Hello to all my fellow providers and comrades engaged in the business of taking care of critically ill patients. I'm Chet Morrison, an Associate Professor of Surgery, Trauma, and Critical Care at Central Michigan University, and I'll be discussing healthcare literacy during a pandemic, a very important topic in time of plague. Actually it's an important topic even when we're not in time of plague, but I think we all agree that in these days it's a topic that takes on even greater importance. It is important in approaching this topic that we think about how people get their information in the first place, period. There's television, which is near ubiquitous in most societies and has its upsides, but also has its downsides, particularly in people's perception. A good source of healthcare literacy and health information is, and of course should be, us, the physicians and other providers who counsel patients as to healthcare information and also the best approaches for any one disease or condition. I think in the main, we do an okay job of this and we're certainly well-motivated, however there are certain gaps that will often happen when we try and communicate with patients. Certainly there's social media, which is near ubiquitous with all its adherence, but of course, as we all know, the information in social media is of varying quality, and I should point out that some of the misinformation on social media is unfortunately spread by us and I have seen this myself. Newspapers are also a factor. They seem kind of quaint, but I would point out that about a million people or a billion people still read newspapers, particularly their online versions, and in fact I myself get a lot of information that way, and I think many of my colleagues do as well. Finally, there's of course cultural aspects to social media. Other people, certain cultures have ways of processing and dealing with information through family ties and although again, it's not exactly peer-reviewed information, it is important for the clinician to keep in mind. When researching this topic, one finds that the literature and the research on what actual health literacy is in people is actually surprisingly limited given the import of the topic and the way that it affects virtually every person on the planet. In fact, when Castro Sanchez surveyed a database over six years on research papers that had been published on this very topic, he found a very limited range of studies in certain very morbid diseases such as malaria and infant diarrhea. They were simply underreported in the literature. In fact, the literature was not robust in any disease outside of HIV, which has been extensively covered. Furthermore, he found that most investigations considered functional literacy, which is a person's understanding of a disease process or treatment, but not critical health literacy, which he defined as people being knowledgeable enough about a certain disease to advocate for meaningful political and social changes that could affect this. Again, in the current days, with the current importance of exactly such advocacy, this is a striking gap. The question comes up of whether health care literacy changes during a pandemic. Well, obviously, in the current pandemic, data is still being gathered, although I'm sure there's going to be some interesting research reports to follow. However, we do have prior pandemics to learn from, and the latest one was the 2009 flu pandemic. And this was looked at in a survey of patients in an Australian emergency room. As the slide indicates, 252 patients were surveyed. Fifty-five percent of them had used traditional mass media for their information about the flu. There was a 70 percent accuracy about transmission, 68 percent of them had taken precautions but 60 percent thought the threat exaggerated. And when in fact, the flu epidemic fortunately turned out to be somewhat milder than had been initially feared, only 40 percent said they would comply in a future pandemic. Another study comes to us from the Netherlands looking at the same pandemic, that is to say the 2009 influenza A pandemic. This survey recruited online participants to do two cross-sectional and one follow-up survey, and these were done during different phases of the pandemic. They measured time trends and risk perception, feelings of anxiety, behavioral responses, and also factors associated with taking preventative measures and a strong intention to comply with government-advised presentive measures in the future. And while the patient sample may not have been entirely representative of the population, they did find that over two months, the level of knowledge regarding influenza A increased while the perceived severity of the new flu, perceived self-efficacy, and intention to comply with preventive measures decreased as the epidemic waned. I had mentioned earlier about the critical role that physicians and other healthcare providers have in communicating health literacy to their patients. A survey from 2003 did show that one third of American adults had limited health literacy but in some vulnerable groups, the rate was over 50%, particularly groups that were in lower socioeconomic status levels. Health disparities, difference in treatment access, living conditions, language, immigration status, risk perceptions, and confidence in the government's ability to respond could exacerbate risks for particular populations. And again, remember, this was written in 2003 before we had our current COVID plague. And this seems to be borne out by the current responses to our COVID plague. It reminds us that communications must successfully instruct, inform, and motivate appropriate self-protective behavior. It also has to update risk information, and I think very important, build trust in officials and dispel rumors. In these current days of COVID-19, the level of healthcare literacy in a population is obviously of more than academic interest. And so I thought I would discuss some ways that have been shown to help in the communication of healthcare literacy to our patients. Some of the best recommendations come out of the family practice literature, which, as a critical care physician, is not something I regularly peruse. However, for this topic and for these techniques, it can be very helpful. Weiss, in fact, in a very good review article, the reference of which is included in this slide, specifically states five interventions that can help. These are explaining things without using medical terms, which is something we have to sort of coach ourselves with, but people often will not tell us that they don't understand these medical terms, and I myself have had to wean myself off the preconceived notion that it is insulting to not use medical terms. In fact, patients who are not medically trained will appreciate this. And if they are medically trained, I promise you they won't take insult on it. Second, to focus only on two or three key messages. We all get overwhelmed, certainly, with a number of messages, and some of them can seem self-contradictory. So you pick the things your patients most need to know. Speak slowly. Obviously, you don't want to speak at such a slow pace that you come across as insulting. But again, perhaps because we're time-stressed, as physicians, we do tend to speak fast. Again, I know that I sometimes do that when I see recordings of myself in terms of how I counsel patients. I'm often struck by how fast I'm talking. I might be talking fast now to get this done within a certain time frame. And so speaking at a slower pace might be helpful. Using teach-back, where your patients repeat the instructions back to you in their own words so that you can ensure you explained it to them in a way that was understandable. And finally, use easy-to-understand written materials. The average reading level of society is roughly at an eighth-grade level, except a lot of health care information seems to be written at the 10th-grade level. It is thus important that written material be written so that everyone can understand. So I think I'll conclude my presentation with some sources of information that may be of use. There's the CDC website, whom I recommend virtually everybody I talk with go to. It has very up-to-date and very useful information on all aspects of the current pandemic. Our own SCCM has several open source guidelines and blogs in which useful information is written. And I find these also very up-to-date and evidence-based. In terms of swimming against the tide of expert mistrust, which is quite widespread, at least in our society, it is important to emphasize consensus messaging, areas of broad agreement between various experts and aspects of medicine and health care. And I would point out that the National Network of Medical Libraries has a website that you can see on the slide that's a very good source of health care literacy information in general. I would finally add that this will not end with the pandemic. The pandemic itself will end. The need for health care literacy will not end. And that is critical care experts, we have a unique role to play in the widespread improvement in health care literacy. I'll close with a quote from one of my favorite educators, Marianne Wolf, who said, we humans invented literacy, which means it doesn't come for free with our genes like speech and vision. Every brain has to learn it afresh. Thank you for your attention.

Chet Morrison

healthcare literacy

pandemic

healthcare information

healthcare providers