1. Health Literacy & Provider Communication Kay Hogan Smith, MLS, MPH

2. Conflict of Interest The presenter has no conflicts of interest involved in the information provided.

3. Health Literacy - Objectives Demonstrate a basic understanding of key health literacy concepts Identify the impacts of low health literacy Identify tools to assess health literacy Discuss strategies and resources for improving health literacy Demonstrate how providers can address health literacy issues in practice

4. Health Literacy: Definition How well a person can: Read Understand Act National Library of Medicine - “the ability to read, understand, and act on health information.” Affordable Care Act - "the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions."

5. Newest Assessment of Adult Literacy - PIAAC Initial data published in October 2013, statistics from 2012; supplemental data focusing on older US adults to be released soon. Besides literacy, measures numeracy and “problem solving in technology-rich environments” in US and other countries Scored on 4-5 levels* (from lowest to highest): – Below Level 1 – Level 1 – Level 2 – Level 3 – Level 4/5 *Problem-solving in technology-rich environments scale has 4 levels

6. US Results from Program for the International Assessment of Adult (16-65) Competencies 2012 – Literacy Scale

7. US Results from Program for the International Assessment of Adult (16-65) Competencies 2012 – Numeracy Scale

8. US Results from Program for the International Assessment of Adult (16-65) Competencies 2012 – Problem-Solving in Technology-Rich Environment Scale *Level 3 is the highest proficiency level for this scale.

9. What Is It Like to Be a “Level 1” or Below Reader?

10. Health Literacy - Everyday Examples

11. Causal Relationship b/w Health Literacy and Outcomes Paasche-Orlow and Wolf, 2007. American Journal of Health Behavior

12. Limited general knowledge Do not ask for clarification Focus on details, hard to get them to prioritize Don’t understand “simple” math Essential vocabulary only Check answers without understanding What Happens When People with Limited Literacy Have to Deal with a Health Issue ?

13. Limited Health Literacy Leads to… Underutilization of services Increased medication errors Poor understanding of health Increased hospitalizations Poor health outcomes Increased healthcare costs

14. Health Literacy Is Needed for: Pill bottles Appointment slips Informed consents Discharge instructions Health education materials Insurance applications Etc…

15. Informal Word pronunciation tests Cloze method Newest Vital Sign Question: "How confident are you in filling out medical forms by yourself?" Methods of Assessing Health Literacy 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.

16. Years of education (except at extremes) Race Income Age Reliance on self-disclosure Less effective methods of health literacy assessment

17. How Do You Know If Someone Has Limited Literacy? (Informal Means) Fills out intake forms incompletely – “I forgot my glasses” – “Let me bring this home so I can discuss it with my children.” – “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 Weiss BD. Health literacy: a manual for clinicians. 2003

18. Word Pronunciation Tests Rapid Estimate of Adult Literacy in Medicine (REALM) – Word recognition and pronunciation Wide Range Achievement Test (WRAT) – Word recognition and pronunciation

19. 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: – Background knowledge – Context cues – Semantics – Syntax – General understanding of material – Grammar skills

20. 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. asthma b. empty c. incest d. anemia a. is b. am c. if d. it Sample TOFHLA Reading Comprehension (Cloze method) Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

21. Newest Vital Sign

22. Sensitive topic May offend some If it is seen as a “test” it can be threatening Patients hide low literacy Inappropriate labeling Time Problems with Measuring Literacy

23. Finding & Creating Easy to Read Materials (and Other Health Literacy Resources) Handout

24. Barriers to Self Care Economic Language - limited English proficiency Healthcare system - insurance, appointment, signage Activities of daily living Access to information Provider/patient communication

25. Provider/Patient Communications

26. AMA Health Literacy Video – Communication Skills for Practitioners

27. Effective Communication Provider initiates introductions Provides empathy and support Uses effective non-verbal communication Avoids the use of jargon Confirms diagnosis and explores patient’s understanding of it University of Michigan School of Dentistry

28. Effective Communication Provider prioritizes treatment options and educates patient on these choices Elicits patient’s preferences and commitment to a particular treatment plan Reviews treatment plan and obtains mutual statement of commitment Encourages the patient to ask questions Responds appropriately to patient’s feelings without judgment

29. Strategies for Clear Communication for 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

30. More Clear Communication for Providers and Facilities Symbols and Signage

31. Health Care Symbols & Signage Symbols & signage needed for - – Navigational aids (complex healthcare system) – Patient education – Labels

32. Symbols and Rx Labels 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.

33. Prescription Drug Warning Labels What does this picture mean? – “Someone swallowed a nickel” – “Indigestion” – “Bladder” – “Looks like a ghost – Casper” Wolf MS, Davis TC, Tilson HH, et al. Am J Health-Syst Pharm (2006) 63:1048–55 Terry C. Davis, Michael S. Wolf, et al. J Gen Intern Med. 2006 Aug;21(8):847-51.

34. Prescription Drug Warning Labels Does adding words help? – “Chew pill and crush before swallowing” – “Chew it up so it will dissolve, don’t swallow it whole or you might choke.” – “Just for your stomach” 47% of patients with low literacy understood these instructions

35. Prescription Drug Warning Labels What does this picture mean? – “Somebody is dizzy” – “Don’t touch this stuff” – “Take anywhere” – “Chills or shaking” – “Having an experience with God”

36. Prescription Drug Warning Labels “Use extreme caution in how you take it” “Medicine will make you feel dizzy “Take only if you need it”

37. Directional Signs Ambulatory Entrance Hospital XYZ Some people become confused about whether this entry was intended for ambulances or for patients Ambulatory Entrance The use of visuals clarify the message Contrast in color makes it easy to read Try to be consistent when hanging signs

38. Approaches to Address Health Literacy System vs. personal approaches (or both) Literacy assessment tools Finding easy to read materials (handout) Health care provider approaches – e.g., teach- back method, creating shame-free environment, etc. Health care symbols and signage Remember to involve your local librarian!

39. Health-Literate Care: A Patient’s Experience. Koh H K et al. Health Aff 2012;31:434-443 ©2012 by Project HOPE - The People-to-People Health Foundation, Inc.

40. Questions?