Abstract
BACKGROUND: Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients’ limited HL improves care processes or outcomes.
OBJECTIVE: To determine whether notifying physicians of their patients’ limited HL affects physician behavior, physician satisfaction, or patient self-efficacy.
DESIGN: We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills.
PARTICIPANTS: Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL.
MEASUREMENTS: After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients’ self-efficacy, feelings regarding HL screening’s usefulness, and glycemic control.
RESULTS: Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients’ post-visit self-efficacy scores were similar (12.6 vs 12.9, P=6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful.
CONCLUSIONS: Physicians are responsive to receiving notification of their patients’ limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.
Similar content being viewed by others
References
Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academics Press; 2004.
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA. Health literacy: report of the Council on Scientific Affairs. JAMA. 1999;281:552–7.
Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274:1677–82.
Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545–51.
Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and Health Outcomes. Rockville, MD: Agency for Healthcare Research and Quality; 2004.
Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–75.
Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475–82.
Spandorfer JM, Karras DJ, Hughes LA, Caputo C. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med. 1995;25:71–4.
Williams MV, Baker DW, Honig EG, Lee TM, Nowian A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–15.
Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D. Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med. 2000;18:325–31.
Kalichman SC, Rompa D, Cage M. Reliability and validity of self-reported CD4 lymphocyte count and viral load test results in people living with HIV/AIDS. Int J STD AIDS. 2000;11:579–85.
Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001;32:313–20.
Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027–30.
Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acq Immun Defic Syndr. 2000;25:337–44.
Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–8.
Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among medicare managed care enrollees. Am J Public Health. 2002;92:1278–83.
Schillinger D, Bindman A, Stewart A, Wang F, Piette J. Functional Health Literacy and the quality of physician-patient communication among diabetes patients. Patient Educ and Counsel. 2004;52:315–23.
Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–73.
Bass PF III, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039–41.
Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol. 2002;186:938–43.
Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician. 1996;53:205–11.
Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–34.
Doak CC, Doak LG, Friedell GH, Meade CD. Improving comprehension for cancer patients with low literacy skills: strategies for clinicians. CA. 1998;48:151–62.
Weiss BD, Hart G, McGee DL, D’Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992;5:257–64.
Bennett IM, Robbins S, Al-Shamali N, Haecker T. Screening for low literacy among adult caregivers of pediatric patients. Fam Med. 2003;35:585–90.
Hospital Provision of Care, Treatment, and Services Crosswalk, Vol. 2004. Washington, DC: Joint Commission on Accreditation of Healthcare Organizations; 2004.
Bass PF III, Wilson JF, Griffith CH. A shortened instrument for literacy screening. J Gen Intern Med. 2003;18:1036–8.
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.
Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52.
Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med. 2003;18:893–902.
Aljasen LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. Diabetes Educ. 2001;27:393–404.
Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003;18:624–33.
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes. Arch Intern Med. 1998;158:166–72.
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–75.
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.
Lipkin M, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag, 1995.
Alazri MH, Neal RD. The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus. Diabetes Med. 2003;20:486–90.
Pernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19:167–74.
Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Counseling. 1996;27:33–9.
Baker DW. Reading between the lines: deciphering the connections between literacy and health [editorial; comment]. J Gen Intern Med. 1999;14:315–7.
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.
Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Counseling. 1999;38:33–42.
Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.
Nurss JR, Parker RM, Williams MV, Baker DW. TOFHLA: test of functional health literacy in adults. Snow Camp, NC: Peppercorn Books & Press; 1995.
Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. Philadelphia, Pa: JB Lippincott; 1996.
Keyserling TC, Samuel-Hodge CD, Ammerman AS, et al. A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: impact on physical activity. Diabetes Care. 2002;25:1576–83.
Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Counseling. 1998;35:83–8.
Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002;34:383–9.
(AHRQ). Strategies for Improving Minority Healthcare Quality. Report No.: Evidence Report/Technology Assessment Number 90, 2004 January.
Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview [see comments]. JAMA. 1997;277:678–82.
Levinson W, Stiles WB, Inui TS, Engle R. Physician frustration in communicating with patients. Med Care. 1993;31:285–95.
Howie JG, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract. 1998;15:165–71.
Barton P, Gurrin L, Sly P. Extending the simple linear regression model to account for correlated responses: an introduction to generalized estimating equations and multi-level mixed modelling. Stat Med. 1998;17:1261–91.
Statistical Analyses System (SAS). Version 8. Gary, NC: SAS Institute Inc.; 1999.
Lobosco AF, Newman DL. Teaching special needs populations and teacher job satisfaction: implications for teacher education and staff development. Urban Educ. 1992;27:21–31.
Rosenberg MS, Griffin CC, Kilgore KL, Carpenter SL. Beginning teachers in special education: a model for providing individualized support. Teacher Educ Spec Educ. 1997;20:301–21.
Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. BMJ. 2002;325:934.
Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.
Nelson HD, Nygren P, McInerney Y, Klein J. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:387–96.
Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH. Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The Screening and Intervention in Primary Care (SIP) Study. Ann Intern Med. 2003;138:372–82.
Krichbaum K, Aarestad V, Buethe M. Exploring the connection between self-efficacy and effective diabetes self-management. Diabetes Educ. 2003;29:653–62.
U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd edn. Baltimore, MD: Williams & Wilkins; 1996.
Lachs MS. Screening for family violence: what’s an evidence-based doctor to do? Ann Intern Med. 2004;140:399–400.
Grimes DA, Schulz KF. Uses and abuses of screening tests. Lancet. 2002;359:881–4.
Roter DL, Russell NK. Validity of physician self-report in tracking patient education objectives. Health Educ Q. 1994;21:27–38.
Author information
Authors and Affiliations
Corresponding author
Additional information
The authors have no conflicts of interest, financial or otherwise, to report for this article or this research.
See editorial by Montori, p. 1071
Dr. Seligman was supported by a DHHS-HRSA Research Fellowship Grant 5 D14HP00178-03-00. Dr. Piette is a VA Research Career Scientist. Dr. Schillinger was supported by a NIH Mentored Clinical Scientist Award K-23 RR16539-03, UCSF Hellman Family Research Award, and a Pfizer Inc. Health Literacy Research Award Electronic data were made available through the San Francisco General Hospital GCRC grant M01RR00083-42.
An erratum to this article is available at http://dx.doi.org/10.1111/j.1525-1497.2005.00309.x.
Rights and permissions
About this article
Cite this article
Seligman, H.K., Wang, F.F., Palacios, J.L. et al. Physician notification of their diabetes patients’ limited health literacy: A randomized, controlled trial. J GEN INTERN MED 20, 1001–1007 (2005). https://doi.org/10.1111/j.1525-1497.2005.00189.x
Received:
Revised:
Accepted:
Issue Date:
DOI: https://doi.org/10.1111/j.1525-1497.2005.00189.x