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Learning Theories and Health Literacy

PTP 783

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1. Review learning theories

2. Discuss a framework in which learning can occur in Geriatric PT practice.

3. Discuss how health literacy impacts Geriatric PT practice.

4. Identify strategies to address assessing health literacy in verbal and written communications.

Objectives

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Can a patient learn anything a physical therapist tells them if they are not ready to learn?

What are the barriers to learning?

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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.”

Healthy People 2010

Health Literacy

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Population >65

Non-English Speaking

Medications Prescribed

Specialists

Hospital Stay Length

Time spent with

Patients

Reimburse-ment

The Health Care System is Becoming More Complex

More Self Management in the Home

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The complexity of the healthcare system exacerbates literacy

vulnerabilities

Payment structures

Testing

Appointments & Referrals

We Have a Problem:

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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

How information is communicated Aging and disease/treatment factors

Factors contributing to low health literacy

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Fills out intake forms incompletely

Misspelling many words

Leaves the clinic before completing forms

Gets angry about forms

Identifies medication by looking at pill rather than reading the label

Informal methods to assess health literacy

Weiss BD. Health literacy: a manual for clinicians. 2003

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n = 19,714

● Most up to date portrait of literacy in U.S.

● Scored on 4 levels

● 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 Assessment of Adult Literacy (NAAL)*

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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90 million Americans have trouble understanding & acting on health information

Unfamiliar/complex text most difficult to read

3 billion Rx written a year

Pharmacist/physician time is limited

Elderly fill 30 Rx/year, see 8 physicians, on average

Patient SafetyMedication error: most common medical mistake

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“How would you take this medicine?”

• 46% did not understand instructions ≥ 1 labels

• 38% with adequate literacy missed at least 1 label

395 primary care patients in 3 states

Davis TC , et al. Annals Int Med 2006, slide by T Davis

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“Show Me How Many Pills You Would Take in 1 Day”

John Smith Dr. Red

Take two tablets by mouth twice daily.

Humibid LA 600MG1 refill

Slide by Terry Davis

71

8089

63

84

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Davis TC , et al. Annals Int Med 2006 19

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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

Adult Hospitalization

*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.

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Literacy and Mortality

Sudore et al. JGIM 2006; 21: 806-812

Health, Aging, and Body Composition Study

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Simple Familiar Wording Understood by Most Patients

84%

(1st grade.)

Slide by Terry Davis

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More Complex Message Limited Comprehension

59%

(10th-12th grade.

Slide by Terry Davis

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Unfamiliar Multi-step Instructions Rarely Understood

8%

(12th-13th grade)

Slide by Terry Davis

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Comprehension Increased with Patient Literacy Level

In multivariate analysis only literacy and age predicted comprehension.

Patients with low literacy (< 6th gd.) 3x more likely to incorrectly interpret warning labels.

<6 7-8 >9

79% 86% 88% †

35% 66% 78% *

8% 64% 82% *

8% 18% 23% *

0% 6% 15% *

* p<.0001, †

p<.05

Davis et al. JGIM 2006; 21:847–851.

% with a correct response

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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

Common Instruments

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Word recognition and pronunciation

Read aloud a list of 66 medical words

Takes 2-3 minutes to administer

Highly correlated with other standard tests of reading ability (0.88-0.97)

Does not test comprehension

Not available in other languages

REALM (Rapid Estimate of Adult Literacy in Medicine)

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fatflupilldoseeyestresssmearnervesgermsmealsdiseasecancercaffeineattackkidney

hormonesherpesseizurebowelasthmarectalincest

fatiguepelvicjaundiceinfectionexercisebehavior

prescriptionnotify

gallbladdercalories

depressionmiscarriagepregnancyarthritisnutritionmenopauseappendixabnormalsyphilis

hemorrhoidsnauseadirected

allergicmenstrualtesticlecolitis

emergencymedicationoccupationsexuallyalcoholismirritation

constipationgonorrheainflammatorydiabeteshepatitisantibioticsdiagnosispotassiumanemiaobesity

osteoporosisimpetigo

REALM

Prevention & Patient Education ProjectTerry Davis, PhDP.O. Box 33932Shreveport, LA 71130-3932

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17 numeracy items

50 reading comprehension items

Tests ability to read and understand several health care related items

Takes 20-30 minutes to administer

Best for research purposes

Well correlated with REALM and WRAT (Wide Range Achievement Test)

Available in Spanish

TOFHLA (Test of Functional Health Literacy in Adults)

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Doxycycline100 MGTake 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?

Sample TOFHLA Numeracy Question

Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

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Your doctor has sent you to have a _________ X-ray.

a. stomachb. diabetesc. stitchesd. germs

You must have an ________ stomach when you come in.

a. asthmab. emptyc. incestd. anemia

Sample TOFHLA Reading Comprehension

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

Short-TOFHLA

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REALM vs. TOFHLA

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

6 questions are verbally administered

Assesses literacy and numeracy

Takes 3 minutes

Validated against the TOFHLA

Available in English and Spanish

The Newest Vital Sign (NVS)

Weiss et al., Ann Fam Med; 3(6) 2005

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NVS: Example Question

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?

Weiss et al., Ann Fam Med; 3(6) 2005

Available at Pfizer Clear Communication Initiative: http://www.pfizerhealthliteracy.com/physicians-providers/newest-vital-sign.html

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REALM vs. NVS

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

For research purposes, REALM is good, but may consider other instruments depending on goal of research

Which Instrument Should I Use?

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Sensitive topic

Patients go to great lengths to hide problems

May offend some

Inappropriate labeling

Problems with Measuring Health Literacy

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Raise awareness among providers Develop easier to read materials

◦ Including your brochures- readability assessment Improve communication skills Practice-redesign Literacy training / adult education

Interventions to Improve Health Outcomes for Patients with Low Literacy

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Good health information is hard to come by

Most written at too high of a reading level

Few health care systems have comprehensively integrated educational materials in their overall care plans

Educational Materials

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Teach-back method

Patient centered learning◦ What is required of them to learn

Survival skills◦ What pt. needs to know in order to get through session.◦ 3-5 things that are need to know

Ask Me 3◦ Three questions about topic

Therapeutic alliance

Repetition/reinforcement

Educational Strategies

Understanding

Clarify

Assess

Explain

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Teach-back

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Speaking or writing in every day language

Limit & organize the information◦ Get the message quickly and clearly ◦ Makes sense

Focus on behaviors & be realistic

Use carefully phrased words as there is a tendency to take words literally

3-5 ‘need to know’ points

Plain Language

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Frame the message: tell them what you are going to tell them before you do.

Give specific examples and real world examples.

Use analogies for key points.

Use repetition, rephrasing and interactivity

Verify understanding with teach-back technique.

Plain language

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Every MS Office product has this capability

Your brochures will be tested for readability

Other resources: see the BB shell

Readability

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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?

Some Issues

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Extras…..

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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?

Kleinman’s Tool to Elicit Health Beliefs

Dr. Arthur Kleinman, Patients and Healers in the Context of Culture.The Regents of the University of California. 1981