Health Literacy Practical Tools for improving Communication Paul D. Smith, MD, Associate Professor UW Department of Family Medicine

Topics today General health literacy information How to recognize people with low literacy How to improve communication Factors to consider when creating documents

Literacy skills

What is Literacy? National Adult Literacy Survey (NALS 1992) National Assessment of Adult Literacy (NAAL 2003) “Using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential.”

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

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.”

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.”

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.”

Real People with Real Problems Insert video clip here

National Adult Literacy Survey Federal survey conducted in ,000 people over age 15 Living in households and prisons Divided into 5 levels

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

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

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

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

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

National Adult Literacy Survey 47-51% of Americans in Levels 1 and 2

National Adult Literacy Survey 39% of Wisconsin adults in Levels 1 and 2

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

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

Literacy Levels Change with Age Document Literacy

Literacy Levels Change with Age Document Literacy 80 and over Level %

2003 National Assessment of Adult Literacy Data released 12/05 ~17,000 people participated Changed reporting methodology

New Reporting Method 80% correct responses moved down to 67% 4 categories Below basic Basic Intermediate Proficient

2003 National Assessment of Adult Literacy 43%55% 34%

2003 National Assessment of Adult Literacy The Bottom Line Not much change Prose a bit worse Document a bit better Quantitative a bit better

2003 National Assessment of Adult Literacy NAAL health literacy assessment 28 questions specifically related to health 3 clinical 14 prevention 11 system navigation

NAAL Health Literacy Assessment Background questions Self-rated health status Health insurance Sources of health information

NAAL Health Literacy Assessment Basic and Below Basic Health Literacy Entire population 36% White 28% Native Americans 48% Blacks 58% Hispanics 66%

NAAL Health Literacy Assessment Basic and Below Basic Health Literacy Age % Age %

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%

NAAL Health Literacy Assessment Basic and Below Basic by Insurance type Employer provided 24% Privately purchased 37% Medicare 57% Medicaid 60% No Insurance 53%

NAAL Health Literacy Assessment Percent of people that NEVER obtain health information from the internet Proficient 12% Intermediate 14% Basic 58% Below Basic 80%

Clinician Survey 16 question survey Sent to 411 Wisconsin family physicians 28% response rate

Impact on Quality and Outcomes Number of Respondents Impact Health Outcomes Impact Quality of Care 55%

Results : Prevalence Number of Responses Mean = 17.4% NAAL = 34-55%

Results Assess reading level of education materials?

Results Does your clinic screen patients?

The Bottom Line Clinicians are aware of literacy impacting on health and health care They underestimate the extent of the problem

The Impact of Low Literacy on Health  Poorer health knowledge  Poorer health status  More hospitalizations  Higher health care costs

Poorer Health Knowledge Diabetics that know low glucose symptoms 50% 94%

Poorer Health Knowledge Hypertensives that know exercise lowers BP 40% 68%

Poorer Health Status Diabetics with HgbA1c <7.3 20% 33%

Poorer Health Status Diabetics with retinopathy 36% 19%

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

More Hospitalizations 2 year hospitalization rate for patients visiting ED 31% 14%

Increased Health Care Costs Total annual Medicaid charges $10,688 $2,890

Increased Health Care Costs Based on NALS data Majority from increased hospitalizations Friedland R. New Estimates of the high cost of inadequate health literacy. In Pfizer Inc. Proceedings Report from Promoting Health Literacy: A Call to Action. New York City, October 7-8, 1998:6-10.

Low Literacy is Overlooked Clinicians don’t 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

Low Literacy is Overlooked Patients do not volunteer their literacy problem Many are ashamed Some do not recognize their inadequate literacy Lack of trust

The Big Secret % of low literate adults that have not told their: Children52% Friends62% Spouse68% Health care providers75% Co-workers85%

More likely to have Low Literacy Older Immigrants Less education Non-white

NALS Level 1 Immigrants after age 12>50%

More likely to have Low Literacy Low-income Medical Assistance Incarceration

Low Literacy is Overlooked Many Level 1 people don’t fit the stereotypes 75 % born in USA 50% are white 40% hold full or part time jobs

Other Issues Effecting Literacy Visual Impairments 60 and older 17% 80 and older 36%

Other Issues Effecting Literacy Cognitive impairment Learning disability 65 and older 6% severe dementia % mild-moderate Increases with advancing age

Screening for Low Literacy Upside-down test Rapid Estimate of Adult Literacy in Medicine REALM Test of Functional Health Literacy in Adults TOFHLA Newest Vital Sign NVS

Common Clues of Low Literacy Patients say things like: “I lost my glasses” “I don’t need to read this through now, I’ll read it when I get home” “I’d like to discuss this with my family” “I have a headache now and can’t focus

Common Clues of Low Literacy Intake forms incomplete or strange answers Frequent missed appointments Claims compliance but treatment does not work

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

Common Clues of Low Literacy Non-compliance Medications Testing Consultations

Coping Mechanisms Watch the patients as they fill out the forms: 98% will bring someone with them who reads. 88% will watch others or copy. 90% will ask for help from the staff -- not the doctor!!! 80% will ask for help from other patients.

Patient Communication Processes Patient-staff communication Patient history Informed consent Medical instructions

Patient Communication Processes Patient education materials Prescription labeling Responding to medical and insurance forms Navigating the clinic or hospital

Front Desk/Registration Always offer to help complete forms Simplify registration forms Only ask for information that you need

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

Verbal Communication Strategies SLOW DOWN Simple terms Use monosyllabic and colloquial terms. Avoid or explain the medical jargon. Start with context

Verbal Communication Strategies Tell them what you want them to DO. Begin with important information first and limit new information. Repeat the information/instructions

Verbal Communication Strategies Have the patient repeat the information, use the “teach back” method. No more than one or two instructions at a time—and check each time: “Chunks and Checks”. Write it down.

Verbal Communication Strategies Use models, sketches, pictures. Give instructions to family members. Consider follow up phone calls. If you are rushed, get someone else to do it.

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.

Written Materials- Common Mistakes Too much detail Hard words are not explained Pictures do not reinforce the message No examples

Written Materials Review materials for reading level 5 th – 6 th grade reading level Flesch-Kincaid grade level

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

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

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

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)

Written Materials Look on the internet. Print as is. Use as a place to start. Rewrite as necessary.

Written Materials Use short sentences. Simple language Monosyllable words “Plain language movement”

Written Materials Be consistent with words and terminology. Define technical or difficult words.

Written Materials Important concepts first Use bulleted lists instead of blocks of text Use headings and subheadings

Written Materials Use a readable type style—usually one with serifs—the little “feet” on the bottoms of the letters that you see in this type. Arial Helvetica Times New Roman

Written Materials Use point type for text. Use point bold type for headings. Use upper case and lower case for the text. ALL CAPITALS ARE HARDER TO READ

More hints…. Have a 50/50 blend of white space and type. Use summary techniques. Read over the instructions—highlight important parts with color. Use pictures.

Examples of Good and Bad Pictures

Diabetes Pamphlet Example

Beyond handouts Pictures and models Audiotapes and CDs Videotapes and DVDs CD-ROM Internet

Summary Low literacy is a common problem Low literacy affects health

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

What can YOU do? Change your own behavior Be a catalyst for change

What can YOU do? 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

What can YOU do? Raise awareness Physician colleagues Office staff Hospital staff and administrators Health insurers Legislators

What can YOU do? Be a patient. Review processes Review documents

What can YOU do? Health Literacy Definition 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. Universal Design

What can YOU do? Partner with your local Literacy Council

What can be done? Advocate for increased funding for adult basic education. 1 million Wisconsin adults qualify for adult literacy and English language services. Only 50,000 adults in need of services are currently receiving them. 786,000 Wisconsin adults over age 16 are not in school and are not HS grads.

What can be done? Address the issues of: High school graduates that are functionally illiterate. Low literacy in design of Medicaid and Medicare documents and processes.

What can be done? Health Literacy Summit Sponsored by Wisconsin Literacy Thursday June 21, 2007 Chula Vista Resort, Wisconsin Dells Seeking funding sponsors

Health Literacy Summit Goals 1. Raise awareness Adult Literacy organizations. Wisconsin Department of Health and Family Services. Statewide health care organizations, hospitals, health insurers, dentists, nurses, pharmacists and other health care providers.

Health Literacy Summit Goals 2. Develop 4 regional plans that cover the entire state to raise awareness of the issue of health literacy. 3. Facilitate linkages between local literacy organizations, public health officials and health care providers.

Health Literacy Summit Goals 4. Health Literacy Train-the-Trainer workshops. 5. Writing documents for low literate adult workshops. 6. Health Literacy curriculum discussion.

Wisconsin Literacy Coordinating organization for community- based adult literacy organizations. ~50 Organizations scattered around the state. Four Regional Coordinators.

Wisconsin Literacy Michele Erikson, director

“Action expresses priorities.” “Be the change that you want to see in the world.” ---Mohandas Gandhi