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Health Literacy. Paul D. Smith, MD, Associate Professor University of Wisconsin Department of Family Medicine [email protected] Topics today. General health literacy information Results of WAFP Health Literacy Survey Communication Issues What can you do?. Literacy skills.

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Health Literacy

Paul D. Smith, MD, Associate Professor

University of Wisconsin

Department of Family Medicine

[email protected]


Topics today

  • General health literacy information

  • Results of WAFP Health Literacy Survey

  • Communication Issues

  • What can you do?


Literacy skills


What is Literacy?

National Adult Literacy Survey 1992

“Using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential.”


More than just reading grade level

  • Prose Literacy

    • Written text like instructions or newspaper article

  • Document literacy

    • Short forms or graphically displayed information found in everyday life

  • Quantitative Literacy

    • Arithmetic using numbers imbedded in print


What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”


What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”


What is Health Literacy?

The Institute of Medicine 2004

“The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”


Real People with Real Problems

  • Insert video clip here


National Adult Literacy Survey

  • Federal survey conducted in 1992

  • 26,000 people over age 15

  • Living in households and prisons

  • Divided into 5 levels


National Adult Literacy Survey

  • Level 1 – find one piece of information

  • Level 2 – find two related pieces of information

  • Level 3 – integrate multiple pieces of information

  • Level 4 – respond

  • Level 5 – analyze, formulate


National Adult Literacy Survey

  • Level 1 – find one piece of information

    • Can:

      • Sign name on a document

      • Identify a country in a short article

      • Total a bank deposit slip


National Adult Literacy Survey

  • Level 1 – find one piece of information

    • Cannot:

      • Enter information on a social security card application

      • Locate an intersection on street map

      • Calculate the total cost on an order form


National Adult Literacy Survey

  • Level 2 – Find two related pieces of information

    • Can:

      • Identify YTD gross pay on a paycheck

      • Determine price difference between tickets for 2 shows


National Adult Literacy Survey

  • Level 2 – Find two related pieces of information

    • Cannot:

      • Use a bus schedule

      • Balance a check book

      • Write a short letter explaining error on a credit card bill


National Adult Literacy Survey

47-51% of Americans in Levels 1 and 2


National Adult Literacy Survey

39% of Wisconsin adults in Levels 1 and 2


How Age Effects NALS Data

  • Adults age 60 and over

  • Living in households or prisons

  • 68-80% are in Level 1 and 2

  • More in Level 1 and 2 with advancing age

  • 89-99% Level 1 and 2 age 80 and over


Literacy Levels Change with Age

Document Literacy


Literacy Levels Change with Age

80 and over

Level 1 + 2

89%

Document Literacy


Literacy Levels Change with Age

BUT, they do not recognize their problem

Age 60 and older

  • 91% Read well or very well

  • 88% Write well or very well

  • 83% Do arithmetic well or very well


2003 National Assessment of Adult Literacy

  • Data released 12/05

  • ~17,000 people participated

  • Changed reporting methodology


New Reporting Method

  • 80% correct responses moved down to 67%

  • 4 categories

    • Below basic

    • Basic

    • Intermediate

    • Proficient


2003 National Assessment of Adult Literacy


2003 National Assessment of Adult Literacy

The Bottom Line

  • Not much change

    • Prose a bit worse

    • Document a bit better

    • Quantitative a bit better


Clinician Survey

  • 16 question email survey

  • Sent to 411 Wisconsin family physicians

  • 28% response rate


Impact on Quality and Outcomes

>87%

Number of Respondents

Impact Health Outcomes

Impact Quality of Care


Results : Prevalence

Mean = 17.4%

NALS= 47-51%

Number of Responses


Results

Does your clinic screen patients?


The Bottom Line

  • Physicians are aware of literacy impacting on health and health care

  • They underestimate the extent of the problem


The Impact of Low Literacy on Health

  • Poorer health knowledge

  • Poorer health status

  • More hospitalizations

  • Higher health care costs


Poorer Health Knowledge

Diabetics that know low glucose symptoms

94%

50%


Poorer Health Knowledge

Hypertensives that know exercise lowers BP

68%

40%


Poorer Health Status

Diabetics with retinopathy

36%

19%


Poorer Health Status

  • 2923 new Medicare enrollees

  • Inadequate literacy had increased frequency of:

    • Diabetes

    • Hypertension

    • Heart failure

    • Arthritis


Poorer Health Status

  • Medical Outcomes Study (SF-36)

  • Inadequate literacy had

    • Decreased:

      • Physical function

      • Mental health

    • Increased

      • Limitations in activity due to physical health

      • Pain that interferes with normal work activities


More Hospitalizations

2 year hospitalization rate for patients visiting ED

31%

14%


Increased Health Care Costs

Total annual Medicaid charges

$10,688

$2,890


Increased Health Care Costs

Based on NALS data

Majority from increased hospitalizations


Reading Levels

  • 20% of American adults read at or below the 5th grade level

  • Most health care materials are written above the 10th grade level.


Low Literacy is Overlooked

  • Clinicians don’t ask about literacy

    • Some are not aware of the problem

    • Not sure how to ask

    • Not sure how to respond

    • Do not want to open the can of worms


Low Literacy is Overlooked

  • Patients do not volunteer their literacy problem

    • Many are ashamed

    • Some do not recognize their inadequate literacy

    • Lack of trust


The Big Secret

  • % of low literate adults that have not told their:


More likely to have Low Literacy

  • Older

  • Immigrants

  • Less education

  • Incarceration


More likely to have Low Literacy

  • Non-white

  • Low-income

  • Medical Assistance


Low Literacy is Overlooked

  • Many Level 1 people don’t fit the stereotypes

    • 75 % born in USA

    • 50% are white

    • 40% hold full or part-time jobs


Common Clues of Low Literacy

  • Patients say things like:

    • “I lost my glasses”

    • “I’d like to discuss this with my family”

    • “I have a headache now and can’t focus”


Common Clues of Low Literacy

  • Medication review

    • Looking vs reading

    • Unable to name med

    • Do not know why taking med

    • Do not know medication timing


Common Clues of Low Literacy

  • Non-compliance

    • Medications

    • Testing

    • Consultations


Patient Communication Processes

  • Patient-physician communication

    • Patient history

    • Informed consent

    • Medical instructions


Patient Communication Processes

  • Patient education materials

  • Prescription labeling


Patient Communication Processes

  • Responding to medical and insurance forms

  • Navigating the clinic or hospital


Verbal Communication Strategies

  • Whole staff must be aware and sensitive

  • Create a culture of helpfulness

  • Quiet room with minimal distractions


Front Desk/Registration

  • Always offer to help complete forms

  • Simplify registration forms

  • Only ask for information that you need


Verbal Communication Strategies

  • SLOW DOWN

  • Simple terms

    • Use monosyllabic and colloquial terms

    • Avoid or explain the medical jargon.

  • Begin with important information first and limit new information.

  • Repeat the information/instructions


Verbal Communication Strategies

  • Have the patient repeat the information, use the “teach back” method.

  • No more than one or two instructions at a time—and check each time: “Chunks and Checks”.

  • Write it down.


Verbal Communication Strategies

  • Use models, sketches, pictures.

  • Give instructions to several of family members.

  • Consider follow up phone calls.


Written Materials- Common Mistakes

  • Readability level is too high

  • Too much detail

  • Hard words are not explained


Written Materials- Common Mistakes

  • Pictures do not reinforce the message

  • No examples


Written Materials

  • Review materials for reading level

    • 5th – 6th grade reading level

    • Flesch-Kincaid grade level


Objectives

  • Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.

  • Identify people at increased risk of low literacy

  • Acquire an understanding of specific activities they can do to improve verbal communication with all patients, especially low literacy adults

  • Identify the important issues to address when developing educational documents for low literate adults

    Flesch-Kincaid Grade Scale: 12


Objectives

  • Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.

  • Identify people at increased risk of low literacy

  • Acquire an understanding of specific activities they can do to improve verbal communication with all patients, especially low literacy adults

  • Identify the important issues to address when developing educational documents for low literate adults

    Flesch-Kincaid Grade Scale: 12


Topics today

  • General health literacy information

  • How to recognize people with low literacy

  • How to improve communication

  • Factors to consider when creating documents

    Flesch-Kincaid Grade Scale: 12


Topics today

  • Health literacy.

  • Finding people with low literacy.

  • How to improve communication.

  • How to make things easier to read.

    Flesch-Kincaid Grade Scale: 7.1 (talking for communication = 5.1)


Beyond handouts

  • Pictures and models

  • Audiotapes and CDs

  • Videotapes and DVDs

  • CD-ROM

  • Internet


What can be done?

  • Raise awareness

    • American Medical Association Foundation

      • Low Health Literacy: You Can't Tell By Looking

      • Health Literacy: Help Your Patients Understand

    • Institute of Medicine

      • Prescription to End Confusion


What can be done?

  • Distribute the handouts about health literacy resources.

  • Consider partnering with a local Community-based adult literacy organization.


What can be done?

  • Be a patient.

    • Review processes

    • Review documents

  • The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed tomake appropriate decisions regarding their health.


Summary

Low literacy is a common problem.

Low literacy affects health.


Summary

Low literacy is hard to identify.

Most of our documents are written at a reading level that is too high.


Wisconsin Literacy

  • Coordinating organization for community-based adult literacy organizations

  • 44 Organizations scattered around the state

  • New funding for regional facilitators


Wisconsin Literacy

  • www.wisconsinliteracy.org

  • Michele Erikson, director

    • 608-257-1655

    • [email protected]


“Action expresses priorities.”

---Mohandas Gandhi


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