November 18th, 2013
I have never met Dr Jeremy Krebs but I already like him. Dr Krebs provides independent commentary for the Diabetes and Obesity Research Review.
A few issues ago he commented on a published article about diabetes and diet and he started his commentary with “I could slit my wrists……”. I must say I felt the same when I read this recent news article from Medline Plus: Patients might benefit from health literacy tests.
All the years I have been working in health literacy I have pushed back on the idea that patients and whānau should have their health literacy assessed. It amazes me that health professionals think it is appropriate to hand out a written test to patients to check the patient’s reading ability (because this is what these tests assess).
Imagine if, every time we went into a hardware shop, we were asked to demonstrate our proficiency at using whatever product we are purchasing (actually ACC might think that is a good idea given the number of DIY accidents that occur in New Zealand).
On reflection, diagnostic testing is such an important part of modern health care you can understand why health professionals think there will be an accurate diagnostic test for health literacy.
The really frustrating aspect about this article is that they claim that using the health literacy assessment test did no harm to patients and may in fact have improved patient satisfaction.
For two years all women at a Phoenix, Arizona breast surgery clinic had their health literacy assessed using the Newest Vital Sign. Of all the health literacy tests, the Newest Vital Sign at least assesses a real life task – reading a food label and working out energy, etc, values. However, the label is from an ice cream container and I am sure that the women visiting the breast cancer clinic would not have been that focussed on the energy content in ice cream.
The article goes on to say that in the second year of the study the staff made a formal effort to communicate better with those women who scored lowest on the test (1,229 out of the total group of 2,025 women). The clinic’s staff used diagrams and informational videos with this group to explain procedures (such as biopsies) and treatments. Staff also made a special effort to report key “take home” messages and information when talking to these patients.
There are a number of issues with the approach taken in this study.
The concept of health literacy had its initial roots in the whole idea of “patients as a risk”. A number of tests (REALM, TOFHLA) were developed to test patients to see if they were a risk to the health professionals and health care organisations treating them.
But health literacy has evolved considerably since then with a greater emphasis on system approaches and reducing the demands the system places on patients. In fact, the actions the staff took (using visuals and being clear about take home messages) are good examples of reducing the system demands as well as building patients’ health literacy.
In addition, why wasn’t the Universal Precautions approach used. This approach has been significantly promoted by the Agency for Healthcare Research and Quality (AHRQ).
If a Universal Precautions approach had been used with all the participants in the study (not just the low health literacy ones) then it is highly likely that the patient satisfaction level may have increased even more.
While some of the women in the study were able to work out the energy in a serving of ice cream they may in fact have had low health literacy about breast cancer (because this was their first diagnosis of the disease).
All women with breast cancer would have appreciated clearer descriptions of biopsies and treatments and greater communication efforts from the staff around taken home messages.
Indeed this was the theme picked up by AHRQ’s Cindy Brach when she commented on the article.
This article shows that the original concept of health literacy about “risky patients” is still alive despite significant efforts by AHRQ and high profile researchers.
In this article it is not clear whether the health professionals had any idea that they had the prime responsibility to build health literacy in their patients notwithstanding the scores on the health literacy assessment.
Oh well. Like Dr Krebs and diabetes, there is always work to be done.
Posted in News
October 31st, 2013
I have just read a document from the Medical Council of New Zealand called ‘You and Your Doctor: A guide to your relationship with your doctor’. It is not a new document – last reprinted in 2008 – but Labour Weekend provided the opportunity to catch up on the huge stack of professional reading (as well as some gardening).
The document is about the relationship b etween patients and families, and their GP or family doctor. The guide is straightforward and informative. The audience is very clear and, while the purpose is more implicit than explicit, the sub-title ‘A guide to your relationship with your doctor’ helps clarify the purpose.
The document is laid out well – lots of white space, uses plain English and questions as headings. It has a logical flow – choosing a doctor, making an appointment, expectations of your doctor, services, your doctor’s expectations of you and ending the relationship. There are also useful sections on informed consents, patients’ rights, patient/doctor boundaries, patient records and taking part in medical research or education.
There is also a quaintly named section on ‘Internet medicine’ which is where the guide starts to show its age. In the seven years since this guide was reprinted, finding information on the internet is the norm for a lot of patients and families. This section also shows that well respected New Zealand sites such as Health Navigator have been established relatively recently.
This is all good common sense advice but how do people access it?
How do people who need to understand how the primary care system works get this information? Do they get it by osmosis, or by direct questioning, or because their primary health care provider makes a point of giving them the information.
Most of the time I think everyone assumes that patients and families understand how the primary health care sector works (after all, they use it don’t they) so all is well.
In health literacy (as in life) making assumptions can be both good and bad. In this case, I think it is an unrealistic assumption that everyone does know how the system works, particularly as the roles undertaken by primary care expand. And if patients and families don’t understand how primary care works, how are they going to understand the complexities of secondary and tertiary care systems?
Posted in News
October 29th, 2013
Emmi Solutions is a US healthcare communications company which focuses on providing information to patients and families. Emmi Solutions’ Geri Baumblatt has a blog called Engaging the Patient where high profile healthcare experts write about their work and their goals. The topics vary from day to day but the focus is that patients are the biggest untapped resource in healthcare. This blog covers an issue that is important to all people involved in health.
Whether we call the problem ‘non-compliance,’ ‘non-adherence,’ or a ‘behavioral failure,’ it is pretty well known that a large number of individuals living with a chronic disease don’t take all of their medicine as prescribed. While this may not be surprising, the consequences of not taking medication safely, consistently and appropriately can be devastating. For many adults, it may mean falling short of getting the optimal benefit from their treatment. In other cases, poor adherence can lead to significant harm or even death.
So why is taking medication so hard? On the ground level, this is arguably one of the most complex and dynamic health behaviors a patient may have to manage. To take medications appropriately, patients must take all their doses, space them out correctly and follow complicated, and sometimes conflicting, warnings and instructions on a daily basis. And often there are multiple medications involved, which require even greater organization, especially when regimens are constantly evolving as physicians prescribe new medicines or titrate existing ones. Add to this that medication regimens may involve not only pills, but injections, inhalers, liquid drugs, and/or tapered doses, and the seemingly simple task of taking medication turns out to be quite complicated.
Making medication-taking ever more difficult is the lack of clarity amidst the label instructions, the often vague guidance provided by doctors and pharmacists, and the increasing trend towards using multiple pharmacies and providers. There is a reason so much attention is given to helping patients take their medication as prescribed, not only in the short-term, but over the course of a lifetime. And to this point, we have just been talking about the act of taking medicine, and not whether one can afford it, wants to take it, or can handle the side effects or associated treatment fatigue. It is tiresome just to briefly summarize the challenges involved!
But this is a very fruitful health literacy agenda and one deserving of our focus and attention. In thinking about how one engages in ‘medication self-management’, any solution needs to map to the root cause of the problem. To that end, strategies aimed at helping patients get the most out of their prescription regimen will need to be multifaceted and capable of helping to resolve whatever the specific issue may be for a particular patient.
Is it cost? Is it memory? Do you understand how to take the medicine, and how to find the most efficient daily routine with the smallest footprint left on one’s lifestyle? Are you informed and prepared for any common side effects? Do you know when to stop taking the drug and seek care?
Health literacy lives between the complexity of a given healthcare task and the ability of the patient in need of completing it. Therefore, interventions must aim to simplify the ask, while supporting the patient in the process of performing behaviors.
This is where we can innovate, and given the expanse of known problems with self-managing drug regimens, there should be ample opportunity for improvement.
Michael Wolf, PhD MPH is Professor of Medicine & Learning Sciences, Associate Division Chief for Research, and Director of the Health Literacy and Learning Program (HeLP) within General Internal Medicine & Geriatrics at the Feinberg School of Medicine, Northwestern University
Stacy Cooper Bailey, PhD MPH is an Assistant Professor in the Division of Pharmaceutical Outcomes and Policy at the University of North Carolina at Chapel Hill Eshelman School of Pharmacy.
Posted in News
October 23rd, 2013
I often hear the term “the active engaged patient”. There are a range of definitions but a holistic definition includes a patient who takes care of their health, engages in prevention and screening activities, and leads a healthy lifestyle of healthy eating and appropriate exercise. This patient also seeks information from a range of sources, including health professionals, and asks a lot of questions.
There are aspects of this definition that are aspirational for me (the exercise and healthy eating parts although I try very hard) but one thing I have always been good at is asking lots of questions of health professionals. And I do this not just for myself, but for family members and friends. In fact, I am so good at it that I once noticed in my patient notes (literacy people are usually very good at reading upside down) the sentence “This patient asks lots of questions”. At the time, I took this as a badge of courage and I haven’t changed my opinion.
I appreciate that asking questions can, at times, be irritating to health professionals who are likely to be time constrained. However, answering patient questions and in fact encouraging questions as a matter of routine is a critical way for health professionals to build health literacy with patients and families.
People often tell us in focus groups how they really appreciate it when health professionals explain what is wrong with them in simple terms while referring to an x-ray or picture or even drawing a diagram. People often keep these personal diagrams folded in their wallets and proudly unfold tatty coffee-stained pieces of paper that a doctor or nurse has given them.
So I was very interested to read a recent British Medical Journal article about how doctors can encourage patient-initiated questions and so improve the consultation process. This study was situated in an oncology clinic in the UK and found that patients’ direct questions were designed to find out specific information about the person’s cancer, treatment options or their symptoms.
The study also found that patients usually ask direct questions after they have received test results and most importantly, that using scan or x-ray results led to more direct patient questions. The study concludes by saying that using diagnostic evidence (scans and x-rays) is an effective way to increase the number of questions a patient asks.
While this study confirms previous research that patients should be encouraged to ask questions, the article actually contains examples of conversations between doctors and patients. Some of them are not that inspiring (at times they seem desultory) but I am really aware they have been taken out of context. However, all of them involve use of x-rays and scans as discussion points.
There are three other aspects to take into account:
1. Checking to see if patients have questions. The time honoured tradition is to finish a consultation and say “Do you have any questions?”. Try “Most people have lots of questions. What are your questions?”.
2. Wait time. Often patients need time to think of questions so it pays to wait at least 30-60 seconds to see if patients have questions. This will seem a very long period of time but you can busy yourself by doing some minor administrative tasks while waiting.
3. Prompting questions. One health professional I know has a list of the most commonly asked questions about a particular condition or treatment plan and give these to patients and families as prompts. “Here are some questions a lot of my patients ask. Have a look and see if any of these questions are ones you would like to ask. Or you might have another question.”
Good luck and enjoy the article.
Posted in News
October 21st, 2013
Health literacy research like so much other research can be a tad boring to read even for someone who is as interested in it as I am.
Apparently clinical guidelines are even more boring to read and often the people writing them don’t think about what we in literacy call the two most important aspects of any written document – audience and purpose. Who are you writing for and why are you writing this document are the first questions any writer should be asking (and be able to answer). Too often we see patient education materials where the purpose and audience are neither explicit nor even implicit.
We know that health professionals are inundated with the amount of material they have to read and absorb and it all takes time and a commitment to reading and making the changes to practice. I only read a tiny fraction of what must pass over a GP’s desk and at times I know that there are often a number of emails lurking in my Inbox that need looking at.
So I am also interested in having a look at the New Zealand review summaries delivered by New Zealand Research Reviews as they are short, relevant and include commentary by New Zealand health professionals and researchers. I particularly like the commentaries by Dr Matire Harwood and Dr Jeremy Krebs.
However over the last two weeks I have come across more novel approaches which are both amusing but also ensure you get the message.
Childhood asthma is a significant cause of childhood ambulatory sensitive hospitalisations (ASH) rates in New Zealand. There is a lot of research to show that routinely Māori and Pacific children are not given peak flow meters or, if they are, they are not shown how to use them apart from one cursory lesson.
So when I saw this video explaining to health professionals how to follow guidelines for asthma management I was impressed not just by the catchy lyrics (I like the song anyway) but how they had melded the video, the lyrics and the key messages.
(The fact that the title had a touch of the North Shore about it helped also.)
And then today I came across another video explaining the need for evidence based practice set to, of all things, a Coldplay song. Coldplay has never been one of my favourite musical groups but this might cause me to reconsider. As my father said (who had a number of sayings that he used to punctuate his conversations) there is more than one way to skin a cat.
Posted in News
October 17th, 2013
Just yesterday I signed up to a gym membership to get rid of the winter kilograms and strengthen my right arm.
I guess the winter weight increase and the summer decrease are always going to be a part of my life. However, I had a shoulder reconstruction in March 2012 and with no post operative complications, you may ask why I am strengthening my arm 19 months later.
Following surgery, I visited a physiotherapist paid for by ACC for two to three months, three days per week. A large part of my programme included strengthening exercises.
When I read “The importance of health literacy in physiotherapy practice” written by Briggs and Jordan (2010), I reflected on my sessions and thought about how disengaged I was in my recovery.
Briggs and Jordan talk about the important role physiotherapists play in engaging and educating patients to recovery and self management.
These same authors, Briggs & Jordan, undertook a study where they examined the health literacy of patients with lower back pain. This study showed that even though physiotherapists are experts in back pain, the physiotherapist failed to engage the patient and improve patient outcomes because the physiotherapist used biomedical terminology and limited teaching methods.
Fundamental to the role of any health practitioner is helping the patient to self manage. The first step to patient self management is finding out what the patient knows. This helps to ensure that the prescribed activities are practical and fit with the lifestyle, beliefs and attitudes of the patient, talking in terms that they understand, and asking the patient to demonstrate what they have been instructed. This is health literacy.
After receiving endless photographs of people performing exercises, purchasing a door pulley and a strengthening rubber band, I was still unclear about what activities I was supposed to do. Today my arm remains weak, at high risk for future injury and potentially a risk for future dependence on health services.
Thinking back what would have helped me when I first had my shoulder reconstruction would have been an assessment of what I already knew, what I understood and what I needed so that I would use the information. The physiotherapist would then have had a greater chance of engaging me, strengthening my arm and reducing the risk of re-injury.
Posted in News
October 11th, 2013
I recently had the pleasure of attending The APAC Forum on Quality Improvement in Healthcare held in Auckland.
On day two I attended Professor Mason Durie’s session on “Healthcare and Equity: Why It Matters And How To Achieve It”.
He stressed that socio-economic disadvantage should not be an inhibitor to good health when health practitioners can contribute to equitable health outcomes through Whānau Ora.
He emphasised the integrated approach of Whānau Ora encompassing the whole community as well as Government or community agencies linked by health literacy to build family capability, integrated delivery, innovation and whānau self-management.
I noted that the majority of Professor Durie’s slides included the term ‘health literacy’.
I had also noted on day one of the Conference that Maureen Bisognano (President and CEO of Institute of Healthcare Improvement) also focused on the importance of health literacy.
I have worked amongst health professionals and I know that many of my health professional friends have never heard of health literacy or, if they have, they attribute the term to poor education or low intelligence and they confuse the term with cultural competency, resulting in the responsibility for health literacy to be placed on the patient.
Unfortunately no speaker defined health literacy at the Conference.
We know that there are many definitions of health literacy. In New Zealand we have the definition in Kōrero Mārama which is the very standard definition “a person’s ability to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions”.
There have been a flurry of e-mails on the newly re-established health literacy discussion list service about different definitions of health literacy.
To some extent it doesn’t matter what definition you use as long as you understand there are a number of stakeholders involved, including the patient, families and communities, to reduce health literacy demands and build new health literacy skills and knowledge so people are able to take action.
However, there is one health literacy definition that does stand out because it covers all areas.
The Calgary Charter on Health Literacy includes a description about how health literacy applies to individuals, health care professionals and systems.
Posted in News
October 10th, 2013
I’ve just finished reading though a pile of information on kidney disease for an upcoming project we are taking part in. The project is about live kidney donation in Māori and Pacific communities. These groups have been specifically targeted because of the high rate of kidney disease and other co-morbidities, such as diabetes mellitus, that are present in their communities.
It’s been a fascinating read and one which has made me think about the issues of health literacy and access a number of times.
A report by Mauri Ora Associates called Māori Pacific Attitudes Towards Transplantation: Professional Perspectives caught my eye. The report was commissioned by the Ministry of Health and provides information about what health professionals in the renal sector believe are the beliefs and attitudes of Māori and Pacific peoples towards kidney transplants.
Of particular interest was the idea was that the kidney patient ‘pushes’ the health system to advocate their desire for a new kidney. Self-advocacy is a difficult skill to master and one which patients with low health literacy do not often possess. The idea of self-advocacy also runs against certain cultural norms in Māori and Pacific communities, which expect the patient to adopt a more passive role in the health encounter and defer important decisions to their health professional(s).
How are these patients supposed to learn this skill? If the expectation is that they just figure it out for themselves then, as the report points out, these patients would be at a definite disadvantage when it comes to getting a kidney transplant.
On a personal note, I am rather concerned about my salt intake. I eat copious amounts of salt and apparently this is bad for your kidneys. However after reading about the consequences of kidney failure, I think I’m going to cut down on my salty treats.
Posted in News
October 9th, 2013
I read an interesting article today by Suri, Sheppes, Schwartz and Gross. They identified that one potential source of medical non-compliance (I prefer the term non-adherence) is patient inertia.
The authors identify that there are a number of reasons for medical non-compliance – quality of doctor/patient relationship, number of medicines prescribed, complexity of regimens, side effects, social norms regarding compliance, lack of access to medications or health professionals and not being able to afford medical care. All these reasons are commonly listed and some of them are amenable to health literacy interventions.
The authors define patient inertia as something which prevents patients from initiating and sustaining health professional contact or adhering to recommended drug regimens. We know from US research (referred to in Kōrero Mārama) that low health literacy has an impact on both these causes. However, the authors distinguish these causes by identifying another cause – status quo bias (SQB).
SQB is the tendency to maintain a previous decision either by actively choosing the default or by doing nothing. The authors carried out a number of studies and interestingly suggested providing support to encourage a shift from SQB. They distinguish their idea from that identified by Thaler and Sunstein in their book Nudge where they stated that individuals could be nudged to select more optimal options as long as these options were made the default options.
However, the authors of this article have a different take on it. They hypothesise that, based on their studies, it would be better to use resources to induce people to undergo some sort of procedure as a first time experience (e.g. have the flu vaccination) rather than take a much broader approach to encourage everyone to have the flu vaccination (including those for whom vaccination is already the status quo). This way, the following year a greater number of people will have flu vaccinations as their SQB. The authors do suggest that the study needs to be extended as their studies were undertaken in a laboratory.
From my limited experience SQB can be influenced by reducing demands using health literacy approaches and helping people anticipate the next steps.
Posted in News
October 2nd, 2013
I have already done a health literacy month activity today – I have driven to Hamilton to be interviewed for Central TV. And for those that know me, you will know that being videoed or photographed is not my favourite activity.
However what I really wanted to post about is another health hero Atul Gawande a US surgeon who is an expert on reducing error, increasing efficiency and improving patient safety in surgery.
Recently Gwande wrote a column in The New Yorker about Slow Ideas and why some innovations spread fast and what you can do to spread the ones that don’t.
And it made me wonder, is health literacy a slow idea whose time has come? Or is it a slow idea that needs speeding up? Health literacy has been around a long time from the 1970s in the US to the present day. And in New Zealand we are trying to learn from the US and understand what they have done and adapt it for New Zealand.
More on that later this month but here is an old post from 2009 looking at the early history of health literacy in the US and, particularly, about the work of Ceci and the late Len Doak.
Posted in News