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Health Literacy: Helping Patients Get the Message


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Title: Health Literacy: Helping Patients Get the Message

Health LiteracyHelping Patients Get the Message
  • Professor Pamela Zarkowski, JD, MPH
  • University of Detroit Mercy
  • Dental Continuing Education
  • June 19. 2013

(No Transcript)
  • Take two tablets on an empty stomach
  • Take a tablet by mouth twice each day
  • Two tablets twice daily- (two tablets a day)

Consider Literacy
  • Literacy in Context
  • Time and Place
  • Circumstances
  • Background
  • Speaker/writer
  • Listener/reader
  • Culture
  • Speaker/writer
  • Listener/reader
  • 5 Core Skills of
  • Literacy
  • Reading
  • Prose
  • Documents
  • Writing
  • Numeracy
  • The Oral Exchange
  • Speaking
  • Listening

Literacy Skills for the 21st Century
  • Literacy influences ones ability to access
    information and to navigate the highly literate
    environments of modern society

  • Most health care materials are written at a
    10th-grade level or higher.
  • Most adults read between the 8th and 9th grade
  • Approximately one half of adults are unable to
    understand printed health care material, and
    approximately 90 million adults have fair to poor
  • Twenty-one to 23 percent of adults read at the
    lowest reading level, approximately fifth-grade
    or lower.
  • For patients whose primary language is not
    English, the problem is compounded.
  • A survey of patients at two hospitals revealed
    that 35 percent of English-speaking patients and
    62 percent of Spanish-speaking patients had fair
    to poor health literacy.

Changing Concept
  • At first, health literacy was considered to be a
    characteristic of the individual. Increasingly,
    researchers and practitioners are looking at both
    sides of the coin the provider and the patient.
  • Health literacy is a shared function of social
    and individual factors.
  • Health and Human Services, Communicating Health,
    2003. Institute of Medicine Health Literacy A
    Prescription to End Confusion, 2004
  • Health Literacy is an interaction
  • Institute of Medicine Health Literacy A
    Prescription to End Confusion, 2004

What Can we Do?
  • Change the Skill Side
  • Improve literacy skills of the public
  • Improve communication skills of professionals
  • Change the Demand Side
  • Recalibrate the norm and identify literacy
  • Lower demands
  • Remove barriers

Professional Concern
  • Health Literacy in Dentistry
  • Strategic Action Plan
  • 2010-2015
  • Vision
  • The Council and its ad hoc advisory committee on
    health literacy in dentistry share a vision that
    dentists and dental team members, and the ADA and
    related health organizations, will use and
    promote clear, accurate and interactive
    communication with colleagues, patients and
    policy makers to achieve optimal oral health for
    all. This vision may be realized when the
    following promising and best practices are used.
  • American Dental Association (ADA), Council on
    Prevention and Interdisciplinary Relations

Health Literacy
  • Create a respectful and shame-free environment
    and use a universal standards approach, where all
    patients are offered assistance to better
    understand and use printed and written
  • Periodically assess office/clinic for ways to
    improve communication.
  • Use clear and plain language in talking and
  • Encourage question-asking and dialogue.
  • Use teach-back or teach-to-goal method to
    check on successful communication by asking
    patients to repeat their interpretation of
    instructions and other information that has been
  • Offer take-home tools designed for easy use with
    clear directions.
  • American Dental Association, Council on
    Prevention and Interdisciplinary Relations

Health Literacy
  • The degree to which individuals have the capacity
    to obtain, process, and understand basic health
    information and services needed to make
    appropriate health decisions.
  • Health People 2010, http//
  • The capacity of an individual to obtain,
    interpret, and understand basic health
    information and services and the competence to
    use such information and services in ways which
    are health-enhancing.
  • Health Education Standards

Health Literacy
  • Patients are often faced with complex information
    and treatment decisions. Some of the specific
    tasks patients are required to carry out may
  • evaluating information for credibility and
  • analyzing relative risks and benefits,
  • calculating dosages,
  • interpreting test results, or
  • locating health information.

Health Literacy
  • In order to accomplish these tasks, individuals
    may need to be
  • visually literate (able to understand graphs or
    other visual information),
  • computer literate (able to operate a computer),
  • information literate (able to obtain and apply
    relevant information), and
  • numerically or computationally literate (able to
    calculate or reason numerically).

Reading Level A Test
  • Count the number of polysyllabic (more than three
    syllables) words in the chain of 30 sentences and
    look up the approximate grade level on the SMOG
    conversion table.
  • Professional literature
  • Patient education pamphlet

Reading Level
Total polysyllabic word counts Approximate grade level (/- 1.5 grades)
0-2 4
3-6 5
7-12 6
13-20 7
21-30 8
31-42 9
43-56 10
57-72 11
73-90 12
91-110 13
111-132 14
133-156 15
157-182 16
183-210 17
211-240 18
Health Literacy
At Risk Vulnerable Populations
  • Minority populations
  • Immigrant populations
  • Low income - Approximately half of
    Medicare/Medicaid recipients read below the
    fifth-grade level http//
  • People with chronic mental and/or physical health
  • Vulnerable populations include
  • Elderly (age 65)
  • Two thirds of U.S. adults age 60 and over have
    inadequate or marginal literacy skills, and 81
    of patients age 60 and older at a public hospital
    could not read or understand basic materials such
    as prescription labels (Williams, MV. JAMA,
    December 6, 1995).

Influencing Factors
  • Cultural, social, and family influences shape
    attitudes and beliefs and therefore influence
    health literacy.
  • Lack of educational opportunity - people with a
    high school education or lower.
  • Learning disabilities.
  • Cognitive declines in older adults.
  • Use it or lose it
  • Reading abilities are typically three to five
    grade levels below the last year of school
    completed. Therefore, people with a high school
    diploma, typically read at a seventh or eighth
    grade reading level.

Influencing Factors
  • Native language, socioeconomic status, gender,
    race, and ethnicity along with mass culture as
    represented by news publishing, advertising,
    marketing, and the plethora of health information
    sources available through electronic channels are
    also integral to the socialcultural landscape of
    health literacy.

Health Literacy and Health Outcomes
  • Health Status
  • Report their health as poor
  • Healthcare costs
  • Use services to treat complications of disease
    more less use of services to prevent
  • Stigma and shame
  • Psychological effects
  • Use of Preventive Services more likely to skip
    important preventive measures, e.g. Pap smear and
    flu shots.
  • Knowledge about medical conditions and treatment
    more likely to have chronic conditions.
  • Rates of hospitalization higher rates of
    hospitalization and use of emergency services.

Literacy NVS-Ice Cream Label
  • If you eat the entire container, how many
    calories will you eat?
  • If you are allowed to eat 60 g of carbohydrates
    as a snack, how much ice cream could you have?
  • Your doctor advises you to reduce the amount of
    saturated fat in your diet. You usually have 42 g
    of saturated fat each day, which includes 1
    serving of ice cream. If you stop eating ice
    cream, how many grams of saturated fat would you
    be consuming each day?
  • If you usually eat 2500 calories in a day, what
    percentage of your daily value of calories will
    you be eating if you eat one serving?
  • Pretend that you are allergic to the following
    substances Penicillin, peanuts, latex gloves,
    and bee stings. Is it safe to eat this ice cream?
    Why or why not?

Behaviors Indicating Low Literacy
  • Patient registration forms that are incomplete or
    inaccurately completed.
  • Asking staff for help.
  • Bringing along someone who can read
  • Inability to keep appointments.
  • Making excuses (I forgot my glasses.)
  • Noncompliance with medication.

Behaviors Indicating Low Literacy
  • Poor adherence to recommended interventions
  • Postponing decision making (May I take the
    instructions home? or Ill read through this
    when I get home.).
  • Watching others (mimicking behavior).
  • Lack of follow-through with laboratory tests or
    referrals to consultants.
  • Patients say they are taking their medication,
    but laboratory tests or physiological parameters
    do not change in the expected fashion.

What is feels like..
  • Your naicisyhp has dednemmocer that you have a
    ypocsonoloc. Ypocsonoloc is a test for noloc
    recnac. It sevlovni gnitresni a elbixelf gniweiv
    epocs into your mutcer. You must drink a laiceps
    diuqil the thgin erofeb the noitanimaxe to naelc
    out your noloc.

Tools to Evaluate Low Literacy
  • REALD-99 after REALM, where words on the
    instrument are ranked in order of increasing
    difficulty and the score is based on the number
    of words the subject pronounces correctly.
  • REALM Rapid Estimate of Adult Literacy in
  • REALD Rapid Estimate of Adult Literacy in
  • TAFHLAL Test of Functional Health Literacy in

Answers to Label Quiz
(No Transcript)
Cultural and Linguistic Competency
  • Culture affects how people communicate,
    understand, and respond to health information.
    Cultural and linguistic competency of health
    professionals can contribute to health literacy.
    Cultural competence is the ability of health
    organizations and practitioners to recognize the
    cultural beliefs, values, attitudes, traditions,
    language preferences, and health practices of
    diverse populations, and to apply that knowledge
    to produce a positive health outcome. Competency
    includes communicating in a manner that is
    linguistically and culturally appropriate.

Influencing Factors Cultural Competence
  • Cultural competence has been variously defined by
    different organizations.
  • Cultural awareness A deliberate, cognitive
    process in which health-care providers become
    appreciative and sensitive to values, beliefs,
    lifestyles, practices, and problem-solving
    strategies of clients cultures.
  • Cultural knowledge The process of seeking and
    obtaining a sound educational foundation
    concerning worldviews of various cultures goal
    is to understand clients world views, or the way
    individuals or groups of people view the universe
    to form values about their lives and the world
    around them.
  • Speaking of Health (IOM, 2002)

Cultural Competence
  • Cultural skill The ability to collect relevant
    cultural data regarding clients health histories
    and presenting problems, as well as accurately
    perform culturally sensitive physical histories.
  • Cultural encounter A process that encourages
    health-care providers to engage directly in
    cross-cultural interactions with clients from
    culturally diverse backgrounds (IOM, 2002).

Six Steps to Enhance Understanding Among
Patients with Low Health Literacy
  • Slow down, and take time to assess the patients
    health literacy skills.
  • Use living room language instead of medical
  • Show or draw pictures to enhance understanding
    and subsequent recall.
  • Limit information given at each interaction, and
    repeat instructions.
  • Use a teach back or show me approach to
    confirm understanding. This approach involves
    having physicians take responsibility for
    adequate teaching by asking patients to
    demonstrate what they have been told (e.g.,
    repeat how to take their medication) to ensure
    that education has been adequate.
  • Be respectful, caring, and sensitive, thereby
    empowering patients to participate in their own
    health care.

Improve the Usability of Health Information
  • Limit the number of messages, use plain language
    and focus on action.
  • Supplement instruction with visuals
  • Make written communication look easy to read.
  • Improve the usability of information on the
  • Identify the intended users of the health
    information and services
  • Evaluate users understanding before, during and
    after the introduction of the information and
  • Acknowledge cultural differences and practice
  • Accepted roles of men and women
  • Tradition medicine vs. Western medicine
  • Favorite and forbidden foods
  • Manner of dress
  • Body language

Confusion in Labeling
  • Costco
  • Warning 1 "If you drink alcohol, discuss the
    safe use of alcohol while taking this this
    medication with your healthcare professional
  • NOTE This warning appears inconsistent with the
    approved FDA prescriber information that states
    "Avoid alcohol consumption."
  • Warning 2 "Do not take aspirin products without
    doctor approval. Continue taking low-dose aspirin
    to prevent heart attack/stroke unless doctor
    tells you to stop"

Treating Strep Throat
  • Take your pills 2 times each day (once in the
  • morning and once in the evening).
  • Take the medicine every day for 10 dayseven if
    you feel better before then.
  • Stopping the pills before 10 days can result in
  • serious heart problems.
  • (43 words 6th-grade reading level)

(No Transcript)
Are you speaking clearly and listening carefully?
  • Ask open ended questions
  • Check for understanding
  • Summarize what you want the patient to do.
  • Check for understanding I want to be sure I
    didnt leave anything out out that I should have
    told you. Would you tell me what you are to do so
    that I can be sure you know what is important?
  • Source Doak CC, Doak LG, Root JH 1996 Teaching
    Patients with Low Literacy

Use Plain Language
  • Plain language is a strategy for making written
    and oral information easier to understand. It is
    one important tool for improving health literacy.
  • Plain language is communication that users can
    understand the first time they read or hear it.
    With reasonable time and effort, a plain language
    document is one in which people can find what
    they need, understand what they find, and act
    appropriately on that understanding.

  • Keep metaphors to a minimum, for example the
    phrase "Make like a tree and leave" is understood
    as (an attempt) at a pun by native
    English-language speakers.
  • Examples
  • My dogs are killing me
  • That smarts
  • It went up in smoke
  • Current communication techniques eg. Texting
  • Inappropriate language/phrases/slang
  • Some phrases can be confusing
  • For instance, when you say "I give up," you mean
    "I surrender," "I quit," or "I yield." But the
    newcomer to the English language may be puzzled.
    What does it mean to make a gift in an upward
  • Idiomatic expressions
  • Whats up?
  • Can you work the graveyard shift?

Teach Back Method
  • The teach-back method enhances communication.
    The person receiving the health information is
    asked to restate it in their own wordsnot just
    repeat itto ensure that the message is
    understood and remembered. When understanding is
    not accurate or complete, the sender repeats the
    process until the receiver is able to restate the
    information needed. Consumers also can be asked
    to act out a medication regimen.
  • I want to be sure I went over everything. Tell me
    how you will take this medicine.
  • Just to check if Ive covered everything Tell me
    what you will say to your wife when you return
  • Just to be sure I was clear Show me how you will
    use this peak flow meter.

Usability of Health Forms and Instructions
  • Revise forms to ensure clarity and simplicity
  • Test forms with intended users and revise as
  • Provide plain language and in multiple languages
  • Provide clear information for assistance
  • Train staff to give assistance in completing

  • eHealth - the use of interactive technologies to
    improve health behavior and disease management
  • Examples
  • http//

  • Office of Minority Health
  • http//
  • Pfizer Clear Health Communication Initiative
  • http//
  • National Institute for Literacy
  • http//
  • Health Literacy AMA
  • http//
  • Ask Me 3
  • http//
  • Sponsored by the Partnership for Clear Health
    Communication at the National Patient Safety
  • Ask Me 3 promotes three simple but essential
    questions that patients should ask their
    providers in every health care interaction
  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

  • Designed to improve communication from the
    Federal Government to the public, this Web site
    contains excellent tools and examples of plain
  • Visit http//
  • Health Literacy A Prescription to End Confusion
  • Released in 2004 by the Institute of Medicine
    (IOM), this report examines the body of knowledge
    that applies to the field of health literacy and
    recommends actions to promote a health-literate
  • Available at

Online Resources
  • CDC Health Literacy for Public Health
    Professionals. Available at
  • Improving Health Literacy Training Resources.
    University of Michigan Library. Available at
    Department of Health and Human Services, Office
    of Disease Prevention and Health Promotion.
    Health Literacy online A guide to writing and
    designing easy to-use health Websites. Washing,
    D.C. Available at

Thank you!
  • W 313.993.1585