Valley strives to improve health illiteracy

Feb 7, 2010 — The Fresno Bee

Barbara Anderson

Feb. 7, 2010 (McClatchy-Tribune Regional News delivered by Newstex) -- As lawmakers debate how to help the tens of millions of Americans who lack health insurance, patient advocates are quietly taking aim at a lesser-known obstacle to care -- a widespread inability to understand basic medical instructions.

The problem, known as "health illiteracy," is believed to be even more common than a lack of insurance.

About 90 million adults in the United States -- nearly half the population -- have difficulty reading prescription labels and following doctors' orders, according to a widely accepted study by the nonprofit Institute of Medicine.

And that comes at a cost: Misreading prescription labels leads to about 1.5 million preventable medication errors each year, another researcher found. Health illiteracy has been linked with poor health and poor access to health-care services -- and it is a stronger predictor of a person's health than age, income, employment status, education level and race, according to the American Medical Association.

Those problems drive up the price of care for everyone as patients make repeated visits to doctors and hospital emergency rooms, advocates say.

And a big share of the blame rests with the failure of health professionals to communicate with patients in ways they can understand, the advocates say.

"We clinicians speak two languages," said Dr. Dean Schillinger, a leading health-literacy advocate and professor of medicine in residence at the University of California at San Francisco. "And we tend to talk shop with our patients, where some concepts and terms are not going to be understood."

Linda Hewett, a Fresno neuropsychologist, calls it arrogance when clinicians "speak over the clients' head."

There's no good way to count just how many people in the Valley have poor health literacy, but the region has large at-risk populations -- including the elderly, minorities, immigrants and the low-income.

"It's fairly obvious we have a multiplicity of cultures and languages," said Hewett, co-director of the UCSF-Fresno Geriatric Education Center. "And because of our poverty level and poorer levels of education, it clearly is an issue."

Efforts are being made to improve health literacy. Hewett recently helped develop and taught a health-literacy curriculum that focused on improving communication with elderly patients.

Children's Hospital Central California recently won a health-literacy and patient-safety award for putting day-surgery hospital discharge instructions on audiotapes that parents could access by telephone for two weeks. Hospital officials believe it's the first of its kind in the country.

Public health agencies have printed health materials at the fifth- or sixth-grade level, said Schillinger.

And soon it will be easier to read the labels on prescription drug bottles. Under a state law that takes effect next Jan. 1, language on the labels will be simpler, and the print will be larger.

But more needs to be done, advocates say.

Language dangers

A Hmong translation on a prescription bottle would have saved Kayla May Vang of Fresno from taking a life-threatening dose of warfarin, a blood-thinning drug.

Vang speaks limited English. Her prescription called for her to take one warfarin pill a day. Instead, Vang, now 68, mistakenly took three pills daily for 10 days. A pharmacist caught the error when a family member tried to refill the bottle for a 30-day supply of pills that was empty in less than two weeks.

But it was too late to prevent damage. Vang's blood had become so thin, she was bleeding inside her brain. "They said my blood was like water," she said.

Sharon Stanley, executive director of Fresno Interdenominational Refugee Ministries and a family friend, was at the hospital when doctors told Vang's family they doubted she would live. They operated on Vang's brain to release pressure from the blood that was pooling inside her head.

Vang spent weeks in the hospital. That was three years ago.

"It's miraculous that she survived -- that she recovered," Stanley said.

A group of researchers is studying how directions for taking prescriptions can be translated into five written languages -- Spanish, Russian, Vietnamese, Chinese and Korean, said Virginia Herold, executive director of the California State Board of Pharmacy. If that's successful, Herold said, it's possible other languages could be translated.

And the wording on bottles should be simpler. For example, "take two pills daily" can be confusing. To make it clearer, the new wording could be: "Take one pill in the morning and one pill at bedtime."

Draft regulations for the labels are expected to be approved at a hearing of the California State Pharmacy Board on Feb. 17 in Sacramento, Herold said.

Education matters

Poor health literacy doesn't mean a patient is uneducated. College graduates can need to run to a dictionary when doctors begin spouting medical jargon instead of using everyday language.

"Most of us don't know how to talk to our doctors -- and our doctors don't know how to talk to us," Hewett said.

But health literacy is particularly an issue for those who have lower literacy levels in general. High illiteracy rates in California and the Valley compound the problem, Schillinger said.

Statewide, 23% of adults lacked basic literacy skills, compared to 14% nationwide, according to 2003 estimates by the National Center of Educational Statistics, the latest available. The study estimated that more than 25% of adults in Fresno, Kings, Madera and Tulare counties are below the most basic level.

By contrast, most health information is written at the 12th grade level, Schillinger said.

The average American reader reads at an eighth-grade level -- and on average Medicare and Medi-Cal patients read at the fifth-grade level, he said.

"We're really talking about how the educational system affects health," Schillinger said.

It's not surprising that patients with low health-literacy levels fall through the cracks in the health-care system, health-literacy experts said.

"The system places a heavy burden on patients to care for themselves," said said Dr. Rebecca Sudore, a health-literacy researcher and UCSF assistant professor of medicine at the Veterans Affairs hospital in San Francisco.

Doctors get 10 to 15 minutes for each patient's appointment, Sudore said. "We don't have time right now to talk to people," she said.

Her research has explored a host of problems associated with health illiteracy, including the effect of misreading prescription labels.

Community Regional Medical Center recognizes that a hospital stay can be overwhelming, and it's trying to simplify communication.

The hospital has started using universal symbols -- for X-ray and other services -- instead of printed signs wherever possible, said Robyn Gonzales, associate administrator.

Most of the hospital's printed patient-education materials are written in fourth- to sixth-grade language, she said. And a patient-family education work group gathered recently to discuss modifying more materials, she said.

Some say that's not enough.

Elvira Mendoza of Fresno said she did not get information on how to care for herself when she left the hospital after emergency surgery for appendicitis in April 2008.

One of three surgical cuts became infected, and she ended up back in the emergency room about a week later, she said.

"I think it is because they are so busy," said Mendoza, 25, who speaks fluent Spanish and is conversant in English. "They have so many people in there."

Gonzales couldn't comment specifically on Mendoza's case but said hospital policy requires a nurse to give discharge instructions verbally.

Medical jargon

Making changes to signs and simplifying patient materials makes the health-care system more health-literacy friendly, but doctors also need better patient-communication skills, the UCSF health-literacy experts said.

Doctors need to be taught how to communicate with patients, Sudore said. "We say things like 'hypertension.' Maybe [patients] know what high blood pressure means, but not hypertension."

One technique doctors can use is called "teach back," in which physicians ask patients to repeat information and instructions they've just been given, Sudore and Schillinger said. From the patients' response, doctors can quickly tell whether the patients understood -- or whether more explanation is necessary, they said.

Schillinger is an advocate of using technology, such as the telephone system employed by Children's hospital, to bridge the communication gap between doctors and patients. Automated telephone technology is low-cost, and it works, he said.

Children's got the idea for recording discharge instructions from Dr. Sam Lehman, the hospital's director of patient safety.

Lehman said he thought audio messages might be helpful in communicating with parents, and day-surgery was a small, controlled area inside the hospital to try it out.

Children's received a $25,000 grant from Cardinal Health, a global health-care company, to create the audio-messaging pilot project. Interpreters for families who spoke Hmong, Spanish and Mixteco-Bajo agreed to let themselves be taped as they gave instructions to families.

Instead of remembering a nurse's information on how to clean a wound or when to feed a child recovering from an operation, parents had access by telephone to the recordings for two weeks.

The hospital's initiative won a Service Quality Award in January from the Institute for Healthcare Improvement, a Massachusetts-based nonprofit organization that works to improve patient care. The Children's pilot project, which ended last September, improved health literacy and patient safety, the institute said.

Hospital officials are discussing how to expand the approach.

Children's was surprised how often the telephone-message system was used by parents for discharge instructions, said Simranjit Kaur, the hospital's patient safety project manager.

The pilot project enrolled 132 families between April and September 2009, and 30% of the families called in one or more times, she said.

The response shouldn't be surprising, Lehman said. "Eighty percent of patients forget instructions when they leave a doctor's office."

The reporter can be reached at banderson@fresnobee.com or (559) 441-6310.

Newstex ID: KRTB-0069-41862241