Health literacy from discussion to action may 2012
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Health Literacy: From Discussion to Action May 2012. Rima E. Rudd, Sc.D. Harvard School of Public Health Boston, Massachusetts USA. Kia Ora. With gratitude. Down Under Explorations New Zealand Journey Partnership Developments. Literacy. Core components Reading Writing Speaking

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Health literacy from discussion to action may 2012

Health Literacy:From Discussion to ActionMay 2012

Rima E. Rudd, Sc.D.

Harvard School of Public Health

Boston, Massachusetts USA


Kia ora

Kia Ora

With gratitude

  • Down Under Explorations

  • New Zealand Journey

  • Partnership Developments


Literacy

Literacy

Core components

  • Reading

  • Writing

  • Speaking

  • Listening

  • Calculating [math, math concepts]

Social Meaning

  • Identity

  • Dignity

  • Inclusion & participation

    • Civic

    • Economic

    • Cultural

    • Intellectual

Dr. Rima E. Rudd - May 2012

3


Pedagogy paulo freire

Pedagogy: Paulo Freire

Naming and Owning the World

The word is not the privilege

of some few men, but the right

of every man

Pedagogy of the Oppressed, 1967

Dr. Rima E. Rudd - May 2012

4


Literacy in industrialized societies

Literacy in Industrialized Societies

Literacy influences one’s ability to access information and to navigate the highly literate environments of modern society

Dr. Rima E. Rudd - May 2012

5


Literacy and social factors

Literacy and Social Factors

People with high literacy skills are more likely to

  • Be employed

  • Have access to resources/wealth

  • Have at least high school education

  • Hold majority status

  • Live in geographically accessible and developed areas

  • Use libraries, read newspapers, vote

    [Rudd, Kirsch, Yamamoto, 2004]

Dr. Rima E. Rudd - May 2012

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Health literacy

Health Literacy

  • A new field of inquiry

  • Starting point

    • Publication and dissemination of findings in 1990s: Literacy skills of adults

    • Question: What are the implications for health?

Dr. Rima E. Rudd - May 2012

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Literacy health research findings

Literacy & Health:Research Findings

Literacy is linked to:

  • Information / Knowledge

  • Health care navigation

  • Participation in health promotion

  • Participation in disease prevention

  • Management of chronic diseases

  • Morbidity & Mortality

IOM, 2004

ETS, 2004

AHRQ 2004, 2011

Dr. Rima E. Rudd - May 2012

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Research studies health outcomes

Research Studies: Health Outcomes

Key Finding: Patients with limited reading skills have poorer health outcomes

  • Less likely to engage in screening & preventive action

  • Less likely to have chronic disease under control

  • Less likely to advocate for themselves

  • More likely to be hospitalized

  • More likely to report poor health

  • More likely to die earlier

    Conclusion: Significant differences in health outcomes based on patients’ reading skills

Dr. Rima E. Rudd - May 2012

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Analysis missing perspective

Analysis: Missing Perspective

Health literacy studies has kept its eye on the patient

BUT: Literacy is contextual

For example:

Reader&Text

Speaker & Listener

Dr. Rima E. Rudd - May 2012


Health literacy and the focus of attention

Health Literacy and the Focus of Attention

Recommended Action for Individuals & Communities:

Participate

Find

Comprehend

Evaluate

Use

Determine

Who carries

the burden of change?

Dr. Rima E. Rudd - May 2012

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Refocus

Refocus

Health

Care

Public

Health

Demands

Expectations

Processes

Culture

Professional skills:

Roles

Language

Skills

Processes

Commercial Sector

Civil

Society

Dr. Rima E. Rudd - May 2012

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Health literacy application of skills in health contexts for health tasks

Health Literacy: Application of skills in health contexts for health tasks

Health Literacy is an interaction between skills of individuals and the demands of health systems

IOM Committee on Health Literacy,

April 2004

Dr. Rima E. Rudd - May 2012

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Consider the demands of the health sector

Consider the Demands of the Health Sector

World wide, we see an increased demand from complex health care systems & increased responsibility for individuals interacting with health care systems

Adult Literacy and Lifeskills Surveys 2003

Dr. Rima E. Rudd - May 2012

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Consider literacy demands in health settings

Consider Literacy Demands in Health Settings

Dr. Rima E. Rudd - May 2012


Reading

Reading

Consider the quality of health materials:

  • Explanations

  • Directions

  • Instructions

16


Writing

Writing

Consider expectations & materials provided

  • Questionnaires & survey instruments

  • Forms

  • Consent & other legal documents

17


Oral exchange

Oral Exchange

  • Listening: Consider the speech & language of a wide variety of health professionals

  • Speaking: Consider what people are asked to describe and present.

  • Question asking: Consider power & efficacy

18


Health literacy from discussion to action may 2012

Math

Consider:

  • Needed calculations

  • The variety of tools provided

  • The words/concepts often unexplained

    • Range

    • Normal

    • Probability & Likelihood

    • Risk

19


Characteristics of health systems

Characteristics of Health Systems

Culture of science & medicine

Language of specialized professional groups

Perspective based on science & medicine

Hierarchies within and among professional groups

Patterned behaviors reflecting bureaucratic needs

Accepted processes for history taking, diagnosis, tests, procedures, care, consent…

Complexity of procedures, processes, institutions

Expectations related to knowledge and appropriate behaviors

Dr. Rima E. Rudd - May 2012

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Interaction

Interaction

Individual Factors

Literacy & numeracy skills

Language skills

Emotional state

Health status

Experience

Background knowledge

Health Sector Factors

Communication skills of professionals

Institutional characteristics

Procedures & processes

Materials in use

Assumptions

Dr. Rima E. Rudd - May 2012

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What happens when words get in the way

What Happens When Words Get in the Way?

Lose your way

Make errors

Run out of words

Retreat into silence

Cover up

Limit participation

Miss opportunities

Be assigned a passive role

Lose dignity

Lose entitlements

Lose rights

Endanger health

Dr. Rima E. Rudd - May 2012

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Needed emphasis balancing act

Needed Emphasis:Balancing Act

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Change practice

Change Practice

“The definition of insanity is continuing to do the same thing over and over again and expecting a different result”

Variously attributed to Benjamin Franklin / Albert Einstein

Dr. Rima E. Rudd - May 2012

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How a public health lens

How? A Public Health Lens

Reciprocal relationship between persons & environment

  • Epidemiology

  • Health Education

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Strategy nothing so practical as a good theory

Strategy: Nothing so practical as a good theory

  • Consider facilitating factors and barriers

  • First: Identify and remove barriers

  • Then: Strengthen facilitating factors

    Lessons from

    Kurt Lewin’s

    Force Field Analysis

Dr. Rima E. Rudd - May 2012

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Health literacy from discussion to action may 2012

Who?

What can we do?

  • Journalists

  • Public Health Officers

  • Health Care Managers

  • Health Care Professionals

  • Academics & Researchers

  • Policy Makers

  • Public/Members of Communities

Literacy teachers

Dr. Rima E. Rudd - May 2012

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Journalists

Journalists

  • Focus on the full picture [both sides of the coin]

  • Improve access to information

    • Be attentive to existing skills

    • Draw lessons from health literacy studies [scientific and medical cultural assumptions, jargon, complexity]

    • Help the diffusion process

    • Enhance communication skills of health researchers & professionals

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Public health officials and practitioners

Public Health Officials and Practitioners

  • Improve access to information

    • Examine and modify tools & materials

    • Examine and modify health environments

    • Insist on rigor [regulate production of critical texts]

  • Engage in participatory processes

    • Work in and with communities

    • Engage intended audiences in development and reviews

  • Build and enhance community resources

    • Share expertise and information

    • Promote opportunities for analyses

    • Engage in community based problem solving

Dr. Rima E. Rudd - May 2012

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Health literacy from discussion to action may 2012

Dr. Rima E. Rudd - May 2012

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Research studies health materials

Research Studies: Health Materials

Key Finding: Most health materials are written at a level that far exceeds the reading skills

of the average high school graduate

Conclusion: A majority of adults in most industrialized nations do not have the

literacy skills needed to use health related print materials and tools with accuracy and consistency.

Health materials & tools are poorly written & poorly designed

Dr. Rima E. Rudd - May 2012

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Change materials consider the task and tools

Change Materials:Consider the Task and Tools

Finding: Over 1,500 studies demonstrate a mismatch between health resources and the skills of the intended audience

Suggestion:

Assess information in print, on-line, in oral presentations

Apply rigorous research

Pilot, modify, pretest with members of the intended audience

Dr. Rima E. Rudd - May 2012

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Model good practice

Model Good Practice

Protocols for Development

Requirements for ease of use

Rigor for user reviews

Regulations

Dissemination

Materials as models of communication

Critical Texts

Reports

Brochures

Response to complaints

Informed consent

Test results

Instructions [e.g. discharge documents]

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Health care managers

Health Care Managers

  • Link health literacy to patient safety

  • Address emerging legal responsibilities:

    Failure to provide patients with information

    about their care in ways that they can

    understand, will continue to undermine

    other efforts to improve patient safety.

    Joint Commission

    Public Policy White Paper, 2007

Dr. Rima E. Rudd - May 2012

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Identify and eliminate literacy barriers

Identify and Eliminate Literacy Barriers

How literacy friendly are your

healthcare settings?

Are navigation tools/aides

readily available?

Is technology put to good use?

Do words serve as barriers to access, navigation, care, consent, dignity?

Dr. Rima E. Rudd - May 2012

35


Develop accessible organizations

Develop Accessible Organizations

Physical environment: remove barriers to entry, navigation, services

Social context: change expectations, norms, language, rituals, & encourage dialogue

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Orient and train health care workers

Orient and Train Health Care Workers

  • Normative change

    • Staff as ambassadors

    • Questions welcomed

  • Integration of HL into orientation and training for all

  • Scripts & tool boxes for common interactions

Dr. Rima E. Rudd - May 2012


Create shame free environments

Create Shame Free Environments

Offer help to all

Encourage questions & sharing concerns

Let patients know that others have difficulties

Define medical and scientific words

Explain procedures [what is next]

Literacy and Patient Safety: Help Patients Understand. Manual for clinicians. AMA Foundation, 2007

Dr. Rima E. Rudd - May 2012

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Institute protocols and policies

Institute Protocols and Policies

Institute rigor for critical texts

  • Protocols for materials development

  • Requirements for review

    • Scientific

    • Lay public

  • Standards for assessments

Dr. Rima E. Rudd - May 2012


Health professionals

Health Professionals

  • Enhance Professional Education

    • Diffusion of information: Mismatch between demands/skills

    • Communication skills

  • Require and support dual language skills[professional language and everyday language]

  • Encourage question asking

  • Apply teach back

Dr. Rima E. Rudd - May 2012


Researchers

Researchers

Expand Scope of Inquiry

  • 5 Aspects of literacy

  • Both sides of the coin

  • Implementation studies

Consider the Data

  • Interview protocols

  • Questions

  • Inclusion/Exclusion

  • Validity

Dr. Rima E. Rudd - May 2012


Policy makers

Policy Makers

  • Articulate expectations for professional rigor related to critical health materials

  • Consider health systems

    • Social and Physical Environment

    • Processes

    • Work Force Development

  • Consider Regulations

Dr. Rima E. Rudd - May 2012

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Regulations

Regulations

  • Standards for critical texts

    • Processes for all vendors

    • Review boards & articulated processes

  • Environmental standards

  • Accreditation requirements for institutions

  • Professional training & licensing requirements

  • Staff orientations

Dr. Rima E. Rudd - May 2012

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Policy us example

Policy – US Example

Potential for change:

Public Law 111–274 111th Congress

An Act

To enhance citizen access to Government information and services by establishing that Government documents issued to the public must be written clearly…

111TH CONGRESS 2d Session

COMPILATION OF PATIENT PROTECTION

AND AFFORDABLE CARE ACT

Dr. Rima E. Rudd - May 2012


Members of communities

Members of Communities

  • Identify trustworthy sources of information

  • Ask questions

  • Offer feedback

  • Expect and ask for translations [from jargon to plain words]

  • Advocate for change

Dr. Rima E. Rudd - May 2012

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All reorientation

All: Reorientation

  • Share wisdom & experience

  • Make information accessible

  • Ease entry and access

  • Develop partnerships for action

Dr. Rima E. Rudd - May 2012


Urgency

Urgency

Health Disparities

  • Morbidity

  • Mortality

Equity

Literacy skills have implications for social justice

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Attention to disparities

Attention to Disparities

  • Distribution of literacy skills is linked to social factors

  • Literacy is a social determinate

  • Match/Mismatch between demands and skills has implications for justice & dignity

    • Access to information

    • Participation & Agency

      • In prevention and early detection

      • For chronic disease management

      • For informed choice [personal and policy]

Dr. Rima E. Rudd - May 2012

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Time for outrage

Time for Outrage

Stephane Hessel

Time for Outrage: Indignez-vous!

New York, NY: Twelve. 2011.

We must rely on our belief in human rights, the violation of which must provoke our indignation

Dr. Rima E. Rudd - May 2012

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Time for action

Time for Action

Documented: Literacy skills of adults in industrialized nations

Documented: Links between literacy and health outcomes

Documented: Mismatch between demands and skills

Business as usual

is unethical

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Possible benefits

Possible Benefits

  • Participation

  • Increased agency

  • Enhanced access

  • Reduced Disparities

  • Social Justice

  • Equity

Healthy People

Healthy Communities

Dr. Rima E. Rudd - May 2012

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Cautionary note

Social & Behavioral Sciences

Culture

Norms

Resources

Power

Efficacy

Education

Persuasion ...

Health Literacy

Access+

Communication

Dialogue

Mutual respect

Foundation for action

Cautionary Note

Dr. Rima E. Rudd - May 2012


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