Kay Hogan Smith, MLS, MPH

Health Literacy & Provider Communication

Conflict of Interest

• The presenter has no conflicts of interest involved in the information provided.

Health Literacy - Objectives

• Demonstrate a basic understanding of key health literacy concepts

• Identify the impacts of low health literacy• Identify tools to assess health literacy• Discuss strategies and resources for improving

health literacy• Demonstrate how providers can address

health literacy issues in practice

Health Literacy: Definition

How well a person can:

Read Understand Act

National Library of Medicine - “the ability to read, understand, and act on health information.”

Affordable Care Act - "the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate

health decisions."

*Problem-solving in technology-rich environments scale has 4 levels

Newest Assessment of Adult Literacy - PIAAC

• Initial data published in October 2013, statistics from 2012; supplemental data focusing on older US adults to be released soon.

• Besides literacy, measures numeracy and “problem solving in technology-rich environments” in US and other countries

• Scored on 4-5 levels* (from lowest to highest):– Below Level 1– Level 1– Level 2– Level 3– Level 4/5

US Results from Program for the International Assessment of Adult (16-65) Competencies 2012

– Literacy Scale

12%

36%34%

14%4%

Level 4/5Level 3Level 2Level 1Below Level 1

US Results from Program for the International Assessment of Adult (16-65) Competencies 2012

– Numeracy Scale

9%

27%

34%

20%

10%

Level 4/5Level 3Level 2Level 1Below Level 1

*Level 3 is the highest proficiency level for this scale.

US Results from Program for the International Assessment of Adult (16-65) Competencies 2012 –

Problem-Solving in Technology-Rich Environment Scale

6%

33%

41%

20%

Level 3Level 2Level 1Below Level 1

What Is It Like to Be a “Level 1” or Below Reader?

Health Literacy - Everyday Examples

Causal Relationship b/w Health Literacy and Outcomes

Paasche-Orlow and Wolf, 2007. American Journal of Health Behavior

• Limited general knowledge• Do not ask for clarification• Focus on details, hard to get them to prioritize• Don’t understand “simple” math• Essential vocabulary only• Check answers without understanding

What Happens When People with Limited Literacy Have to Deal with a Health Issue?

Limited Health Literacy Leads to…

• Underutilization of services• Increased medication errors• Poor understanding of health• Increased hospitalizations• Poor health outcomes• Increased healthcare costs

Health Literacy Is Needed for:

• Pill bottles• Appointment slips• Informed consents• Discharge instructions• Health education

materials• Insurance applications• Etc…

• Informal• Word pronunciation tests• Cloze method• Newest Vital Sign• Question: "How confident are you in filling out

medical forms by yourself?"

Methods of Assessing Health Literacy

Davis TC, Kennan E, Gazmararian J, Williams MV. Literacy Testing in Health Care Research. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago: AMA Press; 2004.

• Years of education (except at extremes)• Race• Income• Age• Reliance on self-disclosure

Less effective methods of health literacy assessment

How Do You Know If Someone Has Limited Literacy? (Informal Means)

• Fills out intake forms incompletely– “I forgot my glasses”– “Let me bring this home so I can discuss it with my

children.”– “My hand hurts too much to write”

• Misspelling many words• Gets angry about forms• Identifies medication by looking at pill rather

than reading the labelWeiss BD. Health literacy: a manual for clinicians. 2003

Word Pronunciation Tests

• Rapid Estimate of Adult Literacy in Medicine (REALM)– Word recognition and pronunciation

• Wide Range Achievement Test (WRAT)– Word recognition and pronunciation

Cloze Method

• Test of Functional Health Literacy in Adults (TOFHLA)• Allows students to "intelligently guess" and fill in

missing words from a written passage.• Tests reading comprehension using skills like:

– Background knowledge– Context cues– Semantics– Syntax– General understanding of material– Grammar skills

Your doctor has sent you to have a _________ X-ray.

a. stomachb. diabetesc. stitchesd. germs

You must have an ________ stomach when you come in for ___.

a. asthmab. emptyc. incestd. anemia

a. isb. amc. ifd. it

Sample TOFHLA Reading Comprehension (Cloze method)

Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

Newest Vital Sign

• Sensitive topic• May offend some• If it is seen as a “test” it can be threatening• Patients hide low literacy• Inappropriate labeling• Time

Problems with Measuring Literacy

Finding & Creating Easy to Read Materials (and Other Health Literacy Resources)

Handout

Barriers to Self Care

• Economic• Language - limited English proficiency• Healthcare system - insurance, appointment,

signage• Activities of daily living• Access to information• Provider/patient communication

Provider/Patient Communications

AMA Health Literacy Video – Communication Skills for Practitioners

University of Michigan School of Dentistry

Effective Communication

• Provider initiates introductions• Provides empathy and support• Uses effective non-verbal communication• Avoids the use of jargon• Confirms diagnosis and explores patient’s

understanding of it

Strategies for Clear Communication for Providers and Staff

• Whole staff must be aware and sensitive• Assess baseline understanding• Explain things clearly using plain language• Start with most important information first and

limit new information• Effectively encourage patients to ask questions• Use teach-back to confirm understanding• Provide useful educational materials• Repeat important points

More Clear Communication for Providers and Facilities

Symbols and Signage

Health Care Symbols & Signage

• Symbols & signage needed for -– Navigational aids (complex healthcare system)– Patient education– Labels

Symbols and Rx Labels

• Labels are seemingly simple but not necessarily clear.

• Mistakes are more likely the more medication a patient takes.

• Ability to read a Rx label does not guarantee ability to understand and act.

Prescription Drug Warning Labels

• What does this picture mean?– “Someone swallowed a

nickel”– “Indigestion”– “Bladder”– “Looks like a ghost –

Casper”

Wolf MS, Davis TC, Tilson HH, et al. Am J Health-Syst Pharm (2006) 63:1048–55Terry C. Davis, Michael S. Wolf, et al. J Gen Intern Med. 2006 Aug;21(8):847-51.

Prescription Drug Warning Labels

• Does adding words help?– “Chew pill and crush

before swallowing”– “Chew it up so it will

dissolve, don’t swallow it whole or you might choke.”

– “Just for your stomach”

47% of patients with low literacy understood these instructions

Prescription Drug Warning Labels

• What does this picture mean?– “Somebody is dizzy”– “Don’t touch this stuff”– “Take anywhere”– “Chills or shaking”– “Having an experience

with God”

Prescription Drug Warning Labels

• “Use extreme caution in how you take it”

• “Medicine will make you feel dizzy

• “Take only if you need it”

Directional Signs

Ambulatory Entrance

Hospital XYZ

Some people become confused about whether this entry was intended for ambulances or for patients

Ambulatory Entrance

The use of visuals clarify the message

Contrast in color makes it easy to read

Try to be consistent when hanging signs

Approaches to Address Health Literacy

• System vs. personal approaches (or both)• Literacy assessment tools• Finding easy to read materials (handout)• Health care provider approaches – e.g., teach-

back method, creating shame-free environment, etc.

• Health care symbols and signage• Remember to involve your local librarian!

Health-Literate Care: A Patient’s Experience.

Koh H K et al. Health Aff 2012;31:434-443

©2012 by Project HOPE - The People-to-People Health Foundation, Inc.

Questions?