, Roper ASW,
May 2002
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Six steps to improving patient understanding

• Limit the amount of information provided at each
  visit
• Slow down
• Avoid medical jargon
• Use pictures or models to explain important
  concepts
• Assure understanding with the show-me technique
• Encourage patients to ask questions

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Strategies to Improve Patient Education Materials

• Supplement text with pictures
• Tailoring medication schedules to fit a persons
  routine color-coding medications, using daily
  events as reminders
• Videotaped patient education materials
• Use text at the 5th grade reading level (most
  medication leaflets are written at a 10th-12th
  grade level)

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Example of Health Communication That May Not
Reach a Broad Consumer Audience
70
150
Good Range
TooHigh
TooLow
What You Need to Know About Low Blood Sugar Treat
low blood sugar quickly. If you have signs of
low blood sugar, eat or drink something that has
sugar in it. Some things you can eat are hard
candy, sugar-sweetened soda, orange juice, or a
glass of milk. Special tablets or gel made of
glucose (a form of sugar) can be used to treat
low blood sugar. You can buy these in a drug
store. Always have some of these items handy at
home or with you when you go out in case your
blood sugar drops too low. After treating a low
blood sugar reaction, eat a small snack like half
a sandwich, a glass of milk, or some crackers if
your next meal is more than 30 minutes away.
Source The National Institute of Diabetes and
Digestive and Kidney Diseases
Blood Sugar Is Too Low if It Is Under 70
Blood Sugar Is Too High if It Is Over 240
9th Grade Reading Level
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Example of Clear Health Communication That
Reaches a Broad Consumer Audience

• Common visual used to explain concept
• Uses action captions that clarify the point of
  the visual
• Creates interaction with the reader

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Strategies to Improve Patient Education Materials

• Use common, simple words
• chemotherapy becomes drug to fight cancer
• instill becomes put
• take becomes swallow
• Limit education to 1 or 2 important objectives
• Emphasize desired behavior rather than the
  medical facts.

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Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Consider Using This One Instead
Instead of Using This Word
Benign Harmless Chronic Happens again and again
does not end Cardiac Heart Edema Swelling build
up of fluid Fatigue Tired Screening Test Intake Wh
at you eat or drink Generic Not a brand
name Adverse events Side effects
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Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Consider Using This One Instead
Instead of Using This Word
Activity Something you can do Cognitive Learning,
thinking Poultry Chicken, turkey,
etc Support Help with your needs Excessive Too
much Increase gradually Add to Inhibitor Drug
that stops something that is bad for you Oral By
mouth Procedure Something done to treat your
problem operation
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Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Consider Using This One Instead
Instead of Using This Word
Avoid Stay away from Factor Other thing Option
Choice Referral Ask you to see another
doctor Benign Will not cause harm is not
cancer Wellness Good health feeling
good Gauge Measure getter a better idea of
test Significantly Enough to make a
difference Dysfunction Problem
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Teach Back for Patients with Diabetes

• Audio taped visits 74 patients, 38 physicians
• Patients recalled
• Physicians assessed recall 13 of time
• When physicians used teach back the patient was
  9 times more likely to have Hb A1c levels below
  the mean
• Visits that assessed recall were not longer

Schilinger, D. Arch Int Med, 2003
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Slow down !
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Impact of Health Literacy on Warfarin Use in an
Anticoagulation Clinic
J Gen Intern Med 2006 21841-6
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Prescription Labels

• Clear Rx Target Pharmacy

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Standard Prescription Bottles and Labels
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Target Label
ID from top
Drug name clearly delineated
Most important information above line in larger
font
Design allows reading without turning
Storage for more info.
Optional color-coded caps
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Warnings on rear
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Discussion