Taking Action on Health LiteracyCPD Session 5th December 2011Alastair Pringle, Head of Patient Focus & Equalities, SGKate Burton, Public Health Practitioner, NHS Lothian Catriona Carson, Health Improvement Lead for Literacies, NHS Greater Glasgow and Clyde

todayBackgroundThe theory - CatrionaThe practice - KateWhat next?

backgroundHealth Improvement & Patient Focus get our heads together we know there is a problem.Scoping Study 2008/9 recommends focus on the practical integration of the ideas underpinning health literacy into existing programmes, projects and initiatives 2 SeminarsQuality Strategy 2010 commitment to Improve resources to support better health literacy. Resources on Medicines, TeachBack & (NES) Workforce Development Self-Management Establishment of National Literacy Action Group

Health literacyTheory, models, approachesThe impact of limited literacy skills on health has been well documented, giving rise to a new field of study termed health literacy. Wolf (2008)

What is health literacy? In short:the ability to access, understand, and use information for health

Nutbeam (2000)

Unpacking this:What is the relationship between literacy and health literacy?What is the focus of research in related fields?What approaches are employed in tackling health literacy?

Understanding literacy Nutbeam:Literacy can be measured in absolute terms (distinguishing between those who can read and write basic texts and those who cant); In relative terms by assessing the skill differences between adults who are able to perform relatively challenging literacy tasks and those who are not. Literacies are context and content specific e.g. health literacyWhat is the relationship between literacy and health literacy?

Nutbeams model of health literacyFunctional literacy: basic literacy skills to function effectively with regards to health and knowledgeInteractive health literacy: independently obtain relevant health information, derive meaning, and apply information to health circumstances. Critical health literacy: ability to use information to exert greater control over life events and situationsWhat is the relationship between literacy and health literacy?

What is the focus of research in related fields? Links between literacy and health outcomes:Demands of the healthcare system including self-managementInequalities: the lives of those with limited literacy skills Health literacy as a public health outcome i.e. education approaches

Health literacy population surveysNational Consumer Council survey among 2,000 adults (2004). One in five people had problems with the basic skills needed to understand simple information that could lead to better health.Poorer sections of the community were less likely to seek information or help for health problems. Focus of research in related fields: The evidence

Literacy population surveysFindings from the Scottish Survey of Adult Literacies 2009:26.7 per cent may face occasional challenges and constrained opportunities. Within this, 3.6 per cent face serious challenges in their literacy practices.People who score lowest in all three categories are considerably more likely to be 56-65.People from the 15% most deprived areas tend to have lower scores. Focus of research in related fields: The evidence

Self-management of long term conditionsSchillinger et al (2002) found: Diabetic retinopathy36% of patients with low health literacy 19% of those with adequate skills. Optimal blood sugar control 20% of patients with low health literacy 33% of those with adequate skills.Focus of research in related fields: The evidence

Self-management of long term conditionsOmachi et al (paper in preparation):Independent of race, income, and educational attainment, poor health literacy is associated with greater COPD severity and general health status... Attention to health literacy has the potential to improve COPD self-management.Focus of research in related fields: The evidence

Self-reported health and health-related behaviour Poor physical and mental well-being is associated with poor literacy and/or numeracy.Men with lower literacy levels who drank alcohol were also more likely to consume a higher number of units than those with good skills.They were more likely to smoke cigarettes.New Light on Literacy and Numeracy in ScotlandFocus of research in related fields: The evidence

Health improvement interventions Huizinga (2009): Lower literacy skills were associated with less accuracy with poor portion-size estimation skills. Opportunities may exist to improve portion-size estimation by addressing literacy.Focus of research in related fields: The evidence

Medicine and adherence Wolf et al (2007) found that 46% of patients misunderstood one or more dosage instructions. Patients with low literacy were less able to understand instructions compared to those with adequate literacy. Focus of research in related fields: The evidence

Measuring low literacy and low health literacyHealth literacy-related test instruments e.g Newest Vital Sign, REALM, s-TOFHLA Testing of literacy skillsAssessment/self-assessment based on literacy-related practices e.g. the single item screener: How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

Focus of research in related fields: The evidence

The impact of communication interventionsFor example, Ask Me 3 What is my main problem? What do I need to do? Why is it important for me to do this?

Galliher et al 2010: no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. No evidence of better adherence to prescription medications or lifestyle recommendations.Focus of research in related fields: The evidence

What approaches are adopted in tackling the issue?Programmes of work to address inequalitiesRudd:Improve the literacy skills of the publicImprove the communications skills of health care staffRecalibrate the norm and identify literacy barriersLower demandsRemove barriersWhat approaches are adopted in tackling the issue?

Health literacy as an outcomeEducation programmes incl. patient education for long term conditionsPublic information and campaignsAccessible information policy and practiceCommunication interventions

What approaches are adopted in tackling the issue?

A dual focusWeiss et al (2006)RCT with patients assigned either to an intervention group that receiving standard depression treatment plus literacy education control group received standard depression treatment At final follow up depression severity was lower in intervention groupLiteracy skills improved and their depression severity lessened.What approaches are adopted in tackling the issue?

I never knew help was out there until I was asked no one had ever asked me before

Woman aged 57, referred to adult literacy learning through Keep Well programme

Health Literacy is....A critical empowerment strategy to increase peoples control over their health, their ability to seek out information and their ability to take responsibility.

Bumpstart Aim - to improve health outcomes for pregnant women and their familiesTarget pregnant women in North EdinburghDevelopment partnership, funding, time and assessment

Health Literacy InterventionsParent education classesTier 1 Mums Pregnancy PlannerMums ClubsTier 2 Pregnancy CafeTier 3 1:1 literacy support

Health Literacy InterventionsParent education classesTier 1 Mums ClubsMums Pregnancy PlannerTier 2 Pregnancy CafeTier 3 1:1 literacy support

Health Literacy InterventionsParent education classesTier 1 Mums Pregnancy PlannerMums ClubsTier 2 Pregnancy CafeTier 3 1:1 literacy support

How can you identify who has low health literacy?Sorry I forgot my glassesIll take it home to readForms incorrectly completedFrequently missed appointmentsNon-compliance with treatment or medication regimes

Health Literacy InterventionsParent education classesTier 1 Mums Pregnancy PlannerMums ClubsTier 2 Pregnancy CafeTier 3 1:1 literacy support

Kates experience of Bumpstart

Communication & Health Literacy

The biggest problem in communication is the illusion that it has taken place.George Bernard Shaw

Communication strategies for improving health literacy

Ask if they understandDraw picturesGo over and repeat the information several timesWrite it down for themGive them a leaflet or suggest a useful website

Teach-back technique

The only way to know for sure is to ask!Asking patients to explain or demonstrate in their own words what they need to know or doNot a test for the patientChance to check for understanding and re-teaching if necessary

Teachback evidencePatient safety Surgical informed consentChronic disease managementAsthma

Edinburgh GP using teach-backI told a patient to have a blood test in 1 week andphone 3 days later for the test results. I said if theblood results were worse, I would see him thatweek, if not, I would see him in a month. He toldme he understood, but when I did teach-back hethought he had to see me in a week and get theblood test in a month.

Teach-back saves time in the longer term as it reduces unnecessary follow up appointments, medication and treatment errors. Ive recommended it to all my GP colleagues in the practice.

Thank you!Kate BurtonKate.burton@nhslothian.scot.nhs.uk

What nextNational Health Literacy Group high impact interventionsWhat do you think will make the biggest difference?

Reference: M.S. Wolf, R.M. Parker, S.C. Ratzan. Literacy and Public Health. International Encyclopedia of Public Health, 2008, Pages 98-104 Nutbeam D. (2000). Health literacy as public health goal: a challenge for contemporary health education and communications strategies into the 21st century. Health Promotion International, Vol. 15, no. 3. Nutbeam D. (2000), Health literacy as public health goal: a challenge for contemporary health education and communications strategies into the 21st century, Health Promotion International, Vol. 15, no. 3. Sihota, S. & Lennard, L. (2004) Health Literacy: being able to make the most of health. London: National Consumer Council. Schillinger et al. 2002. Association of Health Literacy With Diabetes Outcomes. Association of Health Literacy With Diabetes Outcomes. Journal of the American Medical Association. Vol. 288:pp.475-482. Omachi T, Sarkar U, Yelin EH, Blanc, PD, Katz PP. 2011. Lower Health Literacy Among COPD Patients Is Associated With Poorer COPD Functional Outcomes And Greater Risk Of COPD-Related Emergency Utilization, paper in preparation, abstract shared in June 2011. Scottish Government. 2008. New Light on Adult Literacy and Numeracy in Scotland.Huizinga MM, Carlisle AJ, Cavanaugh KL, Davis DL, Gregory RP, Schlundt DG, Rothman RL. 2009. Literacy, Numeracy, and Portion-Size Estimation Skills. American Journal of Preventive Medicine, 36(4):324328). Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, Clayman M, Parker RM. 2007. To err is human: Patient misinterpretations of prescription drug label instructions, Patient Education and Counseling, 67, 293300. ++ information relating to Bailey, Wolf et al Comparison of Handwritten and Electronically Generated Prescription Drug Instructions Ann Pharmacother January 2009 43:151 taken from Wolf presentationNewest Vital Sign: REALMA-TOFHLAAnn Fam Med Patients Question-Asking Behavior During Primary Care Visits: A Report From the AAFP National Research NetworkRudd, from various presentationsWeiss BD, Francis L, Senf JH, Heist K, and Hargraves R. 2006. Literacy Education as Treatment for Depression in Patients with Limited Literacy and Depression: A Randomized Controlled Trial, J Gen Intern Med. August; 21(8): 823828.