Health Literacy Competencies for Health Professionals ...
Health Literate Communication Training for Health Care Workers: Competencies and Best Practices Cliff Coleman, MD, MPH Assistant Professor Department of Family Medicine Oregon Health & Science University [email protected] 2013 Wisconsin Health Literacy Summit: Changing Systems, Changing Lives April 9, 2013 Communication works for those who work at it -- John Powell, composer Disclosure statement Funding support:
National Cancer Institute grants number 5K07 CA121457-05 and 3K07 CA121457 04S2 (Behavioral & Social Sciences as Core Elements of the Medical School Curriculum) Health Resources and Services Administration grant number 1D58 HP15234 01-00 (Curriculum Activities for Learning Mood Disorders and Community Approaches to Residency Education (CALM CARE)) Learning objectives 1. Describe a set of measurable health literacy best practices for health professionals.
2. Identify the educational competencies which underpin health literacy best practices. 3. Understand how health literacy competencies and best practices can be used in the design and implementation of training curricula for health professionals. Overview Background: why a consensus study? Consensus study design and results Examination of selected best practices Practical applications Best practice wording Associated educational competencies
Limitations, opportunities, and next steps Background: why a consensus study? IOM health literacy report, 2004 Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy
Professional schools and professional continuing education programs in health and related fields, including medicine, dentistry, pharmacy, social work, anthropology, nursing, public health, and journalism, should incorporate health literacy into their curricula and areas of competence (Neilsen-Bohlman et al, 2004, p161) Current state of health care Health professionals generally lack adequate health literacy awareness, knowledge, and skills Many best practices for effective communication with low health literacy patients are not routinely
used by physicians (Coleman, 2011) Current state of health care education Increasing calls for improving training about health literacy for health professionals Proliferation of HL curricula for health professionals HL curricula can positively influence learners knowledge, skills and attitudes
(Coleman, 2011) Current state of health care education At least 30% of U.S. medical schools are not teaching about health literacy (Coleman & Appy, 2012) Less than half of Family Medicine residency programs are teaching about health literacy (Coleman & Nguyen, unpublished)
Little known about other health professions Current state of health care education No published guidelines for the recommended content or structure of health literacy curricula for health professionals Very little empiric data to inform what to teach, or how and when to teach it (Coleman, 2011) Health literacy competencies The knowledge, skills and attitudes which health
professionals need in order to address low health literacy among consumers of health care and health information (Coleman, Hudson & Maine, Unpublished) Health literacy practices Patient-centered protocols and strategies to minimize the negative consequences of low or limited health literacy (Barrett et all, 2008) Consensus study Selection of potential competencies Literature review (2010) yielded a diverse array of recommendations (i.e., best practices)
24 Knowledge items 28 Skill items Competencies 11 Attitude items 32 Practice items Some overlap between domains Methods Specific Aim: To develop a consensus agreement on a common set of core health literacy competencies for U.S. health professions school graduates Methods Design: Modified Delphi consensus process
A commonly used method to capture expert opinions of groups Useful when empiric evidence is lacking Use is well described in healthcare competencies work Modified in that the panel met in person initially Delphi: how it works Identify proposed competencies (literature review) Convene expert panel
Individuals anonymously rate their agreement with items on the list Predetermined levels of agreement Facilitated group discussion helps move the needle on items prior to re-rating Participants opinions important Modifications suggested Process stops when diminishing returns reached Translating best practices into measurable competencies 3 examples Best practice Domain(s)
Competency. The learner Operationalization. The learner 1. Use Knowledge Knows which common words Skills kinds of words, when speaking Practices phrases, or to patients concepts may be jargon to patients
Selects jargon words from a list Explains why jargon terms may be misinterpreted 2. Speak Skills clearly and at a Practices moderate pace Demonstrates ability to speak slowly and clearly with patients Speech is perceived as appropriate pace, volume and clarity.
Speech is always intelligible 3. Confirm Knowledge patients Skill understand Practices what they need to know and do by asking them to teach back directions Routinely uses a tech back or show me
technique to check for understanding Confirms patients understanding by asking patient to explain back in their own words (or show) what they have heard/seen at end of encounter Puts onus on self, by saying I dont always explain things well. Tell me what youve heard. Example of consensus project rating scheme: knowledge item Methods Sample:
Executive leadership representatives from member organizations of the Federation of Associations of Schools of the Health Professions (FASHP): American Association of Colleges of Nursing American Association of Colleges of Osteopathic Medicine American Association of Colleges of Pharmacy American Dental Education Association Association of Academic Health Centers Association of American Medical Colleges Association of Chiropractic Colleges Association of Schools & Colleges of Optometry Association of Schools of Allied Health Professions Association of Schools of Public Health Association of University Programs in Health Admin National League for Nursing Physician Assistant Education Association
Attendees of a 2-day meeting on teaching health literacy to health professions students St Louis, MO, October 2010 Hosted by Health Literacy Missouri and Saint Louis College of Pharmacy Results 22 FASHP participants Age, mean (n=22) Female (n = 21) White Non-Hispanic Years in health professions education, mean (n = 22) Background in direct patient care (n = 21) Highest level of education attained (n= 20)
Bachelors Masters Doctorate 51.9 years 15 (71.4 %) 21 (95.5%) 21 (95.5%) 19.1 years 19 (90.5%) 1 (5%) 1 (5%) 18 (90%) Would your peers consider you to have expertise on the topic of health literacy? (n = 22) YES
16 (72.7%) NO 6 (27.3%) Results 62 competencies and 32 best practices accepted after 4 rounds Competencies Round One Round Two Round Three
Round Four Total Accept ed -/24/24 Knowledge Items 19/24 5/5 -/-
94/97 Competencies Total Practice Items Total Selected Best Practices Example best practices Spoken communication: 1) 2) 3) 4) Focus on 1-3 key need-to-know items
Avoid medical jargon Elicit questions in a patient-centered manner Assess understanding using teach back Example 1. Focus on 1-3 key need-to-know items Patients typically retain < 50% of information Illness and stress are major barriers to learning Focus on what patients need to do, not on facts Provides action-oriented knowledge Arrange for follow-up to add new information (Sheridan et al, 2011; Schwartzberg et al, 2007; AMA, 1999) Example 1. Focus on 1-3 key need-to-know items Best Practice: Routinely emphasizes one to three need-to-know or need-todo concepts during a given patient encounter (P10)
Underlying Competencies: Knows that patients learn best when a limited number of new concepts are presented at any given time (K19) Demonstrates ability to emphasize one to three need-to-know or need-to-do concepts during a given patient encounter (S22) (P=practice, K=knowledge, S=skills, A=attitudes) Example 2. Avoid medical jargon Even experienced clinicians use jargon (Castro et al, 2007) Research shows that all patients prefer simple plain language health information
(AMA, 1999) Define and teach important unavoidable jargon (e.g., hemoglobin A1c) Video http://www.youtube.com/watch?v=IOK0Vc_Hg7U But jargon is complex! Words Phrases Concepts Numeracy Type of Jargon
Obvious or subtle Description Unfamiliar Misunderstood Misinterpreted Examples Words Phrases Concepts Technical
Words, phrases or concepts with meaning only in a clinical context Glucometer Cardiologist Insomnia Abdomen Cath lab Ortho Acronyms: GERD COPD UTI
Follow-up Referral Chronic PRN PCP Contagous Quantitative Words, phrases or concepts requiring clinical judgment or knowledge Unlikely Increased Tablespoon
Fever Excessive wheezing Twice daily Risk Lay Words, phrases or concepts with two or more meanings or interpretations, one of which is medical Stable
Abnormal Stool Frequency Salt Idioms: Come down with Break out Run a fever Metaphors: ? Example 2. Avoid medical jargon Best Practice: Consistently avoids using medical jargon in oral and written communication with
patients, and defines unavoidable jargon in lay terms (P14) Underlying Competencies: Knows which kinds of words, phrases, or concepts may be jargon to patients (K5) Demonstrates ability to use common familiar lay terms, phrases and concepts, and appropriately define unavoidable jargon, and avoid using acronyms in oral and written communication with patients (S1) Demonstrates ability to recognize, avoid and/or constructively correct the use of medical jargon, as used by others in oral and written communication with patients (S2) (P=practice, K=knowledge, S=skills, A=attitudes) Example 3. Elicit questions in a patient-centered manner No: Do you have any questions? Implies that you expect them to get it (if they dont, something
must be wrong with them) Patients do not answer this honestly Yes: What questions do you have? Implies an expectation that patients should have questions! (DeWalt et al, 2010) Example 3. Elicit questions in a patient-centered manner Best Practice: Consistently elicits questions from patients through a patient-centered approach [e.g., what questions do you have?, rather than do you have any questions?] (P24) Underlying Competencies: Demonstrates ability to effectively elicit questions from patients through a patient-centered approach (e.g., asks
what questions do you have? rather than do you have any questions?) (S19) (P=practice, K=knowledge, S=skills, A=attitudes) Example 4. Assess understanding using teach back Stop asking, do you understand? Implies that patients should understand (if they dont, something must be wrong with them) Start using a Teach Back or show me technique Ask patient to explain back what they are going to do. Say I want to make sure I have explained things well. Please tell me in your own words how you are going to use this medicine. Ask how would you tell a friend to take this medicine?
Show me how you use this inhaler. (DeWalt et al, 2010; NQF, 2008; Schillinger et al, 2003) Video http://www.nchealthliteracy.org/teachingaids.html http://www.nchealthliteracy.org/teachingaids.html Example 4. Assess understanding using teach back Best Practice: Routinely uses a teach back or show me technique to check for understanding and correct misunderstandings in a variety of health care settings (P29) Underlying Competencies: Knows the rationale for and mechanics of using a teach back or show me technique to assess patient understanding (K23)
Demonstrates effective use of a teach back or show me technique for assessing patients understanding (S15) Expresses the attitude that every patient has the right to understand their health care, and that it is the health care professionals duty to elicit and ensure patients best possible understanding of their health care (A9) (P=practice, K=knowledge, S=skills, A=attitudes) Example best practices Written communication: 1) Select written materials at 5th-6th grade level 2) Write for easy understanding Example 1. Select written materials at 5th-6th grade level
The average US adult reads at an 8th grade level (Kutner et al, 2005) Over 1500 studies show that health information is typically written well above the average reading level! (Rima Rudd, 3rd Annual Health Literacy Research Conference, 10/18/11) Most patients will not understand the majority of the educational handouts, consent forms, medical-history questionnaires, and insurance papers they receive (Weiss & Coyne, 1997) Example 1. Select written materials at 5th-6th grade level
Best Practice: Consistently locates and uses literacy-appropriate patient education materials, when needed and available, to reinforce oral communication, and reviews such materials with patients, underlining or highlighting key information (P27) Underlying Competencies: Knows that the average US adult reads at an 8th-9th grade reading level, but that most patient education materials are written at a much higher reading level (K7) Demonstrates ability to recognize plain language principles in written materials produced by others (S4) (P=practice, K=knowledge, S=skills, A=attitudes) Example 2. Write for easy understanding
Content State the purpose Plain jargon-free language 1-2 syllable words 5th-6th grade level Need-to-know info first Focus on action items Format Lots of white space Subject headings
Short simple sentences Bulleted lists 12-point font or larger Serif-style font Reinforcing pictures Use an online health literacy style manual: How to Write Easy-toRead Health Materials http://www.nlm.nih.gov/medlineplus/etr.html Test your product before distribution (Doak et al, 1996) April 16, 2010 Dear _________ Your bloodwork is unremarkable without any signs to suggest parasitic infection, inflammation of blood vessels or other problems. I suspect your
symptoms are functional in nature and not due to a specific disease process. I doubt that further testing would be productive. You may want to consider getting a second opinion and I would be happy to assist in arranging one. Please let me know if I can be of help in that regard. Sincerely, ___________, MD April 16, 2010 Dear _________ Your bloodwork is unremarkable without any signs to suggest parasitic infection, inflammation of blood vessels or other problems. I suspect your
symptoms are functional in nature and not due to a specific disease process. I doubt that further testing would be productive. You may want to consider getting a second opinion and I would be happy to assist in arranging one. Please let me know if I can be of help in that regard. Sincerely, ___________, MD Years of formal education Needed to easily understand this text = 10.8 (http://www.editcentral.com) April 16, 2010
Dear _________ Your blood test was normal. I think your symptoms are not due to a specific disease. I do not think that more tests will help. You may want to get a second opinion from another doctor. I would be happy to help set that up. Please let me know if I can be of help with that. Sincerely, ___________, MD Years of formal education Needed to easily understand this text = 5.9 (http://www.editcentral.com)
Example 2. Write for easy understanding Best Practices: Consistently follows principles of easy-to-read formatting when writing for patients (P15) Routinely writes in English at approximately the 5 th-6th grade reading level (P17) Consistently avoids using medical jargon in oral and written communication with patients, and defines unavoidable jargon in lay terms (P14) Underlying Competencies: Knows best practice principles of plain language and clear health communication for oral and written communication (K18) Demonstrates ability to follow best-practice principles of easy-to-read formatting and writing in written communication with patients (S3) Demonstrates ability to write in English at approximately the 5 th-6th grade reading level (S6) (P=practice, K=knowledge, S=skills, A=attitudes)
Limitations The 32 identified practices, and 62 underlying competencies are not in rank order Validated measurement tools do not exist for assessing the practices and underlying competencies Opportunities For the first time we have a comprehensive list of health literacy practices Practices and competencies are theoretically measurable
Individuals and organizations can use the list as a menu of options Next steps Consensus group with health literacy experts to prioritize items Empiric studies tracking patient-centered outcomes of health literacy training interventions for health professionals
Communication works for those who work at it -- John Powell, composer References Ali N. Are we training residents to communicate with low health literacy patients? Journal of Community Hospital Internal Medicine Perspectives 2012, 2: 19238 http://dx.doi.org/10.3402/jchimp.v2i4.19238. Accessed 4/1/13 AMA (American Medical Association), Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs. Health literacy: report of the Council on Scientific Affairs. JAMA 1999; 281(6):552-7 Barrett SE, Puryear JS, Westpheling K. Health literacy practices in primary care settings: examples from the field. January 2008. Available at http://www.commonwealthfund.org Castro CM, Wilson C, Wang F, Schillinger D. Babel Babble: Physicians use of unclarified medical jargon with patients. Am J
Health Behav 2007;31(Suppl 1):S85-S95 References Coleman C. Teaching Healthcare Professionals about Health Literacy: A Review of the Literature. Nursing Outlook 2011;59:70-78 Coleman C, Appy S. Health literacy teaching in U.S. medical schools, 2010. Family Medicine, 2012;44(7):504-7 Coleman C, Hudson S. Health Literacy Practices for Health Professionals: A Consensus Study. In review Coleman C, Hudson S, Maine L. Health Literacy Educational Competencies for Students of the Health Professions: A Consensus Study. In review Coleman C, Nguyen N. Health literacy teaching in U.S. Family Medicine Residencies, 2011. Unpublished.
References DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, et al. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 100046-EF) Rockville, MD. Agency for Healthcare Research and Quality; April 2010 Doak CC, Doak LG, Root J. Teaching patients with low literacy skills, 2nd ed. Philadelphia: J.B. Lippincott, 1996 Kutner M, Greenberg E, Baer J. A first look at the literacy of America's adults in the 21st century. Washington, D.C.: National Center for Education Statistics, Department of Education; December 2005. Available at http://nces.ed.gov/NAAL/PDF/2006470.pdf. Accessed 8/6/2012 References
(NQF) National Quality Forum. Safe practices for better healthcare. Washington, DC: National Quality Forum, 2003. Available at http://www.ahrq.gov/qual/nqfpract.pdf. Accessed 27 November, 2008 Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Institute of Medicine of the National Academies, Board on Neuroscience and Behavioral Health, Committee on Health Literacy. Washington, D.C.: The National Academies Press, 2004 References Schillinger D, Piette J, Grumbach K et al. Closing the loop. Physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83-90 Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health
literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav 2007;31(Suppl 1):S96-S104 Sheridan SL, Halpern DJ, Viera AJ, Berkman ND, Donahue KE, Crotty K. Interventions for individuals with low health literacy: a systematic review. J Health Communication 2011;16:30-54 Weiss BD, Coyne C. Communicating with patients who cannot read. NEJM 1997;337(4):272-4
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