Transcript Non-Adherence Or Low Literacy: Do you know the difference?

Non-Adherence or Low Health
Literacy:
Can You Tell the Difference?
Darcel Reyes, RN, ANP-BC, PhD (c)
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Disclosure
The following person has no relevant financial, professional or
personal relationships to disclose:
Darcel M. Reyes, RN, ANP-BC, AAHIVS, PhD (c)
There are no commercial supporters of this activity.
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Learning Objectives
• Recognize the signs of low literacy in a client with HIV
• Use screening tools effectively to assess for low health
literacy
• Implement interventions that will assist the client with
self-management of HIV disease
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What is Literacy?
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Nielsen-Bohlman, Panzer, & Kindig, 2004
What is Health Literacy?
“ the degree to which individuals can obtain,
process, understand, and communicate about
basic health information and services needed
to make appropriate health decisions.”
INFORMED
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McCormack, et al., 2010
The National Survey Of Health
Literacy found:
Healthliteracyinnovations.com
True or False:
• 1. Most people with low literacy skills are minorities.
• 2. Only those who didn’t finish high school have problems
with health literacy.
• 3. Even patients with a well-controlled chronic disease can
have limited health literacy.
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What increases the risk of low
literacy?
• Age greater than 65
• Enrollment in Medicaid, other public insurance or public assistance
• African American race
• Hispanic/Latino ethnicity
• Race and Ethnicity as a risk factor decreases as income and
education increases!
• Fluent in a language other than English
• CAVEAT: This is country specific!
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WHY ARE WE CONCERNED
ABOUT
LOW HEALTH LITERACY?
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True or False:
• 4. People will rarely tell you if they have problems reading.
• 5. Health literacy is about reading skills.
• 6. Most providers can tell if someone has low health
literacy.
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Parikh, et al., 1996
How is the Health Literacy in
your community?
Here is how to find out:
• http://nces.ed.gov/naal/estimates/StateEstimate
s.aspx.
• http://www.pfizerhealthliteracy.com/physiciansproviders/PrevalenceCalculator.aspx#calculator.
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PEOPLE LIVING WITH HIV
AND
LOW HEALTH LITERACY
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HIV, Health Literacy, and
Medications
In a study of 157 patients in a community clinic, 48% the
participants read below a 9th grade level; one third could
not name their HIV medications (p.<.01); two thirds did
not know how to take their medications correctly, three
quarters did not know the meaning of “CD4 count” or
Viral load”
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Wolf, et al., 2006
PLWHA and low health literacy
are more likely to:
• have negative perceptions of their health care experiences
• perceive their care as poor
• have lower CD4 counts and higher VL
•
• Have more frequent hospitalizations, but
• Visit healthcare providers on a monthly basis
• Have misconceptions about how HIV is transmitted.
Kalichman, 2003; Kalichman, 2008
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PLWHA and low health literacy are
less likely to:
• View providers as involving them in decision making
• understand provider explanations of treatment plans
and disease processes
• know the meaning of the terms “CD4” and “Viral Load”
Kalishman, 2008
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HIV and Health Literacy
• The AIDS Treatment for Life International Survey of 2035
PLWH in 2010 found that:
• 35% of PLWH in North America identified HIV drug
resistance as a good thing.
• 24% of PLWH in Africa
• 16% in Latin America
• 14% in Asia
• 15% in Europe
• (p< .05)
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Nachega, et al., 2012, JIPAC 11 (12), 128-133
PLWHA do not perceive that they
are getting adherence messages
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Nachega, et al., 2012, JIPAC 11 (12), 128-133
WHAT’S IT LIKE TO BE A PATIENT WITH
LOW HEALTH LITERACY?
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Can you READ this?
Your naicisyhp has
dednemmocer that you
have a ypocsonoloc.
Ypocsonoloc is a test for
noloc recnac. It sevlovni
gnitresni a elbixelf gniweiv
epocs into your mutcer. You
must drink a laiceps diuqil
the thgin erofeb the
noitanimaxe to naelc out
your noloc.
It says:
Your physician has
recommended that you
have a colonoscopy. A
colonoscopy is a test for
colon cancer. It involves
inserting a flexible viewing
scope into your rectum.
You must drink a special
liquid the night before the
examination to clean out
your colon.
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Weiss, 2007
healthliteracyinnovations.com
Wise teaches me a lesson.
Brian swears he’s taking his once a day regimen
Herman’s HIV is under control, what’s up with his
BP?
Serena brings her medications in.
CASE STUDIES:
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Wise
• He brings these medications to the visit:
• Fluticasone/salmedrol (Advair)
• Tiotropium bromide (Spiriva)
• Lopressor
• Metoprolol
• Toprol XL
• NO HIV medications (he admits to selling them for pain
medicine or illicit drugs)
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Is it drug use or low literacy?
• Here are some hints:
THE WISE SOLUTION
• The counter on the Advair is still on 60
• Wise uses the Spiriva without inserting the capsule in
the dispenser
• He explains that he has been swallowing the Spiriva
capsules
• He is taking the Lopressor, Metoprolol and Toprol XL
together
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• Difficulty explaining symptoms
• Use excuses to avoid reading “I forgot my glasses.”
• Have lots of papers folded up together in purse or pocketimportant, unimportant, and expired
• Missed appointments
• Difficulty explaining how to take medications
• Take overly long or refuses to fill out forms.
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This is one simple tool to assess for
health literacy
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Assess health literacy with four
simple questions
Do you like to read?
or
How happy are you
with the way you
read?
What is the
best way for
you to learn
new things?
Chew, et al., 2004
How confident
are you to fill
out medical
forms by
yourself?
Chew, et al., 2004
How often do you
have problems
learning about
your health
because of
difficulty
understanding
written
information?
Chew, et al., 2004
Brian and Emily
• Brian cannot read or write, but he has his own
business in home remodeling (numeracy)
• Brian was on a once a day regimen
• Brian insists that he takes his medications faithfully
•
• New labs show a viral load of >1000
• The genotype showed resistance in all classes
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What’s the problem with Brian?
A.
Brian was taking his medicine, but is now selling his
medication to finance his business
B.
Brian has relapsed
C.
Brian is busy with his business, he takes his medications
intermittently, creating resistance
D. Brian is taking his medications and the genotype is
showing archived mutations
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Brian’s past has caught up with him
• These are old mutations
• Because Brian cannot read or write, he has no record of his
previous regimens
• Now Brian needs a new regimen consisting of five pills
• Some pills Brian will take twice a day
• Some pills Brian will take once a day
• Emily wants to help Brian
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The Newest Vital Sign
Give the patient this Ice Cream
Label
Ask these questions and score
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Brian has “visual literacy.” He can identify his medications
easily, and you know he has “numeracy” skills
You can use these two skills to help Brain take his new
regimen by using the “teach back” strategy.
WHAT IS “TEACH BACK”?
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Herman’s Blood Pressure
• Herman's HIV is under control: his CD4 count is in the 400s,
and his viral load is undetectable
• His blood pressure is consistently high
• Herman insists he is taking his medications.
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Why is Herman’s blood pressure so high?
A.
Herman is just telling you that he taking his blood pressure
medicine because he thinks that is what you want to hear
B.
The medicine needs to be changed or increased because it is
not working for him
C.
Herman believes the medicine is causing ED and ruining his
love life
D. Herman can’t read, so he doesn’t know how to take his
medicine
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Herman shows you his medicine
Loratadine 10 mg once a day
Lisinopril 10 mg once a day
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Serena’s Cholesterol
• Serena is adherent to her once a day HIV medication
• Her cholesterol is out of control
• Her diabetes is poorly controlled
• You have changed medications, added medications and sent
Serena for nutritional counseling many times
• You decide to do a medication review
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Serena brings in her meds
But that wasn’t all
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HIV medications look like this:
How different do these medications
Look to you?
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What’s a simpler word?
• Cellulitis
• Lipids
• Monitor
• Mutation
• Resistance
• Anti-inflammatory
• Inflammation
• “the results are negative”
• Skin infection
• Fats in blood
• Keep track of, keep an
eye on it
• The virus changes
• The virus fights the HIV
medicine
• Less swelling and
irritation
• Irritation, swelling,
infection
• Normal test
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What are our goals for today?
Teach your patient to ask:
• What is my main problem?
• What do I need to do about the problem?
• Why is it important for me to do it?
Pfizerhealthliteracy.com
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How much information can
people retain?
The experts say people only remember 5-7 bits of
information!
Most healthcare visits result in:
INFORMATION OVERLOAD
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Doaks, Doaks, & Root, 1996
End your visit with this
statement:
I bet a lot of questions have been on your mind as we’ve
talked.
Tell me 1 or 2 questions you’ve been thinking about.
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True or False:
• 8. Writing material for a 5-6th grade reading level is just
“dummying down” the information.
• 9. Most health information is written at a much higher
reading level than the average reading ability of patients.
• 10. Well educated people are insulted when given lower
level reading material.
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INTERNET HEALTH INFORMATION:
AS RELIABLE AS CONVERSATION
AT A BAR
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What’s the problem with most
health information websites?
• The reading level of most are 11th grade
• Use scientific language or medical jargon
• Lots of words!
• People can’t tell the difference between commercial
websites, government websites, or research institutions
or…
• The difference between advertisements and real
information
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How many HIV websites
are out there?
GOOGLE:
203,000,000
YAHOO:
134,000,000
BING:
137,000,000
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Why is this important?
84% of people start with a
search engine
13% start at a health
website
2% start at Wikipedia
1% start at a social
network
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How reliable are HIV
websites?
• A survey of 137 HIV health information websites found:
• 35% did not have a current date within 1 year of the
survey
• Only 7% had information reviewed by an expert
• Only 4% had information that was journal referenced
• One website promoted avoidance of HIV medications
and provided anecdotal stories of cures without HIV
medications Horvath, Harwood, Courtnay-Quirk, McFarlane, Fisher…Rosser, 2011
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Results of a study of PLWH and high health
literacy who used the internet showed that :
• Believed that HIV did not cause AIDS
• Scientist were still debating the cause of AIDS
• There were herbal and natural cures for HIV and
AIDS
• Experienced more HIV symptoms, had less
adherence to treatment regimens, and were less
likely to be undetectable
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What makes a website
reliable?
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Some Tips:
• KISS
• Keep It Short and Simple
• Pictures speak louder than words
• Personalize, don’t Generalize!
• See it, hear it, and do it and repeat it!
• Safest internet sources: .gov, .edu, and .org, and sites with a
HON designation
• Literacy is the latest vital sign!
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Review Questions
What are some of the RED FLAGS of low health
literacy?
1. Refusing to complete forms
2. Asking a lot of questions
3. Difficulty describing symptoms
4. Items 1 and 3 only
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Review Questions
Health literacy can be assessed by:
1. Determining the patient’s reading level
2. Using the Newest Vital Sign
3. Asking 4 simple questions
4. All of the above
5. 2 and 3 only
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Health Literacy Resources
•
•
•
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http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf
http://nchealthliteracy.org/communication.html
http://www.healthyroadsmedia.org/index.htm
http://www.cms.gov/WrittenMaterialsToolkit/
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Parting Words
“The illiterate of the future will not be the person who cannot
read. It will be the person who does not know how to learn.”
Alvin Toffler
Future Shock
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Thank You!
Darcel Reyes, RN, ANP-BC, PhD (c)
[email protected]
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