MAKING STONE SOUPT 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

d

t o L o w H e a l t h L i t e r a c y

Michael Wolf, MA MPH PhDProfessor, Medicine & Learning SciencesDivision of General Internal Medicine & GeriatricsFeinberg School of MedicineNorthwestern UniversityChicago, IL USA

Greetings from Chicago

Greetings from Chicago

A Parable…d

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

Health Literacy Skillsd

t h e s o u p s t o n e

A Need for Clarity gained prominence as a skill set

~ 600 original studies comprise 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.

HL

HL

Cognitive & Social Skill Set.

Reading

Numeracy

Memory

Attention

Speed

Reasoning

Communication

HEALTH LITERACY

A Need for Clarity gained prominence as a skill set

~ 600 original studies comprise 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.

HL

HL

A Need for Clarity gained prominence as a skill set

~ 600 original studies comprise 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.

HL

HL

A Need for Clarity gained prominence as a skill set

~ 600 original studies comprise 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.

HL

HL

2 Primary Objectives

► A Risk Factor: Health & Healthcare Equity

1. Reduce literacy disparities in health

► An Outcome: Clear Health Communication

2. Promote for all healthcare consumers

HL

2 Primary Objectives

► A Risk Factor: Health & Healthcare Equity

1. Reduce literacy disparities in health

► An Outcome: Clear Health Communication

2. Promote for all healthcare consumers

HL

Available, imperfect metrics Mostly – intervention trials

What is the Root Cause?

Knowledge?

Experience?

Reading?

Cognitive Decline?

Numeracy?

Self-Efficacy?

Activation?

Communication?

Beliefs?

What is the Root Cause?

Knowledge?

Experience?

Reading?

Cognitive Decline?

Numeracy?

Self-Efficacy?

Activation?

Communication?

Beliefs?

D O E S I T M A T T E R W H Y ?

Health Literacy ≠ Activation

BOTH IMPORTANT

2 Primary Objectives

► A Risk Factor: Health & Healthcare Equity

1. Reduce literacy disparities in health

► An Outcome: Clear Health Communication

2. Promote for all healthcare consumers

HL

Available, imperfect metrics Mostly – intervention trials

2 Primary Objectives

► A Risk Factor: Health & Healthcare Equity

1. Reduce literacy disparities in health

► An Outcome: Clear Health Communication

2. Promote for all healthcare consumers

HL

Available, imperfect metrics Mostly – intervention trials

Variable, tailored metrics Widely dispersed studies

Daily Mail 25 May 2009

… & Simplify.

Reduce healthcare complexity and demands

to match consumer abilities

Alastair J.J. Wood, MD

“Can we confuse patients less?”

Deconstruct the Taskd

m e d i c a t i o n u s e

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

Case Example: Medication Use

But What About…

Health Literacys

r e s e a r c h a g e n d a

An Abundance of Low Hanging Fruit

Improve Written & Multimedia Health

Information

Train Healthcare Professionals on

Spoken ‘Best Practices’

Empower Patients to Ask Questions and Be Involved

Modify Delivery of

Healthcare Services

Set Policies and Standards

Start Early: Familiarize Youth to Healthcare System

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

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

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

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

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

Measures

Existing Tools

Individual traits

Research vs. clinical

Variable thresholds reported

Limited modality

Resilience over time

Aging

SES

Performance preserved: - Verbal Ability- REALM

Performance declines:- Long-term

memory- Working memory- Inductive

Reasoning- Processing Speed- TOFHLA- NVS

Performance preserved: - Verbal Ability- REALM

Outcomes

Outcomesisk Factor Background Knowledge (retrieve, recall)

‘Functional Understanding’ of Behaviors (apply)

Self-Efficacy (information-seeking)

Activation

Communication

Behavior change/maintenance

Health Services Use

Outcomes

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

HLDIRECT

Outcomesisk Factor Background Knowledge (retrieve, recall)

‘Functional Understanding’ of Behaviors (apply)

Self-Efficacy (information-seeking)

Activation

Communication

Behavior change/maintenance

Health Services Use

Outcomes

HL

DISTAL

Implementation

Health Information

Evidence strong for best practices:

Plain language, written materials (Doak 1993; AHRQ 2012)

- 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)

High

Improve Drug Information.

Yin et al., JAMA Pediatrics, 2008

Rx Label

OTC Label

Case Example: Transplant

Provider Interactions

Limited evidence for verbal counseling

Single Event

‘Teach back’ technique (Schillinger 2003; Kandula 2011)

Implementation Intention (Park 2007; Armitage 2009)

Repeat Event

Teach-to-goal (Baker et al. 2011)

Brief Counseling (DeWalt 2009; Wallace 2009)

Speech Rate! (Gordon et al 2009)

Moderate

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?

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

Multifaceted Interventions

- necessary but difficult to implement (Kripalani 2012)

- Deconstructing what actually worked (Rothman et al. 2004)

Low

Premium

Deductible

Co-pay

COBRA

Enrollment

Pre-existing condition

Subsidy

County care

The Exchange

Obamacare

Co-insurance

Network

Out of pocketPreferred provider

Claim

Allowed amount

Essential health

benefits

Preventive care

Marketplace

A New and Simpler Health Insurance Provider

Rx Adherence (pill count)

Demonstrated Proper Use

9 months

3 months

1.19 (0.65, 2.18)

2.08 (1.10, 3.98)

1.85 (1.31, 2.60)

1.07 (0.74, 1.57)

Better Rx Labeling, Better Adherence R01HS01768

7January 8, 2013

Reprogrammed, Default ‘Sigs’Epic EHR view

Going (Gone) MobileFigure X. SMS text for UMS instructions.

Interventions

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

Recommendations

Include measures in research

- preferences?

Report Standard Thresholds

- gradient or threshold effect?

Have reasonable, objective outcomes

- what to power to?

Test for interactions (Goal 1)

HL

Recognize performance is dependent on the system, not just individual

- can you include system attributes?

Mediating, Moderating Factors

Consider Activation Separately among others

Recommendations (cont.)

Michael Wolf, MA MPH PhDProfessor, Medicine & Learning SciencesAssociate Division Chief – ResearchGeneral Internal Medicine & Geriatricsmswolf@northwestern.edu