Health Literacy: Raising awareness Lindsey Murphy Senior Knowledge Manager: Health Literacy

Overview Learning outcomes An increased knowledge of what health literacy is and why it is important Increased awareness of the tools and techniques to support and promote health literacy in practice An awareness of the resources and information that is available to support you in promoting health literacy Ask people their thoughts on the video, specifically ask people what they thought about the quotes that generally people will forget 50% of information once they leave a consultation and that of the 50% they remember they will only remember half of that correctly. Can people identify with this?

What is health literacy? “Health literacy is about people having enough knowledge, understanding, skills and confidence to use health information, to be active partners in their care, and to navigate health and social care systems” (Making it Easy: national health literacy action plan, Scottish Government 2014) Highlight that health literacy refers to all types of communication including spoken, written and visual.

Health Literacy “The personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health” (WHO, 2015) Sometimes the term health literacy almost puts responsibility on the person or the patient as if they are to blame. This isn’t the case, we as the professionals have a responsibility to promote understanding and support people to develop their health literacy. This quote from WHO highlights that as well as personal characteristics health literacy is dependent on social resources. Similar to most HL definitions it focuses on accessing, understanding and appraising health information to make decisions about health.

The Policy Context Realising Realistic Medicine (Scottish Gov, 2017) Health and Social Care Delivery Plan (Scottish Gov, 2016) A National Clinical Strategy for Scotland (Scottish Gov, 2016) Chief Medical Officer’s Annual Report ‘Realistic Medicine’ (Scottish Gov, 2016) Making it Easy: national health literacy action plan (Scottish Gov, 2014) 2020 Vision (Scottish Gov, 2011) The Healthcare Quality Strategy for Scotland (Scottish Gov, 2010) Gaun Yersel’ (ALLIANCE, 2011) Patients Rights (Scotland) Act 2011 Health inequalities Realising Realistic Medicine – states the national health literacy action plan will support realistic medicine, recognises the work and findings from the Demonstrator Programme in NHS Tayside and discusses the use of teach back as a tool for use in practice. HSC Delivery Plan – five year plan for delivery on health and social care, this includes a commitment to refreshing and renewing the health literacy action plan (by end of 2017). Clinical strategy - If we are to support people having an increased voice in their treatment choices, and support them in self-management, we need to improve communications with patients, to increase health literacy (the understanding of health, healthcare interventions, and their likely impacts). Initial work has been developed by the Scottish Government on improving heath literacy, which needs to continued. Also discusses the digital and other resources required to support person centred care and informed decision making. Realistic medicine – CMO identifies that the information we provide in Scotland is too complex for the people it is for, recognises health literacy as a determinant of health and suggests that improving health literacy can tackle health inequalities Making it easy – aim of Scotland being a health literate society and sets out national actions i.e. Demonstrator, building workforce capability and developing an online resource which we will go on to discuss. 2020 vision = focus on self management HC Quality Strategy – focus on PCC, health literacy sits within this agenda Patients rights act – staff have a legal responsibility to communicate with people in a way that they can understand Health literacy is closely linked with health inequalities. Those experiencing inequalities are more likely to have low health literacy and also health literacy can impact on a persons health and health outcomes resulting in inequalities.

Some facts Scottish Government Health Literacy Action Plan, 2014 The proportion of the population with inadequate health literacy in a sample of eight European countries is 47% – almost half the population1 43% of English working-age adults will struggle to understand instructions to calculate a childhood paracetamol dose The cost to the US economy, because of inadequate health literacy, is estimated to be in the region of $106-$236 billion per year 26.7% of people in Scotland have occasional difficulties with day-to-day reading and numeracy. 3.6% will have severe constraint Ask people their thoughts on the paracetamol fact, are they surprised? Scottish Government Health Literacy Action Plan, 2014

Impact of poor HL More likely to experience poor health outcomes Poorer health and self reported health Wait until we are sicker before we go to the Dr Find it harder to access the right services Find it harder to understand labelling and take medicine correctly Less able to communicate with health staff Less likely to engage in health promotion activities Difficulty in self management of self and others (Making it Easy: national health literacy action plan, Scottish Government 2014) Low health literacy may result in people misinterpreting messages regarding health and healthy behaviours, it can contribute to a range of adverse health situations including those on the slide, which link to the points below: Less likely to manage prescribed treatment and self care More likely to be hospitalised, longer stays in hospital, higher rates of admission to emergency service Less skilled in navigating healthcare system. Poorer health status and less likely to use preventative care. Less knowledge of disease management and health promoting behaviours. Less able to make appropriate health decisions. Make less use of preventive services More medicine and treatment errors. Less likely to adhere to prescribed treatment and self care plans. Decreased ability to communicate with healthcare professionals and share in decision-making. Incur substantially higher healthcare costs Those with long term conditions who have health literacy issues are at greater risk as they have more to manage. People with poorer health literacy are also at greater risk of increased hospital admissions.

Improving and supporting health literacy can result in: Improved health and health outcomes for patients Better patient and professional relationships Improved understanding of medication information, instruction and adherence Reduced risk of serious health problems resulting from misunderstanding and communication Reduced readmissions and repeat appointments Reduced health inequalities By improving people’s health literacy we can improve their health and improve their health outcomes, for example, they will be better able to self manage conditions and medications meaning they are likely to deal with these things a lot better and live better than if they have poor health literacy. Patients will be more likely to ask questions, speak to staff and trust what is being said to them. I have already mentioned patient safety but it is very important in terms of health literacy, for example, people understanding what medicines are for and how to take them safely. People are more likely to understand what is communicated to them if it is communicated effectively, and therefore are less likely to repeatedly present for appointments for the same issue It can help reduce inequalities as those at risk of least understanding are supported to look after their health, understand health messages and healthy behaviours.

Who is at risk? Who do you think is most at risk of poor health literacy? May suggest – LD, prisoner, homeless, low literacy, limited education, older people Everyone can be at risk dependent on the circumstance, never assume and always take a universal precautions approach. Consider if hearing some new or distressing news i.e. Diagnosis or new medication and how difficult it can be to take in the information.

Five tips for making it easy Teach back Chunk and check Use pictures Use simple language Routinely ask people if they would like help

Teach back Regardless of a patient’s health literacy level staff must ensure that people understand the information they are being given. This technique asks patients to state in their own words what has been discussed and what they need to know or do about their current condition/issue. This is a way to confirm that you have explained things in a manner your patients/clients understand. The show me method is related and is used when you are asking people to undertake a physical practice i.e. Applying a cream or giving an injection. Teach back is appropriate for use with all patient contact and can help: Improve understanding and adherence Decrease call backs and cancelled appointments Improve patient satisfaction and outcomes Roughly 50% of information provided to patients is forgotten and the 50% that is remembered nearly half of that is incorrect/misunderstood

Teach back cont. It is not a test of the patients knowledge, it is a test of how well you have explained things Plan your approach and how you will ask people to ‘teach back’ Clarify and check again if needed Practice! Use education/information to support understanding

Using teach back I would like to check that I have explained things properly, would you mind telling me what it is we have discussed and what we have agreed you will do? Can you tell me how you are going to explain things to your family when you get home tonight? How would you check for understanding? What words would you use? Everyone is different and it depends on your relationship with the client. After today’s training try to think about how you could use teach back, even incorporate it into one of your appointments/discussions each day and practice it and then continue to use it with more people. I want to make sure you have understood, can you tell me what I’ve asked you to do? Have you understood everything we have discussed?

Chunk and check This approach can be used in conjunction with teach back, you break down the information that you are giving into small sections/chunks and after each chunk you check for understanding before moving on. Don’t wait until the end of a potentially long discussion where you are providing lots of information to check for understanding.

Use pictures/visuals It has been found that showing images can help to both convey messages and to support understanding. Examples could include: Highlighting images in education/information materials to support understanding of the text around them Use of images like the body on the slide to support discussions Use of images to guide what people are being asked to do i.e. On the body this is where you apply the patch/cream, here is a picture of the pills and the number you take against the times on a clock Drawing things as you describe them. Does anyone have other examples they have seen or think could work?

Use simple language There are a wide range of terms we use everyday that could be confusing for others i.e. Radiology – x-ray Smoking cessation – stop smoking Diet – what you eat Phlebotomist – person who takes blood! Think about your day to day practice and the terms, acronyms and words that you routinely use but that could cause confusion for others.

Routinely offer help You can not assume who might need help with paperwork, forms etc. so offer everyone help. Offer help in a friendly non-stigmatising way: ‘I have a few forms I need you to complete, you can either fill them out now or the ..... Can help you fill these out once they see you’ ‘Please let me know if there is anything on the form that isn’t clear and I’ll be happy to go over it with you’ ‘Would you like me to go over the form with you to make sure we get all the information we need, some of the questions are not always clear and we want to make sure we capture everything’

You may notice people bringing someone to appointments with them or making excuses such as sore hand or forgotten glasses so they don’t have to deal with paperwork.

Resources and information The Health Literacy Place website is the national resource for health literacy information in Scotland: www.healthliteracyplace.org.uk Give a very short overview of the website.

Action after today Add health literacy as a subject interest on People Connect Sign up as a ‘health literacy supporter’ Visit and make use of the website Contribute to the website news/blogs/ case studies Add us on Twitter @healthlitplace Share the learning with others and let them know about the website and training

Contact: Lindsey Murphy Senior Knowledge Manager – Health Literacy NHS Education for Scotland Tel: 0141 531 2677 Email: lindsey.murphy@nes.scot.nhs.uk