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Clinical Crossroads |

Caring for Patients With Limited Health Literacy:  A 76-Year-Old Man With Multiple Medical Problems

Michael Paasche-Orlow, MD, MA, MPH, Discussant
JAMA. 2011;306(10):1122-1129. doi:10.1001/jama.2011.1203.
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Health literacy is the degree to which individuals have the capacity to obtain, process, and understand health information, skills, and services needed to make informed health decisions and take informed actions. Narratives from Mr J, a 76-year-old man with multiple medical problems and limited health literacy, and his physician exhibit some of the difficulties experienced by patients with limited health literacy. Clinicians can help patients with limited health literacy by removing unneeded complexity in their treatment regimens and in the health care system and by using teach-back methods to assess and improve understanding. Rather than a selective screening approach for limited health literacy, a patient-based universal precaution approach for confirming patient comprehension of critical self-care activities helps ensure that all patients have their health literacy needs identified.

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Addressing Mr. J's Limited Health Literacy
Posted on August 18, 2011
Nancy R Kressin, PhD
Boston VA Healthcare System; Boston University School of Medicine
Conflict of Interest: None Declared
Low health literacy is common (1), affects patients' understandings of their health, adherence to therapy, and outcomes (2,3). Clinicians tend to overestimate patients' literacy (4); moreso for African American patients (3). Mr. J, an older African American man originally from the rural South, has a longstanding relationship with his doctor, who recognizes his patients' low literacy. Thus, literacy screening is not needed here; caregivers should go beyond screening, to better understand this patient and target his specific literacy gaps.
Mr. J says his eyesight is his 'only' problem, suggesting that neither diabetes, heart disease, nor sleep apnea is his priority; he indicates that the prescribed medicines don't make him FEEL any better, and that doctors don't always explain their purpose very well (perhaps limiting his motivation to take them). A key part of his literacy gap may be around the goals for the risk factor reduction medications he is taking and the need to clarify that such medications don't necessarily make one feel better, but reduce risk for future health problems. It seems worth assessing whether Mr. J has any sense of that or cares about it. He may feel that he has lived to 76 years (nearly 6 years more than the average African American man (5)) and is now most concerned about his quality of life, for which vision is central. Identifying his priorities is a starting point to determine the emphasis of therapy and the most important point(s) around which to increase his literacy.
Caregivers need more information about several aspects of Mr. J's self-management. What is his adherence to prescribed therapies; what does HE say about why he does or does not adhere, or what might help him to do so? Does he agree that the conditions for which they are prescribed are important, or that he should be taking such medications? The biggest breakthroughs have been around identifying strategies to help Mr. J with adherence (blister packs, Lantus pen), but these necessitated an understanding of the barriers to his self-management. Developing more of this understanding is critical.
Strategies such as asking patients to repeat back their understanding or view of a condition, diagnosis or recommended therapy can help identify literacy gaps or misunderstandings. Approaches such as 'building a history' (6) can help elicit patients' understandings of their health and priorities, which can in turn help clinicians better target additional information or strategies to address barriers to self-care. Regular monitoring - of blood pressure, blood sugar, and adherence - could help identify additional literacy gaps and emergent problems.
1.Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004.
2. Bass III PF, Wilson JF, Griffith CH, Barnett DR. Residents' ability to identify patients with poor literacy skills. Acad med 2002; 77: 1039-41.
3. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol 2002; 186: 938-43.
4. Kelly, PA, Haidet, P (2007) Physician overestimation of patient literacy: A potential source of health care disparities. Patient Education and Counseling 66; 119-122.
5. Life expectancy: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
6. Haidet, P, Paterniti, DA. (2003). 'Building' a History Rather than 'Taking' One: A Perspective on information sharing during the medical interview. Arch Intern Med 163:1134-1140.
Conflict of Interest: None declared
Teach back, involve, and individualize
Posted on August 10, 2011
Fran London, MS RN
Phoenix Children's Hospital
Conflict of Interest: None Declared
Mr. J's problem: "I don't think, despite numerous discussions, he understands what heart disease is, or understands dialysis, or the many consequences that are associated with chronically elevated blood sugars." Is there a learning barrier, or does Mr. J need to be involved in the process, so teaching can better be individualized to his needs? The success of prepackaged medications in blister packs is an example of successful individualization. The most direct way to determine if health literacy is an issue is to have the patient teach back your instructions in his or her own words. It does not take long, and will immediately bring to light misunderstandings that can be corrected on the spot. Albert Einstein said, "If you can't explain it simply, you don't understand it well enough."
Then ask the patient the chance that he or she could and would follow through on your prescriptive advice. That would have revealed the challenge of a perceived $98 prescription much earlier in the process.
Yes, this takes time, but overall less time and fewer resources if you address it up front. Remember, the term Doctor comes from docere, meaning to teach.
References:
Agency for Healthcare Research and Quality. (2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review: Executive Summary No. 199. Retrieved from http://www.ahrq.gov/clinic/epcsums/litupsum.pdf
Dewalt, D. A., Callahan, L. F., Hawk, V., Broucksou, K., Hink, A., & Rudd, R. (2010). Health Literacy Universal Precautions Toolkit. Available from http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf
Joint Commission. (2007). "What Did the Doctor Say?:" Improving Health Literacy to Protect Patient Safety Retrieved 3/14, 2009, from http://www.jointcommission.org/NR/rdonlyres/F53D5057-5349-4391-9DB9- E7F086873D46/0/health_literacy_exec_summary.pdf
Schuz, B., Marx, C., Wurm, S., Warner, L. M., Ziegelmann, J. P., Schwarzer, R., et al. (2011). Medication beliefs predict medication adherence in older adults with multiple illnesses. J Psychosom Res, 70(2), 179-187.
Wolf, M. S., Curtis, L. M., Waite, K., Bailey, S. C., Hedlund, L. A., Davis, T. C., et al. (2011). Helping patients simplify and safely use complex prescription regimens. Archives of Internal Medicine, 171(4), 300- 305.
Conflict of Interest: None declared
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