Download Health Literacy: Practical Tools for Improving Communication

Health Literacy
Paul D. Smith, MD, Associate Professor
University of Wisconsin
Department of Family Medicine
[email protected]
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
47-51% of Americans in Levels 1 and 2
35
30
25
20
%
15
10
5
0
Level 1
Level 2
Level 3
Level 4
Level 5
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
80
Document
Literacy
70
60
50
40
30
20
10
0
80 and over
Level Level
Level Level
1
Level
2
3
4
5
60-69
Literacy Levels Change with Age
80
80 and over
70
Level 1 + 2
60
89%
Document
Literacy
50
40
30
20
10
0
80 and over
Level Level
Level Level
1
Level
2
3
4
5
60-69
Literacy Levels Change with Age
BUT, they do not recognize their problem
Age 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
Proficient
Intermediate
Basic
at
ive
Q
ua
nt
it
en
t
Below Basic
Do
cu
m
Pr
os
e
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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
Number of Respondents
Impact on Quality and Outcomes
50
>87%
40
30
20
Impact Health
Outcomes
10
0
Don't
Know
Minimal
Some
Impact
Impact Quality of
Care
Moderate
Impact
Major
Impact
Number of Responses
Results : Prevalence
40
30
Mean = 17.4%
NALS = 47-51%
20
10
0
>5% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Percent of Patients with Low Literacy
Results
Does your clinic screen patients?
Screening Patients
Don't Know
4%
Yes
7%
No
89%
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
94%
100
80
50%
60
%
40
20
0
inadequate
adequate
Poorer Health Knowledge
Hypertensives that know exercise lowers BP
68%
70
60
40%
50
%
40
30
20
10
0
inadequate
adequate
Poorer Health Status
Diabetics with retinopathy
36%
40
35
19%
30
25
% 20
15
10
5
0
inadequate
adequate
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
31%
35
30
14%
25
%
20
15
10
5
0
low
adequate
Increased Health Care Costs
Total annual Medicaid charges
$10,688
12,000
10,000
8,000
6,000
$2,890
4,000
2,000
0
low
higher
Increased Health Care Costs
Based on NALS data
Majority from increased hospitalizations
1998 - $73 Billion
Other private,
3.2
Other public,
7.6
Medicare, 28.3
Medicaid, 10.3
Patients, 11.5
Employers,
12.1
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

[email protected]
“Action expresses priorities.”
---Mohandas Gandhi