I recently attended the 6th Patient Adherence and Advocacy Summit in Philadelphia. There were a number of interesting presentations and panel discussions, but one that really resonated with me concerned health literacy. In a presentation given by Laurie Myers, Leader of Health Literacy Strategy at Merck, the focus was on Merck’s efforts to redefine patient communications and optimize comprehension barriers.
The presentation highlighted the many issues regarding low health literacy. Ms. Myers talked about the importance of redefining how to apply health literacy principles to our direct and indirect communications with patients, including clinical trials, medication labeling for patients, and patient education. It’s not surprising that clinical language is relatively useless to a significant portion of any given patient population, but the degree to which it is a problem is surprising.
How significant is this problem? According to the Journal of the Medical Library Association, poor health literacy “is a stronger predictor of a person’s health than age, income, employment status, education level, and race.” The U.S. Department of Health & Human Services reports that only 12% of American adults have proficient health literacy, affecting people of all ages, races, incomes, and education levels. Some population groups are particularly vulnerable, including the elderly, recent immigrants not fluent in English, minorities in general, and people with low incomes.
“Health literacy depends on the context in which the information is given,” Ms. Myers said. Even people with advanced degrees and reading skills face health literacy challenges. Patient health behaviors and outcomes are directly linked to low health literacy, including:
- Preventive services – tending to make less use of preventive care and screenings, and entering the healthcare system too late
- Knowledge and treatment – tending to have less knowledge of their chronic conditions making them less likely to ask questions
- Utilization – generally tending to have more hospital admissions, including emergency room visits
- Adherence – tending to not understand why they need to take their medications and failing to discuss difficulties in affording their medications
On a national level, significant efforts are being made to improve health literacy. These are mainly tied to reducing costs within the system by improving outcomes. The Affordable Care Act contains specific provisions and guidelines aimed at improving health literacy. In October 2010, The Plain Writing Act was enacted, designed to improve the effectiveness and accountability of federal agencies by promoting clear government communication that the public can easily access and understand. While these programs have faced their challenges and have experienced some mixed results, Ms. Myers points out that they are steps in the right direction.
Concern about “dumbing down” health information is misplaced, according to Cindy Brach, Senior Health Policy Researcher at the Agency for Healthcare Research and Quality. “People worry about ‘dumbing things down’
When it comes to in-office conversations between patients, caregivers, and healthcare professionals, Ms. Myers referred to what is known as the “teach-back” technique. The concept is simple and effective. For example, the doctor would say to the patient, “When you go home today, what will you tell your family about what we discussed?” If the patient can’t restate the instructions or discussion correctly, the doctor explains again by drawing pictures or using simpler words. The challenge here, of course, is the severely limited amount of time the doctor has with the patient. This requires educating the physician about the most efficient way to use the teach-back method and its importance regarding outcomes.
Merck has put its money where its mouth is, investing time and resources to a comprehensive health literacy initiative. Merck’s Chief Medical Officer and the Health Literacy Strategy team worked with academic experts from Northwestern and Emory Universities to leverage a diverse range of expertise to improve patient labeling and create internal best practices. The objective is to provide an ongoing study of research methodologies that will facilitate testing patient labeling with healthcare consumers. Research included patient focus groups as well as qualitative research to patients with either limited or adequate health literacy skills. Since the researchers found that requiring computers unintentionally eliminated some patients from participating, multi-modal interviewing (in person, by phone, and computer) was used.
Patient product information was developed that tested very well with qualitative research. The average comprehension test score was 93%, with an overall “clarity rating” of 9.2 out of 10. Materials developed in the initiative were easy to understand: what it treats, potential side effects, and how to store it, easy to read/clear sections, good font size, the “just right” amount of information, and less wordy/less confusing language. Ms. Myers said that this approach of teaming up with academia is viewed as a model that could be adapted by the FDA, other pharmaceutical companies, as well as health insurers and health systems that generate patient-facing communications.
Merck is applying these principles beyond patient product information to materials such as labels. The Merck Engage website illustrates their best-practice approach to patient education using clear, effective, and friendly language and graphics. Other pharma companies are aggressively pursuing health literacy goals, and we can expect to see big improvements in the next few years. Although Ms. Myers focused on Merck’s efforts, she made it clear that health literacy is a problem throughout the healthcare system and she welcomes any and all viewpoints on how to fix the system.