October 2009




Do your patients really understand you?

by Vanessa Caceres EyeWorld Contributing Editor


Strengthen communication with your low literacy patients

You ask a patient to take 30 mg of a pill a day—each pill is 5 mg, but the patient is still not sure how many pills to take.

You instruct a parent whose first language is not English to use drops in her daughter’s inflamed eye three times a day. The child returns a few days later with the eye in worse condition because the parent mistakenly administered the medicine orally, just as she did with her child’s multivitamin drops.

While these kinds of misunderstandings could happen between any physician and patient, such gaffes are more likely to occur with patients who have low literacy or numeracy skills.

“Low literacy is ubiquitous,” said Andrea J. Apter, M.D., M.Sc., professor of medicine, Allergy and Immunology Section, University of Pennsylvania Medical Center, Philadelphia. “Patients won’t tell you they have low literacy as it would probably make them more anxious,” she said.

An assessment of general literacy and health literacy skills in 2003 by the National Assessment of Adult Literacy found that 36% of American adults, or about 78 million people, had only basic or below basic health literacy skills. The assessment judged participants’ ability to perform certain tasks grouped into four categories, ranging from Below Basic to Proficient. The Below Basic category asked patients to, among other things, circle the date of a medical appointment on a hospital appointment slip. Only 12% of participants had proficient health literacy skills. Keeping tabs on patients’ literacy levels may help improve their health outcomes, said Ian Moore Bennett, M.D., Ph.D., assistant professor, Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia, who studies the relationship between low literacy and reproductive health disparities in women.

“Most clinicians are surprised to learn that literacy is one of the strongest predictors of health status,” according to the American Medical Association’s (AMA) guide “Health literacy and patient safety: Help patients understand,” written by Barry D. Weiss, M.D. The guide adds that literacy is a stronger predictor of someone’s health than income, employment, education, and race or ethnicity. Literacy also affects patient adherence to medication regimens. Researchers in a 2006 study in the American Journal of Ophthalmology did not find a link between glaucoma medication refills and age, gender, or race, but they did find a positive relationship between subjects’ level of health literacy and the number of refills obtained.

“Interventions specifically targeting patients with low literacy may improve medication adherence,” wrote Kelly W. Muir, M.D., Durham, N.C., and co-investigators.

A 2008 study published in the Archives of Ophthalmology and led by Mark S. Juzych, M.D., M.H.S.A., Detroit, found that glaucoma patients with poor health literacy—50% of those tested in the study—had poorer compliance, worse disease progression, and less understanding of the disease than patients who had better health literacy scores.

Literacy problems not only tie into adherence and compliance; patient education could hit some roadblocks as well. “We couch most health information as prevention, which means risk, and that means ratios and percentages, which are difficult for these patients,” Dr. Apter said. This may also involve the use of tables, charts, and graphs that could be lost on these patients, she added.

Additionally, these patients may be more likely to have health problems such as depression that is related to their low literacy skills, Dr. Bennett said. While low literacy is not always associated with age or ethnicity, elderly patients and patients whose first language is not English are sometimes more likely to have problems reading and writing. For example, the National Assessment of Adult Literacy found that 59% of participants age 65 and older only had a Basic or Below Basic health literacy level, compared with 28% of participants aged 25 to 39 and 32% of participants aged 40 to 49. Sixty-six percent of Hispanics and 58% of black participants had only Below Basic or Basic health literacy scores, compared with 24% of whites and 31% of Asians.

How to boost compliance and comprehension

Here are some suggestions to work better with patients who may have weak reading, writing, or even math skills as they relate to health.

Use “universal precautions,” suggested Dr. Bennett. He doesn’t mean donning gloves and masks when working with all patients; he means that physicians should treat all patients as if they may have literacy barriers. In fact, even patients with a higher level of education will often appreciate health information presented in a clear, easy-to-understand manner, he said.

This approach is especially important as physicians cannot always guess who has a higher level of education or literacy, said Harry A. Quigley, M.D., Wilmer Eye Institute, Johns Hopkins University, Baltimore. “I had a sweet little lady come into my office with a cane who looked as if she might watch soap operas all day; she was a national security advisor,” he said.

Informally gauge patients’ literacy, recommended Dr. Quigley, who has co-authored a number of studies relating to medication adherence and socioeconomic factors. He makes a point to ask patients about their career, if they work outside the home, or what they’ve most recently read. The AMA guide notes a few other ways to tell if patients may have limited literacy: • Their registration forms are incomplete or inaccurately completed. • They lack follow-through with lab tests, imaging tests, or referrals.

• They may say something like, “I forgot my glasses. I’ll read this when I get home.”

• They are unable to name medications or explain what the medications are for. Along those lines, patients with limited literacy are often less likely to ask questions of their doctor, Dr. Bennett said. Because of this, the patients may not get information they need to help them better advocate for their health problems.

Some practices have discussed offering a formal health literacy test to all patients so they can adjust patient education information accordingly. Such testing may be an eye opener to see what percentage of patients actually faces literacy challenges, Dr. Bennett said. On a larger scale, Dr. Muir and Paul P. Lee, M.D., J.D., both of Duke University Medical Center, Durham, wrote an editorial in the May 2009 issue of Archives of Ophthalmology to advocate the use of a two- to three-minute literacy test during the informed consent process for glaucoma clinical trials. This test is known as REALM, or the Rapid Assessment of Adult Literacy in Medicine.

Tone down “doctor talk” and use plain English

Juan C. Celedón, M.D., Dr.P.H., associate professor of medicine, Channing Laboratory, Brigham and Women’s Hospital, Boston, sometimes hears residents and interns use a number of technical terms when speaking with patients about their health problems—yet they are completely unaware that their explanation was lost on the patient and the family, he said. “Doctors fall into the trap of communicating with patients like they communicate with their colleagues,” Dr. Bennett said.

Instead, use simpler terms, focus on three major points, and ask patients to repeat information back to you, Dr. Bennett recommended. “I ask them how they would teach someone the instructions they just learned,” Dr. Apter said. Also, don’t be afraid to repeat information.

It’s also helpful for all patients—whether or not they face literacy challenges—to be crystal clear on their medication regimen, Dr. Celedón said. So instead of asking a patient to take 30 mg of a medication daily, with each pill containing 5 mg, he would tell the patient to take six pills a day.

Dr. Celedón likes to give patients analogies related to medication use that they’ll remember. “For asthma patients, I tell them their daily medicine is like their wife and their albuterol [rescue medicine] is like their friend,” he said.

Demonstrate to patients how they should use their drops, advised Sade Kosoko-Lasaki, M.D., professor of surgery and preventive medicine and public health, Division of Ophthalmology; and associate vice president, Health Sciences’ Multicultural and Community Affairs, Creighton University School of Medicine, Omaha. She had a patient whose first language was not English think that the eye drops for her child should be given by mouth, just like her child’s multivitamin liquid; the misunderstanding occurred even though a translator was present. Because of the risk for misunderstanding with any patient, Dr. Kosoko-Lasaki likes to show patients how to use their eye drops. If patients rebuff the demonstration and say they have taken eye drops before, she asks them to show her how they use drops.

Use visuals and clear written information

Just as spoken information should be clear for patients, written information should also be easy to follow, physicians said. Visuals related to eye diseases can help explain conditions; you can also ask a sampling of patients—say, 10 to 20 of them—to review newly designed patient education handouts and see if they are clear, Dr. Celedón said.

If you’re using tables, charts, or graphs, keep them simple, Dr. Apter recommended. For example, a graph to show a 10% risk for a certain disease may have 100 small human figures with 10 of them colored in to show the 10% risk, Dr. Apter suggested.

Take into account language and culture issues that may—or may not—be connected to literacy. Sometimes, a person whose first language is not English may be struggling because of a lack of literacy in their native language, Dr. Celedón said. Other times, misunderstandings may be tied into cultural preferences, such as consulting family members before a major health decision, Dr. Kosoko-Lasaki said. Research co-authored by Dr. Quigley has found that medication adherence may have less of a connection to education and income and more of a connection with certain cultural preferences.

See sidebar for further suggestions to work with patients whose first language may not be English.

Use resources designed to help with health literacy issues

The AMA guide (and accompanying DVD) is available on the AMA Web site (www.ama-assn.org). Dr. Kosoko-Lasaki is author of the book Cultural Proficiency in Addressing Health Disparities. A 2008 article from Dr. Apter, published in the Journal of General Internal Medicine, discusses how to address numeracy problems related to medical care. Studies from researchers such as Drs. Quigley and Bennett continue to explore relationships between health disparities, adherence to medication regimens, and low literacy. In fact, Dr. Quigley is working with a number of studies to assess how phone calls and electronic monitoring devices help (or hinder) patient compliance with glaucoma medication.

Editors’ note: The doctors interviewed did not indicate any financial interests related to their comments.

Contact information

Apter: 215-349-5120, apter@mail.med.upenn.edu
Bennett: 215-614-0849, ian.bennett@uphs.upenn.edu
Buznego: 305-598-2020, cbuz@comcast.net
Celedón: 617-525-0964, juan.celedon@channing.harvard.edu
Kosoko-Lasaki: 402-280-2332, skosoko@creighton.edu
Quigley: 410-955-2777, hquigley@jhmi.edu

Do your patients really understand you? Do your patients really understand you?
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