Gezondheidsgeletterdheid, patiënteneducatie en zelfmanagement

Gezondheidsgeletterdheid,
patiënteneducatie en zelfmanagement:
een “heilige” drievuldigheid
Prof. Dr. Fabienne Dobbels
Ziekenhuis- en Verplegingswetenschap (KU Leuven)
[email protected]
An (un)exceptional case?
Nielsen-Bohlman et al. Health Literacy: a prescription to end confusion. 2004
http://www.nap.edu/download.php?record_id=10883
The health decision-making paradox
-
People are challenged to make healthy lifestyle choices
Emphasis on self-managing their personal and family journeys
Through complex environments and healthcare systems
Health decisionmaking paradox
-
Health literacy
crisis
People are not prepared or supported well in these tasks:
- Health care systems are increasingly difficult to navigate
- Education systems fail to provide people with adequate
skills to interpret information to improve their health
(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf)
Overview of presentation
1
2
3
• What do we mean by low health literacy?
• What is the association between health literacy,
self-management and clinical outcomes?
• How to deal with low health literacy?
Overview of presentation
1
2
3
• What do we mean by low health literacy?
• What is the association between health literacy,
self-management and clinical outcomes?
• How to deal with low health literacy?
A comprehensive conceptual definition of
health literacy
“Health literacy is linked to literacy and entails people’s
knowledge, motivation and competences to access,
understand, appraise, and apply health information in order
to make judgments and take decisions in everyday life
concerning healthcare, disease prevention and health promotion
to maintain or improve quality of life during the life course”
Competencies
Access
Understand
ability to seek, find and obtain health information
ability to comprehend the information accessed
Appraise
ability to interpret, filter, judge and evaluate this info
Apply
ability to communicate and use information to make
a decision to maintain or improve health
(Sørensen et al. BMC Public Health 2012, 12:80)
Health literacy across 8 European countries
47%
http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf
Overview of presentation
1
2
3
• What do we mean by low health literacy?
• What is the association between health literacy,
self-management and poor outcomes?
• How to deal with low health literacy?
Underlying causes of chronic illness
• 33% overweight and 14% obese
• 26% sedentary and 58% limited physical activity
• 25% smoking
Preventing Chronic Diseases: a vital investment. Geneva, World Health Organization, 2005.
http://www.belgium.be/nl/nieuws/2010/news_gezondheidsenquete-2008-rapport-1.jsp
Poor health behaviors as main risk factors of
burden of chronic disease 2010
Estimated deaths and disability-adjusted life years
attributable to the independent effects of 67 risk factors
DALY= sum of years lived with disability and years of life lost
(Lim et al. Lancet 2012; 380: 2224–60)
Treatment after chronic disease onset:
Chronic
A complex therapeutic regimen
illness
management
Medication
Chronic
illness
management
Healthy
lifestyle
Treatment of
multimorbidity
Success will depend very much on the patient’s ability to
manage their chronic illness adequately in daily life
Most of the care of patients takes place outside
a hospital environment
1-20%
80-99%
3o
2o
1o
Providing
professional
patient care
Self-management
support
Per Ake Zillen (kidney transplant patient, Sweden):
“there are 8760 hours in a year; I spent 5 hours within the
Health care system. The other 8755 hours are my responsibility”
Proportion of nurses being confident that patients
are able to care for themselves after discharge
% of nurses being (very) confident
100
90
80
70
60
55
50
40
34
39
43
44
NO
ES
57
58
59
IE
FI
NL
65
66
CH
UK
69
71
DE
SE
26
30
20
10
0
All
PL
GR
BE
The objective of RN4cast: to determine how hospital nurse staffing, skill mix, educational
composition, and quality of the nurse work environment impact hospital mortality, failure
to rescue, quality of care, and patient satisfaction
http://www.rn4cast.eu/
Patients struggle to follow the complex
treatment regimen after chronic disease onset
behavior
Number of
studies
Prevalence of
nonadherence
328
20.6%
Screening
9
27.2%
Physical activity
13
28.0%
Health behavior
88
30.3%
Appointment keeping
57
34.1%
Diet
25
40.7%
Medication taking
(DiMatteo MR. Med Care 2004; 42: 200-209)
1
0,8
0,6
0,4
0,2
0
-0,2
-0,4
-0,6
-0,8
-1
OVERALL
Risk difference
Risk difference for poor outcome between
nonadherent and adherent patients
Risk difference(%)
OR (95% CI)
Overall
0.26 [0.20; 0.32]
2.88 [2.23; 3.73]
Adult patients
0.23 [0.15; 0.29]
-
Pediatric patients
0.33 [0.24; 0.49]
-
(DiMatteo et al. Med Care 2002; 40: 794)
Understanding the relationship between poor
health literacy, self-management and outcomes
(Berkman et al. Evidence report / technology assessment No 199)
Overview of presentation
1
2
3
• What do we mean by low health literacy?
• What is the association between health literacy,
self-management and clinical outcomes?
• How to deal with low health literacy?
Low health literacy: an (in)visible problem
• Present in all walks of life or socio-economic groups
• Not possible to recognize based on appearance or speech
• 80% describe themselves as being able to read well
• Shame and embarrassment: attempts to hide reading problems
“ I will read it when I get home”
“ I forgot my glasses”
Formal assessment is indicated that goes beyond
Simple “can you read and write” questions
Newest vital signs to measure ability to understand
language and numbers in health context
Examples of the 7 questions
How many calories (kcal) will you eat if
you eat the whole container?
If you are advised to eat no more than
60 grams of carbohydrate for dessert,
what is the maximum amoung of ice cream
you could have?
Other widely used tests
TOFHLA: time consuming
• 10 min. for short version
• 22 min. for full version
REALM: short (3 minutes); does not measure
word comprehension/numeracy
GENERAL LITERACY TESTS not recommended
(Rowlands et al. BMC Public Health 2013; 13: 116)
Self-management support:
much more than patient education…
SELF-MANAGEMENT= actions patients can perform for themselves to follow
their prescribed therapy, avoid health deterioration and to preserve function
From knowing
TOWARDS
Why and what to do
“how” to do it
Lorig et al. Ann Behav Med 2003; 26: 3
Patient education: the basic principles
Getting started:
• Find out how your patient likes to learn
• Focus on what your patient needs to know, not on what’s nice to know
• Respect their limits / Give the right amount of information
Basics to be covered in any type of patient education:
•
•
•
•
•
What your patient needs to do and why
When your patient can expect results (if applicable)
Warning signs (if any) your patient should watch for
What your patient should do if a problem occurs
Who your patient should contact for questions or concerns
(http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000455.htm)
(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf)
Example of the universal medication schedule
Do not say: “take 2 tablets by mouth twice daily”, but.....
(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf)
Audit of leaflets on treatment modalities for
kidney disease in UK
Score
Flesch readability score
21-30
Extremely difficult
% of leaflets (N= 31)
6%
(e.g. New England J Med)
31-40
Very difficult
13%
(e.g. JAMA)
41-50
Difficult
52%
(e.g. Life insurance policy)
51-60
Fairly difficult
19%
(e.g. Time magazine)
61-70
Standard
10%
(e.g. Reader’s digest)
Most materials are written at high school or university level, while
they should be written on a 5th or 6th-grade reading level
(Winterbottom et al. Nephrol Dial Transplant 2007; 22: 2291-2296)
Check the readability level of
all your educational materials!
The Flesch readability test
total words
206,835 – 1,015
total syllables
- 84,6
total sentences
total words
Lower score = more difficult
If score is < 60: rewrite materials
online readibility calculator:
http://www.readabilityformulas.com/freetests/six-readability-formulas.php
http://read-able.com/
(http://en.wikipedia.org/wiki/Flesch-Kincaid_Readability_Test)
An example: e-mail from Emilien Lauwelier (23/6)
“Graag zet ik nog even de afspraken op mail die we gemaakt hebben ivm de
studienamiddag op donderdag 11 september 2014 (Provinciehuis Leuven).
Zoals aangegeven zullen er 30min voorzien worden per lezing: 20 minuten
presentatie,
10 minuten vragen.
Welevel:
hebben
u als eerste ingepland, na de
Flesch-Kincaid
Grade
12,3
aankondiging,
te starten vanaf
13u00. Ease
Gezienscore:
we de 40,6
deelnemers aan de
Flesch-Kincaid
Reading
studienamiddag willen voorzien met slides van de lezingen, vragen we u vriendelijk
om de presentatie op voorhand te voorzien. We hadden afgesproken dat u de
presentatie tegen 1 september 2014 naar me zou doormailen. Indien iets u zou
verhinderen deze deadline te halen, laat u dit gerust weten, dan bekijken we samen
wat wel mogelijk is. We zullen de slides dan ook – in PDF formaat – via onze website
ter beschikking stellen aan de deelnemers. “
Graag vat ik ons gesprek nog even samen. Uw lezing vindt plaats op donderdag 11
Grade level:
6.9 U krijgt 20 minuten. Nadien is
septemberFlesch-Kincaid
om 13u in het Provinciehuis
in Leuven.
er 10 minuten
voorzien voorReading
vragen. We
willen
graag61.4
copies aan alle deelnemers
Flesch-Kincaid
Ease
score:
geven. Nadien worden de slides ook op onze website geplaatst.
Kan u ons daarom uw slides bezorgen tegen 1 september?
Health literacy interventions build upon
relationships and are context-specific
http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf
The foundations of a health-literacy organization
(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf)
A toolbox for healthcare facilities
(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf)
Other useful resources
• http://www.euro.who.int/__data/assets/pdf_file/0008/19065
5/e96854.pdf
– Relatively short document with tips to improve health literacy at
different levels
• http://www.iom.edu/Reports/2004/health-literacy-aprescription-to-end-confusion.aspx
– Free book
Take home messages
• Low health literacy is common, also in Europe
• It impacts self-management and clinical outcomes
• Health literacy should be formally assessed in every patient
• Appropriate strategies to overcome health literacy problems
should be implemented, focusing not only at the patient, but
also at professionals and the health care setting
• Several interesting resources are available online for free
Don’t let the situation confuse you...
The different layers within health literacy
HEALTH LITERACY
Basic/functional literacy
• Basic reading and writing skills needed to develop a basic knowledge of
health conditions and health systems
Communicative/interactive literacy
• Communication and social skills which can be used to extract
information and derive meaning from different forms of communication
and to apply new information to changing circumstances
Critical literacy
• The advanced cognitive and social skills, which can be applied to
critically analyse information, and to use this information to exert
greater control over life events and situations relation to individual and
community level wellbeing goals
(Nutbeam Health Promot Int 2000; 15: 259-267)
Prevalence of chronic disease and
causes of death in Belgium
27.2% of Belgian population suffers from ≥ 1 chronic illness
Healthcare expenditure: 10.5% of GDP in Belgium
An estimated 70-80% is spent on chronic illness management
10,7
2,2
5,8
28,4
10,4
2,1
8,1
infections
cancer
endocrine
psychiatric
cerebrovascular
respiratory
external
other
32,3
http://www.zorg-en-gezondheid.be/Cijfers/Sterftecijfers/Cijfers-over-doodsoorzaken/
KCE report 190A. Position paper: organisatie van zorg voor chronisch zieken in België, 2012
Determinants of nonadherence:
a multi-faceted problem
Socioeconomic
Healthcare
systemrelated
Patientrelated
Conditionrelated
Treatment
related
Sabate. World Health Organization 2003
http://whqlibdoc.who.int/publications/2003/9241545992.pdf
Self-management support: what’s in a name?
a portfolio of techniques
and tools that help people choose healthy behaviors
Important to understand the skills
clinicians need which support they
need to help people to change
Information provision alone is
unlikely to be sufficient to
motivate behavioral change
and improve outcomes

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