This webinar was recorded on Thursday, June 16, 2022

Dr. Michael Bowman will lead a discussion on how to provide appropriate clinical care and patient education with a focus of health literacy level to best reach each person to improve health outcomes.


  • Dr. Michael Bowman
  • Tonya Winders


Transcript: This transcript is automatically generated. While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Speaker 2    00:10

Hello, this is Tonya Winders, President and CEO of Allergy and Asthma Network. It’s my pleasure to welcome you today to the asthma and COVID-19 Care and education at appropriate literacy levels webinar. We are so pleased that you’ve chosen to join us today and we really work together to truly reach people who are struggling with COVID-19 and at those of you who are caring for those individuals and ensure that the language we use resonates and matters. It makes a real difference in the way that we work together to communicate in a meaningful and impactful way. And so we thank you for joining us for today’s webinar. This webinar series is the actual thirty seventh in our covid nineteen COVID-19 by Allergy and Asthma Network. The network continues to work toward its mission of ending the needless death and suffering due to asthma, allergies and related conditions like COVID-19 through our four mission areas, outreach, education, advocacy and research. Today we welcome Doctor Purvi Parikh. And Doctor Michael Bowman to our webinar as our speakers. Doctor Parikh is an adult and pediatric allergist and immunologist at Allergy and Asthma Associates of Murray Hill. She is currently on faculty as the clinical assistant professor in both departments of medicine and Pediatrics at NYU School of Medicine. She’s been passionate about health policy and serves on the board of the Advocacy Council for the American College of Allergy, Asthma and Immunology. Doctor Parikh is the national spokesperson for Allergy and Asthma Network and frequently makes appearances as a medical contributor on our behalf to the major news networks, including NBC, Fox, CNN, Wall Street Journal and CBS. Welcome Doctor Parikh. Next, I’d like to welcome Doctor Michael Bowman. Doctor Bowman is a retired pediatric pulmonologist who has spent his career caring for children with chronic lung disease. His key areas of asthma effort include dealing with schools and sports homes and environmental issues addressing. Ethnic barriers and disparities, as well as issues of health literacy. Doctor Bowman is a passionate educator and he has been active in the South Carolina Asthma Alliance as well as the Association of Asthma Educators. He has long worked with Allergy & Asthma Network for many years in order to achieve a greater impact in the fight against asthma. We are so grateful to have both. Doctor freak. And Doctor Bowman with us today. So here is how we will spend the balance of our time together, as we always do. I will begin by giving the current state of COVID-19 and then I will turn it over to Doctor Parikh for a discussion around vaccines and current studies. As we conclude our time together, Doctor Bowman will highlight asthma and COVID-19 care and education at appropriate literacy levels. So let’s get started with our program. First, we’d like to always, we always, like to know who’s with us. So we will launch our very first poll of the day. If you could please respond which category best describes you, physician, physician, assistant, nurse practitioner, nurse, school nurse, respiratory therapist, asthma educator, health educator or patient and caregiver. We know that as we enter into these summer months, and many people are traveling and we have fewer here on the line today. But we’re so grateful that each of you have just chosen to join us and that we do have this multidisciplinary group on the line. And again, we value your time and really appreciate your interest, continued interest and the topics that we are offering through this COVID-19 webinar series. It just a minute longer looks like we’ve got most of our attendees registering their response. Close the poll and share. So again, we do have about 5 % PA’s nurse practitioners, 48 % nurses, school nurses, 43 % respiratory therapist, asthma educators, health educators and 5 % patients and caregivers. So a very diverse group. And again, we know that this will be a robust discussion around health literacy and education at COVID-19 Again, remember to please put your questions in the box at any time. We’ll get to as many as we possibly can. Throughout the program. So let’s look at our current state of COVID-19 We always like to begin by taking a look at the Johns Hopkins COVID-19 dashboard. Here you/we can again follow the case rates by country, by region, the continent, but also look directly at the 28 day trends in each of those especially here in the US and So what you can see is that we do have over 537 million cases total and unfortunately over 6 3 million deaths total. We are still seeing those 28 day case rates in a pretty high level at 14 million over fourteen million and the 28 day death toll rate still at 40,000, greater than forty thousand. Now, the good news is, again, we’ve got lots of shots and arms with that total vaccination doses administered and we’re still seeing vaccination doses administered. But we need to continue those vigilant efforts to ensure that everyone has not only their first two doses, but also their boosters along the way as is advised by the public health authorities. Now when we look at the CDC and specifically the current cases of COVID-19 in the US, again the darker the coloring of blue, the more evident those current cases of COVID-19 are. So we see a little bit of different clustering at this point in the early summer of 2022 Certainly the West Coast where I happened to be today, California is that darker blue as well as Florida and then certain portions of the country are in those darker blue areas as well and interestingly enough we’re still seeing both Hawaii and Puerto Rico as well as Alaska with high rates of COVID-19 at this point also. And when we look at the headlines, listen to the news, what is taking the forefront, certainly that latest coronavirus wave that has affected most of the US is showing signs of improvement in the Northeast. But we do have reports of more than 29,000 that were hospitalized with covid COVID-19 in the country and this is an increase of 16 % over the last two weeks and more than 3000 of those were patients who required intensive care. And so it seems that you know, we thought maybe we were turning a corner where we would see fewer more severe cases of acute COVID and yet unfortunately that trend is not bearing to be the case. So we’re still seeing an increase in cases across the country and that still a significant number of ICU cases now in the Northeastern states hospitalizations have begun to decline and in Vermont in fact. Numbers have dropped by more than 40 % just in these last weeks, but they are continuing to decline over 20 % in Massachusetts and roughly 10 % in the northeast of Maine, Connecticut, New York. Now all the other regions across the country seem to have this rise in hospitalizations and specifically the southern states of Alabama and my home state of Louisiana, where unfortunately hospitalizations have risen by at least. 70 % in the last 30 days. So we’re seeing that these pockets really are very evident in different parts of the country and the experience that you may be having is very different based off of where you are. Also in the news, we did have note from the FDA advisors, they voted last Wednesday to recommend authorizing both Moderna and Pfizer COVID-19 vaccines for young children for that under five age group. So this is one of the big hurdles, the final hurdles that we need to get our youngest Americans vaccinated and we will definitely continue to talk about this in upcoming section and in upcoming webinars as well. Now there was a very interesting study that came out over the last couple of weeks that says that dogs can actually detect COVID with high accuracy even in asymptomatic cases. So even in individuals who aren’t necessarily demonstrating symptoms of COVID-19 dogs can be trained to detect COVID. And this particular study accurately identified 97 % of positive cases. After the dog sniffed the human sweat samples so it actually made them more sensitive than some of the rapid antigen tests that are on the market, I just a really fascinating thought of how attuned and astute are our pets may be to recognizing and detecting COVID-19 Now again we like to look at these daily trends in COVID-19 cases over the course of time. We can go back to January of 2020 and see again that was when really SARS could be two was just coming into the US we were just beginning to recognize COVID-19 as a pandemic and then we have those very high peaks of late 2020 and even greater peaks in early 2020 Too, but where we are here in the mid year of 2022 you can see is mirroring around August of last year and certainly just shy of the peaks of the November 2020 So still pretty high case rates in looking at those daily trends of COVID-19 cases across the US according to the CDC. Now when we look at the hospitalization and death numbers coming out of CDC, again, you can see that these are better data points at this particular moment in time. So many home COVID tests are now being done. And so oftentimes we’re not getting the full picture right. So death rates seem to have sort of leveled off hospitalizations as we said going up, but the total number of cases may not be fully reflected. Because we’ve got a lot of home testing that doesn’t go into the national database and then get pulled up to the CDC or to the Johns Hopkins database. So let’s go to our next poll question. Have you personally been vaccinated for COVID-19 We’ll go ahead and launch that poll, yes, no or yes with all available boosters. So you may just choose one of those that best identifies you, and we’ll see how our audience stacks up today comparative to the national scene on vaccination 30. Give it just another moment. And we’ll close the poll and share the results. So it looks like that greater than half of our audience today has been vaccinated with all of their boosters. And then another 46 %, almost half have been vaccinated but not with all boosters. And then we’ve got 2 % on the line that had not been vaccinated for one reason or another. So thank you all for sharing. We, you know, like to continue to collect this data because it is evolving each and every month and this is the current recommendations and scenarios. Are evolving and so it’s helpful for us to track this over the course of time. So now I am going to turn it over to Doctor Parikh and she is going to give us our update on vaccines and current studies. Doctor Parikh, thank you very much, and I personally can attest through my own practice that COVID cases for sure are not going away and they’ve been rising. In fact, in the last two months I’ve prescribed the COVID antivirals almost every day or every other day. So I think a lot of it is related to the lifting a lot of the mask mandates and restrictions. So again, please be careful, especially if you’re high risk and consider continuing to mask and take those precautions because. They are seeing a lot of cases. Luckily many are out in the outpatient setting. But you never know, you know how this virus will behave in any given individual. So with that, I’ll just get started. So you know, Speaking of the CDC COVID-19 vaccination info. So to date it is quite, you know, his moment in history over seven hundred fifty six million vaccines have been distributed of those close to. 591,000 have been administered and 221.5  million people are fully vaccinated, which is just amazing if you think about what a testament that is to you know when people work together and modern science and 104.5 million have one booster dose and 16 6 million have now received their second booster dose. Next slide. So this is a great map that kind of goes through the vaccine coverage in the US and the Center for Disease Control and Prevention provides it. I think it’s helpful especially as we come to summer travel months. If you’re curious as to where if some you might be traveling to visit friends or family, you should know what’s going on in that local region because then it may change what activities you partake in you know if you want to be more aggressive with masking in those areas but. As you can see, you know, the darker the green, the better the vaccination coverage is in that given area. So it’s just a good idea. So i’m glad to see mostly green, but you know, I would love to see the whole country, that very dark Forest Green. So the big news in this past week for vaccines for kids ages 5 and under, you know, many parents have been waiting for a very long time to get this, you know, because many of us have had the huge sigh of relief, you know, December 2020 January 2021 But these young children have not had that respite. So many people have still been living how we were living in the first year of the pandemic. You know, it’s just very stressful if you remember. So the FDA committee, Umm, just yesterday recommended two vaccines for children 5 and under, one with Moderna, one with Pfizer. The key difference is the dosing. So they’re both for age, six months to four years for Pfizer and six months to five years for Moderna. But Modernas is only two doses, and it’s a higher dose than Pfizer. It’s 25 micrograms, whereas Pfizers is 3 micrograms and three doses are required, and the Vaccine Committee even mentioned that. You know the two dose, one is important especially for children because you know it is hard enough to get kids, you know, one dose of something. So if we were able to fully vaccinate someone in two doses, that’s a big benefit, you know, and for that reason Moderna may show that the full vaccination is reached faster because after two doses of Pfizer, it wasn’t fully protective without that third dose. So these are just things to keep in mind if you’re timing things for your children. And then the other thing is we don’t know long term. Like boosters will be needed for children and how often. But of course that will understand us as the vaccines get rolled out and we study them. And again, this isn’t the final sign off to administer the shots. The votes will now go, you know, through another process on Tuesday and then we’ll go to the FDA to give the official emergency use authorization before they’re widely available in pharmacies. But this is an important first step. And then of course, the final sign off is from the CDC director and then the arm. The shots are available in arms, thighs, wherever you’d like them. So a much needed and a sigh of relief for many parents who’ve been anxiously waiting for this next slide. So vaccine effectiveness, now this is a question that comes up a lot you know and it’s hard because we’re kind of studying effectiveness real time. So that can change and it also changes variance come up and other factors come into play. But basically a recent study did show in January 2022 that the effectiveness of the three vaccines.  That meaning, the first two and the boosters declined after the Delta variant became very prominent predominance. Sorry, but the effectiveness against hospitalizations remained high and that includes severe COVID-19 and death from COVID-19 with modest declines in limited to Pfizer and Moderna recipients in 65 and up. So this is important because often, you know, the naysayers will say, oh, but if it declines, why should I get it? Because it’s still going to save your life. It’s still going to keep you out of the hospital. And you know, to be honest over time, as I’m hoping more of. Our community becomes vaccinated and more of us are exposed to different variants. That efficacy should only improve, you know, so it’s still in everybody’s best interest to be vaccinated. So this kind of, just kind of, reaffirms what we already suspected. Now the effectiveness with the Omicron variant. Umm, what we were, what we found in recent studies is that you know, there are the primary immunizations with the 1st 2 doses of either the adenovirus vaccines, meaning AstraZeneca or Johnson and Johnson or Pfizer provided very limited protection against symptomatic disease caused by the Omicron variant. But I will say even though it was limited against the symptomatic disease, I still believe they even just the two first two doses. Are very effective still against death and hospitalizations especially in younger healthier populations, but a booster substantially increased the protection that and that may also wane over time. But one criticism I have of a lot of these studies is that I feel not enough is looked into the actual T cell. So everybody is focused on these antibodies that may wane over time. But what other studies have shown is that two shots, the T cells still did very well. And newer variants and of course with three shots even better. And T cells are our cells that our bodies use that are very important in fighting off viruses. So actually I think these vaccines are even more effective than we think. But by all means, you know, when we’re in a public health crisis, we want to be overly cautious, right? So that’s why 3rd and fourth boosters are recommended, especially for our most high risk individuals and now in the pediatric population. The conclusion? Was, you know, in age 5 to 11 that the COVID-19 vaccine regimen consisting of two ten microgram doses twenty one days apart was found to be safe, immunogenic and very efficacious. You know, so now of course it’s a little bit different for the under five age group, but we’ll hopefully have data on that soon as that vaccine rollout occurs. Next slide. So the fourth dose of you know, Moderna, Pfizer nationwide setting. So the fourth dose the conclusion was as you know we had mentioned before, it’s very effective in reducing the short term risk of COVID-19 related outcomes and symptomatic disease in those individuals who have received a third dose at least four months earlier. And the timing is important because there is something that occurs in your immune system if you get doses too close together because often people ask me well you know. And I just keep getting boosters every month, every two months. And that’s actually a bad idea because if your immune system sees something too regularly, it becomes too used to it. And then we want the immune system to have those gaps of at least four months, six months. So then when they get the vaccine again, that immune response is that much more robust and stronger and longer acting. So it is important that people follow the recommendations that are set forth by these committees. So, oh, sorry yeah thank you, doctor. Erika, I’m going to turn it over to Doctor Bowman here for our next section. But really appreciate those overviews of the most recent studies and data specifically around the COVID vaccine and the boosters. You know, we get that same question quite frequently about is it better just to maybe get it every month or every six weeks or every two months and so your reiteration of just. Following the recommendation for that guidance and waiting on the recommended time of you know is very well heated and appreciative. All right. So next we’re going to go to Doctor Bowman and he is actually going to be presenting his slides. So let me do one quick thing here. I will make him the presenter and we will welcome Doctor Bowman now.

Speaker 1    24:12

Ok. I appreciate very much the opportunity to talk to you all today. It’s a great privilege. And my topic is going to be a little bit off the usual track for talking about asthma management because it’s not going to be talking about specific medications and that sort of thing, but it’s talking about the underpinnings of how we get what we want to get to a patient. Actually into the patient. So let’s start talking about adult literacy. And the Barbara Bush Foundation has recently put out an annual report that shows that a hundred thirty million or 54 %  of seventy four year olds only read at a level of sixth grade or less, and 40 to 60 million read below the 3rd grade level. And I was just blown away when I learned that number. They also estimate of getting everyone’s literacy up just to a sixth grade level would probably generate something like two trillion dollars per year in the GNP. It’s clear that there is a family impact on younger generations for literacy or problems with literacy, because kids develop with parents who talk to them, read to them, encourage homework and that sort of thing. So the family impact is hopefully something we can improve now for future benefits. There’s also the workability that the Barbara Bush Foundation also estimates that 75 % of future jobs will require digital literacy, which we’ll talk about in a few minutes. But overall, work inability and inability to hold jobs is tied to severe economic disadvantage. There is also the concept of numeracy, which means understanding basic math functions, and that is generally developed in the sixth grade eighth grade sort of area. And so both numeracy and literacy are important issues in terms of who knows how much to stay employed. So what is personal health literacy? Well, it’s as you can see here, it’s the degree to which individuals have the ability to find, understand and use information and services to inform health related decisions and actions for themselves and others. So you have to be able to understand and then utilize, not just recite the words, but interpret and utilize the information. So what are some of the problems or determinants related to health literacy? It requires 2 people. The speaker, the listener, and frequently other folks. It’s important to realize that when two people who work together or are dealing with the same care, patient care, if they are saying the same concepts but with different words, that can be very confusing to people who aren’t literate or are less than outstanding in their understanding and generally. And as you know, when you’ve dealt with patients who are uncertain about what is going on, very often if someone gets a new medication and in the pharmacy, if they don’t really know that it’s the right one, rather than ask about it, they just won’t take it. And so very often the discrepancies in terms of what people are being told lead to inaction. And very often for asthma care. We want action and not inaction as you would expect body language. Can be good or bad in terms of how it impacts things, and then there are a variety of situations that can impact effective communication. It’s said that even PhD educated adults who are likely, are in a setting, and they receive the diagnosis of cancer, they hear nothing from the rest of the communication, so it’s not all related to educational level. So it’s interesting. There was healthy people 2020 and now there is healthy people 2030 And one of the things that healthy people 2030 added was organizational health literacy. And so it relates to how an organization equips its people, its customers, its patients to get and understand and utilize the information they’re trying to pass along. Because again, the people who are receiving the information have to make decisions, and we realize that shared decision making is now a key feature of healthcare in the United States. And it’s also worth recognizing that technological approaches are being used increasingly. And so the access for the community to digital and technological things is extremely important, and that is. Far worse than we might expect. What’s impaired or limited health literacy? We’re going to talk about that for the next several slides. It’s the failure to understand what’s being communicated in a particular healthcare setting, and it’s not totally dependent on education level. It has a relationship, but not totally. As I mentioned, the stress of a situation can totally overwhelm what someone might be able to understand if they’re just sitting calmly talking with someone. It’s very common and it occurs in a variety of settings, especially with respect to patients with asthma. It occurs in the emergency department. So as we’ll talk a little bit more, the emergency department is not a place to do much education and impaired health literacy is related to literacy in general and also to the social determinants of health. But it’s not all that we need to have pharmacies. Who are cognizant and other social service providers being cognizant of needing to address limited health literacy? So why is it so important? Well, patients and families need to understand communications in order to participate in the decisions and to do what we ask. They also have to understand in order to ask appropriate questions that we need to be able to answer. We need them to have the ability to carry out instructions and that depends upon understanding. You know, asthma care is complex. It must be repeated many times. If you add in COVID instructions or information that makes it even more challenging. There are multiple child care providers for every youngster at least and they haven’t been to clinic and so the effectiveness that we have in educating  our people who are the parents who come to clinic, that’s the highest point of understanding that we’re going to get because they have to be the ones to explain to grandparents, babysitters, non custodial parents, people at school what’s going on and why. So we need to recognize that and then we also need to. Improve the understanding in order to improve outcomes. So who does limited health literacy affect? Well, it affects patients, but they don’t know what they have and what they’re supposed to do. So then they frequently do nothing. Or they may get so frustrated that they go to another healthcare provider. And so they may have difficulty getting where you want them to be. And there may be stops in between times. Also, medications are often similar, so we need to pay attention to that. Any healthcare setting is at risk. And it’s especially true with forms such as asthma action plans and consent forms. So when there’s ever something, whenever there’s something that needs to be read, it can be a challenge. This is well known for people who study literacy. Many patients who have difficulty understanding, they’re very reluctant to admit they don’t understand. They spend a lot of their lifetime being afraid that someone’s going to find out that they don’t understand. So we recognize that patients must understand that asthma can be modified, and frequently they don’t understand that. And so teaching them with understandable language can be. Extremely helpful because if they think that asthma was just given to them in the severity that they have and they can’t do anything about it, they’re not going to be very effective in follow-up care. So we want to avoid the go to the emergency department mentality that leads to a lot of my patients had in terms of if things weren’t going well, they didn’t think that they could do anything at home even though we tried to explain what to do and they would just go to the Ed. So there’s a concept of health literacy, universal precautions. It stems from the concept of universal precautions for infections that started in the late 1980s with HIV and the need that you need to protect yourself in any health setting. Well, health literacy universal precautions came about because you can’t tell by looking who has limited health literacy, so it’s recommended that we assume that it affects everybody and to that consideration, it’s now said that only 12 % of US adults have the literacy skills to fully understand Health Communications in all settings. I find that very disappointing. And in one summation, that’s the reason for this talk today. And the rec, the health Literacy toolkit is posted at the bottom there. So literacy impairment may be only an issue in certain settings. So it may be that it’s just when they go to the primary care or to the specialist where they’re particularly worried or the pharmacist. So it’s not all the time everywhere, but it’s something we need to pay attention to. And when we’re, especially when we’re having significant education sessions, it’s helpful to have a second person involved for the family who can listen and take notes. And that allows there to be someone to answer the questions when the patient and family go home. What did they say? Well, they can actually put together a reasonable discussion. So it’s important to realize that literacy, spoken language and educational levels are separate. First of all, people vary in how they like to learn and how they best learn and understand. It can be visual, it can be written, it can be spoken, but we need to always ask their preferences. Also, Speaking of foreign language doesn’t guarantee literacy in that language. I think it took our CF clinic over five years to realize that the Spanish speaking parents of one of our patients. The mother was illiterate in Spanish. We had been dutifully giving them all of our handouts in Spanish, but she couldn’t understand those as well. She could understand spoken Spanish from her part of Mexico, but we were very ineffectual in our giving her effective education. So caregivers always have to check, did you get it? And what we’re trying to convince and we need to recognize and not criticize the patient when in certain situations. Especially stressful ones. They’re understanding is paralyzed, and it may be spotty within a communication. They may learn or understand a little bit, but not the whole picture. And as I said, the emergency department is a horrible place to try to teach about asthma. That’s why I try to coach folks to utilize what I call the 48 hours of panic after an ED visit for best teaching. I think that after families don’t have to worry about getting the car back home in the morning. Or who’s going to get the other kids to school, et cetera, if after they’ve settled down, they’re likely to interpret correctly educational episodes from their primary caregiver. And unfortunately, it seems that within two or three days that interest and the impact wane significantly. So try to be cognizant of the 48 hours of panic after an acute flare. So what is plain language? And talking about health literacy, we talk about not. Using medical jargon jargon because it’s hard for many to understand, and we say we’re supposed to speak in fourth or fifth grade level, but we don’t know what that is. When we’re trying to talk, we don’t know exactly what’s going to be interpretable. So what I recommend is don’t use 3 syllable words. It’s much easier to do when you’re in the midst of preparing or talking, communicating, and you’re preparing your next sentence, not using 3 syllables. Words are much easier to do effectively without stumbling. So we need to recommend or remember that current issues are important to what’s going on right now, but we also need to effectively convey

health concepts to our child care providers, the patients and the parents. So there’s a lot that we need to communicate very clearly. So how can an individual caregiver address limited health literacy? Well, first of all, they have to recognize the importance of clear and effective communication. It’s worth teaching both parents and children, especially for preteens and teens. Make it the teens own condition, so speak directly to him or her in order to try to get it across. Not only do we need to avoid medical jargon, but using pictures and demonstrations is extremely helpful. And then we need to use the teach back method, which is part of the health literacy universal Precautions toolkit. And by that, what we’re doing is asking folks to tell me what I just told you. So what we’re doing is we’re putting the burden on ourselves. Did I explain it well rather than on the patient? Did you understand what I said? Because very often when we ask do you have any questions, families, especially hesitant ones, will say no nothing but they didn’t understand a bit of what we said. Whereas if we as a provider or someone else in the clinic after the visit is near the end. If they say tell me what Doctor Bowman told you to do and they have no clue, then either I or the staff member can address that. So the teach back method is something that’s crucial and we need to use it in all settings including the Ed. So and to give you a couple of examples of simplifying your speech. Many situations we would say bronchospasm causes wheezing. That may not say very much and compare it to his breathing tubes closed down, which makes him make that high pitched noise when he wheezes. When he breathes out it’s slightly longer, but it’s more clear to a lot of our patients. There’s another example of triggers and irritants causing airway hyperreactivity. I have heard myself and others say that, but the alternative might be she has problems with certain things in the air that make her lungs slow down. She has to stay away from them. We want to show pictures of the medications prescribed. And then another example is her PFT show. Her FEV1 is low and she has a bronchodilator response. The resident who’s worked very hard to succeed on their pulmonary elective or their allergy elective may have done that. And yet it would be more effective to say her breathing tests show that her Airways are closed down, the albuterol opened them up so she can breathe better, and then show the flow volume curve, not just the 83 % or the 78 % predicted of the FEV1. So as I said, visual aids can be very helpful. Many inhalers look similar. So the chart from the AN when it’s updated, be sure to get it and put it in every clinic or care setting where you see patients. It’s important to point out the dose counter on each of them and also ask the patient to point to the medicines they take. I’ve had many situations where the parent will say, Oh yeah, he’s taking this or that, but yet when our nurse asks the patient to point to the medicines they take, they have no clue what our medicines look like. So it’s a check and balance situation. We need to try to put medication pictures on action plans so that providers such as grandparents or babysitters will see what medicine needs to be taken in an emergency. We need to have the patient demonstrate how they use their medicines and their devices, as well as use videos to teach techniques. And we need to do that repeatedly. As an example, I would say that no one would try to coach football or soccer with just written instructions, and I think of asthma. Techniques in a similar way. So, unfortunately, patients with limited literacy are hesitant to acknowledge the lack of understanding. They are reluctant to admit it. They are in constant fear of being discovered for not being able to understand. It can be a very important problem related to consent forms. They’re apparently people who have signed the paper, quite happily, to consent to a much great, more extensive surgical procedure than they thought they were doing. And then it affects both spoken and written communication. So we need to be cognizant of that. So how can an institution address limited health literacy? Well, first, there needs to be a commitment to establish an open shame-free, helpful environment and culture and to not have patients be told “you know, we’ve gone over this several times already”. We need to repeatedly demonstrate support for every one of our patients. We need to watch for cues that a patient is struggling with forms and then kind of sidle up on the side and say, can I help you with that? Certainly not saying, “wow, this sure is taking quite a while where we missed you”. And we need to offer and provide personal communication helpers out of the staff that are available in the setting that’s available. And then provider patience is crucial. All of our staff members should never appear exasperated with patients who are slow or hesitant or unable to understand what are the institutional benefits of this approach. While patients are more likely to return as instructed if they feel welcomed and supported, we have better outcomes. Patients are much more likely to follow instructions with better. Satisfaction will get better word of mouth recommendations and hopefully fewer lawsuits down the line. And then there should be fewer readmissions with their potential fines. So what’s digital health literacy? That’s the ability to use information and communication technologies to find, evaluate, create and communicate information. And it requires both cognitive and technical skills. It’s even now a major community issue. So digital HealthEquity is digital literacy as it is apportioned through all aspects of the population. Those who have access to the Internet have a device to access it knowledge how to use both show digital literacy. So there are three different parts that are that need to be functional. Health information is widely available on the Internet as we know, but not all of it is true and we need to help our patients when they can get on the Internet to sift out which is the valuable or the non valuable parts. Institutions depend on communication electronically with patients such as appointment reminders, results, education and overall interactions as well as. Communication and new web-based visits. So there are lots of approaches there that we need to address. Then some would ask if this is the newest social determinant of health, and I would suggest that it probably is. And I want you to be aware of the Digital Equity Act of 2021 you can find that online, and it’s a program from the federal government to encourage financially states to address broadband access throughout the whole state. And it’s worse when folks have poor digital literacy, they will probably have worse outcomes. They will be frustrated if they’re, if they sense criticism. Or I sent you that I thought you would have gotten it by now. Why are you asking me again? Those sorts of things are problematic. So what about, how does this all relate to asthma and COVID? Well, for asthma, care providers and patients have got to understand. They need to understand. What they have, what to do about it, when to come back, and especially how to treat the patient both long-term and acutely. And remember, that requires the person in clinic being able to educate and explain to other caregivers. So they must know and trust their medicines. And I would encourage that you utilize the teach back method to check that they have understood what you’ve tried to teach and explain. With respect to COVID-19 if this weren’t bad enough for just asthma, understanding COVID is tough and there’s so much misinformation out in the community online COVID-19 management prevention are just added on top of complex asthma care and understanding. And as I mentioned, there are many sources of information about COVID, so providers need to check what the patient and family have heard, what they understand, what they believe and what they do. With respect to COVID, superimposed on their asthma care and then you need to correct any misunderstandings, hopefully and easily understandable language. So our take home messages for today include to put effort into communicating effectively with everyone and it doesn’t have to take more time, but it improves quality of care, outcomes and satisfaction. It does not mean just talking louder and slower. And as I said, we shouldn’t be condescending. We need to have our patients show and tell members of our staff or ourselves what they understand and what they plan to do from every encounter we have. And then digital literacy is important for patients. We need to assess it and work statewide to improve it. Thank you very much. I really appreciate the opportunity to talk to you.

Speaker 2    48:24

Thank you, Dr. Bowman, that was fascinating, and you know, it reinforced so many things that we say commonly at Allergy & Asthma Network. And I appreciate you highlighting some of the resources and tools that we have developed to really focus on communicating these conditions in a meaningful, easy to understand format. So let’s go to our next poll question and then to your questions. So our next poll is, do you have a better understanding? About health literacy in healthcare, after this presentation, if you’ll go ahead and log in your response, I often say it really does come down to a few simple rules, like not using those 3 syllable or greater words and, you know, thinking about communicating in someone’s native language or having someone translate into that native language. Some of those things are very basic, but so very important in making sure that. We’re communicating effectively, so really appreciate everybody staying with us this afternoon and answering this final quick poll before we get to your questions and answers. Give it just another moment. I’ll close the poll and share the results look like 99 % overwhelmingly everyone says yes, they have a better understanding. So thank you so much Doctor Bowman for helping us to gain that better understanding of health literacy and healthcare at today and specifically around asthma and COVID-19 great pleasure yeah let’s go to the audience and your questions at this time. Let’s see. It looks like we have a question here from Nancy who says that she’s a school nurse in Anchorage, Alaska. So thanks for being with us Nancy, one of the local primary care practices that prescribe paxlovid did liver function tests 1st and there Nancy’s wondering if this is common practice for that antiviral. So maybe doctor Parkh, if you’ll take that one. So no, not necessarily. But if you do have a history of any issues with your liver or any, you know, reason why your liver function might be compromised, it’s not a bad idea because definitely for the kidney the dose has to be adjusted if you have any type of kidney dysfunction and for the liver, we may choose to do a different treatment option if there you do have abnormal liver function because Paxlovid is 2 medicines that are heavily metabolized by your liver, so it’s not commonly done, but if there’s a reason that it has that a doctor chooses to check it, it’s probably for good reason because the metabolism of the medicine. That’s a great response and thank you for that clarification, very helpful. Now the next question comes from Charlie who asked, would the ability to train dogs to detect COVID-19 do you feel that it would be beneficial to put those within the highest susceptibility range with a COVID service dog, perhaps our how might we go about even setting off that kind of program? Do you think that might be a way that we move forward in the future? Doctor Bowman, you want to take that one?

Speaker 1    52:02

The thing that comes to mind to me is using them in. Possibly in transportation areas they have dogs that go through sniffing for drugs, and so that’s a possibility. And another one would be utilizing them in nursing homes, having a weekly visit or something like that. One could also conceivably have one stationed at where visitors come into a hospital or an but it’s a fascinating idea that gives. Lots of chance for innovation.

Speaker 2    52:41

Yeah, I agree and I think in those high risk populations it would be a welcome addition to maybe detecting COVID and so a really interesting thought appreciate that. Now I love this next comment that comes from Tiffany here reminds us not to forget about the importance of our asthma educators in the care team. We know that these are individuals who are specifically trained with those low literacy techniques and abilities to effectively train. And communicate those individuals living with asthma specifically on self management skills and Tiffany, I know Doctor Bowman would not forget as educators and certainly we don’t because they are such a vital part of the cure team. Any follow-up comments to that Doctor Bowman?

Speaker 1    53:31

My communication, my discussion was focused on everyone who teaches. And I look, I actually had a program in our South Carolina Asthma Alliance to try to get asthma educators into virtually every pediatric office that had four or more providers. And we even made a proposal that schools have asthma educators. Among their nursing staff, so that they would have one asthma educator for about each 20 school nurses. So anyway, I totally agree that we need more educators and they are the keynote for how we teach.

Speaker 2    54:17

And I think just to add, I think to Doctor Bowman’s point, not every facility has the benefit of having an asthma educator. So all of us should be equipped to educate properly and know where the gaps may be. Absolutely. Now, the next question is a good one that I’d love for both of you to respond to because you both treat in different areas of the country. But what are some of the most common cues that you have seen that indicates someone struggling with health piracy, especially if they are that avoiding to admit it or hesitant to really admit that they’ve got those issues.

Speaker 1    54:57

Why i mentioned about taking a long time filling out consent forms, and I think that your desk staff can observe who, when someone has given their questionnaire, their pre visit questionnaire, if they’re to fill it out before them, do they go through it smoothly or do they puzzle over it, scratch their head, worry about it, and then the information from the teach back method can be just remarkably helpful.

Speaker 1    55:33

Yeah, great point, Dr. Parikh.. Yeah, I mean the one thing I would add for me, you know, all those are important and body language is also huge. Body language and facial expressions. So, well, you know, if you’re explaining something, you can usually tell pretty quickly from the look on someone’s face if they’re understanding,, you know, because there are subtle things like nodding or eye contact or you know, them asking questions. The teach back method goes into this. But you can tell a lot by facial expression. So that’s helpful. And I always ask people to repeat back what I said because sometimes I’ll speak quickly, right? And I think they heard everything, but may have only had 30 % or 50 % of it. And I think repetition is also very important because to Doctor Bowman’s point, emergency rooms are awful, you know, to teach in because people are in a stressful state. You know, they’re in kind of a crisis state. And the same thing goes even in the office. Someone’s coming in because they’re uncontrolled or flared up. Of course that’s an appropriate time to try to teach, but not everything may be absorbed, you know. So I’ll always ask. Ok, so I guess it is similar to teach back method, but you know, what did I just say? And i do reinforce it with every visit because you’re in a completely different mindset when you come back for a follow-up than for an acute visit. Really important point. Thank you so much. Doctor Parikh a comment here by Marie who reminds us that has a wonderful health literacy toolkit, a PDF that is a free download. So go to the AHRQ.Gov website and we also will share this link in our communication after today. But their health literacy toolkit is a very effective one indeed. So I think that has covered most of our questions. I want to once again thank you all for listening and participating today. I want to thank Doctor Parikh as well as. Doctor Bowman for being on this journey with us and supporting us through this time of the COVID-19 pandemic. Our next webinar is actually going to be held on June twenty second at four PM eastern, and will be by Doctor Louis Fonacier talking about new treatments in atopic dermatitis. Remember, you can always get the recordings of all of our webinars by visiting on that home page down at the bottom, you’ll see where there is a link to all of our webinars. Now as we close today’s program, please do remain on the line for just a moment and complete that evaluation form. Once again, thank you so much for joining us. We at the network really just feel so honored that you have continued to turn to us and be a part of our Community as we navigate the pandemic together. And on behalf of the staff, I just want to once again thank you and please encourage you to stay connected so that we can Breathe. Better Together as we communicate more effectively and address the unmet need and burden associated with allergies, asthma and related conditions such as COVID-19 Thank you and have a wonderful day.