This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this
material constitutes acceptance of that license and the conditions of use of materials on this site.
Copyright 2010, The Johns Hopkins University and Lori A.H. Erby. All rights reserved. Use of these materials
permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or
warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently
review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for
obtaining permissions for use from third parties as needed.
The Implications of Health
Literacy for Clinical
Interpersonal Interactions
Lori A H Erby, PhD, CGC
Health, Behavior and Society
Objectives





Understand the concept of health literacy
Review a variety of health literacy assessment
techniques
Appreciate the role of health literacy in health
communication and health outcomes
Review interventions aimed at clinicians
Review interventions aimed at patients
Literacy levels in the U.S.
2003 National Assessment of Adult Literacy
Literacy levels in the U.S.


In our study: 2% less than 4th grade, 10.8%
4-6, 32.5% 7-8, 54.7% high school or better
In Baltimore, 38% at Level 1 and additional
35% at Level 2 based on 1993 National Adult
Literacy Survey
Functional Adult Literacy Worldwide

International Adult Literacy Survey (IALS)
assessing how well adults use information
to function in everyday tasks.

22-countries
(1994 to 1998)
  administered at home
  nationally representative samples
  Ages 16-65

Functional Adult Literacy
Inadequate Literacy (Level 1 <
5th grade equivalent)
42.6% - Poland
22.6% - Ireland
21.8% - UK
20.7% United States
19.3% - Switzerland (German)
18.4% - Belgium (Flanders)
18.4% - New Zealand
17.6% - Switzerland (French)
17.0% - Australia
16.6% - Canada
14.4% - Germany
10.5% - Netherlands
7.5% - Sweden
Marginal Literacy (Level 2 <
8th grade equivalent)
35.7%
34.5%
34.2%
33.7%
30.3%
30.1%
29.8%
28.2%
27.3%
27.1%
-
Switzerland (German)
Poland
Germany
Switzerland (French)
United Kingdom
Netherlands
Ireland
Belgium (Flanders)
New Zealand
Australia
25.9% United States
25.6% - Canada
20.3% - Sweden
Health Literacy Defined by the AMA

The ability to read and comprehend
prescription bottles, appointment slips, and
other essential health related materials.”-- Ad
Hoc Committee on Health Literacy of the AMA,
1999

Notice limitation to printed materials
Applies Literacy Skills to Health
Context


The capacity to obtain, process, and understand
basic health information and services needed to
make appropriate health decisions -- Surgeon
General’s Report: Healthy People 2010
Broader definition incorporated in the Surgeon
General’s report focusing on the capacity to
obtain process and understand information (not
limited to print) for use in making health
decisions.
Domains of Health Literacy
IOM report, 2004
Patients Don’t Tell Us
Source: Parikh et al, 1996. Adapted from Weiss BD, 2007
What Clues May Indicate Low
Literacy

No studies have attempted a systematic assessments of oral
literacy demand within medical dialogue, however, the AMA
has suggested the following red flags:






Unable to name medications
Unable to explain a medication’s purpose
Unable to explain timing of medication administration
Incomplete or inaccurately complete patient registration forms
“I forgot my glasses.”
“Let me bring this home so I can discuss it with my children.”
Health Literacy: Help your patients understand: AMA Foundation
Summary of Health Literacy
Screens




Single item assessments
Decoding measures
Measures of reading comprehension and
numeracy
Context-specific assessments
REALM
List 1
fat
flu
pill
dose
eye
stress
smear
nerves
germs
meals
disease
cancer
caffeine
attack
kidney
hormones
herpes
seizure
bowel
asthma
rectal
incest
Davis, 1993; Bass, 2003
List 3
List 2
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
fatigue
pelvic
jaundice
infection
exercise
behavior
prescription
notify
Gallbladder
calories
Depression
miscarriage
pregnancy
arthritis
nutrition
Menopause
appendix
abnormal
syphilis
hemorrhoids
nausea
directed
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
allergic
menstrual
testicle
colitis
emergency
medication
occupation
sexually
alcoholism
irritation
constipation
gonorrhea
inflammato ry
diabetes
hepatitis
antibiotics
diagnosis
potassium
anemia
obesity
osteoporosis
impetigo
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
TOFHLA




Reading comprehension and numeracy
67 items
Cloze items (fill in the blank)
Content: patient education, prescription labels,
registration forms, diagnostic test instructions
Your doctor has sent you to have a _________ X-ray.
a.  Stomach
b.  Diabetes
c.  Stitches
d.  Germs
Newest Vital Sign
6 questions:
1.  If you eat the entire container, how
many calories will you eat?
2.  If you are allowed to eat 60g of
carbohydrates as a snack, how much
ice cream could you have?
  3-minute screen
  Very sensitive, but not very specific
  Not correlated with health outcomes in a single study in which STOFHLA was.
  Perhaps ok for clinical use
Weiss BD, 2005; Osborn CY, 2007
Context-Specific Measures


Reduce stigma
Opportunity for identifying unfamiliar terms
Literacy Assessment for Diabetes (Nath, 2001)
Rapid Assessment of Adult Literacy in Genetics (Erby, 2008)
Derived from analyses of session
transcripts
Includes 63 words in 3 columns
Correlation with REALM = 0.83
Assessment Considerations



Sensitivity vs. specificity needs
Time constraints
Acceptability in practice
The role of health literacy in health
communication and health
outcomes
IOM report, 2004
Health Literacy Demand in
Print Is Widely Recognized



Consent forms – 8th grade level (Paasche-Orlow, NEJM,
2004).
Studies analyze the suitability and reading level of health
education materials for diverse patient and community
populations
A review of the literature found a single doctoral dissertation,
from 1953, that analyzed oral communication difficulty by
applying indices of readability to transcripts of group
conversation.
Low Literacy Affects More Than
Poor Reading & Comprehension of
Print Materials
Technical
terminology
General
language
complexity
Client – Provider
Verbal Interaction
Client
satisfaction
with
information
and rapport
Dialogue pacing,
density and
interactivity
Concept density
Patient -–centeredness
Client –Provider
Nonverbal Interaction
Client
ratings
nonverbal
skill
Client
attribution
of affective
demeanor
Counselor
ratings of
Satisfaction,
effectiveness
and
rapport
Roter et al, 2007
Additional Outcomes
Cognitive
Recall
Comprehension
Psychological
Anxiety and distress
Decisional comfort and
confidence
Behavioral
Informed decision-making,
Utilization of medical
services
Adherence with medical
recommendations
Risk reduction through
use of screening and
preventive services
Healthful lifestyle and
behavior changes
Health
Disease management and
control
Quality of Life
Morbidity and Mortality
indicators
Societal
Health Disparities
Provider Outcomes
Enhanced satisfaction
Enhanced self-efficacy
Oral Literacy Demand: Study Aims
1)  Explore the manifestation of oral
literacy burden within the context of
genetic counseling practice and its
likely cognitive and affective
consequences
2)  Examine impact of communication on
patient knowledge and satisfaction
Work supported by NIH 1R01HG002688-01A1; PI: Debra Roter
Oral literacy demand study:
Implications
•  Challenges of communicating information related to
genetics:
-jargon use
-Language
-Turn-taking
-Speech speed
frame
-Focus on information with a general vs. personal
• Tailoring communication to patient needs – differences
based on patient literacy and scenario
Oral Literacy Demand Study:
Implications


Challenges of communicating information related to
genetics:
  Jargon use
  Language
  Turn-taking
  Speech speed
  Focus on information with a general vs. personal
frame
Tailoring communication in patient needs – differences
based on patient literacy & scenario
Interventions for Clinicians

Train clinicians to assess health literacy

Teach clinicians more effective communication
Interventions for Clinicians

Physicians who were notified of S-TOFHLA
scores:
  More
likely to report using suggested
communication management techniques
  Less likely to be satisfied with the visit

No differences in patient self-efficacy
(Seligman HK et al, 2005)
Interventions for Clinicians

AMA Training Program: Help Patients
Understand
  Slow
down
  Use plain language
  Show or draw pictures
  Limit the amount of information
  Repeat information
  Teach-back
  Encourage patient questions
Weiss, 2007
Interventions for Clinicians
Variety of teaching techniques
  Use
of standardized patients
  Videotaped feedback
  Small-group workshops
  Individual behavioral prescription
Kripalani et al, 2006
Interventions for Clinicians


Many studies have shown the ability of
communication programs to change clinician
behavior more generally
Video-supported feedback with individualized
communication analysis showed changes in
residents’:
  Verbal
dominance
  Open-ended question-asking
  Partnership-building
Roter et al, 2004
From Schwartzberg et al, 2004
Understanding Health Literacy
Interventions for Patients

Patient activation studies have shown positive
impact on patient communication, questionasking in particular
Roter et al, 1977; Harrington et al,
2004
Interventions for Patients


Sponsored by the Partnership for Clear Health
Communication (consortium including the
AMA)
Uses brochures and posters to encourage
patients to ask 3 key questions
Interventions for Patients



What is my main problem?
What do I need to do (about the problem)?
Why is it important for me to do this?
Interventions for Patients

Program has demonstrated change in patient
self-reported question-asking behaviors
Mika VS et al, 2007
Prenatal Literacy Intervention:
Aims

To develop a computer-based, interactive
communication intervention for low-literate,
pregnant women at their first prenatal visit
designed to build communication skills to
facilitate disclosure and discussion about
sensitive emotional and psychosocial topics,
including stressors and depression
NIH 5R01HD050437-03
Prenatal Literacy Intervention:
Aims

To conduct a randomized trial to evaluate the
effect of the communication intervention on a
variety of outcomes
Prenatal Literacy Intervention:
Theory

Based on Bandura’s Social Learning Theory
  Cognitive
Priming
  Vicarious Modeling
  Mental rehearsal
  Reinforcement
Prenatal Literacy Intervention:
Communication Skills





Stating primary concern/worry
Prioritizing concerns
Asking questions
Asking for clarification
Paraphrasing to be sure of understanding
Prenatal Literacy Intervention:
Assessing Effectiveness









Baseline vs. intervention period (intervention vs. control)
Communication skills of patients
Communication patterns of physicians
Informed choice about prenatal genetic screening
Satisfaction with communication
Prenatal care utilization
Post-partum appointment keeping
Depression
Baby outcomes (pre-term delivery, birthweight)
Prenatal Literacy Intervention:
Assessing Effectiveness
Control condition:
Implications of Low Literacy for
Interpersonal Communication




Patient literacy can affect oral communication
and health outcomes
Need to tailor communication to patients’
needs
Need to determine patients’ needs
Interventions may target clinicians and
patients