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Health LiteracyHealth Literacy
Laura Owens, PhD, RNLaura Owens, PhD, RNDebra Walden, MNSc,RNDebra Walden, MNSc,RNArkansas State UniversityArkansas State University
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The National Literacy ActThe National Literacy Actdefines literacydefines literacy
• The ability to read, write, and speak The ability to read, write, and speak English, and compute and solve problems English, and compute and solve problems at levels of proficiency necessary to at levels of proficiency necessary to function on the job and in society, to function on the job and in society, to achieve one’s goals, and develop one’s achieve one’s goals, and develop one’s knowledge and potential.knowledge and potential.
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LiteracyLiteracy
• Using printed and written information to Using printed and written information to function in society, to achieve one’s goals, function in society, to achieve one’s goals, and to develop one’s knowledge and and to develop one’s knowledge and potential.potential.– National Adult Literacy Survey (2003) US National Adult Literacy Survey (2003) US
Department of EducationDepartment of Education
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NAALNAAL
• The National Assessment of Adult Literacy The National Assessment of Adult Literacy (NAAL) 2003 (NAAL) 2003
• Conducted by the National Center for Conducted by the National Center for Education Statistics Education Statistics
• Sample of more than 19,000 adultsSample of more than 19,000 adults
• Instruments that directly measured literacy Instruments that directly measured literacy tasks tasks
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NAALNAAL
• Three types of literacy were Three types of literacy were measured in the NAALmeasured in the NAAL
–Prose literacy Prose literacy
–Document literacyDocument literacy
–Quantitative literacyQuantitative literacy
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Prose LiteracyProse Literacy
• The knowledge and skills needed to The knowledge and skills needed to search, comprehend, & use information search, comprehend, & use information from continuous texts.from continuous texts.
• Editorials, news stories, brochures, and Editorials, news stories, brochures, and instructional materials.instructional materials.
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Document LiteracyDocument Literacy
• The knowledge and skills needed to The knowledge and skills needed to search, comprehend, & use information search, comprehend, & use information from noncontinuous texts. from noncontinuous texts.
• job applications, payroll forms, job applications, payroll forms, transportation schedules, maps, tables, & transportation schedules, maps, tables, & drug and food labels.drug and food labels.
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Quantitative literacyQuantitative literacy
• The knowledge and skills needed to The knowledge and skills needed to identify and perform computations using identify and perform computations using numbers that are embedded in printed numbers that are embedded in printed materials. materials.
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Quantitative LiteracyQuantitative Literacy
balancing a checkbookbalancing a checkbook
figuring out a tipfiguring out a tip
completing an order formcompleting an order form
determining the amount of interest on determining the amount of interest on a loan a loan
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Four literacy levelsFour literacy levels
• Assessment results were reported at four Assessment results were reported at four levelslevels
• Below BasicBelow Basic
• BasicBasic
• IntermediateIntermediate
• ProficientProficient
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Below Basic
• No more than the most simple and concrete literacy skills
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Basic
• Can perform simple and everyday literacy activities
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Intermediate
• Can perform moderately challenging literacy activities
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Proficient
• Can perform complex and challenging literacy activities
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Literacy Results Literacy Results
• 11 millions adults are could not even be 11 millions adults are could not even be tested!tested!
• 7 million adults could not answer simple 7 million adults could not answer simple test questionstest questions
• 4 millions adults could not test because of 4 millions adults could not test because of a language barriera language barrier
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Average scores of Average scores of participantsparticipants
• Prose literacy – low intermediate literacyProse literacy – low intermediate literacy
• Document literacy – low intermediate Document literacy – low intermediate literacyliteracy
• Quantitative literacy – high basic literacyQuantitative literacy – high basic literacy
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Results: Prose LiteracyResults: Prose Literacy
• Below Basic 14% or 30 millionBelow Basic 14% or 30 million• Basic 29% or 63 millionBasic 29% or 63 million• Intermediate 44% or 95 millionIntermediate 44% or 95 million• Proficient 13% or 28 millionProficient 13% or 28 million
• 43% of adult Americans cannot 43% of adult Americans cannot perform moderately challenging perform moderately challenging prose literacy activitiesprose literacy activities
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Who Has the Lowest Literacy Who Has the Lowest Literacy Level?Level?
Those who:Those who:
Have not graduated from high schoolHave not graduated from high school
Did not speak English in the home before Did not speak English in the home before starting schoolstarting school
Are Hispanic or blackAre Hispanic or black
Are over the age of 65Are over the age of 65
Have multiple disabilitiesHave multiple disabilities
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Interested in learning more?Interested in learning more?
• Other significant correlations were found in Other significant correlations were found in the NAAL related to employment, income, the NAAL related to employment, income, family and community. These can all be family and community. These can all be found at the National Center for Education found at the National Center for Education Statistics website.Statistics website.
• http://nces.ed.govhttp://nces.ed.gov
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Literacy in Arkansas Literacy in Arkansas
• More than 20% of Arkansas adults read at More than 20% of Arkansas adults read at or below a fifth-grade levelor below a fifth-grade level
• 25% do not have a high school diploma25% do not have a high school diploma• 35% of those who didn’t complete high 35% of those who didn’t complete high
school have only an 8school have only an 8thth grade education grade education• Lack of a high school diploma correlates Lack of a high school diploma correlates
with lower literacywith lower literacy– Arkansas Literacy CouncilArkansas Literacy Council
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So what does this mean for Healthcare?
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It means…. It means….
• Adults ages 65 and older have the lowest Adults ages 65 and older have the lowest average literacy scores of all age groupsaverage literacy scores of all age groups
• Average literacy increased with each Average literacy increased with each increasing level of educationincreasing level of education
• White adults had higher prose literacy White adults had higher prose literacy scores than Black and Hispanic adults for scores than Black and Hispanic adults for all levels of educationall levels of education
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Health Literacy
• The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
• Healthy People 2010
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Health Literacy
• Health literacy is the ability to apply the literacy skills needed to function fully and effectively as a patient.
• Davis et. al, 1996.
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Health literacy affects people’s ability to read:
• -patient education information• -prescription labels• -appointment cards• -consent forms
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Low health literacy affects people’s ability to:–Navigate the healthcare system, following signs and reading maps
–Share personal information with health care providers
–Understand mathematical concepts such as risk/benefit ratios
–Calculating medication dosages
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Literacy is:
•The single best predictor of health status– More than
•Age•Income•Employment status•Education level•Racial or ethnic group
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Noncompliance…
• May be due to low literacy
– Low literate persons may not take their medications correctly or at all
– Might miss appointments
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Reading Level
• Reading level is often lower than stated years of education
• Most health education materials are written at a reading level of 10th grade or above
• The average reading level of Americans is at the 7th or 8th grade level
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National Assessment of Adult Literacy: NAAL 2003
– Health literacy of adults measured for first time
– Health literacy measured by tasks usually required of adults in the healthcare system
– The health tasks measured by three NAAL scales: prose, document, and quantitative literacy
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NAAL 2003
• Tasks used to measure health literacy were organized around three domains of health –
– Clinical– Prevention– Navigation of the healthcare
system
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NAAL 2003
• Background questionnaire– General demographic and background
questions– Specific health related questions
• Health status• Preventative health practices• Health insurance coverage• Sources of information about health issues
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NAAL 2003
• Scores for health literacy were grouped in the same levels as for the general literacy– Below basic– Basic– Intermediate– Proficient
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Examples of Health Literacy Tasks: 2003
Below basic– “Circle the date of a medical
appointment on a hospital appointment slip”
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Examples of Health Literacy Tasks: 2003
Basic- “Give two reasons a person with no symptoms of a disease should be tested for a disease, based on information in a clearly written pamphlet.
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Examples of Health Literacy Tasks: 2003
• Intermediate– “Find the age range during which
children should receive a particular vaccine, using a chart that shows all the childhood vaccines and the ages the children should receive them.”
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Examples of Health Literacy Tasks: 2003
• Proficient– “Calculate an employee’s share of
health insurance costs for a year using a table that shows how the employee’s monthly cost varies depending upon income and family size.”
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Demographic Findings Related to Health Literacy
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Gender
• Women had higher health literacy scores than men
• More men (16%) had Below Basic health literacy than women (12%)
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Race and Ethnicity
• White and Asian/Pacific Islander adults had higher health literacy than Black, Hispanic, American Indian and Multiracial adults.
• Hispanic adults had lower health literacy than any other group. Black adults had the next lowest scores.
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Age
• Adults aged 65 and older had lower health literacy than any other age group.
• Fewer adults over 65 were in the intermediate and proficient categories when compared to adults from younger age groups
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Educational Attainment
• Starting with high school graduates, health literacy increased with each higher level of educational attainment.
• Never completing or attending high school is a strong predictor of below basic health literacy scores
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Poverty Threshold
• Adults living below the poverty level had lower health literacy than adults living above the poverty level.
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Overall Health
• Adults with higher literacy reported better overall health as reflected by higher scores on the “self report of health”
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Health Insurance Coverage
• Those who received health insurance coverage through their employer, the military or private insurance had higher average health literacy than those who received Medicare, Medicaid or had no health insurance.
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How People Get Health Information
• Adults with lower literacy were more likely to receive health information through radio or television than through written sources.
• Adults with higher health literacy were more likely to receive health information through written sources such as newspapers, magazines, books, brochures, or the internet.
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NAAL 2003Average Literacy Scores
• 12% had Proficient health literacy
• 53 % of adults had Intermediate health literacy
• 22% had Basic health literacy
• 14% had Below Basic health literacy
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Other Current Research Findings…
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Health Literacy & Age
• Health literacy decreases with advancing age– After age 65 studies show a decrease in health
literacy with marked declines after age 85– These studies controlled for health status,
education level, and various behavioral factors
–So….older adults have poorer health literacy
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Self-reported Poor Health
• Persons with inadequate functional health literacy were consistently more likely to report poor health than patients with adequate reading skills.
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Health Literacy & Preventative Care
• Poor health literacy is a barrier to:– Immunizations– Colorectal screening– Mammography– Digital rectal examinations– Pap smears
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Knowledge of Chronic Diseases & Other Health
Issues– Those with poorer health literacy
•have significantly less knowledge of their chronic diseases, such as hypertension, diabetes, asthma, HIV
•And less knowledge about smoking, postoperative care, contraception
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Health Literacy & Health Behaviors
• Many studies show an inverse relationship between health literacy and smoking
• Mothers with higher literacy are more likely to breastfeed
• Many studies show a relationship between health literacy and adherence to HIV regimens and control of the disease
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• Diabetic patients with higher health literacy are more likely to have better glycemic control and have fewer complications of diabetes
• Mother’s literacy predicts child’s diabetic control
• Low literacy negatively effects cancer incidence, mortality, and quality of life
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Health Literacy & The Health Care System
• Patients with low literacy – Have more emergency room visits– Make more clinic visits– Are hospitalized more often
– A documented financial burden on the system
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In Summary…
• Low health literacy affects all areas of health– Prevention and screening activities– Treatment of illness– Management of chronic disease– Knowledge of chronic disease
* So the lower the literacy level, the poorer the outcome…
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Assessment and Interventions
• We know there is a problem….so
• How do we find these people? And…
• How do we help them?
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Screening Tools for Clinical Practice
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The REALM
• Rapid Estimation of Adult Literacy in Medicine (REALM)
• Instrument that utilizes word recognition and pronunciation to assess health literacy
• Quick and reliable method to estimate grade level reading ability
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Newest Vital Sign (NVS)
• Three minute instrument
• Nutrition label that is accompanied by six questions
• Patients with four correct responses are unlikely to have low literacy
• Reliable and accurate measure of literacy in the clinical setting
• Available in both Spanish and English versions.
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Identifying Persons with Low Literacy
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What You Might See…
• Non-compliance with medications or treatment regimen
• Missed appointments and lack of follow-through with tests or referrals
• Filling out forms incompletely or incorrectly
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What You Might See….
• Difficulty navigating their environment
• Unable to name medications or explain their purpose
• Identifying medications by color or shape rather than by name
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How To Begin The Discussion…
Be compassionate and empatheticBe aware of the shame of low literacyAvoid closed ended questions such as: “Can you read this?” or “Do you have
difficulty reading?” Instead ask: “How happy are you with the way that
you read?”
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Things to Remember
• Asking about grade completed in school only gives a limited picture of literacy
• Offer assistance with reading or completing forms by saying:“Filling out these forms is difficult for many people, would you like some help?”
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Improving Communication with
Patients with Low Health Literacy
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How to Improve Written Communication with Low
Literacy Patients
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Instructions: Making Them Easy to Read
• Use conversational tone– You and we– Use plain language not jargon
•“Drugs to treat cancer” vs. Chemotherapy
•“Pain killer” vs. Analgesic•“Get bigger” vs. Enlarge•“Not cancer” vs. Benign
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Instructions: Making Them Easier
• Demonstrate how to take needed action
• Provide visual step-by-step diagrams
• Be specific in instructions– Take two pills each day, once in
the morning, once in the evening.• 6th grade reading level
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Instructions: Making Them Easier
• Evaluate the patient’s level of understanding
• ‘Can you tell me what you are supposed to do?’
• Provide in multiple languages• Train staff to provide assistance
when completing forms
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General Principles Related to Written Material
• Limit message to a few key points• Present information concretely
– Put pills in a pill box…
• Repeat most important points• Content should be age and culturally
appropriate• No higher than 5th grade reading level
– 3rd for limited literacy populations
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General Principles
• Add simple line drawings to illustrate a point
• Avoid complex diagrams with unnecessary detail
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General Principles: Fonts
• Use large type font – At least 12pt
• Limit the number of font styles used– Use a font with serifs to improve readability
• Avoid ALL CAPITOL LETTERS
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General Principles: Layout
• Use headings and bullets• Avoid long sentences• Leave white space• Use captions to highlight
information
Key Information
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• Your nacicsyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.
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How to Improve Verbal Communication with Low
Literacy Patients
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Verbal Communication
• Listen to the client• Speak slowly• Sit during the meeting rather than
stand• Ask patient to explain their
understanding of the medical condition and treatment– Use the “teach back” method
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Verbal Communication
• Create opportunities for discussion• Encourage a list of questions and
concerns– Many older adults will not
question a health professional– Ask, “What questions do you
have?” not “Do you have any questions?”
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Verbal Communication
• Use plain language– “‘Living room” language
• Use orienting statements– “‘Now we will talk about your high
blood pressure”
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Verbal Communication
• Limit information at each meeting• Stress the most important point
– “Your blood pressure is too high and you need to start taking medicine to lower your blood pressure”
– Information about hypertension physiology, complications…should be discussed later.
• Always review important points!
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Verbal Communication
• Use or draw a picture to illustrate a point– Simple line drawing is best– Avoid adding details that are irrelevant
• Use with verbal and written explanation not as a substitute
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Verbal Communication
• Verify understanding of material– “Some people get dizzy taking this
medicine. If that happens to you what will you do?”
– Ask patient to explain or demonstrate what they have learned.
• Summarize the points made during the teaching session
• Conclude with what the patient can expect next
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Strategies Helpful for Older Adults with Low
Literacy
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Teaching Strategies for Older Adults
• Scheduling issues– Timed when energy level is high– Brief ‘mini-sessions’ as opposed to 1 hour
• Relate new information to past experience– Use stories to connect information in a
personal way
• Present information 1 step at a time– Omit unnecessary information
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Strategies for Working with Older Adults
• Create a supportive environment– Welcome patients with attitude of helpfulness – Provide assistance with paperwork and
insurance issues– Provide a quiet place to talk and ask questions– Use straight back chairs– Have a person, not a machine answer the
phone– Ask them to bring in all medicines to the first
visit
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Strategies for Working With Older Adults
Supportive Environments:– Use large, easy to follow signs– Provide directions or guide to find
unfamiliar locations– Provide assistance with scheduling
return or referral appointments– Consider visual and hearing impairment
in addition to literacy concern
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Alternative Teaching Methods
• Audiotapes and CD• CD-ROM instruction• Interactive CD-ROM and Internet• www.usability.gov for resources
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Thank You!
