Transcript Learning theoriesand health literacy

PTP 783
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1.
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Review learning theories
Discuss a framework in which learning can
occur in Geriatric PT practice.
Discuss how health literacy impacts
Geriatric PT practice.
Identify strategies to address assessing
health literacy in verbal and written
communications.
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“The degree to which individuals have the
capacity to obtain, process, and understand
basic health information and services
needed to make appropriate health
decisions.”
2010
Healthy People
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Hospital
Stay Length
Population
>65
Non-English
Speaking
Medications
Prescribed
Time spent
with
Patients
Reimbursement
Specialists
More Self Management in the Home
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Appointments
& Referrals
Testing
Payment
structures
The complexity of the healthcare system
exacerbates literacy vulnerabilities
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“Every system is perfectly
designed to get the
results it gets”
“The definition of insanity
is continuing to do the
same thing over and over
again and expecting a
different result”
−Albert Einstein
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“As a former nurse, trauma
surgeon, and public health
director [I realized] there was a
wall between us and the people we
were trying to serve.
Health care professionals do not
recognize that patients do not
understand the health information
we are trying to communicate.
We must close the gap between
what health care professionals
know and what the rest of America
understands.”
Dr. Richard Carmona,
U.S. Surgeon General 2002-2006
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General literacy
Experience with health care system
Complexity of information
Cultural and language factors:
◦ ESL
◦ Cultural experience
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How information is communicated
Aging and disease/treatment factors
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Fills out intake forms incompletely
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Misspelling many words
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Leaves the clinic before completing forms
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Gets angry about forms
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Identifies medication by looking at pill
rather than reading the label
Weiss BD. Health literacy: a manual for clinicians. 2003
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n = 19,714
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Most up to date portrait of literacy in
U.S.
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Scored on 4 levels
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Levels 1 and 2 cannot:
◦ Use a bus schedule or bar graph
◦ Explain the difference in two types of
employee benefits
◦ Write a simple letter explaining an error on a
bill
National Center for Educational Statistics, U.S. Department of Education
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Outcomes Associated with Health
Literacy
Health Outcomes/Health Services
• General health status
• Hospitalization
• Prostate cancer stage
• Depression
• Asthma
• Diabetes control
• HIV control
• Mammography
• Pap smear
• Pneumococcal immunization
• Influenza immunization
• STD screening
Behaviors Only
• Substance abuse
• Breastfeeding
• Behavioral problems
• Adherence to medication
• Smoking
Knowledge Only
• Birth control knowledge
• Cervical cancer screening
• Emergency department
instructions
• Asthma knowledge
• Hypertension knowledge
DeWalt, et al. JGIM 2004;19:1228-1239
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Medication error: most common medical mistake
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90 million Americans have trouble
understanding & acting on
health information
Unfamiliar/complex text most
difficult to read
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3 billion Rx written a year
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Pharmacist/physician time is limited
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Elderly fill 30 Rx/year, see 8 physicians, on average
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“How would you take this medicine?”
395 primary care patients in 3 states
• 46% did not understand instructions ≥ 1
labels
• 38% with adequate literacy missed at least 1
label
Davis TC , et al. Annals Int
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Med 2006, slide by T Davis
John Smith
Dr. Red
Take two tablets by
mouth twice daily.
Humibid LA
1 refill
600MG
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Slide by Terry Davis
89
84
71
80
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Davis TC , et al. Annals
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Int Med 2006
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People with low literacy have 30-70%
increased risk of hospitalization
RR = 1.29 (1.07-1.55) Medicare Managed
Care
RR = 1.69 (1.13-2.53) Urban Public
Hospital
*Adjusted for age, gender, socioeconomic status,
health status, and regular source of care.
Baker et al. AJPH. 2002.
92:1278.
Baker et al. JGIM. 1998. 13:791.20
Health, Aging, and Body Composition Study
Sudore et al. JGIM 2006; 21: 806812
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Simple Familiar Wording
Understood by Most Patients
84%
(1st grade.)
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Slide by Terry Davis
More Complex Message Limited
Comprehension
59%
(10th-12th grade.
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Slide by Terry Davis
Unfamiliar Multi-step Instructions
Rarely Understood
8%
(12th-13th grade)
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Slide by Terry Davis
Comprehension Increased with
Patient Literacy Level * p<.0001,
†
p<.05
<6
7-8
>9
79%
86%
88%
35%
66%
78% *
8%
64%
82% *
8%
18%
23% *
0%
6%
15% *
†
% with a
correct
response
In multivariate analysis only literacy and age predicted comprehension.
Patients with low literacy (< 6th gd.) 3x more likely to incorrectly
interpret warning labels.
Davis et al. JGIM 2006; 21:847–851.
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Rapid Estimate of Adult Literacy in
Medicine (REALM)
Test of Functional Health Literacy in
Adults (TOFHLA)
The Newest Vital Sign (NVS):
◦ recently developed and tested
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Word recognition and pronunciation
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Read aloud a list of 66 medical words
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Takes 2-3 minutes to administer
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Highly correlated with other standard tests
of reading ability (0.88-0.97)
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Does not test comprehension
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Not available in other languages
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REALM
Prevention & Patient
Education Project
Terry Davis, PhD
P.O. Box 33932
Shreveport, LA 71130-3932
fat
flu
pill
dose
eye
stress
smear
nerves
germs
meals
disease
cancer
caffeine
attack
kidney
hormones
herpes
seizure
bowel
asthma
rectal
incest
fatigue
pelvic
jaundice
infection
exercise
behavior
prescription
notify
gallbladder
calories
depression
miscarriage
pregnancy
arthritis
nutrition
menopause
appendix
abnormal
syphilis
hemorrhoids
nausea
directed
allergic
menstrual
testicle
colitis
emergency
medication
occupation
sexually
alcoholism
irritation
constipation
gonorrhea
inflammatory
diabetes
hepatitis
antibiotics
diagnosis
potassium
anemia
obesity
osteoporosis
impetigo
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17 numeracy items
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50 reading comprehension items
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Tests ability to read and understand
several health care related items
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Takes 20-30 minutes to administer
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Best for research purposes
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Well correlated with REALM and WRAT
(Wide Range Achievement Test)
Available in Spanish
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Doxycycline
100 MG
Take medication on empty stomach one hour
before or two hours after a meal unless otherwise
directed by your doctor.
If you eat lunch at 12:00 noon, and you want to
take this medicine before lunch, what time should
you take it?
Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)
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Your doctor has sent you to have a _________ X-ray.
a. stomach
b. diabetes
c. stitches
d. germs
You must have an ________ stomach when you come in.
a. asthma
b. empty
c. incest
d. anemia
Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)
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High correlation between first two reading
comprehension passages and entire
assessment (including numeracy items)
Administer only the first two reading
comprehension passages
Takes 5-7 minutes
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REALM
TOFHLA
Word recognition
Cloze method
2-3 minutes
5-7 minutes
Grade levels
Inadequate/marginal/
adequate
English only
English and Spanish
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Patients are given a nutrition label
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6 questions are verbally administered
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Assesses literacy and numeracy
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Takes 3 minutes
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Validated against the TOFHLA
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Available in English and Spanish
Weiss et al., Ann Fam Med; 3(6) 2005
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If you usually eat 2500 calories
in a day, what percentage of
your daily value of calories will
you be eating if you eat one
serving?
Available at Pfizer Clear
Communication Initiative:
http://www.pfizerhealthliteracy.co
m/physicians-providers/newestvital-sign.html
Weiss et al., Ann Fam Med; 3(6) 2005
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REALM
NVS
Word recognition
Problem-solving
2-3 minutes
3 minutes
Grade levels
Number correct (1-6)
English only
English and Spanish
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If just for screening, the REALM is likely the
best choice
◦ Easiest to explain to patients
◦ Fastest
◦ Reasonably accurate
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For research purposes, REALM is good, but
may consider other instruments depending
on goal of research
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Sensitive topic
Patients go to great lengths to
hide problems
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May offend some
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Inappropriate labeling
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Raise awareness among providers
Develop easier to read materials
◦ Including your brochures- readability assessment
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Improve communication skills
Practice-redesign
Literacy training / adult education
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Good health information is hard to come by
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Most written at too high of a reading level
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Few health care systems have
comprehensively integrated educational
materials in their overall care plans
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Teach-back method
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Patient centered learning
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Survival skills
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Ask Me 3
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Therapeutic alliance
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Repetition/reinforcement
◦ What is required of them to learn
◦ What pt. needs to know in order to get through session.
◦ 3-5 things that are need to know
◦ Three questions about topic
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Teach-back
Explain
Assess
Clarify
Understanding
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Speaking or writing in every day language
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Limit & organize the information
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Focus on behaviors & be realistic
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Use carefully phrased words as there is a
tendency to take words literally
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3-5 ‘need to know’ points
◦ Get the message quickly and clearly
◦ Makes sense
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Frame the message: tell them what you are going
to tell them before you do.
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Give specific examples and real world examples.
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Use analogies for key points.
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Use repetition, rephrasing and interactivity
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Verify understanding with teach-back technique.
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Every MS Office product has this capability
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Your brochures will be tested for readability
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Other resources: see the BB shell
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Chew et al in 2004:
Used 16 health literacy screen questions on a 5 pt
Likert scale followed by S-TOFHLA (n=322)
3 questions were effective:
1. How often do you have someone help you read hospital
materials?
2. How confident are you filling out medical forms by
yourself?
3. How often do you have problems learning about your
medical conditions because of difficulty understanding
written information?
Wallace followed up in 2006 identifying just the second
question above was most accurate with detecting limited
health literacy skills (83.3% sensitivity).
-more accurate than a screen of demographicS
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Should we measure literacy and target
interventions or should we institute
“universal precautions”?
When low health literacy is identified, what
do we do?
Is it enough to recognize that many
patients have this problem?
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What do you call your problem? What name does it
have?
What do you think caused your problem?
Why do you think it started when it did?
What does your sickness do to you? How does it
work?
How severe is it? Will it have a short or long course?
What do you fear most about your disorder?
What are the chief problems that your sickness has
caused for you?
What kind of treatment do you think you should
receive?
What are the most important results you hope to
receive from the treatment?
Dr. Arthur Kleinman, Patients and Healers in the
Context of Culture.
The Regents of the University of California. 1981
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