Health Literacy June 10

HEALTH LITERACY:Costs, Consequences,

and Clinical Implications

Peggy Sissel-Phelan, Ed.D.

Community Health Centers of Arkansas Annual ConferenceJune 14 – 15, 2010

Defining LiteracyAn individual’s ability to read, write, and speak English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.

Workforce Investment Act (1998)

The ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential.

National Assessment of Adult Literacy (2003)

Historic Perspectives Multiple meanings Changing measures

20th Century Changes 1900 – 1950’s . . . . . . . . Industrialization 1960’s . . . . . . . . . . . . . . Space race 1970’s . . . . . . . . . . . . . . International development 1980’s . . . . . . . . . . . . . . Technological advancement 1990’s . . . . . . . . . . . . . . Globalization

Literacy Needs in Context

Assessing Literacy

2003

National Assessment of Adult Literacy

(NAAL)

19,000 adults ages 16+

107 incarcerated

1992

National Adult Literacy Survey

(NALS)

16,000 adults ages 16+

1,000 incarcerated

Methodology NAAL

Tested literacy tasks Prose, Document, and

Quantitative 5 reading skill levels

Below Basic Basic Intermediate Proficient Not literate in English

Health Literacy Component

NALSTested literacy tasks Prose, Document, and

Quantitative 5 reading skill

levels Level 1 – approx. 1st grade Level 2 – approx. 4th

grade Level 3 – approx. 8th

grade Level 4 – approx 12th

grade Level 5 - College

Results 2003 NAAL

14% Below Basic

29% Basic

43% at Basic or Belowplus

5% not literate in English

=97 million U.S. adults

1992 NALS

23% Level 1

28% Level 2

51% at Level 1 or 2

=90 million U.S. adults

State by State Extrapolation

1992 NALS results synthesized with 1990 census data

Late 90’s Findings Released State Congressional District County City

Arkansas

NALS and Communities

Note:

Level 1 equates to about 1st grade reading skills

Estimated Adults at Level 2 Literacy Skills or Below

Number of Counties

n = 3

n = 8

n = 19

n = 29

n = 12

n = 3

43-45% 46-51% 52-59% 60-69% 70-79% 80-89%

Note:

Level 2 equates to about 4th grade reading skills

Percentage of Adults in Arkansas Towns at Level 2 or Below 30-39%

40-49%

50-59%

60-69%

70-79%

FayettevilleSherwood

Arkadelphia Bentonville Conway Fort SmithJacksonville Jonesboro

Benton MagnoliaN. Little RockParagouldVan Buren

BlythevilleCamdenEl DoradoHot Springs

Forrest CityPine Bluff

Little Rock Rogers RussellvilleSearcySpringdale

StuttgartTexarkanaW. Memphis

Literacy Across Generations: Arkansas

Percent100

908070605040302010

0

Children

Parents/Adults

Children whose parents have low literacy skills are more likely to become adults with low literacy skills than children whose parents are good readers.

Thomas Sticht, 2002

Below or Below Basic Literacy Skills

Basic or Below BasicParents/Adults 8th Graders City

32% 34% Fayetteville

44% 37% Bentonville

48% 40% Springdale

42% 46% Conway

44% 50% Jonesboro

42% 57% Rogers

46 % 55% Searcy

50 % 58% Benton

49 % 61% Arkadelphia

Note: Parents data derived from National Adult Literacy Survey, 1992Students data derived from National Assessment of Educational Progress, 2002


Basic or Below Basic

Parents/Adults 8th Graders City

46 % 70% Little Rock

59% 58% Magnolia

58% 68% Paragould

54% 77% North Little Rock

63% 69% El Dorado

64% 70% Blytheville

62% 83% Texarkana

71% 92% Pine Bluff

78% 90% Forrest City


Almost half of U.S. adults lack the basic skills needed to function successfully in society.

These Adults Can Not: Find which foods contain a specific vitamin Identify a specific location on a map Use fractions Interpret a growth chart or table

Functional illiteracy impedes health and economic well-being.

Practical Implications

Perspectives ofHealth Literacy

Levels of Literacy Skills & Health?

Levels of Understanding & Health?

Chronic

Acute

Systemic

Preventative

Perspectives ofHealth Literacy

Levels of Literacy Skills & Health?Chronic – persistent in daily livingSystemic – resistance and culture of medical

settings

Levels of Understanding & Health? Acute – situationalPreventative - cultural

Defining Health Literacy

The ability to read and comprehend prescription bottles,

appointment slips, and the other essential health-related

materials required to successfully function as a

patient.

(AMA Council of Scientific Affairs, 2000)

The degree to which individuals have the capacity to

obtain, process, and understand basic health

information and services needed to make appropriate

health decisions. (Ratzan and Parker, 2000)

ROLELEVELACTIONEXPECTATION

Defining Health LiteracyThe ability to read, understand, and act on health care

information.

(Healthy People 2010, US Department of Health and Human Services,

Office of Disease Prevention and Health Promotion, 2000, )

The ability to use printed and written information associated

with a broad range of health-related tasks to accomplish one’s

goals at home, in the workplace, and in the community (including

health care settings).

(NAAL, 2003)

ROLE LEVELACTIONEXPECTATION


Health literacy allows the public and personnel working in

all health-related contexts to find, understand, evaluate,

communicate, and use information. Health literacy is the

use of a wide range of skills that improve the ability of

people to act on information in order to live healthier lives.

These skills include reading, writing, listening, speaking,

numeracy, and critical analysis, as well as

communication and interaction skills. (Calgary Charter on Health Literacy, 2008)

ROLE ROLELEVELACTIONEXPECTATION


Health literacy allows the public and personnel working in all

health-related contexts to find, understand, evaluate,

communicate, and use information. Health literacy is the use of a

wide range of skills that improve the ability of people to act on

information in order to live healthier lives. These skills include

reading, writing, listening, speaking, numeracy, and critical

analysis, as well as communication and interaction skills. (Calgary Charter on Health Literacy, 2008)

* The interconnected expectation of improving ability to act as a result of being health

literate does not address key resource and access issues (distance, price, cultural

norms, living conditions, personal constraints)



Health literacy allows the public and personnel working in all

health-related contexts to find, understand, evaluate,

communicate, and use information. Health literacy is the use of a

wide range of skills that improve the ability of people to act on

information in order to live healthier lives. These skills include

reading, writing, listening, speaking, numeracy, and critical

analysis, as well as communication and interaction skills. (Calgary Charter on Health Literacy, 2008)

* Not simply being acted upon as the subject of care, but empowering individuals to

address their own, and others’ health as a “partner” with health care providers and

systems.


Changes in Care 35 yrs. ago Today

Treatment of Acute 4 - 6 weeks bed 2-4 days Myocardial Infarction rest in hospital in hospital

# Prescription Drugs 650 10,000 +

on the market

Treatment of new 3 weeks +/- outpatient onset Diabetes in hospital classes 0-3 hrs.

2 hours a day of diabetic classes

Health Literacy Needs in Context

Source: Balydon, Glusman, and Sharkey-Asner, 2009For Reach Out and Read Illinois

NAAL Health Literacy Component Health literacy and relationship to

prose, document, and quantitative skill.

Address deficiencies in health literacy skills○ Policies○ Programs○ Development of appropriate health

information


NAALData on target audiences Relationship between health

literacy and ○ educational attainment○ age○ race/ethnicity ○ where adults get information about

health issues, and ○ health insurance coverage



Question types

ClinicalNavigationPreventive

Assessment MethodsPerform a task (circle word)Decode words (read instructions)Locate words or section (review and respond)Interpret (infer applicability)

Elements of Health Literacy

Accessing health care system Levels of existing health information Locating information Understanding rights/responsibilities Decoding information Making inferences about care needs Carrying out directives Formulating questions Interpreting Oral information

NAAL Results

Reports poor health 1 or more disabilities No health insurance or Medicaid Fewer preventive health

measures Lower Educational Achievement Gets no health information from

the Internet

Low Health Literacy: Social Characteristics

NAAL Results

Poverty Racial and ethnic minorities English as a Second Language Single Parent Families Older adults Prison inmates

Low Health Literacy: Social Characteristics

Consequences of Low Literacy

Access

Misunderstanding Diagnosis

Unable to Read Patient Education

Materials

Understanding and Following Health

Related Instructions, compliance issues

Low Literacy Affects Access

Locating, obtaining, navigatingie: 84% of Medicaid patients do not

understand rules and regulations of the application form

Adhering to and accepting careWhile still in the clinic 26% did not

understand when return appointment was scheduled

Cultural and beliefs stress no need for care

Feelings of rejection, abuse, by health care staff

Consequences of Low Literacy

Medication Errors

Poor Outcomes

2 x more likely to be hospitalized

Higher rates of medication and treatment

errors

Link: Low literacy, poor health, and early

deathRelated factors: housing, diet, addiction, violence

Costs $38 -53 billion in unnecessary

costs annually (Center for Health Care Strategies,

Inc, 2001)

$73 billion (Friedland, Georgetown University, 2003)

$106-$236 billion (Vernon, University of

Connecticut, 2007)

Medical costs for adults with low literacy skills are four times the national average - $21,760.

You Can’t Always Tell

In the Below Basic Literacy Group

37% have a HS or some college education

52% speak only English 54% have no physical or mental

disabilities

Kutner M et al, Nat Center for Educ Statistics 2005

The Stigma

Patients who have never told: %

Supervisor 91%Spouse 68%Children 53%Anyone 19%

Parikh N, et al., Patient Educ Couns, 1996.

How Does It Feel?The following passage simulates

what a reader with below basic general literacy sees on the printed page.

Read the entire passage out loud.

You have 1 minute to read.

Hint: The words are written backwards and the first word is “cleaning”

How Does It Feel?GNINAELC – Ot erussa hgih ecnamrofrep,

yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-red edixo selcitrap. Esu a nottoc baws denetsiom htiw lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.

How Does It Feel? How do you clean the capstan?

Red Flags: What to Look for

Unable to name medications, or explain purpose or timing of administration

Difficulty explaining medical concerns Detour, letting doctor miss the concern Have no questions Incomplete registration forms Frequently missed appointments Skipped tests and referrals Non-compliant with meds

Red Flags: What to Look for

Seeking help only when illness is advanced

Walking out of the waiting room Becoming angry, demanding Clowning around, using humor Being quiet, passive Making excuses Pretending they can read

Or . . “I forgot my glasses. I’ll read

this when I get home.”

“Let me bring this home so I can discuss it with my husband.”

Strategies: Make Changes Lessen stigma: Approach all patients

the same way Be non-judgmental. There is no one correct way to ask There are natural times in the history

during which you can bring this up Never ask “do you have questions” Use, what kind of questions do you

have?

Strategies: Enhance Communication Attitude of helpfulness, caring and

respect by all staff Conduct patient-centered visits Explain things clearly in plain

language Focus on key messages and repeat Use a “teach back” or “show me”

technique to check for understanding Use patient-friendly educational materials to enhance interaction

Anti-inflammatory

Benign

Contraception

Hypertension

Oral

Echocardiogram

Stops SwellingNot CancerBirth ControlHigh BPBy MouthPicture of the heart

Strategies: Use Plain Language:

Examples

Plain Language: It’s not just medical terms!

We are disseminating information about….

We are giving out information about…

How do you administer the medication?

How do you give the medicine?

Have you ever purchased generic medications?

Do you ever buy store brand medicine?

This product has an extensive list of symptoms that it treats…

This medicine can help with many things like fever, or pain, etc….

Strategies: Use Patients’ Social History How far did you go in school? Did you ever have any difficulty in school? Has reading ever been a problem for you?

Other possible ways to ask:Have you ever had difficulty reading materials the doctor gave you?

Has a doctor ever been unclear when they explained things to you?

D.I.R.E.C.T.D- Do you have any Difficulty readingI- Are you interested in ImprovingR- We have Referrals/resources

availableE- Ask EveryoneC- This is a Common problemT- Take down the barriers to

obtaining the resources and take down current barriers to providing effective care

Source: Balydon, Glusman, and Sharkey-Asner, 2009For Reach Out and Read Illinois

Strategies: Written materials Simple words (1-2 syllables)

Short sentences (4-6 words)

Short paragraphs (2-3 sentences)

No medical jargon

Headings and bullets

Lots of white space

Strategies: Teach Back

Ask patient to demonstrate understanding

“What will you tell your spouse about your child’s condition?”

“I want to be sure I explained everything clearly, so can you please explain it back to me so I can be sure I did.”

Academic settings can use the resident or student/attending interaction to do this

Do not ask, “Do you understand?”

Strategies: Use Visuals

Show or draw simple pictures Focus only on key points Emphasize what the patient

should do Minimize information about

anatomy and physiology Be sensitive to cultural

preferences Visual aids can include

handouts, pictures, models etc.

System Change Identify patients Identify the barriers faced by

both patients and clinicians Identify and implement

strategies to enhance health literacy

Advocate for system change

ResourcesPfizer Clear Health Communication

Initiative http://www.pfizerhealthliteracy.com

NYU Patient and Family

Resource Center http://www.nyupatientlibrary.org/medcenter/build-skills

Center for Health Care Strategies Health Literacy Fact Sheets

http://www.chcs.org/publications3960/publications_show.htm?doc_id=291711

http://www.pfizerhealthliteracy.com/

http://www.nyupatientlibrary.org/medcenter/build-skills



ResourcesInstitute for Healthcare

Advancementwww.iha4health.orgMichael Villaire, MSLMDirector, Programs and [email protected](800) 434-4633 x202

American Medical AssociationHealth Literacy Program and Kitwww. ama-assn.org

http://www.iha4health.org/

http://www.ama-assn.org/

ResourcesCommunicating Health Information. Editorial.

Critical Care Nurse. 2004;24: 8-13http://ccn.aacnjournals.org/cgi/content/full/24/4/8

Assessing the Nation’s Health Literacy:Key Concepts and Findings of the National Assessment of Adult Literacy (NAAL)

Sheida White, PhDNational Center for Education Statistics

A Publication of the American Medical Association Foundation “Help Your Patients Understand.” Video Available from AMA Foundation

http://www.ama-assn.org/ama/pub/category/8035.html

http://ccn.aacnjournals.org/cgi/content/full/24/4/8

http://www.ama-assn.org/ama/pub/category/8035.html

Documents

Health Literacy June 10