Institute for Healthcare Advancement
7th Annual Health Literacy Conference
Health Literacy in Primary Care: Best Practices and Skill Buildin
Hyatt Regency, Irvine, California
May 1-2, 2008
Conference Recap-Part 2
Friday, May 2, 2008
"Health Literacy in Obesity"
George L. Blackburn, MD, PhD
Harvard Medical School/Deaconess Medical Center
George L. Blackburn, M.D., Ph.D. is the Associate Director of the division of Nutrition at Harvard Medical School. He is also Chief of the Nutrition/Metabolism Laboratory and Director of the Center for the Study of Nutrition Medicine, which are affiliated with the Beth Israel Deaconess Medical Center in Boston, Massachusetts.
"It has only been recently that obesity has been recognized as a disease," said Dr. Blackburn. "I'll make it easy for you. Here is the take-home message: cut the calories, eat healthy, and exercise. That doesn't take rocket science for you to do, but the challenge is, you hear the words, yet how do you do it?"
It sounds simple enough but, with 70% of the population needing to cut calories, weight loss can be intimidating. The problem starts because there is a disconnect when it comes to eating healthy. Seventy-six percent of consumers say they have healthy eating habits, yet 57% of them still consider themselves overweight.
"We know that if people eat healthy, they won't have a problem with being overweight," says Dr. Blackburn. "People are constantly saying the reason they don't eat better is because they don't know what healthy foods are. They are really misdirected." People are misdirected and confused in that they think by eating some healthy foods, they have an overall healthy diet.
There are many medical complications that are directly related to obesity: pulmonary disease, non-alcoholic fatty liver disease, gall bladder disease, osteoarthritis, skin, gout, cancer, severe pancreatitis, coronary heart disease, reproductive issues, stroke and cataracts, just to name a few. Added Dr. Blackburn, "You are most at risk for gaining weight between the ages of 40 to 60. Don't gain any more weight. If you stop your weight gain, it will decrease your mortality."
"If we can get people to eat 10% less, all other things will fall into place," said Dr. Blackburn. When you go past this 10% you get the rubber-band effect-the farther you stretch a rubber band, the faster it will snap back at you. The same goes for weight loss. Rapid weight loss is usually followed by a rapid regaining of the weight - if not more. Our bodies were designed to store energy and gain weight. They cannot adapt to a drastic drop in weight.
One weight loss tip is to eat slowly. "Please let 20 minutes go by between the first bite and the last bite. It takes 20 minutes from the time you start eating for the hormones in your intestines to tell your brain to stop eating," said Dr. Blackburn. Most Americans eat their meals in five minutes, which does not allow your body time to tell you it's full.
Dr. Blackburn stressed five key points from his new book, Break Through Your Set Point: How to Finally Lose the Weight You Want and Keep it Off.
· Eat less to weigh less - the type of diet doesn't matter as long as there is a reduction in calories. Follow portion sizes and eat slowly.
· Eat well to stay healthy - eat fresh fruits, vegetables, whole grains and lean proteins. Eliminate junk food. Leave 10% of food on the plate to lose 10% of your body weight.
· Move more to feel good - physical activity means any activity that causes a muscle contraction. Try to spend 10% of your day in motion.
· Sleep more to have energy - failure to regulate sleep and stress often sabotage weight loss.
· Stress less to enjoy life; be happy, be positive
In closing, Dr. Blackburn said that energy balance is the key concept. Health benefits come from just a 5-10% loss. "If you are not gaining weight, then that is the number of calories that you are burning. Get on a scale every day." And don't forget to cut the calories, eat healthy, and exercise.
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"Patient Safety and Health Literacy: Removing Barriers to Better, Safer Care"
Patricia G. Sokol, RN, JD
AMA Foundation
As a lawyer and a former nurse, Patricia Sokol brings her knowledge of medico-legal jurisprudence and over 25 years of clinical experience to her position at the American Medical Association (AMA) as their Senior Policy Analyst, Clinical Quality Improvement and Patient Safety.
"We rely [too much] on the written word for patient instructions," she said. Patients are at risk for harm due to this reliance, along with an increasingly complex health system (more medications, more tests and procedures, growing self-care requirements, etc.). Sokol believes that we may be (or are) operating outside the scope of reasonable behavior under the circumstances. "Our expectations of patients may lead to unintended medical errors," said Sokol. "Expectations of effective staff-to-staff communication may lead to medical errors, systems failures and inefficiencies, and a loss of personal confidence or burnout that increases malpractice risk."
The landmark case, Canterbury vs. Spence, brought health literacy into the spotlight. "All of a sudden in 1972, we have Canterbury vs. Spence and that is the case where we all learn about informed consent," said Sokol. The court confers meaning to patient understanding and distinguishes between the duty to disclose and the duty to inform. Disclosure focuses on the description and content of the information, whereas informing focuses on understanding the content.
"Patient understanding is important because they have to act on this stuff," she said. Sokol pointed out that it is neither just nor fair to expect a patient to make appropriate health decisions and safely manage his/her care without first understanding the information to do so. This also includes the rights of patients to receive accurate information, participate in the treatment decision-making process, and to freely control the course of their own medical treatment.
She went on to say that the courts describe informed consent as a process of educating patients so they understand their diagnosis and treatment. "The Court firmly declares that the consumer standard of 'caveat emptor' does not apply to patients utilizing medical services," she said.
Our health system is in dire need of improvements, she said. A study done in three states with 395 primary care patients on how they would take a particular medication showed findings that are typical of health literacy today: 46% did not understand instructions with more than one label and 38% with adequate literacy missed at least one label. Regardless if the patient had low literacy or adequate literacy, many patients said they understood the instructions, but could not demonstrate how to use it.
Some tips Sokol offered to help with patient understanding:
· Use plain, non-medical language (for both oral and written)
· Slow down; break it down into short sentences
· Organize into two or three concepts and check for understanding
· Use the resources available at Ask Me 3
· Teach back (an efficient use of time)
· SOAP-UP note for assessment of understanding and documentation (Subjective, Objective, Assessment, Plan, Use teach-back, Plan for health literacy help)
· Interpretation if appropriate
· Translation services if needed
· Offer to read aloud and explain
· Underline or circle key points
· Use visual aids to help navigate the healthcare system and understand health information
"Creative thinking is so important. It's important for us and it's important for the patient because everybody is different," said Sokol. "We got into the health sciences to discover and create new ways to help patients.
"Learn from failure as well as success. If it's just not doable, then move on to the next thing."
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Breakout Session
"Patient Action Plans: Baby Steps to Success"
Hilary Seligman, M.D.
UC San Francisco/San Francisco General Hospital
As an Assistant Professor of Medicine at the University of California San Francisco with a clinical practice at San Francisco General Hospital, Hilary Seligman, M.D. has hands-on experience with health literacy and patient self-management. Her recent research work is focused on whether clinicians appropriately target their health promotion counseling to patients with the greatest barriers to healthy behaviors.
Dr. Seligman started off by saying that it is not clear that "screening" patients for limited health literacy in the clinical setting improves patient outcomes. She believes that all patients benefit from improved health promotion counseling and that patients with limited health literacy may preferentially benefit from certain counseling techniques.
Health promotion counseling is a significant part of clinical management that is often overlooked. Counseling about behaviors that could improve health include: diet, physical activity, medication compliance and management, depression and/or stress management, and smoking cessation.
Dr. Seligman stressed this point: "Think of chronic disease self-management as building people's confidence. Not changing behaviors necessarily, although we hope that is going to come. But that we really work on building patient confidence that they can self-manage, that they can be capable managers of their own health."
A way to help a patient build that confidence is with an action plan. Dr. Seligman defines an action plan as being highly specific, easily achievable, short-term activities a patient agrees to do to reach a long-term goal. "I like to think of goals as outcomes. This is what you ultimately want to achieve," said Dr. Seligman. "Action plans are the small steps that you have to use to get to that goal."
For example, with the long term goal of losing weight, a patient's action plan might be to walk around the block before she sits down to watch TV after dinner three times during the next seven days.
Action plans are helpful because they can establish and maintain new behaviors, engage the patient in the process of self-management, and teach problem-solving skills. "My general mantra about this is achieving small goals is a lot more effective than not achieving large goals," says Dr. Seligman.
Added Dr. Seligman, "The first, most critical component of an action plan is that they are patient-generated. Not by you; you facilitate it." Dr. Seligman suggested selecting areas of self-management that patients are motivated to address and incorporate patients' knowledge of their unique barriers to self-management.
The second critical component is that the action plan be easily achievable. The goal is to increase a patient's confidence. "I emphasize that starting small is good. I also try to tie things like new activities to existing activities that are a part of people's regular life that they do habitually. Because what I would love to do is to make the new behavior habitual as a part of their old pleasurable activity," said Dr. Seligman.
The third critical component is to be highly specific. It can usually answer the four key questions of what, how much, when, and how often. Dr. Seligman encourages checking in with the patient about the action plan. For example, asking the patient, "On a scale of 0-10 where zero is not at all sure and 10 is entirely sure, how sure are you that you will be able to." If the patient answers below a seven, the action plan will need to be revised.
If an enthusiastic patient makes a complex action plan, suggest splitting the action plan into several steps and committing to one step at a time. If the patient wants to do something unrelated to their condition, let them! The action plan will still help build problem-solving skills and increase confidence.
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"Universal Symbols in Healthcare: Lessons from Research"
Jim Bolek
The Hablamos Juntos Project
Friday, May 2, 2008
Jim Bolek was the lead researcher and writer for a series of reports on the viability of symbols to aid in the health care wayfinding sponsored by Hablamos Juntos ("We Speak Together"). With more than 19 years' experience as a graphic designer, including the past 15 devoted to environmental graphic design, Bolek was co-leader of the design team that created a series of universal symbols for health care environments.
How does one create a universal symbol for health care when not everyone speaks English? That was the task given to Bolek and his team. Symbols themselves are public domain, but are copyrighted. "In the first part of the research we had to answer some questions such as, are symbols even feasible for this and what signs and symbols are used in a medical setting?" said Bolek. "The second part of the project was to design the symbols and implement them."
Symbol systems exist in the U.S. healthcare system already, but they lack cohesiveness. This is one of the goals for this project, to try and create universal symbols. "One thing we are finding is that symbols, as much as we want them to be intuitive for everybody, are still going to need written words underneath them," said Bolek. "But they are going to help."
Bolek selected a team of designers from around the U.S. and limited the project to 30 symbols for the first phase.
They ended up collecting over 600 symbols and voted on ones they thought were most effective. After whittling down the images, that left about 8-9 symbols in each category, then they set about creating new symbols.
"We're dealing with abstract concepts, and getting the public to understand these right away is part of the challenge," said Bolek. It was important that the symbols have no regional bias, so they tested 300 people from across the country at four different sites to see which part of the U.S. population would understand. "Testing the symbols with the general public, that was something that was different from the other symbol systems that were out there," adds Bolek. "Even the DOT (Department of Transportation) signs that you see along the freeway - they were never really tested."
Public testing included healthcare settings with wayfinding and identification. "We found that there is a lot of stress trying to navigate a hospital. They've become these incredible mazes as they get developed over time. We found that people walked one foot per second faster when they were guided by symbols rather than just walking on their own, trying to find their location," says Bolek.
From the site survey forms, Bolek's team discovered how effective their symbols were at improving communication for way finding and identification in a healthcare environment:
· 1% said text only was effective
· 23% said text only or symbols with text were equally effective
· 75% said symbols with text helped in way finding and identification
· 88% said symbols with text and translations provided the most effective way finding and identification
Another finding was that there needs to be consistency in not only signage, but what professionals call it. There are two audiences, the public and the professionals. For example, a doctor might tell a patient to go to diagnostic imaging and the patient has no idea what he is talking about. If the doctor said go to the x-ray lab, the patient would know exactly what he wanted. Two different names for the same place can cause much confusion. There needs to be consistency in not only signage, but what explanations professionals call the signage.
Bolek ended his presentation by explaining that they are moving on to phase two of the project, which is to develop another 20 symbols. The 28-symbol set is now available on both the Hablamos Juntos and SEGD (Society of Environmental Graphic Design) websites.
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Breakout Session
"Should I Hand This Out? Choosing and Using Patient Education Materials"
Audrey Riffenburgh, MA
Maria Collis, MFA
Plain Lanuguage Works
Audrey Riffenburgh is president of Plain Language Works, and has 20 years' experience in health literacy and adult basic education. Her company provides training to a variety of public health, medical, and academic clients. Maria Collis is vice president of Plain Language Works, and has written and edited low-literacy and plain language materials since 1987.
When deciding whether to use a handout, consider the scope, content, and organization of your handout. Look at the writing style and assess if it is using plain language. Look at the graphic design of the information. "If something looks clean and easy to read, they will probably read it," says Collis.
Low health literacy is not just a problem for adults with limited functional literacy. Well-educated adults struggle in new situations with new demands. Many people have low health literacy as a side effect of medicines or illness, from anxiety and fear, or from being in an unfamiliar environment.
Patients with limited literacy skills feel embarrassed and secretive about their reading problems. They are anxious and fearful that their secret will be discovered and are therefore intimidated by the medical staff. They are often confused and overwhelmed. They are worried about looking unintelligent, so they are not likely to ask questions.
Before you talk to a patient, try to create a safe environment. Sit down and try not to appear hurried. Use active listening and safeguard the patient's dignity by treating them with respect. If necessary, have the patient invite a family member, friend, or interpreter to accompany them during their appointment. Also invite them to bring a tape recorder to appointments, especially if they have a chronic disease.
You can improve your health communication skills by using simple, direct language and give information in small chunks. For instance, use common, everyday terms, e.g., high blood pressure instead of hypertension. Listen to the way patients describe their problems, then use their vocabulary when teaching new terms. Cover only two to three concepts in a visit, and only the information the patient needs in order to carry out the desired action. Always keep in mind that too much information may overwhelm the patient.
"Visuals should support the text and not give new information," says Collis. "Emphasize the behavior you want them to do. The picture repeats the information in the text." For example, pictures of lifting techniques should be correct lifting techniques, not incorrect lifting pictures.
When using a handout with patients, be sure to read key points in the material out loud to the patient. Then take a moment to mark the key points on the handout. For example, circle or highlight important ideas using different colored markers and tell the patient what you are doing. You can also insert different symbols such as a checkmark or a star to highlight important information. Later, patients can look for your marks to find the key points without reading the whole thing. This means they may really use it!
"However, no matter how good a piece, it is not a substitute for verbal instruction," said Collis.
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Closing Keynote
Janet Ohene-Frempong, M.S.
JO Frempong & Associates
Janet Ohene-Frempong, M.S., president of JO Frempong & Associates, is a plain language and cross-cultural communications consultant with over 25 years of experience in patient/provider communications. Her consulting business provides a range of communication services including consumer research, materials development, program development, presentations, seminars, and institution-based coaching and consumer health communications.
In Ohene-Frempong's closing keynote, she helped put together all the information that had been covered in this year's conference. She noted that we are dealing with the issue of communication in the role of health literacy.
Although we need better communication, sometimes things get in the way. One of the issues is a continuing lack of awareness concerning commitment. There seems to be a persistent confusion over terminology and lingering confusion over goals. Another problem is the lack of training and effective communication techniques as well as a lack of resources to apply effective communication techniques.
However, she believes there are pathways to effective communication. She said we need to find ways to increase awareness, we need to clarify terminology, and we need to clarify goals.
Effective health communication recognizes patient-related barriers to communication. Ohene-Frempong believes we should do research and gather more information about what the needs are and how to respond to those needs.
Some of the communication problems we are now seeing could be called system-related barriers to communication. This is often manifest as a lack of awareness and counterproductive attitudes such as not learning English. Ineffective verbal information, ineffective written information and ineffective audiovisual information all add to the problem, resulting in ineffective communication.
"Put an end to 'people don't need print communication;' make it as good as it can get," said Ohene-Frempong.
Ohene-Frempong believes, "You want people to feel inspired. Increase the awareness, interest in and communication of health literacy. But at the same time, clear up the confusion of literacy and health literacy, while clarifying the goals of improved patient communication."
