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Advancing Clear Health Communication to Positively Impact Health Outcomes The Problem: Low Health Literacy – Scope and Impact Finding a Solution The Partnership for Clear Health Communication Ask Me 3 How to Become Involved: Solutions into Action

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presentation sections
The Problem: Low Health Literacy – Scope and Impact

Finding a Solution

The Partnership for Clear Health Communication

Ask Me 3

How to Become Involved: Solutions into Action

For Providers: How Does Clear Health Communication Affect Your Practice

Tips for Enhancing Patient – Provider Communication

Presentation Sections
do you know which critical public health issue
Impacts nearly one in every three people living in the United States

Can hit any population segment, regardless of age, race, education or income

Costs the healthcare system as much as $58 billion a year

Can’t be diagnosed by any new medical technology and is not visible to the eye


Low Health Literacy

Do You Know Which Critical Public Health Issue…
the issue low health literacy
The Issue: Low Health Literacy
  • What is health literacy?
    • The ability to read, understand and acton health information
how big is the problem

Cannot Perform Basic Reading Tasks Required to Function in Society

Have Trouble Reading Maps and Completing Standard Forms

How Big Is the Problem?

More Than 90 Million People in the US Have Difficulty Reading

Approximately 40 to 44 Million Adults in the US Are Functionally Illiterate1

Approximately 50 Million Are Marginally Illiterate1

Average Reading Skills of Adults in the US Are Between the 8th and 9th Grade Levels2


1 Kirsch et al., “A First Look at the Results of the National Adult Literacy Survey” Nat’l Center for Education Statistics, 1993

2 Stedman L, Kaestle C. Literacy and Reading Performance in the US From 1880 to Present. In: Kaestle C, Editor. Literacy in the US: Readers and Reading Since 1880. New Haven (CT): Yale University Press; 1991. P. 75–128

who is at risk for low health literacy
Who Is at Risk for Low Health Literacy?
  • Anyone in the US – regardless of age, race, education, income or social class – can be at risk for low health literacy
    • Ethnic minority groups are disproportionately affected by low health literacy
    • The majority of people with low literacy skills in the US are white, native-born Americans
    • Older patients, recent immigrants, people with chronic diseases and those with low socioeconomic status are especially vulnerable to low health literacy
low health literacy impacts a patient s ability to fully engage in the healthcare system
Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System

The Largest Study Conducted to Date on Health Literacy Found That…

33% Were unable to read basic health care materials

42% Could not comprehend directions for taking medication on an empty stomach

26% Were unable to understand information on an appointment slip

43% Did not understand the rights and responsibilities section of a Medicaid application

60% Did not understand a standard informed consent

Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82

low health literacy negatively impacts health outcomes
Low Health Literacy Negatively Impacts Health Outcomes
  • Adults with low health literacy:
    • Are often less likely to comply with prescribed treatment and self-care regimens1
    • Make more medication or treatment errors1
    • Fail to seek preventive care1
    • Are at a higher risk for hospitalization than people with adequate literacy skills2
    • Remain in hospital nearly 2 days longer3
    • Lack the skills needed to negotiate the health care system1
  • People with low health literacy AND diabetes:
    • Were found to be less likely to have effective glycemic control4
    • Were more likely to report vision problems caused by their diabetes4

1 Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 1999

2 Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798.

3 Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993.

4 Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Sullivan GD, Bindman AB. Association of Health Literacy With Diabetes Outcomes. JAMA. July 24/31 2002 (288) No 4.

low health literacy impacts resource utilization
Adults with low literacy:

Averaged 6% more hospital visits1*

Stayed in the hospital nearly 2 days longer than adults with higher literacy skills1*

Had fewer doctor visits, but used significantly more hospital resources2

Had annual health care costs 4 times higher than those with higher health literacy3

Low Health Literacy Impacts Resource Utilization
  • Among adults who stayed overnight in a hospital

1Kirsch IS, Jugebut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: Department of Education 1993.

2Baker DW, Parker RM, Williams MV, Clark WS. Health Literacy and the Risk of Hospital Admission. Journal of General Internal Medicine. 1998; (13): 791-798.

3Weiss, BD. 20 Common Problems in Primary Care. McGraw Hill. December 1999.

implications of low health literacy
Poor Health Outcomes

Under-utilization of preventive services

Over-utilization of health services

Unnecessary health care expenditures

Limited effectiveness of treatment

Needless patient suffering

Higher patient dissatisfaction

Higher provider frustration

Implications of Low Health Literacy
solutions focus on care providers and materials
Agree that focusing on the patient-provider relationship would provide the most immediate and impactful solution to the issue of low HL

2/3 feel that low HL is driven by poor patient/doctor communication

Believe that providing easy-to-understand health information is key

Solutions: Focus on Care Providers and Materials

Healthcare Thought Leaders:

Source: A National Survey of Health Industry Influencers and Change Agents,KRC Research and Consulting, April 2002

the patient provider relationship

But just 41% of those patients say they have received this kind of assistance

17% of patients report trouble understanding Rx Information

The Patient-Provider Relationship

There Is a Disconnect Between Patient and Provider: Bridging the Information Gap Will Help Improve Health Literacy

70% of physicians say they provide patients with additional resources to help them understand their medications

75% of physicians report patients have trouble understanding Rx information

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

written communication
87% report reading Rx informationWritten Communication

Making Health Information Understandable


  • Yet only 34% believe others read this same information
  • 50% of adults read at below 8th grade reading levels
  • 20% of adults read at below 5th grade reading levels
  • 40% of seniors read at below 5th grade reading levels
  • Consumer healthcare materials written at 10th grade or above, where only 50MM can understand and act

What Do We Do?

Develop Written Materials at 6th Grade or Below, Where 160MM Can Understand and Act

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

example of health communication that may not reach a broad consumer audience
Example of Health Communication That May Not Reach a Broad Consumer Audience



Good Range



What You Need to Know About Low Blood Sugar

Treat low blood sugar quickly. If you have signs of low blood sugar, eat or drink something that has sugar in it. Some things you can eat are hard candy, sugar-sweetened soda, orange juice, or a glass of milk. Special tablets or gel made of glucose (a form of sugar) can be used to treat low blood sugar. You can buy these in a drug store. Always have some of these items handy at home or with you when you go out in case your blood sugar drops too low. After treating a low blood sugar reaction, eat a small snack like half a sandwich, a glass of milk, or some crackers if your next meal is more than 30 minutes away.

Source: The National Institute of Diabetes and Digestive and Kidney Diseases

Blood Sugar Is Too Low if It Is Under 70

Blood Sugar Is Too High if It Is Over 240

9th Grade Reading Level

example of clear health communication that reaches a broad consumer audience
Common visual used to explain concept

Uses action captions that clarify the point of the visual

Creates interaction with the reader

Example of Clear Health Communication – That Reaches a Broad Consumer Audience
verbal communication
Patients experience shame around the issue

Only 14% of patients say they feel awkward admitting they don’t understand; yet 79% feel others don’t understand

Providers experience time challenges

Providers interrupt patients 30 seconds after they start speaking; if not interrupted, patients will speak less than two minutes

Verbal Communication

Up to 80% of Patients Forget What Their Doctor Tells Them As Soon As They Leave the Doctor’s Office – ANDNearly 50% of What They Do Remember is Recalled Incorrectly

What Can We Do?

Create an Environment of TRUST

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

reaching the solution

Enhance Patient-Provider Communication

Best Way to Do It

Improve the Patient-Provider Relationship

What Needs to Be Done

Focus on Clear Health Communication

Reaching the Solution

Best Opportunity for Immediate Impact

finding a solution

Finding a Solution

The Partnership for Clear Health Communication

reaching a solution
The Partnership for Clear Health Communicationisa coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomesReaching a Solution

Introducing the Partnership for Clear Health Communication

partnership steering committee members

Consumer Organizations

Partnership: Steering Committee Members

Provider Organizations


  • American Federation of Aging Research
  • California Health Literacy Initiative
  • National Coalition for Literacy
  • National Council for La Raza
  • National Alliance for Caregiving
  • ProLiteracy Health Worldwide
  • American Medical Association Foundation
  • American Nurses Association
  • American Pharmaceutical Association
  • David Baker, MD – Northwestern School of Medicine
  • National Medical Association
  • National Alliance for Hispanic Health
  • American Public Health Association
  • Janet Ohene-Frempong, President, JO Frempong and Associates
  • National Health Council
  • Partnership for Prevention
  • Pfizer Inc (member and convener)
partnership for clear health communication
Partnership for Clear Health Communication
  • Purpose – Advance the Health Literacy issue, gain critical mass, leverage credibility and drive through the grass roots
  • Who – Nationally recognized organizations with local membership experienced in building and leading coalitions, representing a broad range of constituencies in research, policy and service delivery
  • What – Develop and execute a prioritized and coordinated Health Literacy Action Agenda to drive: Awareness/education, solutions/tools, advocacy, policy, research and evaluation

Shared Interest in Improving Health Outcomes

national action agenda
National Action Agenda

Expand awareness andeducatepatients and providers

Develop and apply practical solutions to improve patient-provider communication, and motivate the healthcare system to adopt them

Conduct nationally coordinated research and evaluation to define the health literacy issue and evaluate solutions

Conduct an active advocacy program to increase support for health literacy policy and funding

the partnership s first solution
Addresses the highest priority Action Agenda items

Awareness and education

Creates a compelling solution and Call to Actionfor patients and providers

Is designed to promote clear communication between patients and providers to improve health outcomes

Was developed with health literacy experts, then tested and validated

The Partnership’s First Solution
for patients
For Patients
  • Health information can be confusing at times
  • Everyone wants help with health information
  • Asking questions helps patients understand how to prevent or manage illness

Patients Should Not Be Anxious About Asking Their Health Care Provider Questions!

for providers
For Providers

Health Care Providers Want Patients to Know:

  • All they can about their condition/medication
  • Why this advice/treatment is important for good health
  • Steps to take to prevent a condition or keep it under control



ask me 3 creates shared responsibility for clear health communication

Provides a consistent approach to patient-provider dialogue

  • Allows patients to get information they need to manage their health
  • Time-efficient for providers to reinforce healthcare instructions
Ask Me 3 – Creates Shared Responsibility for Clear Health Communication



De-stigmatize andReduce Embarrassmentof Low Health Literacy

RecognizePatient Coping Mechanisms

what is ask me 3
Promotes three simple, but essential, questions and answers for every healthcare interaction:

What Is My Main Problem?

  • Why Is It Important for Me to Do This?

What Do I Need to Do?




What Is Ask Me 3
ask me 3 program materials available in english and spanish
Ask Me 3 – Program Materials Availablein English and Spanish

Organizational Brochure


Provider Brochure


Patient Brochure

ask me 3 for patients
Element: Poster


Stimulates curiosity about Ask Me 3

Informs patients and staff about the program

Implementation (hang poster):

In waiting areas

In exam rooms

On the ceiling, abovethe exam table

On a door

In a staff break room

Hang anywhere where provider-patient interaction takes place

Anywhere patients might see it!

Ask Me 3 – For Patients
ask me 3 for patients33
Element: Patient brochure


Educates patients about the Ask Me 3

Motivates patients to ask their healthcare provider questions


Display in waiting rooms/registration area

Distribute to patients upon arrival/sign-in

Distribute with any paperwork

Distribute during events or with mailings to patients

Ask Me 3 – For Patients
ask me 3 for providers
Element: Provider brochure


Explains the scope and impact of low health literacy

Offers communication tips

Emphasizes how effective communication can positively impact patient health outcomes


Distribute to all staff interacting with patients through staff meetings or mailings

Conduct departmental in-service training on Health Literacy and Clear Health Communication

Ask Me 3 – For Providers
ask me 3 for providers35
Element: Organization brochure


Explains the scope and impact of low health literacy

Provides ideas and complementary roles in advancing health literacy


Distribute to partner/affiliate organizations

Ask Me 3 – For Providers
ask me 3 for providers36
Ask Me 3 – For Providers
    • Has everything you need to start acting/implementing
    • Materials can be downloaded/ordered from this website
    • Other health literacy tools available on the site:
      • Bibliography on health literacy
      • List of literacy resources
      • White paper on health literacy
      • Links to other relevant websites
      • Cultural competence primer
how to become involved

How to Become Involved

Solutions Into Action

clear health communication we can all be a part of the solution
Even if you are not in a position to directly answer the three questions, keep clear health communicationin mind and in your dialogue when communicating with patients

Many people have trouble understanding medical terms. Often, these terms are better understood when explained with common words, an example or visual interpretation

Clear Health Communication– We Can All Be a Part of the Solution
clear health communication in action
Clear Health Communication in Action

Start by Decreasing the Use of Medical Jargon

Instead of Using This Word

Consider Using This One Instead

Benign Harmless

Chronic Happens again and again; does not end

Cardiac Heart

Edema Swelling; build up of fluid

Fatigue Tired

Screening Test

Intake What you eat or drink

Generic Not a brand name

Adverse events Side effects

how can your organization become involved
Visit It has background information and tools on Health Literacy/Clear Health CommunicationHow Can Your Organization Become Involved?

To Understand the Issue

To Know What Percentage of Your Practice Is Affected

  • Use the prevalence calculator – gives the approximate percentage of patients at risk of low health literacy in a physician’s practice
how can your organization become involved41
View the webcast at

Conduct an in-service training on health literacy

Include an article on the scope and impact of health literacy and the solutions in your newsletter and on your web site

How Can Your Organization Become Involved

To Educate Your Staff

To Educate Your Patients

  • Download or order the materials you need to start acting on Clear Health Communication at www.AskMe3.organd display them
  • Request a speaker to speak to a group of your patients by calling 1-877-4-ASK-ME-3
how can your organization become involved42
Join the Partnership for Clear Health Communication. Sign up as a member at Adopt the Action Agenda within your own work

Learn how to create easy to read materials using the Pfizer Principles for Clear Health Communication– available at

Dedicate a section or panel to health literacy at your next convention or meeting. Request a speaker by calling 1-877-4-ASK-ME-3

How Can Your Organization Become Involved?

To Become Actively Engaged

To Advocate for CHC

  • Share your concern about low health literacy and Ask Me 3 with your state legislators, congressional representatives and senators and advocacy groups in which you participate
for providers how does clear health communication affect your practice

For Providers: How Does Clear Health Communication Affect Your Practice?

Tips for Enhancing Patient – Provider Communication

how does low health literacy affect your practice
Chances are high that some of your patients are among the 90 million who have low health literacyHow Does Low Health Literacy Affect Your Practice?
  • You may not know that patients with poor health literacy skills are in your care:
    • They use well-practiced coping mechanisms that effectively mask their problem
    • They are often ashamed to admit they have difficulty understanding information and instructions
defining the problem scope
Defining the Problem Scope

Coping Mechanisms for Patients With Low Literacy


Ask Other Patients


Ask for Help From Medical Staff


Watch and Copy Others’ Actions


Bring Someone Who Can Read

Source: Parikh et al., 1996

what can you do
Six steps to improving patient understanding

Limit the amount of information provided at each visit

Slow down

Avoid medical jargon

Use pictures or models to explain important concepts

Assure understanding with the “show-me” technique

Encourage patients to ask questions

What Can You Do?
what else can you do
What Else Can You Do?

People Have Difficulty Making Appointments

Appointment InstructionsAlso see: Urgent Care (if you are too sick to wait for an appointment)Making a medical appointment for the first time, it is straightforward: You call 555-2222 and make a appointment at XYZ Health Services just like you would at any doctor's office.

You can request a specific clinician if you have someone in mind, or you can explain your need or problem to the appointment counselor, and he or she will schedule you with an appropriate clinician at the earliest possible date. At your first appointment you will receive a medical record card -- often referred to as your "gold card" -- which you will keep and use as your XYZ Health Services identification. 

If you are unsure about whether you should make an appointment, you may call the Advice Nurse at 666-7777. Also, in advance of your first appointment, be sure to read "How to Make the Most of Your XYZ Visit."

Please call 643-7177 to make an appointment in the Specialty Clinics, including Allergy & Travel. Specialty appointments require a referral.

You may also drop by the Appointment Office to make a medical appointment. The Appointment Office is located on the first floor in Room 1111. You may also make an appointment in the Specialty Clinics by going to the Specialty Clinic reception desk, located behind the elevators on the first floor.

If you need to cancel an appointment, please call our 24-hour cancellation line at 643-7033. Please note that you will be billed for a broken appointment fee if you do not show up for your appointment and have not called to cancel it.

  • When making an appointment, provide people with simple options and clear facts

Your Name

Your Appointment Date



Our Telephone Number:

Do not eat or drink for 6 hours before the day and time on this card.

what else can you do48
What Else Can You Do?

People Have Trouble Understanding Phone Recordings

  • Phone answered by a tape recording. Speaking quickly, the caller is offered numerous options and alternatives
  • Speak slowly and clearly
  • Provide an easy way to connect with a live person
  • Provide options in other languages
what else can you do49

Ambulatory Entrance

Ambulatory Entrance

Hospital XYZ

What Else Can You Do?

People Have Trouble Reading Signs

  • Some people become confused about whether this entry was intended for ambulances or for patients
  • The use of visuals clarify the message
  • Contrast in color makes it easy to read
  • Try to be consistent when hanging signs
what else can you do50
What Else Can You Do?

People Have Trouble Understanding Maps

Maps are usually hard to follow:

  • Too complicated
  • Codes are hard to understand
  • Names and directions not always match
  • Small fonts

To make maps easier to follow:

  • Match the color in the map with the paint color on walls or floors
  • Match the names in the map to the names on the signs
  • Use 14 point font size or larger
how can enhanced communication with your patients benefit your practice
Patients who understand health care information may:

Be more compliant with instructions and medications

Call back less often

Visit less often

Have fewer hospitalizations

Have better health outcomes

Have increased patient satisfaction

How Can Enhanced Communication With Your Patients Benefit Your Practice?

Greater Provider Satisfaction