Leveling the Challenges of Health Literacy with Ask Me 3

Leveling the Challenges
of Health Literacy
with Ask Me 3
Ask Me 3 is a registered trademark licensed to the
National Patient Safety Foundation
©2016 National Patient Safety Foundation
Leveling the Challenges of Health Literacy with Ask Me 3 • 1
Which health crisis
is described by the following?
• It impacts nearly 9 out of 10
adults living in the United States.
• Everyone is susceptible
regardless of age, race,
education, or income.
• It costs the United States health
system as much as $236 billion
per year.
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 2
Limited health literacy is a
serious issue facing patients
“Nearly 9 out of 10 US adults have difficulty
using the everyday health information that is
routinely available in our health care facilities,
retail outlets, media and communities.”
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 3
Overview
• What is health literacy?
• Limited health literacy
– Prevalence
– Levels
– Impact
• Risk factors and red flags
• What can providers do?
• Using Ask Me 3®
Leveling the Challenges of Health Literacy with Ask Me 3 • 4
What you need to know
about health literacy
Leveling the Challenges of Health Literacy with Ask Me 3 • 5
What is health literacy?
“The degree to which an individual has
the capacity to obtain, communicate,
process, and understand basic health
information and services to make
appropriate health decisions.”
Affordable Care Act, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 6
Prevalence of limited health literacy
Data from the only population-level study of
health literacy skills conducted to date
show the prevalence of LHL
% of Population
12%
14%
Below Basic
22%
53%
Basic
Intermediate
Proficient
Koh et al, 2012.
National Assessment of Adult Literacy (NAAL), 2003.
Leveling the Challenges of Health Literacy with Ask Me 3 • 7
Levels of health literacy
Below Basic and Basic
– Over a third (36%) of US adults have
below basic or basic health literacy1
– These patients “may fail to understand
critically important warnings on the label of
an over-the-counter medication.”2
1 National
2 Koh
Assessment of Adult Literacy (NAAL), 2003.
et al, 2012.
Leveling the Challenges of Health Literacy with Ask Me 3 • 8
Levels of health literacy
Intermediate
– 53% of US adults have intermediate health literacy 1
– These patients are able to “perform moderately
challenging activities, such as summarizing
written text, determining cause and effect
and making simple inferences.”2
– But they may still “find it difficult to define a medical
term from a complex document about
an unfamiliar topic.”3
1 National Assessment of Adult Literacy (NAAL),
2 CDC, Health Literacy—A Public Health Priority
3 Koh et al, 2012.
2003.
Module.
Leveling the Challenges of Health Literacy with Ask Me 3 • 9
Levels of health literacy
Proficient
– Just 12% of US adults are proficient in health
literacy and able to use health information
effectively.1
– These patients can “perform complex activities,
such as integrating, synthesizing and analyzing
multiple pieces of information.”2
– They “might find the information required to
define a medical term by searching through a
document.”2
1 Koh et al, 2012; National Assessment of Adult Literacy
2 CDC, Health Literacy—A Public Health Priority.
(NAAL), 2003.
Leveling the Challenges of Health Literacy with Ask Me 3 • 10
Impact of health literacy on
health outcomes
LHL is consistently linked to poor
health outcomes
– LHL is negatively associated with
self-reported health
– Adults with below basic health literacy skills
are more likely to report their health as
poor (42%)
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 11
Impact of health literacy on
resource utilization
Patients with LHL have higher resource
utilization
– “Have higher rates of hospitalization, emergency
care visits and lower rates of flu immunizations”1
– “Experience more preventable hospital visits and
admissions”2
– “Have higher medical costs and use an inefficient
mix of services”3
CDC, Health Literacy—A Public Health Priority; NNLM, Health Literacy, 2013.
HRSA, Effective Health Care Communications Course.
3 National Action Plan to Improve Health Literacy, 2010.
1
2
Leveling the Challenges of Health Literacy with Ask Me 3 • 12
Impact of health literacy on
comprehension
Research has linked LHL to poor comprehension
– Misunderstanding prescription medication
instructions
– Greater likelihood of taking medications
incorrectly
– Poor comprehension of nutrition labels
– Poor understanding of preventative care
information
NNLM, Health Literacy, 2013.
National Action Plan to Improve Health Literacy, 2010.
Benjamin, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 13
Comprehension by patients
Proportion of adults aged 18 and over who reported that
their health care providers always explained things
so they could understand
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
60.0%
58.2%
59.4%
60.6%
2007
2008
2009
2010
Healthy People 2020 (citing Medical Expenditure Panel Survey data), 2013.
Leveling the Challenges of Health Literacy with Ask Me 3 • 14
Psychological impact
of limited health literacy
• Patients with LHL are often embarrassed
and feel a “sense of shame.”1
• Patients go to great lengths to conceal
their LHL.1
• Most patients have never shared their LHL
struggles with anyone, even family members.2
1 HRSA,
Effective Health Care Communications Course; National Action Plan to Improve
Health Literacy, 2010.
2 Johnson et al, 2013.
Leveling the Challenges of Health Literacy with Ask Me 3 • 15
Coping mechanisms
Patients with LHL employ various coping
mechanisms, including
• Making excuses to avoid reading health
information (e.g., saying “I forgot my
glasses.”)1
• Postponing decision making (e.g., saying
“I will read this when I get home.”)2
1
2
HRSA, Effective Health Care Communications Course.
Johnson et al, 2013.
Leveling the Challenges of Health Literacy with Ask Me 3 • 16
Identifying patients
with limited health literacy
• Often difficult to identify patients
with LHL
• Know what to watch for to identify
patients who may have LHL
– Risk factors
– Red flags
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 17
Recognize at-risk populations
The following populations are most likely
to experience LHL:
– Elderly (over the age of 65)
– Limited education
– Low incomes
– Non-native speakers of English
– Racial and ethnic groups other than White
– Recent refugees and immigrants
– Adults with any type of disability, difficulty,
or illness
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 18
Recognize at-risk populations
Minority groups and lower socioeconomic
groups are disproportionately affected by LHL
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2%
4%
14%
41%
31%
7%
18%
45%
58%
3%
52%
59%
25%
23%
41%
28%
18%
24%
13%
Black
Below Basic
25%
9%
White
Intermediate
Basic
34%
19%
Proficient
Hispanic
9%
Asian/Pacific American
Islander
Indian/Alaska
Native
Multiracial
National Assessment of Adult Literacy (NAAL), 2003.
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 19
Watch for red flag behaviors
Patients with LHL may exhibit the
following behaviors:
– Fail to complete or inaccurately complete
registration forms
– Be unable to describe their medication regimen
– Experience “difficulty in explaining medical
concerns”
– Be unable to “articulate symptoms or time
course of illness”
– Not have a written agenda for their visit
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 20
Listen for red flag responses
Patients with LHL may offer these
responses to questions about their
medication regimens:
– Unable to name medications
– Unable to explain a medication’s purpose
– Unable to explain timing of medication
administration
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 21
Avoid stereotyping
Remember, most adults
struggle with LHL at
some point in their lives.
National Action Plan to Improve Health Literacy, 2010.
Leveling the Challenges of Health Literacy with Ask Me 3 • 22
Adopt universal precautions
• Absence of cues should not be assumed
to mean adequate health literacy
• Adopt universal precautions
– Use clear communication strategies with
all patients, regardless of their apparent
health literacy skills
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 23
Effective Solutions for
Clear Health Communications
Leveling the Challenges of Health Literacy with Ask Me 3 • 24
Clear communication is key
A provider's communication skills
can directly influence a
patient's health literacy
and comprehension.
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 25
What can providers do?
•
•
•
•
•
•
•
Slow down
Limit, but repeat, information at every visit
Avoid medical jargon
Use illustrations to explain important concepts
Use easy-to-read written materials
Make visits interactive
Use “teach-back” to gauge comprehension
HRSA, Effective Health Care Communications Course.
Koh et al, 2012.
Leveling the Challenges of Health Literacy with Ask Me 3 • 26
Slow down
Speak slowly
– Rapid speech may hinder patients’
comprehension of the information shared,
especially for elderly patients.
– Patients with LHL are less likely to ask providers
to slow down or repeat information than other
patients.
HRSA, Effective Health Care Communications Course.
Roter, 2011.
Leveling the Challenges of Health Literacy with Ask Me 3 • 27
Limit the amount of information,
and repeat it
• Patients have trouble remembering information
shared during medical visits
– There appears to be an “inverse relationship”
between the quantity of information shared and how
much a patient is able to recall.1
• To encourage retention of critical information,
limit the amount shared and reinforce it
– Focus on the top 1 or 2 key points that your patient
needs to know.2
Roter, 2011.
2 HRSA, Effective Health Care Communications Course.
1
Leveling the Challenges of Health Literacy with Ask Me 3 • 28
Avoid medical jargon
Strive to use simple, non-medical terms
when conversing with patients
Instead of using
this word
Benign
Cardiac
Chronic
Edema
Fatigue
Screening
Intake
Generic
Adverse events
Consider saying
this
Harmless
Heart
Happens again and again; does not end
Swelling; build-up of fluid
Tired
Test
What you eat or drink
Not a brand name
Side effects
Roter, 2011.
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 29
Use illustrations to
explain important concepts
Pictures and graphs can reinforce important
concepts and recommended actions
– Patients remember visual images better than
words or letters.1
– The use of graphic illustrations can help
patients understand and retain information.2
1 HRSA,
Effective Health Care Communications Course.
2 Weiss, 2007.
Leveling the Challenges of Health Literacy with Ask Me 3 • 30
Use easy-to-read written materials
• All patients, not just patients with LHL, favor
simple, straightforward materials
• Well-designed materials should
– Present information using bulleted lists1
– Focus on only a few key points2
– Leverage headings and subheadings to separate
blocks of information2
– Use simple terms; avoid medical jargon2
– Use active voice2
1 CDC,
Health Literacy—A Public Health Priority Module.
2 Weiss, 2007.
Leveling the Challenges of Health Literacy with Ask Me 3 • 31
Make visits interactive
• Encourage patients to
ask questions
??
– Use Ask Me 3
• Rather than leaving questions
to the end of a visit, welcome
questions throughout
Roter, 2011.
Leveling the Challenges of Health Literacy with Ask Me 3 • 32
Use “teach-back”
to gauge comprehension
• Check for patient understanding using the
“teach-back” method
– Ask the patient to repeat – or “teach back” – the
information shared to gauge comprehension.1
• If patients cannot explain what they have been
told, assume that you have not clearly
communicated the information.2
– Commence a new explanation of the topic
– Ask the patient a second time to “teach-back”
the information
1 Joint
Commission, 2007.
Effective Health Care Communications Course.
2 HRSA,
Leveling the Challenges of Health Literacy with Ask Me 3 • 33
Use “teach-back”
to gauge comprehension
Instead of
saying
Consider saying
instead
“Does this make sense?”
“Please explain to me how
you will take your medication.”
Roter, 2011.
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 34
It only takes a minute!
Estimates indicate
that it only takes
one minute
to put “teach-back”
into practice
HRSA, Effective Health Care Communications Course.
Leveling the Challenges of Health Literacy with Ask Me 3 • 35
Use Ask Me 3
to Promote Clear
Health Communication
Leveling the Challenges of Health Literacy with Ask Me 3 • 36
What is Ask Me 3?
Ask Me 3 is an educational program promoting
three simple, but essential, questions
for every health care interaction:
What is my main problem?
What do I need to do?
Why is it important for me
to do this?
Diagnosis
Treatment
Context
Leveling the Challenges of Health Literacy with Ask Me 3 • 37
Ask Me 3 background
• Created by the Partnership for Clear Health
Communication at the Pfizer pharmaceutical
company
– Developed by health literacy experts
– Tested and validated
• NPSF acquired Ask Me 3 under a licensing
agreement with Pfizer in 2007
Leveling the Challenges of Health Literacy with Ask Me 3 • 38
Ask Me 3 benefits
• Assists patients in becoming more involved in
their health care
• Organizes the provider-patient conversation
• Focuses discussion on the answers to key
questions
• Ensures that patients acquire the information
they need to take care of their health
Leveling the Challenges of Health Literacy with Ask Me 3 • 39
Ask Me 3 brochure
• Provides an overview of the
Ask Me 3 program
• Instructs patients to ask their
health care providers the three
main program questions
• 8-page and 2-page versions available
Leveling the Challenges of Health Literacy with Ask Me 3 • 40
Ask Me 3 poster
• Instructs patients to ask their
health care providers the three
main program questions
Leveling the Challenges of Health Literacy with Ask Me 3 • 41
Ask Me 3 website
• Provides an overview
of the Ask Me 3
program and
available resources
• Includes a video
featuring a patient
speaking to his
physician about his
condition using the
Ask Me 3 questions
Leveling the Challenges of Health Literacy with Ask Me 3 • 42
Conclusion
• Everyone is susceptible to low health literacy
• Low health literacy has been linked to poor
health outcomes, high resource utilization, and
poor comprehension
• You can help by identifying red flag behaviors and
– Speaking slowly
– Limiting the amount of information you give patients,
and repeating it
– Avoiding medical jargon
– Using illustrations to explain important concepts
– Making visits interactive by using “teach-back”
and Ask Me 3
Leveling the Challenges of Health Literacy with Ask Me 3 • 43
References
Affordable Care Act. 2010. U.S. Department of Health and Human Services.
http://www.hhs.gov/healthcare/rights/law/
Benjamin R. 2010. Surgeon General’s Perspective. Public Health Reports. 125(Nov–Dec):784–785.
http://www.publichealthreports.org/issueopen.cfm?articleID=2544
CDC (Centers for Disease Control and Prevention). Health Literacy—A Public Health Priority. In: Health Literacy
for Public Health Professionals. http://www.cdc.gov/healthliteracy/training/page215.html
Healthy People 2020. 2013. Health Communication and Health Information Technology. In: HealthyPeople.gov,
2020 Topics & Objectives.
http://www.healthypeople.gov/2020/topicsobjectives2020/nationaldata.aspx?topicId=18
HRSA (U.S. Department of Health and Human Services, Health Resources and Services Administration).
Effective Health Care Communications Course. http://www.hrsa.gov/publichealth/healthliteracy/
The Joint Commission. 2007. "What Did the Doctor Say?" Improving Health Literacy to Protect Patient Safety. A
Health Care at the Crossroads Report. http://www.jointcommission.org/What_Did_the_Doctor_Say/
Johnson J, Moser L, Garwood C. 2013. Health literacy: a primer for pharmacists. American Journal of HealthSystem Pharmacy. 70(11):949–955. http://www.ajhp.org/content/70/11/949
Koh H, Berwick D, Clancy C, et al. 2012. New federal policy initiatives to boost health literacy can help the
nation move beyond the cycle of costly “crisis care.” Health Affairs. 31(2):434–443.
http://content.healthaffairs.org/content/early/2012/01/18/hlthaff.2011.1169.abstract
Leveling the Challenges of Health Literacy with Ask Me 3 • 44
References continued
National Action Plan to Improve Health Literacy. 2010. U.S. Department of Health and Human Services, Office
of Disease Prevention and Health Promotion. http://www.health.gov/communication/hlactionplan/
National Assessment of Adult Literacy (NAAL). 2003. The Health Literacy of America’s Adults: Results from the
2003 National Assessment of Adult Literacy. Washington, D.C.: Institute of Education Services, National Center
for Education Statistics. http://nces.ed.gov/naal/health.asp
National Network of Libraries of Medicine (NNLM). 2013. Health Literacy.
http://nnlm.gov/outreach/consumer/hlthlit.html
Protheroe J, Rowlands G. Matching clinical information with levels of patient health literacy. 2013. Nursing
Management (Harrow). 20(3):20–21. http://www.ncbi.nlm.nih.gov/pubmed/23841233
Roter D. 2011. Oral literacy demand of health care communication: challenges and solutions. Nursing Outlook.
59(2):79–84. http://www.ncbi.nlm.nih.gov/pubmed/21402203
Weiss B. 2007. Health Literacy and Patient Safety: Help Patients Understand: A Manual for Clinicians. Chicago:
AMA Foundation. http://www.ama-assn.org/resources/doc/ama-foundation/healthlitclinicians.pdf
Leveling the Challenges of Health Literacy with Ask Me 3 • 45
Questions?
Contact the National Patient Safety Foundation
Tejal Gandhi, MD, MPH, CPPS
President
[email protected]
Patricia McGaffigan, RN, MS
Chief Operating Officer
Senior Vice President, Programs
[email protected]
Caitlin Lorincz, MS, MA
Senior Director, Programs
[email protected]
Leveling the Challenges of Health Literacy with Ask Me 3 • 46