Making stone soup: The many faces and eventual solutions to low health literacy. Professor Michael Wolf

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Feinberg School of Medicine, Northwestern University, Chicago USA.
Presentation given at "Health Literacy Network: Crossing Disciplines, Bridging Gaps", November 26, 2013. The University of Sydney.

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  • You may be curious as to what these icons and enhanced labels looked like. The icon was a black hexagon containing two letters, Ac, which denoted acetaminophen. For over-the counter bottles, the icon was displayed on the front of the bottle next to the active ingredient information and on the back of the bottle in the drug facts to the left of the active ingredient information. Prescription bottles displayed the icon below the directions for use and were accompanied by a brief statement indicating the medicine contains acetaminophen. So you’ve probably noticed that the icon is a little hard to see – particularly on the over-the-counter label - and you may wonder why we chose it to be black and white. We originally intended for the icon to be colored and to be displayed more prominently on the bottle, but we had to make compromises in order to allow for the icon to be used across all packaging, both prescription and non-prescription.
  • Making stone soup: The many faces and eventual solutions to low health literacy. Professor Michael Wolf

    1. 1. M A K I N G S TO N E S O U P T h e M a n y F a c e s a n d E v e n t u a l S o l u t i o n s t o L o w H e a l t h L i t e r a c y d Michael Wolf, MA MPH PhD Professor, Medicine & Learning Sciences Division of General Internal Medicine & Geriatrics Feinberg School of Medicine Northwestern University Chicago, IL USA
    2. 2. Greetings from Chicago
    3. 3. Greetings from Chicago
    4. 4. A Parable… d
    5. 5. Rapid Growth.  > 3000 articles (1985 – present)  ~ 2200 articles in past 5 years  ~ 6000 related articles (1964 – present)  Target of every professional society, WHO  Few interventions  Variable definitions
    6. 6. Health Literacy Skills t h e d s o u p s t o n e
    7. 7. A Need for Clarity  HL gained prominence as a skill set ~ 600 original studies comprise HL evidence (crude measures of reading, numeracy, health knowledge)  But we want more from individuals… - motivation, cultural factors (language, beliefs, experience)  …And the health system - accessibility, navigability, communication, follow-up  …And community - education, human services, policy, etc.
    8. 8. Cognitive & Social Skill Set. Reading Numeracy Memory Speed Attention Reasoning Communication HEALTH LITERACY
    9. 9. A Need for Clarity  HL gained prominence as a skill set ~ 600 original studies comprise HL evidence (crude measures of reading, numeracy, health knowledge)  But we want more from individuals… - motivation, cultural factors (language, beliefs, experience)  …And the health system - accessibility, navigability, communication, follow-up  …And community - education, human services, policy, etc.
    10. 10. A Need for Clarity  HL gained prominence as a skill set ~ 600 original studies comprise HL evidence (crude measures of reading, numeracy, health knowledge)  But we want more from individuals… - motivation, cultural factors (language, beliefs, experience)  …And the health system - accessibility, navigability, communication, follow-up  …And community - education, human services, policy, etc.
    11. 11. A Need for Clarity  HL gained prominence as a skill set ~ 600 original studies comprise HL evidence (crude measures of reading, numeracy, health knowledge)  But we want more from individuals… - motivation, cultural factors (language, beliefs, experience)  …And the health system - accessibility, navigability, communication, follow-up  …And community - education, human services, policy, etc.
    12. 12. 2 Primary Objectives ► A Risk Factor: Health & Healthcare Equity 1. Reduce literacy disparities in health ► An Outcome: Clear Health Communication 2. Promote HL for all healthcare consumers
    13. 13. 2 Primary Objectives ► A Risk Factor: Health & Healthcare Equity 1. Reduce literacy disparities in health Available, imperfect metrics Mostly – intervention trials ► An Outcome: Clear Health Communication 2. Promote HL for all healthcare consumers
    14. 14. What is the Root Cause? Reading? Knowledge? Experience? Self-Efficacy? Activation? Communication? Beliefs? Numeracy? Cognitive Decline?
    15. 15. What is the Root Cause? Reading? Knowledge? Numeracy? Cognitive Decline? Experience? Self-Efficacy? Activation? Communication? Beliefs? D O E S I T M A T T E R W H Y ?
    16. 16. Health Literacy ≠ Activation
    17. 17. 2 Primary Objectives ► A Risk Factor: Health & Healthcare Equity 1. Reduce literacy disparities in health Available, imperfect metrics Mostly – intervention trials ► An Outcome: Clear Health Communication 2. Promote HL for all healthcare consumers
    18. 18. 2 Primary Objectives ► A Risk Factor: Health & Healthcare Equity 1. Reduce literacy disparities in health Available, imperfect metrics Mostly – intervention trials ► An Outcome: Clear Health Communication 2. Promote HL for all healthcare consumers Variable, tailored metrics Widely dispersed studies
    19. 19. Daily Mail 25 May 2009
    20. 20. … & Simplify. Reduce healthcare complexity and demands to match consumer abilities “Can we confuse patients less?” Alastair J.J. Wood, MD
    21. 21. Deconstruct the Task d m e d i c a t i o n u s e
    22. 22. Case Example: Medication Use A dynamic behavior (adding, changing, removing medication) Multi-drug regimens, variable doses Multiple devices (pill, injection, inhaler, liquid, nasal, eye drops, lotions, etc.) Tapered and escalating doses Doses dependent on measurement (i.e. weight, blood sugar) Daily vs. non-daily medicines Limited duration vs. chronic, extended duration medicines ‘PRN’ (Pro Re Nata) or ‘As Needed’ and seasonal medicines Multiple prescribers, multiple pharmacies, variable instructions Brand vs. generic drugs (variable trade dress) Unsynchronized fill dates from pharmacy
    23. 23. But What About…
    24. 24. Health Literacy s research agenda
    25. 25. An Abundance of Low Hanging Fruit Start Early: Familiarize Youth to Healthcare System Set Policies and Standards Modify Delivery of Healthcare Services Train Healthcare Professionals on Spoken ‘Best Practices’ Empower Patients to Ask Questions and Be Involved Improve Written & Multimedia Health
    26. 26. What We Need.  Clarity in Definition - ‘Health Literacy’ (Public Health Goal) - New Term (risk factor…HSE?)  New Standard Measures - Construct measures - Outcomes (patient, provider, system)  Implementation of Known Best Practices  Well-Informed Interventions  A Good Sell
    27. 27. What We Need.  Clarity in Definition - ‘Health Literacy’ (Public Health Goal) - New Term (risk factor…HSE?)  New Standard Measures - Construct measures - Outcomes (patient, provider, system)  Implementation of Known Best Practices  Well-Informed Interventions  A Good Sell
    28. 28. What We Need.  Clarity in Definition - ‘Health Literacy’ (Public Health Goal) - New Term (risk factor…HSE?)  New Standard Measures - Construct measures - Outcomes (patient, provider, system)  Implementation of Known Best Practices  Well-Informed Interventions  A Good Sell
    29. 29. What We Need.  Clarity in Definition - ‘Health Literacy’ (Public Health Goal) - New Term (risk factor…HSE?)  New Standard Measures - Construct measures - Outcomes (patient, provider, system)  Implementation of Known Best Practices  Well-Informed Interventions  A Good Sell
    30. 30. What We Need.  Clarity in Definition - ‘Health Literacy’ (Public Health Goal) - New Term (risk factor…HSE?)  New Standard Measures - Construct measures - Outcomes (patient, provider, system)  Implementation of Known Best Practices  Well-Informed Interventions  A Good Sell
    31. 31. Measures
    32. 32. Existing Tools  Individual traits  Research vs. clinical  Variable thresholds reported  Limited modality  Resilience over time  Aging  SES
    33. 33. Performance preserved: - Verbal Ability - REALM
    34. 34. Performance preserved: - Verbal Ability - REALM Performance declines: - Long-term memory - Working memory - Inductive Reasoning - Processing Speed - TOFHLA - NVS
    35. 35. Outcomes
    36. 36. HL Outcomesisk Factor  Background Knowledge (retrieve, recall)  ‘Functional Understanding’ of Behaviors (apply)  Self-Efficacy (information-seeking)  Activation  Communication  Behavior change/maintenance  Health Services Use  Outcomes
    37. 37. HL Outcomesisk Factor DIRECT  Background Knowledge (retrieve, recall)  ‘Functional Understanding’ of Behaviors (apply)  Self-Efficacy (information-seeking)  Activation  Communication  Behavior change/maintenance  Health Services Use  Outcomes
    38. 38. HL Outcomesisk Factor  Background Knowledge (retrieve, recall)  ‘Functional Understanding’ of Behaviors (apply)  Self-Efficacy (information-seeking)  Activation  Communication  Behavior change/maintenance  Health Services Use  Outcomes DISTAL
    39. 39. Implementation
    40. 40. Health Information Evidence strong for best practices:  Plain language, written materials (Doak 1993; AHRQ 2012) High - content, format, quantity(Seligman 2007; Wilson 2010) - understandability vs. actionability  Broader evidence base to guide multimedia - use of imagery or icons w/ text (Morrow et al. 2012) - video vs. print (Wilson et al. 2012) - best practices for video/web design (Wilson 2010; Sweller 2005)  Web/mobile apps require further study(Chomutare 2011)
    41. 41. Improve Drug Information. Yin et al., JAMA Pediatrics, 2008
    42. 42. OTC Label Rx Label
    43. 43. Case Example: Transplant
    44. 44. Provider Interactions Limited evidence for verbal counseling Single Event  ‘Teach back’ technique (Schillinger 2003; Kandula 2011)  Implementation Intention (Park 2007; Armitage 2009) Moderate Repeat Event  Teach-to-goal (Baker et al. 2011)  Brief Counseling (DeWalt 2009; Wallace 2009) Speech Rate! (Gordon et al 2009)
    45. 45. 3 Minutes or Less  Implementation Intention (Dress Rehearsal) - Cognitive planning or ‘mapping’ a behavior - 3 min. counseling adherence (Park 2007) How will you take this? When will you take this? How many pills do you take at a time? It has to be taken with food…when do you eat meals? Where will you keep it so you remember?
    46. 46. Health System Engagement Addressing practice redesign issues  ‘Hardwiring’ patient education in practice - the reality of limited resources (Wolf et al. 2012) - leveraging electronic health records (EHRs) - patient portals Low  Multifaceted Interventions - necessary but difficult to implement (Kripalani 2012) - Deconstructing what actually worked (Rothman et al. 2004)
    47. 47. A New and Simpler Insurance Provider Premium Claim Essential health benefits Health Obamacare Enrollment Marketplace Pre-existing condition Deductible COBRA Network Co-pay Subsidy The Exchange Preventive care County care Allowed amount Out of pocket Co-insurance Preferred provider
    48. 48. January 8, 2013 Better Rx Labeling, Better Adherence 3 months 9 months R01HS017687 Demonstrated Proper Use 1.85 (1.31, 2.60) 1.07 (0.74, 1.57) 2.08 (1.10, 3.98) 1.19 (0.65, 2.18) Rx Adherence (pill count)
    49. 49. Reprogrammed, Default ‘Sigs’ Epic EHR view
    50. 50. Going (Gone) Mobile Figure X. SMS text for UMS instructions.
    51. 51. Interventions
    52. 52. Our Current State.  Few interventions properly evaluated  Most negative results  Those that worked, ‘kitchen sink’ approaches  Need to attend to lessons from other fields  Need buy-in from healthcare system, industry  Measures, measures, measures
    53. 53. Recommendations  Include HL measures in research - preferences?  Report Standard Thresholds - gradient or threshold effect?  Have reasonable, objective outcomes - what to power to?  Test for interactions (Goal 1)
    54. 54. Recommendations (cont.)  Recognize performance is dependent on the system, not just individual - can you include system attributes?  Mediating, Moderating Factors  Consider Activation Separately among others
    55. 55. Michael Wolf, MA MPH PhD Professor, Medicine & Learning Sciences Associate Division Chief – Research General Internal Medicine & Geriatrics mswolf@northwestern.edu

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