Health Literacy

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Health Literacy

• Paul D. Smith, MD, Associate Professor
• University of Wisconsin
• Department of Family Medicine
• Paul.Smith_at_fammed.wisc.edu

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Topics today

• General health literacy information
• Results of WAFP Health Literacy Survey
• Communication Issues
• What can you do?

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Literacy skills
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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.

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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

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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.

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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.

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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.

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Real People with Real Problems

• Insert video clip here

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National Adult Literacy Survey

• Federal survey conducted in 1992
• 26,000 people over age 15
• Living in households and prisons
• Divided into 5 levels

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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

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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

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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

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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

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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

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National Adult Literacy Survey
47-51 of Americans in Levels 1 and 2
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National Adult Literacy Survey
39 of Wisconsin adults in Levels 1 and 2
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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

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Literacy Levels Change with Age
Document Literacy
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Literacy Levels Change with Age
80 and over Level 1 2 89
Document Literacy
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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

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2003 National Assessment of Adult Literacy

• Data released 12/05
• 17,000 people participated
• Changed reporting methodology

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New Reporting Method

• 80 correct responses moved down to 67
• 4 categories
• Below basic
• Basic
• Intermediate
• Proficient

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2003 National Assessment of Adult Literacy
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2003 National Assessment of Adult Literacy

• The Bottom Line
• Not much change
• Prose a bit worse
• Document a bit better
• Quantitative a bit better

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Clinician Survey

• 16 question email survey
• Sent to 411 Wisconsin family physicians
• 28 response rate

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Impact on Quality and Outcomes
gt87
Number of Respondents
Impact Health Outcomes
Impact Quality of Care
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Results Prevalence
Mean 17.4
NALS 47-51
Number of Responses
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Results
Does your clinic screen patients?
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The Bottom Line

• Physicians are aware of literacy impacting on
  health and health care
• They underestimate the extent of the problem

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The Impact of Low Literacy on Health

• Poorer health knowledge
• Poorer health status
• More hospitalizations
• Higher health care costs

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Poorer Health Knowledge
Diabetics that know low glucose symptoms
94
50
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Poorer Health Knowledge
Hypertensives that know exercise lowers BP
68
40
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Poorer Health Status
Diabetics with retinopathy
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Poorer Health Status

• 2923 new Medicare enrollees
• Inadequate literacy had increased frequency of
• Diabetes
• Hypertension
• Heart failure
• Arthritis

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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

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More Hospitalizations
2 year hospitalization rate for patients visiting
ED
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14
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Increased Health Care Costs
Total annual Medicaid charges
10,688
2,890
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Increased Health Care Costs
Based on NALS data Majority from increased
hospitalizations
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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.

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Low Literacy is Overlooked

• Clinicians dont 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

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Low Literacy is Overlooked

• Patients do not volunteer their literacy problem
• Many are ashamed
• Some do not recognize their inadequate literacy
• Lack of trust

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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
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More likely to have Low Literacy

• Older
• Immigrants
• Less education
• Incarceration

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More likely to have Low Literacy

• Non-white
• Low-income
• Medical Assistance

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Low Literacy is Overlooked

• Many Level 1 people dont fit the stereotypes
• 75 born in USA
• 50 are white
• 40 hold full or part-time jobs

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Common Clues of Low Literacy

• Patients say things like
• I lost my glasses
• Id like to discuss this with my family
• I have a headache now and cant focus

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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

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Common Clues of Low Literacy

• Non-compliance
• Medications
• Testing
• Consultations

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Patient Communication Processes

• Patient-physician communication
• Patient history
• Informed consent
• Medical instructions

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Patient Communication Processes

• Patient education materials
• Prescription labeling

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Patient Communication Processes

• Responding to medical and insurance forms
• Navigating the clinic or hospital

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Verbal Communication Strategies

• Whole staff must be aware and sensitive
• Create a culture of helpfulness
• Quiet room with minimal distractions

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Front Desk/Registration

• Always offer to help complete forms
• Simplify registration forms
• Only ask for information that you need

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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

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Verbal Communication Strategies

• Have the patient repeat the information, use the
  teach back method.
• No more than one or two instructions at a
  timeand check each time Chunks and
  Checks.
• Write it down.

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Verbal Communication Strategies

• Use models, sketches, pictures.
• Give instructions to several of family members.
• Consider follow up phone calls.

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Written Materials- Common Mistakes

• Readability level is too high
• Too much detail
• Hard words are not explained

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Written Materials- Common Mistakes

• Pictures do not reinforce the message
• No examples

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Written Materials

• Review materials for reading level
• 5th 6th grade reading level
• Flesch-Kincaid grade level

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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

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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

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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

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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)

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Beyond handouts

• Pictures and models
• Audiotapes and CDs
• Videotapes and DVDs
• CD-ROM
• Internet

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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

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What can be done?

• Distribute the handouts about health literacy
  resources.
• Consider partnering with a local Community-based
  adult literacy organization.

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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.

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Summary

• Low literacy is a common problem.
• Low literacy affects health.

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Summary

• Low literacy is hard to identify.
• Most of our documents are written at a reading
  level that is too high.

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Wisconsin Literacy

• Coordinating organization for community-based
  adult literacy organizations
• 44 Organizations scattered around the state
• New funding for regional facilitators

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Wisconsin Literacy

• www.wisconsinliteracy.org
• Michele Erikson, director
• 608-257-1655
• michele_at_wisconsinliteracy.org

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• Action expresses priorities.
• ---Mohandas Gandhi
  

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