Objectives. What Determines Health Outcomes? Impact of Health Literacy and Socioeconomic Status on Asthma Disparities

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1 Impact of Health Literacy and Socioeconomic Status on Asthma Disparities Tyra Bryant-Stephens MD Director and Founder, Community Asthma Prevention Program The Children s Hospital of Philadelphia, Professor of Pediatrics The Perelman School of Medicine at the University of Pennsylvania Nemacolin Asthma Conference 2016 Objectives Define literacy and health literacy Discuss impact of low health literacy on asthma Discuss strategies to overcome barriers that result from low health literacy What Determines Health Outcomes? Determinants of Health CDC % 20% 50% 20% Lifestyle Biology Environment Health System

2 What Are the Social Determinants of Health? The social determinants of health are the conditions in which people are born, grow, live, work and age. (WHO) Social determinants of health are factors in the social environment that contribute to or detract from the health of individuals and communities (cdc.gov) The Problem: Low Literacy 44% of US adults have basic or below basic literacy (90 million adults) Low literacy associated with adverse health outcomes, reduced health-related knowledge, increased disease morbidity, poor general health status and decreased use of preventive services Limited child literacy associated with negative behaviors Low parental literacy associated with less knowledge, negative parental behaviors and poor outcomes for their children Rosas-Salazar et al National Assessment of Adult Literacy 2003

3 Signs of Low Print Literacy Making excuses for not reading forms (I forgot my glasses) Asking staff for help to fill forms Nodding yes to all questions, Filling forms incompletely or inaccurately, not paying attention to the provider when referring to a form Health Literacy The degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions Healthy People 2020 \ The need for people to understand information that helps them maintain good health IOM 2004 Components of Health Literacy Literacy Cultural & conceptual knowledge Listening Speaking Writing Reading Numeracy IT skills Health Literacy, A Prescription to End Confusion, Institute of Medicine, National Academy of Sciences 2003

4 Parker R. Measuring Health Literacy: What? So What? Now What. In: IOM Measures of Health Literacy: Workshop Summary. Washington, DC. National Academies Press. HEALTH LITERACY Adapted from Parker R. Measuring Health Literacy: What? So What? Now What. In: IOM Measures of Health Literacy: Workshop Summary. Washington, DC. National Academies Press. Numeracy The ability to understand and act on numerical directions Examples: arithmetic, estimation, probability, problemsolving, number sense, risk, understanding graphs and tables Patients encounter numeracy concepts when they receive, follow, and pay for medical care. Limited research of the impact of numeracy on health and no tool that assesses these skills related to asthma. Apter et al developed/validated a 4-item Asthma Numeracy Questionnaire (ANQ) based on NAEPP-3 concepts.

5 Validated Literacy tests REALM (Rapid Estimate of Adult literacy in Medicine) TOFHLA (Test of Functional Health literacy in Adults NVS (newest Vital Sign) Asthma Numeracy Questionnaire Low Health Literacy Found in all patient groups Increased among low income groups, underserved & under-represented minority groups, elderly, those whose primary language is not English Associated with poorer health access and outcomes, higher health costs, less patient satisfaction, unsuccessful patient education Hard to recognize Screening not recommended in patient care Impact of Low Parental Health Literacy Dewalt et al showed that low parental HL (REALM) associated with increased risk of ED visits, IP visits, use of rescue meds and school absences In contrast 2 large cross-sectional studies found no significant association between limited parental HL and indicators of asthma morbidity or control Low HL was associated with worse parental perception of child s overall health, lower parental qol, lower asthma knowledge, lower parental selfefficacy

6 General Health Literacy Barriers Health literacy must be understood and addressed in the context of culture and language. Clinicians have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy. Directions, signs, and official documents, including informed consent forms, social services forms, public health information, medical instructions, and health education materials, often use jargon and technical language that make them unnecessarily difficult to use IOM 2009 Barriers to Health Literacy in Chronic Disease Demands and complexity of chronic disease management Increased use of new technologies Decreased time for patient/provider discussions Legal and regulatory requirements HEALTH LITERACY S IMPACT ON ASTHMA

7 Paasche-Orlow et al, Rosas- Salazar Health Literacy & Asthma Management NAEPP requires patients with persistent asthma to have considerable selfmanagement skills. Numerical concepts as well as print literacy necessary Only 13% of American adults have HL skills to understand health information and navigate our demanding health systems.(brach C et al) Patients with normal literacy cannot teach-back. Low literacy (REALM) has been associated with poorer asthma knowledge and improper inhaler use. (Williams M et al). With education low literacy impact on asthma management may be overcome (Paasche-Orlow et al) MDI step Proportion of Patients Correctly Performing Steps in proper MDI technique according to REALM reading grade level (n=469) Remove the cap and shake the inhaler Exhale to functional residual capacity Activate the MDI at the start of inhalation <3 rd N= th N= th N=149 High school N=130 P-values 64 % <0.001 Inhale slowly <0.001 Hold breath for at least 5s Take one puff at a time and wait for at least 30 s before the next puff Williams, Baker, Honig, Lee, Nowlan. Chest 1998.

8 vania on 05/09/14 HEALTH LITERACY IN ASTHMA PATIENTS TABLE 2. Health literary and patient-reported measures of medical care. Associations with marginal/inadequate health literacy (independent variable) Unadjusted Adjusted Dependent variables Estimate p Estimate p Less satisfied with asthma status More difficult access to asthma care Worse results from care for asthma More difficult access to medical care for other medical conditions Worse results from care for other medical conditions Does not want to participate in making treatment decisions Adjusted for sex, race/ethnicity, language, asthma duration, asthma severity, asthma control. Adjusted for sex, race/ethnicity, language, age, comorbidity. Manusco et al J Asthma 2006 make treatment decisions. Patients with marginal/inadequate health literacy were less likely to want to participate in making decisions (OR.29, 95% CI.13,.65) (Table 2). This result persisted after adjusting for age, sex, race/ethnicity, language, not a patien acces shoul acces full s in ou diffic becau patien Th from may n In add and v were searc this s quest vided had u we gr Clinical Impact of Low Health Literacy on Asthma Patients with inadequate HL more likely to report nighttime awakenings (Rosenfield), hospitalizations and days lost from usual activities(adams) Low HL linked to reduce qol Low numeracy associated with decreased qol and increased risks of hospitalizations, ED visits in adults with asthma Low Parental Numeracy and Asthma Rosas- Salazar et al Chest. 2013

9 Identification of patients with low HL Little correlation with provider s assessment and actual measurements of HL Highest grade of education is often higher than the actual level of literacy Lower communicative health literacy less likely to ask questions Most experts do not recommend screening for HL Embarrassing Time consuming No evidence that literacy testing results in improved delivery of health care or health outcomes Providers Perception of HL and how it impacts treatment Harrington et al, Pediatric Allergy, Immunology and Pulmonology 2013

10 Patient Education Materials Often written at a high literacy level (most at 8 th or 9 th grade) Computer programs do not integrate cultural, local or regional nuances and can be misleading Written asthma action plans have a mean grade level of 8.1 Assume all have low literacy (adage teach to the least educated person in the group ) STRATEGIES TO ADDRESS LOW HEALTH LITERACY

11 Clinician-Patient Level Interventions Patient-centered communication Clear health communication Confirmation of understanding Reinforcement Numeracy and risk Medication reconciliation Sudore and Schillinger, J Clin Outcomes Manag 2009 Oral Communications Speak slowly and use simple words Use Active Voice ( use albuterol rather than albuterol should be used ) Only essential information Simplify numeric concepts Frame instruction effectively Confirm comprehension by using teach-back method Pay attention to nonverbal communication Make patients feel comfortable about asking questions Order information from most to least important Rosas-Salazar et al Teach-back method Where the educator asks patients to explain or demonstrate what they have learned Gives direct feedback to the educator on how effective the explanation was

12 FORM (Revised 3/2014) System-Patient Level Health education materials Medication drug labels Disease self-management support Creating an empowering environment Clinician training Sudore and Schillinger, J Clin Outcomes Manag 2009 Features to include in written Patient education materials Use of active voice Short, simple sentences Pictures and symbols providing visual cues Attractive layout with lots of white space When talking about percentages, risks put in numbers rather than words (e.g.. ½ as likely, rather than fifty percent less likely) Culturally tailor materials Videos IOM Asthma Medicine Medications are one of the most important ways to treat or prevent asthma symptoms. There are two types of asthma medications: quick relief (rescue/reliever) medications and controller medications. Quick-Relief (Rescue or Reliever) Medications Rescue/reliever medications are fast-acting medications used to relieve asthma symptoms within five to 20 minutes. They should be used whenever needed, based on symptoms. These types of medicines are usually inhaled directly into the lungs through an inhaler or a nebulizer. Rescue/reliever medications: Relieve asthma symptoms once they have started. Are fast-acting (start working in five to 20 minutes). Do not control or prevent inflammation in the airways. Relax the tightened muscle bands around the airways (bronchospasm). Should only be needed occasionally. Talk to your doctor if you find you are using quick-relief medications more than twice a week to control your breathing. Using too frequently use may be dangerous. Controller Medications Controller medications work slowly over a longer period of time (weeks to months) to reduce airway inflammation and help prevent asthma symptoms from occurring in the first place. Controller medications: Prevent asthma symptoms from occurring and reduce and/or prevent: Inflammation and scarring in the airways. Tightening of the muscle bands around the airways (bronchospasm). Will not provide quick relief of asthma symptoms. Do not show immediate results, but work slowly over time. Should be taken daily, even when you are not having symptoms. Remember Take your medicines as directed by your doctor, and you: May have more days without asthma symptoms. Won t use quick-relief medications as often. Will have fewer symptoms at night. Will breathe better. May avoid permanent lung function changes/damage. For more asthma resources visit pamf.org/asthma

13 Pictorial Asthma Action Plan Ozyigit et al. J Asthma 2014

14 Community-Patient Level Referrals to adult literacy classes Use of lay health educators/navigators Review asthma action plan Review medications Teach back at office visits Reinforce follow-up Partnering with GED programs Educational Low Health Literacy Interventions Tailored education assuming low literacy in all subjects. Study of children with moderate-to-severe asthma followed six months, conducted weekly asthma education, literacy enhancement and life skills training Found decreased risk of ED and IP during the study period as well as significant improvement in children s reading level and self efficacy

15 CAPP Community Classes Community Classes Design: Each class series consist of three-five 1- hour sessions over five weeks. Teaching method: Parents and children learn from each other with the supervision of a trained Parent and Peer Educator. Community Role: Parent educators are peers from the community. Community sites must commit to organizing and recruiting for class and eventually running classes on their own. Outcomes from Classes Study n=267 caregivers pre/post design Bryant-Stephens, Li. JNMA 2004 Prescription towards Health Literacy Health practitioners communicate clearly using everyday vocabulary. Patients feel free and comfortable to ask questions as part of the healing relationship. Rights and responsibilities in relation to health and health care are presented or written in clear, everyday terms. Informed consent documents used in health care are developed so that all people can give or withhold consent based on information they need and understand

16 Summary Low HL occurs among all SES but it is more common in poor and minority people People with inadequate or low HL are less likely to be knowledgeable or have adequate selfmanagement skills. Low HL results in poorer access, poorer asthma care quality and poor quality of life for asthmatics There are clinical, system and community strategies that should be employed to close the literacy gap which perhaps would result in less asthma health disparities