Health Literacy

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Health Literacy

• Lisa Littman, MD, MPH
• Christina Zarcadoolas, PhD
• Mount Sinai School of Medicine
• Dept. of Community and Preventive Medicine

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• What is health literacy?
• Why is low health literacy a problem?
• What can we do to help?

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What is health literacy?

• The wide range of skills, and competencies that
  people develop over their lifetimes to seek out,
  comprehend, evaluate, and use health information
  and concepts to make informed choices, reduce
  health risks, and increase quality of life.
• (Zarcadoolas, Pleasant Greer, 2003 2006)

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Approximately half of the adults in the US
read at 8th grade level and lower.Half have Low
Health Literacy.(1993 2003)
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Fundamental Literacy

• Reading
• Writing
• Speaking
• Numeracy

The Language of Health Environment
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Who are they ? (Kirshner et al. National Adult
Literacy Study. 1993.)

• From all socio-economic groups
• Low-income and ethnic minority
• 45 of all functionally illiterate adults live
  below the poverty line.
• eg., ½ adults in Central Harlem have not
  completed HS
• Elderly
• 66 of U.S. adults aged 60 and over have either
  inadequate or marginal literacy skills. ( note
  doesnt include hearing loss/cognitive def. )

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One Third Of Medicare Managed Care Enrollees Had
Low Literacy

Gazmarian et al. JAMA 99.
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Implications Public health

• A study of Medicaid participants found that those
  reading at the lowest grade levels had average
  annual health care costs of roughly 13,000
  compared with the average for the population
  studied of 3,000 (Weiss, 1999).
• The National Academy on an Aging Society (1998)
  estimated that excess health care costs generated
  by patients with inadequate health literacy
  (primarily from extra and longer
  hospitalizations) is 73 billion dollars per year.

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Changing health literacy environment

• Complex health system
• Complex and changing science
• increased need for self-management
• conflicting media reports about health hazards
• misconceptions about communicable diseases such
  as smallpox, anthrax, and SARS
• direct-to-consumer advertising about new drugs
  and
• vast amounts of health information available on
  the Internet.

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Implications of Low Health Literacy

• Report poorer overall health
• Less likely to make use of screening and
  preventive services
• Present in later stages of disease
• Are more likely to be hospitalized
• Have poorer understanding of treatment and their
  own health
• Have lower adherence to medical regimens

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The Cost

• 1.5 million people in the United States are
  harmed by preventable drug errors each year
• Treatment of drug-related injuries adds at least
  3.5 billion annually, not counting indirect
  costs such as lost income and ancillary health
  and home care services. (IOM 2006)
• Low Health Literacy 70 billion yrly. (The
  National Academy on an Aging Society 1998)

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Prescription Errors

• 5 common prescriptions - 2/3 mostly low-income
  patients of mixed literacy could read the
  wording, but only 1/3 knew what to do next
• patients with the highest literacy levels erred
  from 5 to 27 of the time
• 70.7 of patients with low literacy correctly
  stated the instructions Take two tablets by
  mouth twice daily,' only 34.7 could demonstrate
  the number of pills to take
• (Davis, et.al., Dec. 19,2006 Annals of
  Internal Medicine)

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The problem with much health outreach /
education/ communications

• Often top down deficit model
• Rarely starts with where people are at
• Seldom mindful of fundamental literacy
• Not mindful of health environmental literacy
  principles

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A central solution fix the language and
cultural mismatch between patients and providers/
patients publics

• Easy to read
• Easy to navigate
• Linguistically appropriate
• Culturally appropriate
• Relevant

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Simplifying
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Clear language is necessary.

• But it is NOT sufficient.
• It will not solve the low health literacy
  problems in the US

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Simplifying does not necessarily lead to
improved health literacy

• A notice from a health insurer
• Due to the fact that this drug is not on our
  formulary we are denying your claim for
  reimbursement.

• Simplified
• We deny (will not pay) your claim. We are
  denying your claim because this drug is not on
  our list of approved medications.

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Health literacy demands of previous message

• The insurance company has the authority to pay or
  not pay bills they do not automatically pay for
  any service or medication, even if the doctor
  recommends it.
• Insurers use a finite (and often changing) list
  of allowable medications that they will and will
  not pay for.
• Not all medicines are the same.
• To greater or lesser degree, consumers must
  understand that they can
• request an appeal,
• speak to their doctor about an alternative
  medication and treatment options,
• think about changing health plans, or even
• become an advocate for health care reform.

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What does this important health message demand of
the consumer/reader?
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Being health literate means much more than
understanding the words and sentences of health
and environmental information.

• Fundamental literacy
• Science Literacy
• Civic Literacy
• Cultural Literacy

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NSF, Public Understanding of Science

• Between 5 and 15 of the public qualify as
  scientifically literate. 
• 18 can be considered an attentive science
  public.

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Science Literacy

• Between 5 and 15 of the public qualify as
  scientifically literate. 
• 18 can be considered an attentive science
  public.
• fundamental scientific concepts, scientific
  process
• Technology technical complexity,
• scientific uncertainty and that rapid change in
  the accepted science is possible.

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Civic Literacy
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Civic Literacy

• judging the source of information
• media literacy skills
• knowledge of civic and governmental systems and
  processes
• knowledge of power, inequity
• knowledge that personal behaviors and choices
  affect others in a larger community and society

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photo caption reads Two residents wade through
chest-deep water after finding bread and soda
from a local grocery store after Hurricane
Katrina came through the area in New Orleans,
Louisiana.(AFP)
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photo caption reads A young man walks through
chest deep flood water after looting a grocery
store in New Orleans on Tuesday, Aug. 30, 2005.
Flood waters continue to rise in New Orleans
after Hurricane Katrina did extensive damage when
it made landfall on Monday. (AP )
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Cultural Literacy

• Ability to recognize, understand and use the
  collective beliefs, customs, world-view, and
  social identity
• Bilateral - experts should understand aspects of
  the culture of the recipient and visa versa.

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Percent Distribution of Foreign Bornby World
Region of Birth 2000
Other Regions 8.1
Europe 15.3
Latin America 51.0
Asia 25.5
Source Current Population Survey, March 2000,
PGP-3
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• The Sioux San Hospital of Rapid City, South
  Dakota, is an Indian Health Service (IHS)
  hospital. (Kibbe Conti,working with Lakota Indians

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What can we do to help?

• Raise awareness
• Research
• Applied use of health literacy concepts in
  creating health education materials
• Continually look for ways to improve the health
  literacy skills of the population

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Expand the focus of health literacy

• health education, medical and public health,
  nursing, pharmacy
• Mount Sinai School of Medicine MPH offers
• Health Literacy Can the public be healthy
  without it?
• Flood, Pestilence Plague Communicating Complex
  Emergencies
• Introduction to Qualitative Research Methods

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Our current health literacy research focus at
MSSM

• Health literacy and reproductive health (HPV and
  the HPV vaccine, reproductive events)
• Mental health literacy
• Health literacy of chronic disease
• Medication taking (adherence)
• Health literacy and emergency preparedness
• Health literacy and technology
• Internet
• Electronic medical records

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Research Goals

• Better understanding of the mechanisms people use
  in health literacy
• Create usable health education materials that are
  matched to the health literacy needs of our
  population. Create materials that empower
  patients to make informed decisions
• Continually look for ways to improve the health
  literacy skills of the population.

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Applied Health Literacy

• DOH Public Health Detailing Kits (obesity,
  intimate partner violence)
• Creation of an educational website about HPV and
  the HPV vaccine (in process)
• Creation of an educational website about ovarian
  cancer (in process)

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Creating information that is matched to the
health literacy needs of your population

• Identify the complexity/opportunity for health
  education using model of health literacy
• Collaborate with target audiences on designing
  needed information/approaches
• Qualitatively field test material/communication
• Revise, contextualize, reinforce messages using
  combination of communication models diffusion,
  social marketing, decision making, etc.
• Evaluate and be ready to revise on an ongoing
  basis

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1.Know your audience

• the audience you have (or might)
• the audience you want
• collaborate with them to develop messages
  and materials

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2. Know your material

• the text you have
• the text you need

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3. Conduct a Health Literacy Load Analysis

• What does the material/message assume/require of
  the patient
• Fundamental literacy
• Science literacy
• Civic literacy
• Cultural literacy

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Health Literacy Load Analysis

• Is the message/material to inform and/or educate?
• Is it intended to produce action or change of
  behavior?
• What medium/technology will be used?
• How culturally appropriate is this message?
• Who is it tailored to?
• What does it require the target audience to
  understand about health / health concepts?
• Is the message reinforced?
• Are the action steps clear?

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Using health literacy domains to develop PH
Detailing kits for the NYC Dept. of Health
Mental Hygiene

• Christina Zarcadoolas, PhD., Joslyn Levy, MPH,
  Michelle Dresser, MPH., Yvette Sealy, PhD., MPH,
  Lisa Littman, MD. MPH., Diego Ponieman, MD.,
  Shiu May Young,MPH, Kelly Larson MPH

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Public Health Detailing

• Modeled after pharmaceutical sales approach
• Selling public health interventions
• Brief, one-on-one interactions with health care
  providers
• Total office call

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www.nyc.gov/health/publichealthdetailing
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Action Kits

• Clinical Tools
• Providers Resources
• Patient Education
• Guidelines
• Other
• Medications
• Health Bulletins
• Incentives (pens, post-it pads)

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Strategy for Kit Material

• Use health literacy domains salient to the
  audience science, civic, cultural
• Use social marketing to make messages noticeable
• Repeat core messages across materials
• Strive for shared decision making empowerment
• Repeat and reinforce messages across materials

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Goal

• In creating materials matched to the health
  literacy needs of the target population (patients
  and providers) we strive to create health
  materials that are usable, understandable,
  readable, compelling

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Applying the domains of health literacy

• Fundamental literacy
• Science literacy
• Civic literacy
• Cultural literacy
• (Zarcadoolas, Pleasant Greer, Advancing Health
  Literacy A Framework for Understanding and
  Action, 2006)

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Research Methods Qualitative, Ethnographic/Discou
rse Analysis

• For the obesity action kit
• 12 provider in-depth interviews
• 12 frontline staff interviews
• 6 focus groups
• 32 English speakers
• 30 Spanish speakers
• 62 individuals (overweight)

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Providers

• They needed new ways to talk about obesity
• Coaching scripts give ways to frame the
  discussion
• Verbal strategies to connect with patients
  health literacy and build commitment

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Consumers

• Felt some messages were like listening to a
  broken record.
• Frustrated
• Needed hope and motivation
• Needed concrete and do-able actions
• Some messages were more compelling than others

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Cultural literacy

• As African Americans, we use food also to be
  hospitable. If I know youre coming over we want
  to cook the collard greens, the macaroni and
  cheese. You have a turkey. You have a ham. You
  have this. You have that. And the same thing
  in our church, every Sunday you go downstairs and
  you see it, you smell it, and youre going to eat
  it.

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Social Equity / Civic Literacy

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Fried chicken and a bottle of Henessey

• Within a span of one block we have McDonalds,
  Taco Belleasier on us to
• This is basically my block(our visual)
• Today you have a choice of greasy and greasier
• They take food stamps, debit cards. That just
  draws them in. The parents will say heres the
  card, now go get dinner. And thats what they
  bring home.

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Place health issue in social context
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Present evidence in accessible novel way
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• Collaborative decision making and disease
  management
• Targeted, cooperative conversations

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Wrapping Up our method of materials development
Collaborate - participatory action research Learn
from and with target audiences Use the language /
discourse of the audience Frame issue based on
their needs, attitudes and perceptions Develop
specific messages focusing on salient domains of
health literacy
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Summary

• What is Health Literacy?
• Why is low health literacy a problem?
• What can we do to help?

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What is health literacy?

• The wide range of skills, and competencies that
  people develop over their lifetimes to seek out,
  comprehend, evaluate, and use health information
  and concepts to make informed choices, reduce
  health risks, and increase quality of life.
• (Zarcadoolas, Pleasant Greer, 2003 2006)

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Why is low health literacy a problem?

• Patients with low health literacy are more likely
  to report poorer health overall, less likely to
  use screening and preventive services, present in
  later stages of disease, are more likely to be
  hospitalized, have poorer understanding of
  treatment and their own health, and have lower
  adherence to medical treatments

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Why is low health literacy a problem?

• Our current social environment contains many
  obstacles to understanding and using health
  information and requires increasing levels of
  health literacy to make informed decisions.

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What can we do to help?

• Understand that this is a significant issue and
  be aware.
• Check for patient understanding, dont assume.
• Simpler language is necessary but not enough.
• Use and create health materials, messages and
  communications that are informed by health
  literacy principles.
• There is a need for continued research in health
  literacy to gain better understanding of the
  mechanisms people use and ways to build upon
  strengths.

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• Lisa.Littman_at_mssm.edu
• Mount Sinai School of Medicine
• Dept. of Community and Preventive Medicine
• Dept of Obstetrics, Gynecology, Reproductive
  Science