Introduction to Health Literacy

UAB GEC Faculty Scholars ProgramJuly 26, 2013

Gabriel Rios, MLISHealth Literacy Consultant

Objectives• Define health literacy• Discuss how low health literacy impacts health• Identify tools to assess health literacy levels• Practice interventions for clients with low health

literacy• Discuss strategies and resources for improving

health literacy

Teaching Tool:LEP Exercise

Define health literacy

What is Health Literacy?

• IOM – “Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

• NLM - “Health literacy is the ability to read, understand, and act on health information.”

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Basic information about a colonoscopy, as perceived…

National Assessment of Adult Literacy (NAAL) 2003• Most up to date portrait of literacy in U.S.• Scored on 4 levels• Lowest 2 levels cannot:

o Use a bus schedule or bar grapho Explain the difference in two types of employee benefitso Write a simple letter explaining an error on a bill

National Center for Education Statistics, U.S. Department of Education

78 Million Adults have Basic or Below Basic Literacy

12%

53%

22%

14%

2003 National Assessment of Adult Lit-eracy

ProficientIntermediateBasicBelow Basic

Trends in Literacy Over Time

• A comparison of National Adult Literacy Survey (1992) and the National Assessment of Adult Literacy (2003)o The percentage of adults with below basic levels of literacy remained

constanto The percentage of adults with proficient levels of literacy has declined

Types of illiteracy• Functional illiteracy• Sensory/physical illiteracy

o Blindnesso Deafnesso Neurological impairments

• Cultural/language illiteracy• Psychological illiteracy• Computational literacy

Health Literacy in Older Adults

Barriers to Self Care• Economic• Language - limited English proficiency• Healthcare system - insurance, appointment,

signage• Activities of daily living• Access to information• Provider/patient Communication• Other barriers?

Why Is Health Literacy Important?

• Health literacy is important because it affects a person’s ability to:o Navigate the healthcare systemo Share personal and health information with providerso Engage in self-care and chronic disease managemento Adopt health-promoting behaviors, such as exercising and eating a

healthy dieto Act on health-related news and announcements (media literacy)

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Review - What is Health Literacy?

Not only reading skill….BUT ALSO• Writing• Speaking• Listening• Numeracy• Cultural and Conceptual knowledge

Discuss how low health literacy impacts health

Limited Health Literacy Leads to…

• Underutilization of services• Poor understanding of health• Increased hospitalizations• Poor health outcomes• Increased healthcare costs• Increased medication errors

Increased Medication Errors

• Labels are seemingly simple but not necessarily clear.

• Mistakes are more likely the more medication a patient takes.

• Ability to read a Rx label does not guarantee ability to understand and act.

Medication Errors - Industry Standards

• Inconsistent labeling• Branding trumps all• Confusing numbers• Poor color

combinations• Curved shape is hard

to read• Tiny type• Older Adults fill 30

Rx/year, see 8 clinicians

Medication Errors - ClearRx

• Easy I.D.• Code Red• Information hierarchy• Upside down to save

paper• Green is for Grandma• An info card that’s

hard to lose• Take “daily”• Clear warnings.

Medication Errors - Instructions

Medication Errors - Instructions

Navigational Errors - Signage

Some people become confused about whether this entry was intended for ambulances or for patients

The use of visuals clarify the message

Contrast in color makes

it easy to read Try to be consistent

when hanging signs

Ambulatory Entrance

Hospital XYZ

Ambulatory Entrance

Teaching Tool: Navigational Errors

• What are the tasks a patient needs to accomplish in a health care visit?

• Diabetes patiento Pre-visito Visito Post-visit

Teaching Tool: Health Care Navigation and Self-Care Tasks

What can we do?• Raise awareness among providers• Develop easier to read materials • Improve communication skills• Practice-redesign• Literacy training / adult education

Identify tools to assess health literacy levels

Less effective methods of health literacy

assessment • Years of education (except at extremes)• Race• Income• Age• Reliance on self-disclosure

Methods of Assessing Health Literacy

• Informal• Word pronunciation tests• Cloze method• Newest Vital Sign

Davis TC, Kennan E, Gazmararian J, Williams MV. Literacy Testing in Health Care Research. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago: AMA Press; 2004.

Identify Low Health Literacy: (Informal)

• Fills out intake forms incompletelyo “I forgot my glasses”o “Let me bring this home so I can discuss it with my children.”o “My hand hurts too much to write”

• Misspelling many words• Gets angry about forms• Identifies medication by looking at pill rather than

reading the label• Other means?

Weiss BD. Health literacy: a manual for clinicians. 2003

Teaching Tool: Newest Vital Sign

Exercise

Newest Vital Sign

Word Pronunciation Tests

• Rapid Estimate of Adult Literacy in Medicine (REALM)o Word recognition and pronunciation

• Wide Range Achievement Test (WRAT)o Word recognition and pronunciation

Cloze Method• Test of Functional Health Literacy in Adults

(TOFHLA)• Allows students to "intelligently guess" and fill in

missing words from a written passage.• Tests reading comprehension using skills like:

o Background knowledgeo Context cueso Semanticso Syntaxo General understanding of materialo Grammar skills

Your doctor has sent you to have a _________ X-ray.

a. stomachb. diabetesc. stitchesd. germs

You must have an ________ stomach when you come in for ___.

a. asthmab. emptyc. incestd. anemia

a. isb. amc. ifd. it

TOFHLA (Cloze method)

Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

Problems with Measuring Literacy

• Sensitive topic• May offend some• If it is seen as a “test” it can be threatening• Patients hide low literacy• Inappropriate labeling• Time

Three Screening Questions

• “How often do you have someone help you read hospital materials?”

• “How confident are you filling out medical forms by yourself?” and

• “How often do you have problems learning about your medical condition because of difficulty understanding written information?”

Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004; 36(8)588–94.

Discuss strategies and resources for improving

health literacy

Strategies: Providers and Staff

• Whole staff must be aware and sensitive• Assess baseline understanding• Explain things clearly using plain language• Start with most important information first and

limit new information• Effectively encourage patients to ask questions• Use teach-back to confirm understanding• Provide useful educational materials• Repeat important points

Understanding

Clarify

Assess

Explain

Teach back

Strategies: Clear Communication

• Assess baseline understanding• Explain things clearly using plain language• Emphasize 1-3 points• Effectively encourage patients to ask questions• Use teach-back to confirm understanding• Write down important instructions• Provide useful educational materials

Helpful phrases• “I want you to explain to me how you will take

your medication, so I can be sure I have explained everything correctly,” or

• “Please show me how you will use the asthma inhaler, so I can be sure I have given you clear instructions,” or

• “When you get home your spouse will ask you what the doctor said—what will you tell your spouse?”

• “We don’t always do a great job of explaining our care plan. Can you tell me in your words how you understand the plan?”

More on teach-back• Do not ask a patient, “Do you understand?”• Ask patients to explain or demonstrate• Ask questions that begin with “how” and “what,”

rather than closed-ended yes/no questions • Organize information so that the most important

points stand out and repeat this information • Ensure agreement and understanding about the

care plan. This is essential to achieving adherence

Teaching Tool: Plain Language Exercise

Resources: AMA Health Literacy Videos• Health Literacy Toolkit from AMA Foundation

o http://bit.ly/fZjvex o http://www.youtube.com/watch?v=FlGDn1r2RwY

Resources: AHRQ Toolkit

• AHRQ Health Literacy Universal Precautions Toolkito http://www.ahrq.gov/qual/literacy/

• Quick start guide• Path to improvement (6 steps to take)• 20 Tools

Strategies: Standards• JCAHO RI.01.01.03• “For communication to be effective, the

information provided must be:o Completeo Accurateo Timelyo Unambiguouso And understood by the patient.”

• Affordable Care Act: Health Literacy Implications• National Action Plan to Improve Health Literacy

o http://www.health.gov/communication/hlactionplan/

Introduction to Standard RI.01.01.03, CAMH Update 2, October 2009

Strategies: Educational Materials

• Good health information is often hard to come by

• Most health information written at too high of a reading level

• Few health care systems have comprehensively integrated educational materials in their overall care plans

Strategies: Use Patient-Friendly Educational Materials• Simple wording, short sentences

o 4th-6th grade level

• Picture based• Focus only on key points• Emphasize patient concerns

o What the patient may experienceo What the patient should do

• Minimize information about disease statistics, anatomy, and physiology

• Be sensitive to cultural preferences

Resources: NIH Senior Health

• http://nihseniorhealth.gov• Health information for older adults• Partnership of National Institute on

Aging and National Library of Medicine• Information comes from

National Institutes of Health• Older Adult-friendly features (large text, sound,

contrast)• Information in bite-sized pieces

Resources: MedlinePlus

• http://www.medlineplus.gov• Launched in 1998• Free • Health information for patients and consumers• Quality filtered credible sources• Spanish language• Low literacy materials

Review• Define health literacy• Discuss how low health literacy impacts health• Identify tools to assess health literacy levels• Practice interventions for clients with low health

literacy• Discuss strategies and resources for improving

health literacy

Resources• AMA Foundation Health Literacy Toolkit

o http://bit.ly/fZjvex

• AHRQ Health Literacy Universal Precautions Toolkito http://www.ahrq.gov/qual/literacy/

• AHRQ Health Literacy Interventions and Outcomes (SR)o http://www.ahrq.gov/clinic/epcsums/litupsum.htm

• MedlinePluso http://www.medlineplus.gov

Questions?Gabriel R. Riosgrios@uab.edu