Transcript Health Literacy Overview - AIDS Education and Training

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, MSW
Melanie 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
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General health status
Hospitalization
Emergency department use
Depression
Diabetes control
HIV control

Adherence / Compliance

Retention
Immunization
STD

Behaviors Only
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Substance abuse
Behavioral problems
Adherence to medication*
Smoking*
Knowledge Only
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Birth control knowledge
Emergency department
instructions
Asthma knowledge
Hypertension knowledge
DeWalt, JGIM 2004
Comprehension of Medicare
% of Respondens
0%
Identify next appointment
11%
32%
14%
20%
23%
Gazmararian, JAMA 1999
Take medicine every 6
hours
Take medicine on empty
stomach
Interpret blood sugar
value
Upper GI instructions (4th
grade
Medicaid Rights (10th
grade)
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
Health Literacy Prevelence
Low Health
Literacy
26%
Adequate
Health Literacy
54%
N=31,129 subjects from 85 Studies
Marginal
Health Literacy
20%
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 level
66%
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

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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

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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
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What does taking medicine “on an empty stomach”
really mean?
Avoid concept words

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“Hamburger” instead of “red meat”
Use analogies

“Arthritis is like a creaky hinge on a door.”
Recommended Strategies to improve
Communication
What could we say instead of…
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Angina
Atherosclerosis
Benign
Carcinoma
Immunization
Hypertension
“Negative” test
Take one tablet twice
daily for seven days
How about….
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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
Case Study 1 - John
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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?
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How can a provider explain the treatment/prevention/risk reduction
regimen for HIV infection?
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Should members of the office staff be involved in the referral process for
biopsy and testing? If so, how?
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How to Test Health Literacy
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Medication review
 Ask
patient to name and explain purpose of one or
two meds
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Screening questions

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“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
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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
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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


1-3 = 4th to 6th grade

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will need low-literacy materials, may not be able to read
prescription labels.
4-6 = 7th to 8th grade
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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.
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
Questions and Answers
Thank you!
Melanie Steilen
Patricia Abshier
[email protected]
[email protected]