Health Literacy Paul D. Smith, MD, Associate Professor University of Wisconsin Department of Family...

Health Literacy

Paul D. Smith, MD, Associate Professor

University of Wisconsin

Department of Family MedicinePaul.Smith@fammed.wisc.edu

Topics today

General health literacy information

Results of WAFP Health Literacy Survey

Communication Issues

What can you do?

Literacy skills

What is Literacy?

National Adult Literacy Survey 1992

“Using printed and written information to

function in society, to achieve one's goals,

and to develop one's knowledge and

potential.”

More than just reading grade level

Prose Literacy

Written text like instructions or newspaper article

Document literacy

Short forms or graphically displayed information

found in everyday life

Quantitative Literacy

Arithmetic using numbers imbedded in print

What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the

capacity to obtain, process, and

understand basic information and

services needed to make appropriate

decisions regarding their health.”

What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the

capacity to obtain, process, and

understand basic information and

services needed to make appropriate

decisions regarding their health.”

What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the

capacity to obtain, process, and

understand basic information and

services needed to make appropriate

decisions regarding their health.”

Real People with Real Problems

Insert video clip here

National Adult Literacy Survey

Federal survey conducted in 1992

26,000 people over age 15

Living in households and prisons

Divided into 5 levels

National Adult Literacy Survey

Level 1 – find one piece of information

Level 2 – find two related pieces of information

Level 3 – integrate multiple pieces of information

Level 4 – respond

Level 5 – analyze, formulate

National Adult Literacy Survey

Level 1 – find one piece of information

Can:

Sign name on a document

Identify a country in a short article

Total a bank deposit slip

National Adult Literacy Survey

Level 1 – find one piece of information

Cannot:

Enter information on a social security card

application

Locate an intersection on street map

Calculate the total cost on an order form

National Adult Literacy Survey

Level 2 – Find two related pieces of information

Can:

Identify YTD gross pay on a paycheck

Determine price difference between tickets for 2 shows

National Adult Literacy Survey

Level 2 – Find two related pieces of information

Cannot:

Use a bus schedule

Balance a check book

Write a short letter explaining error on a credit card bill

National Adult Literacy Survey

0

5

10

15

20

25

30

35

%

Level 1 Level 2 Level 3 Level 4 Level 5

47-51% of Americans in Levels 1 and 2

National Adult Literacy Survey

39% of Wisconsin adults in Levels 1 and 2

How Age Effects NALS Data

Adults age 60 and over

Living in households or prisons

68-80% are in Level 1 and 2

More in Level 1 and 2 with advancing age

89-99% Level 1 and 2 age 80 and over

Literacy Levels Change with Age

Level1

Level2

Level3

Level4

Level5

60-69

80 and over0

10

20

30

40

50

60

70

80Document Literacy

Literacy Levels Change with Age

Level1

Level2

Level3

Level4

Level5

60-69

80 and over0

10

20

30

40

50

60

70

80Document Literacy

80 and over

Level 1 + 2

89%

Literacy Levels Change with Age

BUT, they do not recognize their problemAge 60 and older

91% Read well or very well

88% Write well or very well

83% Do arithmetic well or very well

2003 National Assessment of Adult Literacy

Data released 12/05

~17,000 people participated

Changed reporting methodology

New Reporting Method

80% correct responses moved down to 67%

4 categories

Below basic

Basic

Intermediate

Proficient

2003 National Assessment of Adult Literacy

1992 and 2003 National Literacy data

0%10%20%30%40%50%60%70%80%90%

100%

Prose

Docum

ent

Quant

itativ

e

Proficient

Intermediate

Basic

Below Basic

2003 National Assessment of Adult Literacy

The Bottom Line

Not much change

Prose a bit worse

Document a bit better

Quantitative a bit better

Clinician Survey

16 question email survey

Sent to 411 Wisconsin family physicians

28% response rate

Impact on Quality and OutcomesImpact on Quality and OutcomesN

um

ber

of

Res

po

nd

ents

Impact Health OutcomesImpact Health Outcomes

Impact Quality of Impact Quality of CareCare

>87%>87%

Results : PrevalenceResults : Prevalence

0

10

20

30

40

>5% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Percent of Patients with Low LiteracyNu

mb

er o

f R

esp

on

ses Mean = 17.4%

NALS = 47-51%

ResultsResults

Does your clinic screen patients?

The Bottom Line

Physicians are aware of literacy impacting on health and health care

They underestimate the extent of the problem

The Impact of Low Literacy on Health

Poorer health knowledge

Poorer health status

More hospitalizations

Higher health care costs

Poorer Health Knowledge

Diabetics that know low glucose symptoms

0

20

40

60

80

100

%

inadequate adequate

50%

94%

Poorer Health Knowledge

Hypertensives that know exercise lowers BP

0

10

20

30

40

50

60

70

%

inadequate adequate

40%

68%

Poorer Health Status

Diabetics with retinopathy

0

5

10

15

20

25

30

35

40

%

inadequate adequate

36%

19%

Poorer Health Status

2923 new Medicare enrollees

Inadequate literacy had increased frequency of:

Diabetes

Hypertension

Heart failure

Arthritis

Poorer Health Status

Medical Outcomes Study (SF-36)

Inadequate literacy had

Decreased:

Physical function

Mental health

Increased

Limitations in activity due to physical health

Pain that interferes with normal work activities

More Hospitalizations

2 year hospitalization rate for patients visiting ED

0

5

10

15

20

25

30

35

%

low adequate

31%

14%

Increased Health Care Costs

Total annual Medicaid charges

0

2,000

4,000

6,000

8,000

10,000

12,000

low higher

$10,688

$2,890

Increased Health Care Costs

Based on NALS data

Majority from increased hospitalizations1998 - $73 Billion

Medicare, 28.3

Employers, 12.1

Patients, 11.5

Medicaid, 10.3

Other public, 7.6

Other private, 3.2

Reading Levels

20% of American adults read at or below the

5th grade level

Most health care materials are written above

the 10th grade level.

Low Literacy is Overlooked

Clinicians don’t ask about literacy

Some are not aware of the problem

Not sure how to ask

Not sure how to respond

Do not want to open the can of worms

Low Literacy is Overlooked

Patients do not volunteer their literacy problem

Many are ashamed

Some do not recognize their inadequate literacy

Lack of trust

The Big Secret

% of low literate adults that have not told their:

Children 52%

Friends 62%

Spouse 68%

Health care providers 75%

Co-workers 85%

More likely to have Low Literacy

Older

Immigrants

Less education

Incarceration

More likely to have Low Literacy

Non-white

Low-income

Medical Assistance

Low Literacy is Overlooked

Many Level 1 people don’t fit the stereotypes

75 % born in USA

50% are white

40% hold full or part-time jobs

Common Clues of Low Literacy

Patients say things like:

“I lost my glasses”

“I’d like to discuss this with my family”

“I have a headache now and can’t focus”

Common Clues of Low Literacy

Medication review

Looking vs reading

Unable to name med

Do not know why taking med

Do not know medication timing

Common Clues of Low Literacy

Non-compliance

Medications

Testing

Consultations

Patient Communication Processes

Patient-physician communication

Patient history

Informed consent

Medical instructions

Patient Communication Processes

Patient education materials

Prescription labeling

Patient Communication Processes

Responding to medical and insurance forms

Navigating the clinic or hospital

Verbal Communication Strategies

Whole staff must be aware and sensitive

Create a culture of helpfulness

Quiet room with minimal distractions

Front Desk/Registration

Always offer to help complete forms

Simplify registration forms

Only ask for information that you need

Verbal Communication Strategies

SLOW DOWN Simple terms

Use monosyllabic and colloquial terms Avoid or explain the medical jargon.

Begin with important information first

and limit new information.

Repeat the information/instructions

Verbal Communication Strategies

Have the patient repeat the information, use the “teach back” method.

No more than one or two instructions at a time—and check each time: “Chunks and Checks”.

Write it down.

Verbal Communication Strategies

Use models, sketches, pictures.

Give instructions to several of family members.

Consider follow up phone calls.

Written Materials- Common Mistakes

Readability level is too high

Too much detail

Hard words are not explained

Written Materials- Common Mistakes

Pictures do not reinforce the message

No examples

Written Materials

Review materials for reading level

5th – 6th grade reading level

Flesch-Kincaid grade level

Objectives

Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.

Identify people at increased risk of low literacy Acquire an understanding of specific activities they

can do to improve verbal communication with all patients, especially low literacy adults

Identify the important issues to address when developing educational documents for low literate adults

Flesch-Kincaid Grade Scale: 12

Objectives

Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.

Identify people at increased risk of low literacy Acquire an understanding of specific activities they

can do to improve verbal communication with all patients, especially low literacy adults

Identify the important issues to address when developing educational documents for low literate adults

Flesch-Kincaid Grade Scale: 12

Topics today

General health literacy information

How to recognize people with low literacy

How to improve communication

Factors to consider when creating documents

Flesch-Kincaid Grade Scale: 12

Topics today

Health literacy.

Finding people with low literacy.

How to improve communication.

How to make things easier to read.

Flesch-Kincaid Grade Scale: 7.1 (talking for communication = 5.1)

Beyond handouts

Pictures and models

Audiotapes and CDs

Videotapes and DVDs

CD-ROM

Internet

What can be done?

Raise awareness

American Medical Association Foundation

Low Health Literacy: You Can't Tell By Looking

Health Literacy: Help Your Patients Understand

Institute of Medicine

Prescription to End Confusion

What can be done?

Distribute the handouts about health literacy

resources.

Consider partnering with a local Community-

based adult literacy organization.

What can be done?

Be a patient.

Review processes

Review documents

The degree to which individuals have the capacity to obtain,

process, and understand basic information and services

needed to make appropriate decisions regarding their health.

Summary

Low literacy is a common problem.

Low literacy affects health.

Summary

Low literacy is hard to identify.

Most of our documents are written

at a reading level that is too high.

Wisconsin Literacy

Coordinating organization for community-

based adult literacy organizations

44 Organizations scattered around the state

New funding for regional facilitators

Wisconsin Literacy

www.wisconsinliteracy.org

Michele Erikson, director

608-257-1655

michele@wisconsinliteracy.org

“Action expresses priorities.”

---Mohandas Gandhi