health literacy: a clinician’s point of view
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Health Literacy:A Clinician’s Point of View
Paul D. Smith, MD, Associate ProfessorUW Department of Family Medicine
Paul.Smith@fammed.wisc.edu
Topics today
Social determinants of health.
Health literacy.
Impact of literacy on health and health care.
What can we do about this?
Determinants of Health
Gender
Age
Race/ethnicity
Co-morbidities
Social Determinants of Health
Employment status
Income level
Health insurance status
Marital status
Social Determinants of Health
Education level
High school diploma or equivalent
Literacy level
Question?
What would happen to Wisconsin’s
overall health, if we were able to
eliminate health disparities?
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Men (367)
Milwaukee County (424)
High school or less (459)
Native Americans (592)
African Americans (624)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
Asians (170)
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Men (367)
Milwaukee County (424)
High school or less (459)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
Asians (170)
African Americans (624)
Native Americans (592)(279)
(279)
(277)
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Men (367)
Milwaukee County (424)
High school or less (459)
Native Americans (592)
African Americans (624)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
Asians (170)
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Men (367)
Milwaukee County (424)
High school or less (459)
Native Americans (592)
African Americans (624)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
Asians (170)
(275)
(275)
(266)
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Milwaukee County (424)
High school or less (459)
Native Americans (592)
African Americans (624)
Worst state Mississippi (519)
Best state Minnesota (257)
Asians (170)
Men (367)(225)
Wisconsin (296)(225)
100 200 300 400 500 600 700
Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)
ABCDF
Some college (212)
College graduates (188)
Whites (279)
Women (225)
Suburban (247)
Non-urban(275)
Rural (319)
Men (367)
Milwaukee County (424)
Native Americans (592)
African Americans (624)
Worst state Mississippi (519)
Best state Minnesota (257)
Asians (170)
High school or less (459)(212)
Wisconsin (296)(206)
Effect of Eliminating Disparity by:
Race 296 277
Geography 296 266
Gender 296 225*
Education 296 206*
*Wisconsin becomes the healthiest state in the U.S.
Answer:
Eliminating health disparities in any category
improves Wisconsin’s overall health.
The greatest potential gain is in the elimination
of disparities by education.
2003 National Assessment of Adult Literacy
NAAL health literacy assessment
28 questions specifically related to health 3 clinical 14 prevention 11 system navigation
Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S.Department of Education.Washington, DC: National Center for Education Statistics.
NAAL Health Literacy Assessment
Background questions
Self-rated health status
Health insurance
Sources of health information
NAAL Health Literacy Assessment
Entire population
Below basic 14%
Basic 22%
Intermediate 53%
Proficient 12%
NAAL Health Literacy Assessment
Basic and Below Basic Health Literacy
White 28%
Native Americans 48%
Blacks 58%
Hispanics 66%
NAAL Health Literacy Assessment
Basic and Below Basic Health Literacy
Age16-64 28-34%
Age 65+ 59%
NAAL Health Literacy Assessment
Basic and Below Basic by education level
In High School, GED or HS grad 34-37%
Less than/some High School 76%
NAAL Health Literacy Assessment
Basic and Below Basic by Self-reported health status
Excellent 25% Very Good 28% Good 43% Fair 63% Poor 69%
Sources of Health Information
TV and radio
Family and Friends
Health Care Professionals
Sources of Health Information
Text Media
Newspaper
Magazines
Books or brochures
Internet
Sources of Health Information
Percent of people that NEVER obtain health information from the internet
Proficient 12%
Intermediate 14%
Basic 58%
Below Basic 80%
In Their Own Words
Insert video clip here
The Impact of Low Literacy on Health
Poorer health knowledge
Poorer health status
Higher mortality
More hospitalizations
Higher health care costs
Poorer Health Knowledge
Understanding prescription labels
395 patients
19% low literacy (6th grade or less)
29% marginal literacy (7-8th grade)
52% adequate literacy (9th grade and over)
5 prescription bottles
Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894
Poorer Health Knowledge
At least one incorrect
63% low literacy
51% marginal literacy
38% adequate literacy
Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894
Poorer Health Knowledge
“Take two tablets twice daily”
Stated correctly Demonstrated correctly
71% low literacy 35%
84% marginal literacy 63%
89% adequate literacy 80%
“Show me how many pills you would take in one day.” Counted out 4 tablets-correct
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
Poorer Health Status
Diabetics with retinopathy
0
5
10
15
20
25
30
35
40
%
inadequate adequate
36%
19%
Increased Mortality
Age 70-79
Reading level 8th grade or less
Five Year Prospective Study
Sudore R, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.
Increased Mortality
Risk of Death Hazard ratio: 1.75
19.7
10.6
0
5
10
15
20
%
Low Literacy Higher Literacy
More Hospitalizations
2 year hospitalization rate for patients visiting ED
0
5
10
15
20
25
30
35
%
low adequate
31%
14%
Increased Health Care Costs
Data
2003 Medical Expenditure Panel Survey
2003 National Assessment of Adult Literacy
Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007
Increased Health Care Costs
Annual cost today:
Future costs based on today’s actions (or lack of action):
Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A,
Rosenbaum, S, DeBuono, B. Oct. 2007
$106-238 Billion
$1.6-3.6 Trillion
In Their Own Words
Focus group project
Three community-based literacy programs
Six groups
Fifty-one adults
Limited reading skills- Adult Basic Education
Limited English skills- English Language Learners
Focus Groups Major Themes
Communication and understanding.
Completing/understanding forms
including consents.
Focus Groups Major Themes
Difficulty in accessing healthcare
Medication errors
Anxiety and shame
The “System” is Broken
Pre-school
Children learn to read on the laps of their parents.
K-12 education
Third-fourth grade “watershed.”
HS graduation rates.
Almost 20% functionally illiterate HS graduates.
The “System” is Broken
Adult education
Lack of funding for literacy programs
Family
Workforce
Corrections
The “System” is Broken
Health Care
Highly educated clinicians and support staff.
Medical terminology.
Documents written at a high reading level.
Increasing complexity of medical care.
How do we fix this problem?
Multi-faceted approach
Funding one aspect and ignoring the other
issues will not address the problems today.
Education
Change the health care system
How do we fix this problem?
Pre-school
Effective programs
Reach Out and Read
Refer parents to family literacy programs
How do we fix this problem?
Pre-school
Similar programs in non-traditional settings
Women Infants and Children
Prenatal care
Ethnic community groups
Faith based
How do we fix this problem?
K-12
Everyone graduates functionally literate
Address the social and other issues that
influence HS drop out rates.
How do we fix this problem?
Adult education
More money for effective literacy programs.
Community-based
Family
Workforce
Corrections
How do we fix this problem?
Health content in literacy curriculum
Susan Levy, Ph.D.
Breakout at 3:45
Education Will Not Solve Everything
Health Care
Continuing Medical Education (CME) for
clinicians
Medical education is stuck in the 60’s
Education Will Not Solve Everything
Universal Design
If it works for people with low literacy or low
English skills, it will work for everyone.
The Healthcare System Has to Change
Communication strategies
Improve oral communication
Easier to read written documents
Effective informed consent process
Check understanding
The Healthcare System Has to Change
Commonwealth Fund Report
A team effort, beginning at the front desk.
Use of standardized communication tools
Clinicians partner with patients to achieve goals
Barrett S, et al. Health Literacy Practices in Primary Care Settings: Examples from the Field, January 2008http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=645961
The Healthcare System Has to Change
Use of:
Plain language
Face-to-face communication
Pictorials
Educational materials
The Healthcare System Has to Change
Organizational commitment to create an
environment where health literacy is not
assumed.
More Research is Needed
Effective preschool and K-12 programs.
Effective adult literacy programs.
Effective health literacy interventions.
Summary
Low health literacy is a common problem
Low literacy affects health
Summary
The System has to change
What can YOU do?
Learn more about health literacy
IOM “A Prescription to End Confusion”
Health literacy resource list
Google “health literacy toolkit”
What can YOU do?
Be a catalyst for change
Raise awareness
Raising Awareness
Your own local, state and national organizations.
Health care organizations.
State and federal legislators.
Medical Education.
What can YOU do?
Add health content to curricula.
What can YOU do?
Collaborate with health care groups
Hospitals
Large medical groups
Health care insurers
“Action expresses priorities.”
“Be the change that you want to see in the world.”
---Mohandas Gandhi
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