Transcript Morris Research Symposium Health Literacy

Limited Health Literacy in
Hospitalized Patients
Grant, S., Morris, N. S.,
MacLean, C., Repp, A., &
Littenberg, B.
Disclosure
Disclosures for Steve Grant: Physician
advisor and consultant to EMMI
Solutions, a medical software company
that designs multimedia consent and
educational materials.
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)
Skills needed for
adequate health literacy
Numerically literate
Aurally literate
Visually literate
Computer literate
Information literate
How big is the problem?
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~77 million people, nearly 1/3 the adult US
population have difficulty understanding and
using health information (NAAL, 2003)
People who have low health literacy generally
hide it because it is stigmatized in our society
The estimated added annual cost to the
health care system due to low health literacy,
$106-238 Billion (Vernon et al., 2007)
What is the impact?

Limited health literacy is associated with:
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Less knowledge about chronic disease states
Worse self-management skills
Poorer health outcomes
Lowered use of preventive services
Increased hospitalization rates
All-cause mortality among older adults
Increased health care costs
2003 National Assessment of
Adult Literacy (N=19,000 adults)

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Below Basic – no
more than the most
simple and concrete
literacy skills
Basic - skills
necessary to
perform simple and
everyday literacy
activities

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Intermediate – skills
necessary to perform
moderately
challenging literacy
activities
Proficient – skills
necessary to perform
more complex and
challenging literacy
activities
Adults/Health Literacy Level
(NAAL,2003)
120
100
80
Below Basic 14%
Basic 22%
Intermediate 53%
Proficient 12%
60
40
20
0
Millions
By Race-Ethnicity
(NAAL, 2003)
Relationship of education to
basic/below basic health literacy?
80
70
60
50
40
30
20
10
0
< HS graduate
76%
HS graduate
44%
VocTech 37%
AD graduate
19%
College graduate
13%
Limited health literacy found
more among:
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Elderly
Immigrant populations
Adults with low-income
Adults who have not completed high
school
Adults with chronic mental and/or
physical health conditions
Adults living in rural areas
Interest

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To date most of our knowledge of
health literacy has been derived from
the outpatient setting.
Hospitals - challenging environment
with complex and often unfamiliar
information conveyed to patients in a
very short time.
Purpose

To determine the prevalence and
demographic associations of limited
health literacy in hospitalized General
Medicine patients
a)
b)
Identify perceived difficulty with
health communication
Use of any compensatory strategies
Methods

Cross sectional
survey of a
convenience sample
of patients admitted
to the Internal
Medicine Hospitalist
Service at FAHC
Eligible subjects
 > 18 years of age
 Able to provide
informed consent
 Not previously
enrolled in the study
 Not incarcerated
 Not anticipated to
die during
hospitalization
Recruitment

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To minimize the contribution of the
acute illness data were collected within
48 hours of anticipated discharge from
the hospital.
The research assistant obtained
informed consent and collected all data
from patients available Monday through
Friday during workday hours.
Minimizing the impact of
decreased vision

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Patients were asked to wear their
glasses if appropriate
We offered reading glasses if necessary
All survey questions and responses
(except the assessment of reading ability)
were presented in 18-point font and
were also read aloud to the patient
Measurement
Short Test of Functional Health
Literacy of Adults (S-TOFHLA)
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A 36-item timed reading
comprehension test.
Tests a subject’s ability to read and
comprehend the instructions for a
radiology procedure and the Patient
Rights and Responsibilities section of
a Medicaid application form.
“Do any of these problems make
it hard for you to read?”
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Blindness or decreased
vision
Decreased hearing
Primary language other
than English
Memory problems or
dementia
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Mental or neurologic
problems
Emotional or
psychiatric problems
Not enough
schooling to learn to
read
Dyslexia or reading
disorder
“What would you do if you needed help
reading or understanding medical directions
or health information?”
Prompts
 Ask a family member for help
 Ask a friend for help
 Ask a health care professional for help
 Ask a translator for help
 Use a magnifying glass
Demographic data
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Sex
Age
Race
Marital status
Language spoken in the home
Highest level of education
Household income
Analysis
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We used simple proportions and means with
95% confidence intervals to summarize the
data.
To compare subgroups, we calculated Pvalues using Fisher’s exact test for categorical
variables and nptrend in STATA for
continuous or ordinal variables.
All analyses were performed with STATA 10
(StataCorp, College Station, Texas).
A P < 0.05 was required for statistical
significance.
Subjects (N=103)
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Mean age 66 years *
99% English was primary language
91% White
61% Female
43% Married
47% > High school education*
58% Annual home income < $30,000*
Results
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Mean S-TOFLA score = 16 (range 0-36)
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60% (N=62) Limited health literacy
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(n=55) Inadequate health literacy (score of 0-16)
(n=7) Marginal health literacy (score of 17-22)
40% (n=41) Adequate health literacy
(score of 18-36)
Etiology of reading difficulty
(N=70)
Blindness/low vision
Decreased hearing
Memory Problems
Mental/Neuro Problems
Not enough schooling
Emotion/Psych problems
English not first language
Dyslexia/reading disorder
34
7
6
6
6
4
4
3
Compensatory strategies
Ask health professional
63
Ask family member
24
Ask friend
5
Use translator
1
(N=93)
Discussion

Patients hospitalized on a general medicine
unit have a higher prevalence of limited
health literacy (60%) than the 33-49% that
has been reported in outpatient studies
(Gazmararian, 1999; Schillinger, 2002; Williams, 1998).

Our results are more similar to Wolf and
colleagues (2007) who reported that 51% of
primary care patients at an urban public
hospital had low literacy skills.
Possible explanations for the high
prevalence of limited literacy in
hospitalized patients
1.
Patients with low health literacy are more
likely to be admitted to the hospital (Arozullah
2002; Baker 2002, 1998; Gordon 2002).
2.
3.
Hospitalized patients may experience
changes in cognition secondary to illness,
emotional distress, medical or surgical
interventions, loss of support systems, or
inadequate sleep (Johnson et al., 2002; Price, Garvan,
& Monk, 2008; Stenuit & Kerkhofs, 2007;) potentially
lowering health literacy scores.
S-TOFHLA may not be ideal measure
Decreased vision as etiology?
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This may be due to:
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factors related to organic disease
medications
Possible cover up for reading difficulties
Compensatory strategies
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Patients’ reliance on health care
professionals, family and friends to assist in
understanding health information reinforces
the need to reconsider existing methods of
communicating information to patients.
Providing verbal and written health
information to patients has been shown to
improve communication, knowledge and
satisfaction (Johnson, Sandford, & Tyndall, 2007).
Limitations
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Homogenous population limits the
generalizability of our results.
Convenience sampling means we likely
missed some eligible patients, particularly
those with brief stays who may have been
less ill, less cognitively compromised.
Limitations

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S-TOFHA is measure of print readability
rather than the broader domain of
health literacy.
This is a cross-sectional survey that
does not allow the observation of
literacy over time, measurement of
incident outcomes, or the assignment of
cause and effect.
Conclusions
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Nearly two-thirds of medical inpatients have
less than adequate health literacy
Most patients rely on help from a health
professional or a family member when faced
with challenges in reading or understanding
health information.
The prevalence of marginal or inadequate
literacy is substantially higher in hospitalized
patients than outpatients.
Additional challenges in the health
care environment…
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> 800 studies indicate that many health
materials are written at reading grade levels
higher that the reading skills of an average
high school graduate.
Limited skill set among health care
professionals in successfully communicating
with adults with limited literacy skills.
Time pressures of the health care encounter.
Clear Communication is
Challenging for Many
We need to closely examine the timing
and method of transmitting critical
information to patients and their
families during hospitalization
Thank you,
What questions
do you have?