1. Health Literacy Research The Next Generation
University of Arkansas Health Literacy Research
Grand Rounds
July 22, 2013
Terry Davis, PhD
Professor of
Medicine and Pediatrics
LSUHSC-S

2. DISCLOSURE STATEMENT Research funding: Stocks:
Agency for Healthcare Research and Quality
American Cancer Society
American College of Physicians Foundation
McNeil Pharmaceutical
Unrestricted educational grant
Advisory Board for icons on OTC pain medication
National Cancer Institute
Stocks:
Johnson & Johnson
Abbott Laboratories

3. Literacy and Healthcare: What We Know
Patient literacy linked to health knowledge, behavior, outcomes & navigation skills
The majority of U.S. adults struggle with health information and tasks
Literacy levels in U.S. are getting worse
The demands and expectations of the healthcare system are increasing
AR ranks 39th in literacy and 48th in overall health,
44th obesity , 38th infant mortality and 43rd in preventable hospitalizations
United Health Foundation, Department of Education

4. Judgment/ Interpretation
Literacy Definition (Requirement) Expands With Increasing Demands Of Society
Communicate
Math Skills
Literacy
Write
Problem
Solving
Read
Internet
Skills
Judgment/ Interpretation
“…at a level needed to function on the job and in society.”
National Literacy Act, 1991; S. White, Project Director NAALS 2016

5. Low Literacy is a National Problem (National Adult Literacy Survey)
% Adults with Level 1 Literacy Skills
21% U.S. Adults are Level 1
48% level 1 and 2 – “lack sufficient
literacy skills to function in society”
Hispanic – 79%; African-American – 75%
National Institute for Literacy 1998

6. Low Literacy Rates By County
% Adults with Level 1 Literacy Skills
>30%
20%-30%
15% to 20%
< 15%
22% Arkansas Adults are Level 1
National Institute for Literacy 1998

7. Literacy Forecast for 2030
Here is the 2030 forecast
Overall, the ETS predicts a 5% decline in the literacy skills of the working age population…
Take a look at how the distribution in literacy scores shifts to the left (RED graph)…
This represents a substantial reduction in the % of adults in levels 3 and 4 (note the peak of the red is much lower than the blue)….and take special note of the dramatic increase in the number of people in level 1 (which jumps from 17 to 27%)
Level 3 skills necessary for current economy
From the ETS report America’s Perfect Storm: Three Forces Changing Our Nation’s Future written by Irwin Kirsch, Henry Braun, Kentaro Yamamoto and Andrew Sum. The full report is available from ETS at

8. 1st National Assessment of Health Literacy Assessed functional skills in clinical, preventive, and navigational tasks
n=19,000 U.S. Adults
(quantitative literacy)
Proficient
12%
(13%)
Below
Basic
Intermediate
53%
(33%)
14%
(22%)
Below basic
Hispanic: 41%
Native American: 25%
Adults > 65: 29%
Basic
22%
(33%)
Average
HS grad
National Assessment of Adult Literacy (NAAL):
National Center for Educational Statistics, U.S. Dept. of Education, 2003.
Medicaid

9. 67% probability individual can perform task
Health Literacy Tasks
152 tasks (28 health related)
Below Basic: Circle date on doctor’s appt. slip
Basic: Give 2 reasons a person with no symptoms should get tested for cancer based on a clearly written pamphlet
Intermediate: Determine what time to take Rx medicine based on label
Proficient: Calculate employee share of health insurance costs using table
67% probability individual can perform task

10. 2 out of 3 patients leave MD visit with Rx
Medication Error Most Common Medical Mistake 1.5 M adverse events (patient error >700,000)
2 out of 3 patients leave MD visit with Rx
3.9 Billion Rx filled in 2010
Up 50% - 60% in 10 years
82% adults take at least one med
Elderly fill 20 Rx/year, see 8 physicians
1 in 6 pediatric Rx not dosed correctly
>100,000 OTC meds (>600 contain acetaminophen)
Most labels and inserts are in English only
# of RX filled source: IMS Health
U.S. Census Bureau, 2009; PDR for Non-Prescription Drugs, Dietary Supplements and Herbs (2007); IMS Health 2005; IOM 2006.

11. Calculation: A Hidden Problem Understanding Food Labels
You drink this whole bottle of soda. How many grams of total carbohydrates does it contain?
67.5 grams
32% answered correctly
200 primary care patients
73% private insurance
67% at least some college
78% read > 9th grade
37% math > 9th grade
This is one example from our study. We told people they drink this whole container of soda and asked them to tell us how many grams of carbs they would consume if they drink the whole bottle – which most people do. The correct answer should be 2.5 x 27grams per serving which is 67.5 grams – but only 32% of folks got this correct. Where do they go wrong? Well, many folks did not understand the serving size or how to apply it, some folks made calculation errors, and some folks were confused by the complexity of the label. For example, some folks told us that there were 9grams of carbs because this is the last column that they see – even though this is the percent daily value. For patients with diabetes, a miscalculation of carbohydrate intake could affect their diabetes care.
Rothman R, Am J Prev Med, 2006

12. Video
Its easy to make a mistake

13. of health information and system
Health Literacy 1st Viewed as Patient Deficit Emphasis Shifts to Health System
Skills/ability
of patients
Demands/complexity
of health information and system
Health Literacy
IOM Report (2004)
90 million adults have trouble understanding and acting on health information
Healthy People 2010….and 2020
Improve health communication (plain language materials)
Joint commission (2007)
Patients must be given information they understand
Health literacy is a safety issue
* US DHHS, May 27, (

14. Baby Step Research
Our team’s story of putting 1 foot in front of the other
Curiosity -> Assessing Problems -> Interventions

15. 1st study : Are These Clear?
All short and seemingly simple.
Not regulated by FDA or State Boards of Pharmacy.
Davis T , Bass P, Wolf M , Parker R. J Gen Intern Med

16. What Does This Picture Mean?
“Somebody is dizzy”
“Don’t touch this stuff”
“Take anywhere”
“Chills or shaking”
“Having an experience with God”
Wolf M, Davis T, Parker R, Bass P. Am J Health-System Pharmacy. 2006

17. Does Adding the Words Help?
1 in 10 Adults Struggle With Decoding
“Use extreme caution in how you take it”
“Medicine will make you feel dizzy”
“Take only if you need it”
8% of patients with low literacy understood this instruction

18. Correct Interpretations by Literacy
Labels
< 6th Grade
7th-8th Grade
> 9th Grade
p value 78 86 NS 42 65 60
<0.001 37 73 66 4 36 35 6 14
Davis T , Bass P, Wolf M , Parker R. J Gen Intern Med

19. Improving Target’s Top 10 Warning Labels n=500 LSU & NW patients
Simplified text 2.6 X more likely to be correctly interpreted , simplified text + icon 3.3 times more likely.
Wolf M , Davis T, Bass P, Parker R. Arch Intern Med, 2010.

20. Rx Label Instructions
Can patients understand how to take meds after reviewing label instructions on actual pill bottles?
Minimum Federal oversight for Rx labels. State Boards of Pharmacy regulate labeling but provide little guidance
Davis T, Wolf M, Bass P, Parker R. Ann Intern Med,

21. “How would you take this medicine?”
n=395 patients in 3 states
48% <9th grade reading, averaged 1.4 meds
46% did not understand instructions ≥ 1 labels
38% with adequate literacy missed at least 1 label
<10% attended to warning labels
Davis, Wolf, Bass, Parker. Ann Intern Med, 2006.

22. “Show Me How Many Pills You Would Take in 1 Day”
Rates of Correct Understanding vs.Demonstration
“Take Two Tablets by Mouth Twice Daily”
John Smith Dr. Red
Take two tablets by mouth twice daily.
Humibid LA MG
1 refill 89 84 80 71 63 35
Wolf M, Davis T, Parker R. Patient Educ Couns. 2007

23. Lessons Learned
Labels simple, but not necessarily clear
Ability to read the Rx label does not guarantee correct interpretation
Mistakes are more likely the more meds patients take
Some pts over complicate- take meds more times daily than necessary
Approximately half of physicians don’t mention dose, timing, duration, and possible side effects of meds.
Instructions need to be tested with patients

24. More Precise Labels Aid Comprehension Instructions that require interpretation are poorly understood
n= 375 pts LA, NW, NY
High
Low
Metformin, 1000 mg
Take 1 pill by mouth every 12 hours. 61
30*
Take one tablet by mouth twice daily. 90
70*
Take 2 pills by mouth every day. Take 1 with
breakfast and 1 with supper. 88 78
Glyburide, 5 mg
Take two tablets by mouth twice daily. 71
33*
Take 2 pills in the morning and 2 pills in the
evening. 92
76‡
Take 2 pills by mouth at 8 am and 2 pills at 6 pm. 90 76
*p<0.001, ‡ p<0.01
Davis, Bass, Parker, Wolf. J Gen Intern Med, 2009.

25. Correct Interpretation of Standard vs. Patient Centered Label
N=500 (LSU & NW), Low Lit: 52%, AA: 64%, Avg. 3 Meds
Standard PCL PCL & Graph
Take 2 pills by mouth Take 2 pills in the morning Take 2 pills in the morning twice daily and 2 pills at bedtime and 2 pills at bedtime
77%* % 88%
Take 1 pill by mouth Take 1 pill in the morning, Take 1 pill in the morning,
3 times daily 1 pill at noon, and 1 pill at noon, and
1 pill in the evening 1 pill in the evening
44%* % 91%
*p<.001
Wolf M ,Davis T, Parker R. Medical Care

26. Patient Centered Label Can Improve Understanding and Adherence
RCT in 11 FQHCs.
429 pts w DM and/or HTN.
Average 5 meds
Mean age 52, 28% W,
39% low literacy
Standard Label
PC Label
Understanding
59%
74%
Adherence (3 months)
30%
49%
State Board of Pharmacy in CA passed legislation for this label

27. OTC Health Literacy Challenge
Skills/Ability
Demands/Complexity
Health Literacy
FRAMING:….It’s only everything
The epidemic of poor h.l. actually reflects the magnitude of problems with the both literacy skills and task clarity/complexity.
We not only have epidemic size problems with literacy and health literacy in our country, we have epidemic sized problems in the way health information is communicated to people when trying to determine what they must do to take care of their health.
This framing of health literacy shifts the focus on improving patients’ h.l. to allow for broader system change—As members of broader society, we must encourage efforts to advance general literacy and individual health literacy skills. As health providers and members of health and healthcare systems……We must understand how well we effectively communicate with patients.
In other words, how we must not just ask “how health literate are patients”….we must also ask ourselves….“health literate” are we?
Wal-Mart has 80 sq. feet of pain meds
Most people not aware of active ingredient or its importance

28. Recent OTC Research with Drs
Recent OTC Research with Drs. Wolf & Parker Few consumers aware of active ingredient
Majority of consumers don’t read OTC instructions
People have their own schematic for taking OTCs
Would revised label increase awareness, understanding?

29. DHHS National Action Plan: Road Map to Improve Health Literacy
Aim: Make health information and services easier to understand and use
7 Goals and high priority strategies
Develop and disseminate health information
that is accurate, accessible, and actionable.
Promote changes in healthcare delivery system
Build partnerships, develop guidance, change policies
Increase research, and evaluation of interventions
* US DHHS, May 27, (

30. Research in Rural and Community Health Centers
Few studies conducted in rural areas
In 2012 HRSA required “meaningful use” of EHR

31. Health Literacy and Cancer Screening
5 year quasi experimental evaluation in 8 FQHC’s
Test the effectiveness of health literacy interventions to improve initial and repeat use of CRC and breast cancer screening
Explore patient, provider and system factors that facilitate or impede initial and repeat screening.
We added cost effectiveness
* 1 RO1 CA A2; 10/01/07-9/30/12

32. Study Clinics: Locations and Characteristics
Gilliam (183)
Minden (13,027)
Shreveport (200,199) &
Bossier City (61,306)
Tallulah (9,189)
Wisner (1,140)
Sicily Island (463)
Leesville (6,763)
3 “parent” FQHCs (+ 5 satellites)
Baseline screening rates are extremely low
5-9% mammography
1-2 CRC
Patients lack adequate insurance
59% of FQHC patients have no insurance
11% have private insurance
* CDC.
DeWalt DA, J Gen Intern Med :
Medicare Interactive,
New choice Health: 32 32

33. Colorectal Cancer Baseline Interview Findings
N=961, 77% F
67% AA, 56% Lit
89% PCP visit
prior year
Almost all patients (96%) had heard of CRC
91% would want to know if they had CRC
Only 39% had received a physician recommendation
29% had been given a kit
28% previously completed an FOBT
Over half (57% )not rescreened in > 3 years
Most common reasons for not getting screened
29% put it off
25% didn’t think it was needed
Davis T, Arnold C, et al. J Rural Health. 2012 33 33

34. CRC Screening Barriers Among Rural vs. Urban FQHC Patients
Believe helpful to find CRC early
90%
66%*
Received MD rec 36
46**
Received FOBT Info
15%
32%*
Completed FOBT
22%
46%*
Confident complete FOBT
16%
4%*
*p<.0001, ** p=0.03
Davis TC, Rademaker A, Bailey SC, et al. Contrasts in Rural and Urban Barriers to Colorectal Cancer Screening.
Am J Health Behavior. May 2013; 37(3):

35. Doctor Giving FOBT Kit Dramatically Increases Patient Completion
Baseline survey
Risk Ratio of Patient Completing FOBT
Low literacy
Adequate literacy
MD recommended CRC 4
MD ever given FOBT kit 49 11
Davis T, Arnold C, Rademaker, Wolf M, et al. J Rural Health. 2012

36. Breast Cancer Baseline Interview Findings
98% of all patients had heard of breast cancer
84% seen advertisements that encouraged getting tested
82% had received prior recommendation
(78% AL vs. 59% LL) knew someone who had breast cancer
93% said they knew what a mammogram was; of these 100% defined it correctly
Most common misconception
71% believed screening mammogram needed to begin before age 40
77% had ever had a mammogram 36 36

37. The Influence of Family
88% said if there was one person who told them to get tested they would.
Those included:
38% Child
19% Mother
14% Sister

38. Making Information and Services Easy to Obtain, Understand, and Use
Recommendation
FOBT & no cost mammogram
Pamphlets (5th grade)
Short videos that tell story
Simplified FOBT instructions (3rd grade)
Nurse manager to teach & support with follow-up calls

39. FOBT Screening Completion by Study Arm
Initial n=961
Repeat n=561
By Arm
EUC HL
HL + Nurse
p-value*
Initial FOBT returned
39%
57%
61%
.02
2nd year FOBT returned
36%
33%
51%
<.001
*p-values adjusted for age, race, gender, and literacy- take clustering by clinic into account
Initial Screening Cost
Incremental cost of HL per additional person screened $250 over EUC
Incremental cost of Nurse arm over EUC $1337
Repeat (Annual) Screening Cost
Incremental cost of Nurse arm over EUC $2811
CRC baseline: 1-2%
CRC screen % needed diagnostic colonoscopy
- 8 patients had polyps removed

40. Mammography Completion
n = 1181 Mammogram
By arm
EUC HL
Nurse
p value
Initial
56%
52%
66%
.04*
Repeat
11% 7%
47%
<.0001**
Incremental cost of nurse arm per additional person screened compared to HL was $2,644
Mammography baseline: %
Breast Cancer screen patients had breast cancer
*Adjusted for race, marital status, literacy, and self-efficacy
**Adjusted for race, education, marital status, seen doctor, and ever had a mammogram

41. Challenges Community clinics focus on service not research fidelity
Challenging to find qualified RAs in rural areas
Hiring RAs from clinic staff is a “Catch 22”
High physician turnover in rural areas
Follow-up calls are feasible but phones commonly disconnected then reconnected.
Mailed reminders and FOBT kits years 2 and 3 not sufficient.
Patients lose FOBTS / forget to complete.
At LSU Wait for diagnostic colonoscopy up to a year.
LSU Colonoscopy
Referrals

42. Lessons Learned from Study
Strong ongoing relationship with CEOs and clinic is essential.
Including providers & patients in material development is key.
Clinic in-service helps inform and enlist staff.
RA giving recommendation and FOBT before PCP visit is feasible and well received by providers and patients.
Playing videos revealed RA and patient barriers – pamphlets and FOBT kits were easier to use as teaching tools
Nurse follow-up call to motivate and problem solve screening completion was time consuming.
Unlike mammography, patients did not seem to feel pride when completing FOBT
FQHC Patients
Nurse Manager

43. Wisdom Gained ..the ah ha’s” Life is dynamic - things changed since grant written in 2007
In 2007 concern over reaching poor and rural patients by phone. (now 87% U.S. adults have a cell phone)
FQHC patients can be reached by phone – cells may be disconnected but reconnected at first of next month. Several attempts to reach patients are often needed.
When grant written, colonoscopy was viewed as test to be promoted.
Now increasing emphases on practical, CRC screening using FOBTs. (It is the 1st line screening reported in numerous studies abroad and in large US health systems.)
ACS, USPSTF & professional organizations have updated their recommendations for CRC screening
Now recommend immunochemical tests that have superior sensitivity such as the FIT
In 2012 HRSA requires reporting CRC screening as standard performance measures and meaningful use of EHR.

44. Engage Patients in Self-Management American College of Physicians’ Guides
Guides focused on:
Patient not disease
‘Need to know and do’
Help patients change health behavior:
Increase knowledge and confidence managing disease
Solve self-care problems
Over 5 million distributed nationally
Customer Service ext 2600

45. Brief Self-Management Counseling
4-Step Approach:
1. Introduce Guide
Ask : Is there anything you would like to do this week to improve your health?
2. Help Patient Set Action Plan (short-term achievable goal-pt chooses )
3. Assess confidence - 7 on 10 point scale
4. Check on progress
Maintain, modify or set new action plan
Brief video to train clinic staff:
Lorig, J Am B Fam Med, 2006.
Davis T, Seligman H, Dewalt D, Arnold C, et al. J Prim Care Community Health. 2012

46. Patients Recalled Action Plans Changed Behavior And Problem Solved
225 patients, LSU, UNC, UC-SF Med Clinics
(76% minority; DM 9yrs; BMI 36; A1C 8.6)
2 Week Calls
- Recall AP
Behavior sustained
Other behavior
96%
75%
56%
17 Week Visits
88%
67%
45%
Most patients (89%) chose diet and exercise
Equally effective with low and high literacy patients
Wallace, Seligman, Davis, Schillinger, Arnold, DeWalt, et al. In press
DeWalt, Davis, Schillinger, Seligman, Arnold, et al. In press.

47. Will Plan Work in Community Clinics
Will Plan Work in Community Clinics? Test of 2 Approaches to DM Self-Management ‘Carve In vs. Carve Out’
9 FQHCs in Missouri, 666 patients, mean age % African American, 33% low literacy, A1c 8.5, SBP 140
Carve-In:
Clinic identifies patient “champion” to review guide and engage patients in action planning.
Carve-Out:
Assumes clinics cannot sustain
Clinic distributes guides, refers patients to offsite DM Counselor
DM Counselor reviews guide engages patient in action planning
2 weeks
2 months
6 months
9 months
1 year
Touch Points
3 months
Action Plan
Interview

48. Carve Out More Feasible and Effective
At 1 year carve out patients more likely to:
Recall telephone calls 79% vs 46% p<.001
Set action plans vs p<.001
Find intervention helpful 7/10 vs 4/10 p<.001
Want to continue 76% vs 62% p<.001
Achieve glycemic control (hbA1C<7) 48% vs 21% p<.001

49. Challenges Conducting Research in Distant Community Clinics
Challenging to “hard wire” interventions –robust implementation methods needed
“Efforts of Diabetes Champion “varied widely b/t clinics
“Buy in” from PCPs is key
Staff and physician turnover after orientation
Need to find low cost ,reliable, effective outreach strategies

50. Health Literacy Funding Opportunities IOM Health Literacy Model Guides Interventions
2004: PAR – NIH (13 institutes) issued program announcements focused on “Understanding and Promoting Health Literacy” (re-issued ), “Addressing Health Disparities” ( ) and “Mobile Health Tools to Promote Communication” ( )

51. Adding Literacy as a Variable is Easy
The most commonly used tests
REALM (Rapid Estimate of Literacy Medicine)
TOFHLA (Test of Functional Health Literacy)
NVS (Newest Vital Sign)
These are sometimes referred to as tests of health literacy
Qualitative:
How confident are you filling out medical forms by yourself?
Extremely – Quite A Bit – Somewhat – A Little Bit – Not At All
( 0 ) ( 1 ) ( 2 ) ( 3 ) ( 4 )
Tests and ordering instructions are in resources at the end of the presentation.

52. Health Literacy Research Ideas
Expand technology for patient outreach
Cell phones for automated calls /texts, EHR mandates
Make health numeracy easier to interpret and act on
Address current health care challenges
Hospital discharge, health insurance
Add cost effectiveness if possible
Don’t forget your consent form
Can patients read and understand it
Is it formatted for reading ease?
Is the information included manageable or overwhelming?

53. Consumer Technologies Going (Gone) Mobile
Figure X. SMS text for UMS instructions.
Recent Growth of Mobile Health Apps
2010
4,921
,600
2013
97,000
Rx Mgmt
450
Android activates 1.5 million phones a day
87% US adults own cell phone. 1 in 3 use it for health information.
Latinos, African Americans, people < 50 and college educated, most likely to gather health information this way.
Research2Guidance. Mobile Health Market Report (Vol . 3) March 4, 2013.

54. IOM Focused on HL & Health Insurance
Choosing and using health insurance is unnecessarily complex.
Trust levels for health insurers are very low.
People dread shopping for health insurance (paying taxes is preferable) *
They don’t understand the product (car insurance)
They don’t know the terms
Coinsurance
Benefit maximum
These complex concepts must be used to estimate cost for services.
Do co-pays count towards the deductible or the out- of-pocket maximum?
Allowed amount
Out-of-pocket maximum
* ehealth, Inc., “New Survey Shows Americans Lack Understanding of Their Health Coverage and Basic Health Insurance Terminology,” January 3, 2008, available at

55. What’s Our Action Plan? Address the “Red”
Skills/ability
of patients
Demands/complexity
of health information and system
Health Literacy
Rx and OTC labels and Med Guides – standardize and make easier to see, navigate, understand and act on
Find low cost sustainable outreach strategies to improve cancer screening & chronic disease self-management
Health insurance - get to Apple Store approach!
Make cost transparent. Clarify smart use. Patiently offer help when customers buy it or are confused or overwhelmed trying to use it.
Employ new technologies but remember technology is a “tool” - it does not replace a nice, knowledgeable person helping you. Health is personal!

56. A Perfect Storm is Approaching
Intersection of low literacy and the increasing demands of health care
Are We Prepared?

57. What’s Our Bridge to Action?
How does this talk stimulate your thinking?
What strategies could AR develop and test to make health information/ services more user-friendly?
What research opportunities exist?

58. Useful HL Resources

59. IOM Reports on Health Literacy
Health Literacy: Improving Health, Health Systems, and Health Policy, 07/13
Oral Health Literacy, 02/13
How Can Health Care Organizations Become More Health Literate? 07/12
Promoting Health Literacy to Encourage Prevention and Wellness, 12/11
Improving health Literacy Within a State, 11/11
Health Literacy Implications for Health Care Reform, 07/11
Innovations in Health Literacy Research, 03/11
The Safe Use Initiative and Health Literacy, 12/10
Measures of Health Literacy, 12/09
Health Literacy, eHealth, and Communication: Putting the Consumer First, 03/09
Toward Health Equity and Patient-Centeredness: Integrating Health Literacy, Disparity Reduction, and Quality Improvement, 02/09
Health Literacy: A Prescription to End Confusion, 04/04

60. AHRQ Toolkits (Agency Healthcare Research and Quality)
Hospital Discharge
Project RED (ReEngineered Discharge) (2013)
Informed Consent (2009)
Health Literacy Universal Precautions(2010) (clinic based system)

61. More Toolkits Pharmacy Assessment Tools and Training
AHRQ (2007) Strategies to improve communication between pharmacy staff and patients training program
Website Design
HHS (2010) Health literacy online a guide to writing and designing easy to use health web sites

62. Resources For Healthcare Organizations
Institute of Medicine (2012 ) Ten attributes of Health literacy Healthcare Organizations iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx Health Literacy Environment of Hospitals & Health Centers (2006 ) The Joint Commission (2007) What did the doctor say ? Improving health literacy to protect patient safety National Qualify Forum (2009) Health Literacy a linchpin in achieving national goals for health and healthcare. Communication Climate Assessment Tool (2010) Wynia M: American Journal of Medical Quality

63. Health literacy Websites
CDC
NIH
htm
UNC
Rima Rudd (Harvard School of Public Health)
Helen Osborne

64. Helpful Websites For Nurses
Health Literacy Tools, Reports, and Research Carolina Geriatric Education Center CDC Expert Panel Report: HL for Older Adults

65. Patient Education Development
CMS (2011) Toolkit for making written materials clear and effective NCI (2003) Clear and simple developing effective print materials for low literacy readers simple/page1 Arnold CL, Davis TC, Ohene Frempong J, et al: Assessment of newborn screening parent education materials. Pediatrics. 2006;117: Seligman HK, Wallace AS, DeWalt DA, et al: Developing low- literacy patient educational materials to facilitate behavior change. Am J Health Behav Sep-Oct;31 Suppl 1:S69-78.

66. Patient Education Materials
Institute for Healthcare Advancement
7 easy to read, easy to use guides to better health
What To Do:
When Your Child Gets Sick
When You’re Having a Baby
For Teen Health
American College of Physicians
Helpful Ways To Lose Weight
Caring For Your Heart
End of Life Decision Making
Volandes AE (2010) Medical Decision Making. 30(1):29-34
For Healthy Teeth
When Your Child Has Asthma
When Your Child Is Heavy
For Senior Health
Living With Diabetes
Living With COPD

67. Literacy Tests Used in Healthcare Research
The most commonly used
REALM (Rapid Estimate of Literacy Medicine)
TOFHLA (Test of Functional Health Literacy)
NVS (Newest Vital Sign)
These are sometimes referred to as tests of health literacy
Qualitative:
How confident are you filling out medical forms by yourself?
Extremely – Quite A Bit – Somewhat – A Little Bit – Not At All
( 0 ) ( 1 ) ( 2 ) ( 3 ) ( 4 )
Tests and ordering instructions are in resources at the end of the presentation.

68. REALM 0-18 correct = < 3rd grade 19-44 correct = 4th-6th grade
List 1
List 2
List 3
fat
flu
pill
dose
eye
stress
smear
nerves
germs
meals
disease
cancer
caffeine
attack
kidney
hormones
herpes
seizure
bowel
asthma
rectal
incest
fatigue
pelvic
jaundice
infection
exercise
behavior
prescription
notify
gallbladder
calories
depression
miscarriage
pregnancy
arthritis
nutrition
menopause
appendix
abnormal
syphilis
hemorrhoids
nausea
directed
allergic
menstrual
testicle
colitis
emergency
medication
occupation
sexually
alcoholism
irritation
constipation
gonorrhea
inflammatory
diabetes
hepatitis
antibiotics
diagnosis
potassium
anemia
obesity
osteoporosis
impetigo
REALM
0-18 correct = < 3rd grade
19-44 correct = 4th-6th grade
45-60 correct = 7th-8th grade
61-66 correct = high school
Davis, Fam Med, 1993

69. S - TOFHLA Scoring: 0-16: Inadequate func. HL 17-22 Marginal func. HL
PASSAGE A
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 for ______.
a. asthma a. is.
b. empty b. am.
c. incest c. if.
d. anemia d. it.
The X-ray will ________ from 1 to 3 _________ to do.
a. take a. beds
b. view b. brains
c. talk c. hours
d. look d. diets
THE DAY BEFORE THE X-RAY.
For supper have only a ________ snack of fruit, ________ and jelly, with coffee or tea.
a. little a. toes
b. broth b. throat
c. attack c. toast
d. nausea d. thigh
Scoring:
0-16:
Inadequate func. HL
17-22
Marginal func. HL
23-36
Adequate func. HL
Parker, J Gen Intern Med, 1995

70. NVS
Questions
If you can have 60 grams of carbs for a snack - how much ice cream can you have?
Score :1 point for each correct answer
0-1 Inadequate literacy
2-3 Marginal literacy
4-6 Adequate literacy

71. Cautions for Assessing Health Literacy Clinically
Testing patient literacy level alone will NOT confirm ability to navigate, act, understand, and act on health information and manage care
To get the most accurate measure of health literacy, use “teach back”
No evidence that literacy testing improves health care delivery or outcomes when testing is done strictly for clinical use
“Universal precautions” (plain language) are recommended to make materials user-friendly

72. Ordering Information REALM and REALM-Teen
TOFHLA, TOFHLA-Spanish and STOFHLA
NVS
WRAT

73. Original Citations for Tests
REALM
Davis TC, et al. Rapid Estimate of Adult Literacy in Medicine: A shortened screening instrument. Fam Med 1993;25(6):
REALM-R
Bass PF, et al. Residents' ability to identify patients with poor literacy skills. Acad Med Oct;77(10):
REALM-SF
Arozullah AM, et al. Development and validation of the Rapid Estimate of Adult Literacy in Medicine (REALM) – Short Form. Medical Care. 2007; 45(11):
REALM-Teen
Davis TC, et al. Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine (REALM) Teen: A tool to screen adolescents for below-grade reading in health care settings. Pediatrics. 2006; 118:

74. Original Citations for Tests cont…
NVS
Weiss BD, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med Nov-Dec;3(6):
Qualitative Assessment
Chew LD, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med March;23(5):561-6.
TOFHLA and TOFHLA-S
Parker RM, et al. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:
STOFHLA
Baker DW, et al. Development of a brief test to measure functional health literacy. Patient Education and Counseling. 1999;38:33-42.

75. RED (Re-Engineered Discharge Toolkit) Addresses Low Health Literacy
Aim: effectively prepare patients for hospital discharge
RN ‘Discharge Advocate’ works with inpatients to :
Educate them with individualized instruction booklet (also sent to PCP)
Arrange follow-up appointments
Confirm medication reconciliation
Avg total time: 87 min per patient ( 42 min w /patients, 45 min reviewing EMR, communicating w/ medical team & preparing discharge booklet)
Clinical PharmD calls patients 2-4 days after discharge to review meds and reinforce discharge plan
Avg total time: 26 min per patient (10-19 min counseling)
65% of patients had at least 1 med problem
AHRQ March 2013

76. EACH DAY follow this schedule for your medicines
RED Template for Meds
EACH DAY follow this schedule for your medicines
What time of day do I take this medicine?
Why am I taking this medicine?
Medicine name
Amount
How many do I take?
How do I take this medicine?
Morning
Noon
Evening
Bedtime
Only if you need it for

77. RED Template for Follow-up Appointments
John Doe
What is my main medical problem?
Chest Pain
When are my appointments?
Wednesday
August 8
at 11:30 a.m.
Thursday,
August 16
At 3:20 p.m.
September 12
At 9:00 a.m.
Dr. Mark Avery
Primary care doctor
Dr. Anita Jones
Rheumatologist
Dr. Lin Wu
Cardiologist
100 Main st. 2nd floor
Anytown ST
100 Pleasant Rd, Suite 105
Anytown, ST
100 Park Rd, Suite 504
For a follow up appointment
For your arthritis
To check your heart
Office phone number
(555)
Office Phone#:
(555)
(555)

78. Project RED (ReEngineered Discharge) Effective and Cost Effective
Randomized control trial 30 days after discharge: n=749
RED vs. standard discharge
30% lower hospital use
30% more likely to follow-up PCP
34% lower cost
mean stay: 2.7 days
59% low literacy
mean age 50
50% AA, 27% White
2007 National Quality Forum “Safe Practice” for hospital discharge based largely on RED
Jack BW, Ann Intern Med 2009

79. A Fun Way to Spot Difficult Words www.lextutor.ca/vp/eng
Vocabulary Profiler color codes words in English
1000 most frequently used words (K1)
Second 1000 frequently used words (K2)
Academic words frequently used in academic texts (AWL)
Words which are not found on the other lists (off list)

80. Red & Yellow Warn You

82. Key Test References
Davis T, Kennen EM, Gazmararian JA, Williams MV. Literacy testing in health care research. In: Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding health literacy: Implications for medicine and public health. United States of America: AMA Press; 2005:
White S. Assessing the Nation’s Health Literacy: Key concepts and findings of the National Assessment of Adult Literacy (NAAL). AMA Foundation, 2008.

83. National and State Literacy & Health Data
National Assessment of Adult Literacy
United Health Foundation
Annie E. Casey Foundation
CDC

84. Helpful References
Institute of Medicine (2004) Health Literacy: A Prescription to End Confusion. In Nielson-Bohlman L, Panzer A, Kindig DA, eds. Washington, DC: National Academy Press
Schwartzberg JG (2005) Understanding health literacy: Implications for medicine and public health. AMA Press
Weiss BD (2003) Health Literacy: A Manual for Clinicians. AMA Foundation
Doak CC (1996) Teaching Patients with Low-Literacy Skills, 2nd ed. JB Lippincott
US DHHS (2010) National Action Plan to Improve Health Literacy
The Joint Commission (2008) Strategies for Improving Health Literacy from The Joint Commission Perspectives on Patient Safety. The Joint Commission: Oakbrook Terrace, Illinois

85. 2013 Health Literacy Conferences
Institute for Healthcare Advancement
Irvine, California: May 8-10
iha4health.org
Health Literacy Institute (great conference)
Freeport, Maine: June 2-5
healthliteracyinstitute.net/
Boston University Health Literacy Annual Research Conference (HARC)
Washington, D.C.: October 28-29

86. Department of Medicine and Pediatrics
Terry Davis, PhD
Department of Medicine and Pediatrics
LSU Health Shreveport
(318)
Research Associate:
Robert C. Ross, BS
(318)

87. Plain Language Summary
Health literacy is a problem for people in Arkansas.
Health literacy is a problem for health care.
Research has made medicine labels easier to understand.
Research has improved cancer screenings in rural centers.
Cell phones and electronic medical records may be the next step to better health literacy.