1、Interventions to Improve Health Outcomes for Low Literacy Patients Systematic Review of the Literature Darren DeWalt, MD, MPH & Ashley Hink, BS University of North Carolina at Chapel Hill Sheps Center for Health Services Research,What is Health Literacy?,“The degree to which individuals have the cap
2、acity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”Healthy People 2010,Why is Health Literacy Important?,High prevalence of “low health literacy” Low health literacy associated with:less knowledge about disease greater risk of
3、hospitalization lower odds of receiving preventive services worse control of chronic illnesses,Literacy in America,National Adult Literacy Survey (NALS, 1992) Over 90 million Americans had inadequate functional literacy Level 1 or 2 (out of 5) More common among elderly, minorities, immigrants, low S
4、ESNational Assessment of Adult Literacy (NAAL, 2003) New categories Prose results:,From http:/nces.ed.gov/naal/,National Assessment of Adult Literacy (NAAL),n = 19,714 Most up to date portrait of literacy in U.S. Scored on 4 levels Lowest 2 levels cannot: Use a bus schedule or bar graph Explain the
5、difference in two types of employee benefits Write a simple letter explaining an error on a bill,National Center for Education Statistics, U.S. Department of Education,Outcomes Associated with Literacy,Health Outcomes/Health Services General health status Hospitalization Prostate cancer stage Depres
6、sion Asthma Diabetes control HIV control Mammography Pap smear Pneumococcal immunization Influenza immunization STD screening Cost,Behaviors Only Substance abuse Breastfeeding Behavioral problems Adherence to medication SmokingKnowledge Only Birth control knowledge Cervical cancer screening Emergenc
7、y department instructions Asthma knowledge Hypertension knowledge,DeWalt, et al. JGIM 2004;19:1228-1239,Reducing Health Literacy Disparities,Approaches Improving literacy in the population Simplifying health education materials Improving patient-provider communication Changing systems of health care
8、 management,Review of Intervention Studies: Methods,Inclusion Criteria: Published after 1980 in English Conducted in developed country Use of controlled or uncontrolled experimental design More than 10 subjects Direct measure of literacy among participants Measure of effect on at least one health ou
9、tcome,Pignone et al. J Gen Intern Med, 2004,Review of Intervention Studies: Methods,Search in MEDLINE and CINAHLKeywords: literacy, reading ability, reading skill, numeracy, WRAT, wide range achievement, rapid estimate of adult, TOFHLA, test of functional healthTotal of 37 unique studies met criteri
10、a,Results,Educational Materials 18 studies,Written Use of pictures or graphics Writing at lower grade levels Easy-to-read and understand formatsVideo Graphics, scenarios, patient and provider dramatizationsComputer Interactive DVDs with self-guided components Graphics, videos and self-assessmentsSel
11、f-management Illustrative medication schedule,Images from PDA video to increase HIV knowledge and adherenceBrock et al. International Journal of Medical Informatics, 2007,Educational Materials: Outcomes,Positive Findings Accuracy of self-breast exams Increased receipt of vaccinesMixed Findings Compr
12、ehension of medical information Adherence to medicationsNegative Findings A1c, BMI, Blood Pressure,Intervention to Improve Medication Adherence,Kripilani et al., 2007209 Received personalized, illustrated pill cardREALM 41.6% Inadequate 36.9% MarginalThose with inadequate or marginal literacy report
13、ed greatest use and helpfulness in medication adherence compared to those with adequate literacy (p0.05),Copyright Emory University,1-Time In-person Education Interventions 6 Studies,Group Classes Minimal written materials Motivational Use of role play, visuals, videos and entertainment Personalized
14、 worksheets, notebooksOne-on-One Brief verbal instruction from educators Supporting written materials,Positive OutcomesHigher rates of mammography Medical information knowledge Medication adherence Asthma medication administration Self-care behaviorsNegative OutcomesDietary behaviors,Hill-Briggs et
15、al., 200830 Diabetics, high CVD riskWRAT-3 40% =6th grade level90-minute group class about diabetes and CVD, received easy-to-read written materials and personalized worksheetsFocus on disease information and self-management behaviors,Intervention to Improve Diabetes and CVD Knowledge,Knowledge abou
16、t diabetes and CVD increased for all subjects, regardless of literacy level (p0.005),Complex Interventions 10 Studies,Disease and Case Management Baseline assessment and education by medical providers or health educators Ongoing follow-up via phone or appointment Use of written, easy-to-read self-ma
17、nagement materials Support for addressing barriers to care Social support, employment and literacy trainingOngoing Classes and/or Follow-up Education in group settings Baseline assessments Boosters and reinforcement via phone or mail,Complex Interventions: Outcomes,Positive,HF exacerbations, associa
18、ted costs, hospitalization and deathSystolic blood pressureSelf-care behaviorsDepression HIV viral loadKnowledge about medical information,Mixed,Diabetes control (HbA1c)CD-4 countsMedication adherenceDietary self-efficacy, behaviors and outcomes,Disease and case management interventions generally ha
19、d better outcomes than the serious of education classes,Intervention to Improve Diabetes Outcomes,Rothman et al, 2004RCTIntervention group: 98 Control group: 95 (All adult diabetics)REALM: 38% Low, 61.8%Intervention group received disease management program: education from clinical pharmacist, clini
20、cal interventions, reminder/reinforcement calls, low literacy communication strategies,At 12 months, high and low literacy patients in the intervention group significantly improved their A1c and blood pressure compared to the control group (p0.001, p=0.006 respectively).,Improving Patient-Provider C
21、ommunication 2 Studies,Physicians notified of patients literacy level and informed of possible barriers b/c of low literacyPhysicians attended workshops and received feedback on performance,Positive OutcomesRates of colorectal cancer screening Physician use of communication strategiesNegative Outcom
22、esSelf-efficacy Diabetes control (A1c),Improving Literacy: Intervention for Depression,Weiss et al., 2006RCTIntervention group: 33 Control group: 28All participants with REALM 5Intervention group received ongoing literacy training and depression treatmentControl group received depression treatment o
23、nly,Outcomes:At 12 months, those in the intervention group had significantly improved depression symptoms (PHQ-9 scores) compared to the control group (0=0.04),Discussion,Variety of interventions tested for different disease states and purposesDiabetes CVD Depression Heart failure HIV Preventive car
24、e Health knowledge Adherence Self-care behaviors,Many mixed findings: Knowledge Adherence Dietary behaviors Health outcomesImproved health education materials do not always improve knowledgeClasses and direct education can improve knowledge and some behaviorsComplex, disease-management interventions
25、 show most improved outcomes in health status,Limitations and Gaps,Variable quality of studies Many uncontrolled, pre-post designsOnly a subset of the studies stratified results by literacy level Difficult to ascertain if intervention specifically helps low literacy populationStudies without direct
26、literacy measure excluded Potentially more interventions that may improve outcomesFew studies on patient-provider communication and literacy improvement,Reviewed Studies,Health Education MaterialsWritten Coleman EA, Coon S, Mohrmann C, Hardin S, Stewart B, Gibson RS, et al. Developing and testing la
27、y literature about breast cancer screening for African American women. Clinical Journal of Oncology Nursing. 2003;7(1):66-71. Davis TC, Holcombe RF, Berkel HJ, Pramanik S, Divers SG. Informed consent for clinical trials: a comparative study of standard versus simplified forms. see comments. Journal
28、of the National Cancer Institute. 1998;90(9):668-74. Davis TC, Fredrickson DD, Arnold C, Murphy PW, Herbst M, Bocchini JA. A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level. Patient Educ Couns 1998;33(1):25-37. Davis TC,
29、 Bocchini JA, Jr., Fredrickson D, Arnold C, Mayeaux EJ, Murphy PW, et al. Parent comprehension of polio vaccine information pamphlets. Pediatrics 1996;97(6 Pt 1):804-10. Eaton ML, Holloway RL. Patient comprehension of written drug information. American Journal of Hospital Pharmacy. 1980;37(2):240-3.
30、 Hayes KS. Randomized trial of geragogy-based medication instruction in the emergency department. Nursing Research, 1998;47(4):211-8. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. A randomized co
31、ntrolled trial. JAMA. 1999;282(7):646-50. Michielutte R, Bahnson J, Dignan MB, Schroeder EM. The use of illustrations and narrative text style to improve readability of a health education brochure. Journal of Cancer Education. 1992;7(3):251-60. Raymond EG, Dalebout SM, Camp SI. Comprehension of a pr
32、ototype over-the-counter label for an emergency contraceptive pill product. Obstetrics 28(9):1399-407.,Video Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health 1994;84(1):119-
33、21. Murphy PW, Chesson AL, Walker L, Arnold CL, Chesson LM. Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills. Southern Medical Journal. 2000;93(3):297-304. Brock TP, Smith SR. Using digital videos dis
34、played on personal digital assistants (PDAs) to enhance patient education in clinical settings. Int J Med Inform 2007;76(11-12):829-35. Pepe MV, Chodzko-Zajko WJ. Impact of older adults reading ability on the comprehension and recall of cholesterol information. Journal of Health Education, 1997;28(1
35、):21-7.Self-Management Kripalani S, Robertson R, Love-Ghaffari MH, Henderson LE, Praska J, Strawder A, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Education and Counseling 2007;66(3):368-377.1-time In-Person InterventionsGroups Davis TC,
36、 Berkel HJ, Arnold CL, Nandy I, Jackson RH, Murphy PW. Intervention to increase mammography utilization in a public hospital. J Gen Intern Med 1998;13(4):230-3. Hartman TJ, McCarthy PR, Park RJ, Schuster E, Kushi LH. Results of a community-based low-literacy nutrition education program. Journal of C
37、ommunity Health. 1997;22(5):325-41. Hill-Briggs F, Renosky R, Lazo M, Bone L, Hill M, Levine D, et al. Development and pilot evaluation of literacy-adapted diabetes and CVD education in urban, diabetic African Americans. J Gen Intern Med 2008;23(9):1491-4. Hussey LC. Minimizing effects of low litera
38、cy on medication knowledge and compliance among the elderly. Clinical Nursing Research. 1994;3(2):132-45.One-on-One Paasche-Orlow MK, Riekert KA, Bilderback A, Chanmugam A, Hill P, Rand CS, et al. Tailored Education May Reduce Health Literacy Disparities in Asthma Self-Management. Am. J. Respir. Cri
39、t. Care Med. 2005;172(8):980-986.,Complex InterventionsDewalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL, et al. A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial ISRCTN11535170. BMC Health Serv Res 2006;6(1):30. Holzemer WL, Ba
40、kken S, Portillo CJ, Grimes R, Welch J, Wantland D, et al. Testing a nurse-tailored HIV medication adherence intervention. Nurs Res 2006;55(3):189-97. Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP. The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy a
41、dults. Am J Public Health 1997;87(12):1971-6. Kalichman SC, Cherry J, Cain D. Nurse-delivered antiretroviral treatment adherence intervention for people with low literacy skills and living with HIV/AIDS. J Assoc Nurses AIDS Care 2005;16(5):3-15. Kim S, Love F, Quistberg DA, Shea JA. Association of H
42、ealth Literacy With Self-Management Behavior in Patients With Diabetes. Diabetes Care 2004;27(12):2980-2982. Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, et al. Pharmacist Intervention to Improve Medication Adherence in Heart Failure: A Randomized Trial. Ann Intern Med 2007;146(10):714-725.
43、 Murphy PW, Davis TC, Mayeaux EJ, Sentell T, Arnold C, Rebouche C. Teaching nutrition education in adult learning centers: linking literacy, health care, and the community. Journal of Community Health Nursing. 1996;13(3):149-58. Poresky RH, Daniels AM. Two-year comparison of income, education, and d
44、epression among parents participating in regular Head Start or supplementary Family Service Center Services. Psychological Reports. 2001;88(3 Pt 1):787-96. Rothman R, Malone R, Bryant B, Horlen C, DeWalt D, Pignone M. The relationship between literacy and glycemic control in a diabetes disease-manag
45、ement program. Diabetes Educ 2004;30(2):263-73. van Servellen G, Nyamathi A, Carpio F, Pearce D, Garcia-Teague L, Herrera G, et al. Effects of a treatment adherence enhancement program on health literacy, patient-provider relationships, and adherence to HAART among low-income HIV-positive Spanish-sp
46、eaking Latinos. AIDS Patient Care STDS 2005;19(11):745-59.Patient-Provider CommunicationFerreira MR, Dolan NC, Fitzgibbon ML, Davis TC, Gorby N, Ladewski L, et al. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled tr
47、ial. J Clin Oncol 2005;23(7):1548-54. Seligman HK, Wang FF, Palacios JL, Wilson CC, Daher C, Piette JD, et al. Physician Notification of Their Diabetes Patients Limited Health Literacy. A Randomized, Controlled Trial. Journal of General Internal Medicine 2005;20(11):1001-1007.Improving Literacy 1. W
48、eiss BD, Francis L, Senf JH, Heist K, Hargraves R. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med 2006;21(8):823-8.,Last updated 12.01.08Individuals are welcome to use the slides in this presentation. Please credit authors and the presentation creators. Thank you.,
