1. Lisa Hane Anthony Swanner Assessing Health Literacy

2. Learning Objectives Demonstrate understanding of health literacy and implications to patients and society Understand differences between various assessment instruments Learn how to administer the latest health literacy assessment instrument Evaluate the assessment process

3. What you know about Health Literacy? Which of the following is the strongest predictor of a person's health status? a. Age b. Income c. Literacy skills d. Employment status e. Education level f. Racial or ethnic group “Health Literacy: Report of the Council on Scientific Affairs." (1999). JAMA(281). 552-557.

4. What you know about Health Literacy? How many adult Americans have difficulty reading and understanding health information? a. 9 million b. 90 million c. 150 million d. Fewer than one million "Adult Literacy in America." National Center for Education Statistics, U.S. Dept of Education, Office of Educational Research and Improvement (NCES 1993-275), April 2002

5. What you know about Health Literacy? What percentage of patients forgets what the doctor told them as soon as they leave the office? a. 80 percent b. 50 percent c. 10 percent d. Less than 10 percent Shankar, J. (2003). Patients' memory for medical information. JRSM, 96(10), 520-520.

6. What is 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

7. Measurement Studies documenting worse health outcomes for patients with low health literacy have measured general reading ability Some instruments use medical texts or terms, but are highly correlated with non- medical tests of reading ability Nielsen-Bohlman, L., & Panzer, A. M. (2004). Health literacy: a prescription to end confusion: National Academy Press.

8. Assessment Methods Reading Tests Word pronunciation Informal Comprehension Tests Listening Cloze method Davis, T., Kennen, E., Gazmararian, J., & Williams, M. (2005). Literacy testing in health care research. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, Ill: American Medical Assoc, 157-179.

9. CLOZE tests cough, those, prescription, your, make, you, sputum, this, from, easily, lung, even, bought, be, taking, prescribed, sure. The pharmacist will explain the correct way to take the medication your doctor has prescribed for you. Do not take any ____ or cold remedies, including ___ you buy without a ______, without first checking with _____ doctor. These medications can _____ it more difficult for ____ to cough up the _____ from your lungs. If ______ sputum is not removed _______ your lungs, you can ______ get a respiratory or ______ infection. Remember, mixing medications ______ those that can be ______ without a prescription, can ______ dangerous. If you are ____ medications that have been _____ for other reasons, be _____ to inform your doctor. Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: J.B. Lippincott.

10. Common Assessment Instruments Rapid Estimate of Adult Literacy in Medicine (REALM) o Word recognition and pronunciation Test of Functional Health Literacy in Adults (TOFHLA) o Numeracy and Reading comprehension The Newest Vital Sign (NVS) o Numeracy and literacy

11. REALM-SF Menopause Antibiotics Exercise Jaundice Rectal Anemia Behavior

12. Sample TOHFLA Numeracy Question Doxycycline 100 MG 20/0 Take medication on empty stomach one hour before or two hours after a meal unless otherwise directed by your doctor. If you eat lunch at 12:00 noon, and you want to take this medicine before lunch, what time should you take it?

13. Sample TOHFLA Reading Comprehension Your doctor has sent you to have a _____ X-Ray. a. stomach b. diabetes c. stitches d. germs You must have an ___ stomach when you come in for _____. a. asthmaa. is b. emptyb. am c. incestc. if d. anemiad. it Available from Peppercorn Books & Press Inc. (www.peppercornbooks.com)

14. Newest Vital Sign Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P.,... Hale, F. A. (2005). Quick assessment of literacy in primary care: the newest vital sign. Annals of Family Medicine, 3(6), 514-522.

15. Newest Vital Sign Reflection Evaluate your experience: How long did it take you? What did it feel like taking the test? How would your patient feel during and after this test?

16. Obstacles facing nurses Not enough time Patient experience stigma related to identification of Low Health Literacy (LHL) Organizational resistance - insufficient staffing, funds etc

17. What you know about Health Literacy? Which of the following are coping mechanisms used by patients with low health literacy? a. Say they forgot their eyeglasses to avoid filling out forms or questionnaires. b. Laugh about being forgetful when asked about their medical condition or treatments. c. Nod politely when the doctor speaks and don't ask any questions. d. All of the above. Weiss, B. D. (1999). 20 common problems in primary care. New York: McGraw-Hill, Health Professions Division.

18. Stigma and Shame In one study, 42% were found to have inadequate or marginal functional literacy based on TOFHLA scores Over two-thirds admitted to having trouble reading and reading comprehension; 40% reported feeling shame. Nineteen percent of patients had never disclosed their difficulty reading to anyone.

19. Single Item Literacy Screener How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” 1-Never, 2-Rarely, 3-Sometimes, 4-Often, and 5-Always “2” is cutoff point to capture patients needing assistance Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7(1), 21.

20. Summary - What next... Eliminate Stigma: Simple questions Plain Language Health literacy as a systems issue Meeting patients where they are Constructing nursing teaching to accommodate various learning styles

21. For Additional Information… Pfizer Health Literacy http://www.pfizerhealthliteracy.com http://www.pfizerhealthliteracy.com North Carolina Program on Health Literacy http://www.nchealthliteracy.org/ http://www.nchealthliteracy.org/ IOM Health Literacy Workshop Summary http://www.iom.edu/Reports/2012/How-Can- Health-Care-Organizations-Become-More- Health-Literate.aspx

22. References Davis, T., Kennen, E., Gazmararian, J., & Williams, M. (2005). Literacy testing in health care research. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, Ill: American Medical Assoc, 157-179. Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: J.B. Lippincott. Macabasco-O'Connell, A., & Fry-Bowers, E. K. (2011). Knowledge and perceptions of health literacy among nursing professionals. Journal of Health Communication, 16 Suppl 3, 295-307. Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7(1), 21. Nielsen-Bohlman, L., & Panzer, A. M. (2004). Health literacy: a prescription to end confusion: National Academy Press. Parikh, N. S., Parker, R. M., Nurss, J. R., Baker, D. W., & Williams, M. V. (1996). Shame and health literacy: the unspoken connection. Patient Education and Counseling, 27(1), 33-39. Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P.,... Hale, F. A. (2005). Quick assessment of literacy in primary care: the newest vital sign. Annals of Family Medicine, 3(6), 514-522.