Health Literacy Its Importance to Healthcare Professionals

1. Health Literacy Its Importance to Healthcare Professionals Michelle Burda, MLS mburda@pitt.edu (412) 624-1589 Network and Advocacy Coordinator National Network of Libraries of Medicine Middle Atlantic Region Developed by NN/LM staff. This project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services, under Contract No. HHS-N-276-2011-00003-C with the University of Pittsburgh-Health Sciences Library System.

2. ObjectivesAfter this session you will: • Define the meaning of health literacy • Identify the various types of literacy • Recognize the impact health literacy plays in patient care • Identify methods to evaluate a patient’s health information literacy level

3. Literacy skills are a stronger predictor of health status than: Age Income Employment status Education level Race or Ethnic group Weiss, BD. Health Literacy: A Manual for Clinicians. AMA 2003 p.7.

4. What is Health Literacy? “The degree to which individuals have the capacity to obtain, process, and understandbasic health information and services needed to make appropriate health care decisions.”* *Ratzan, S., and R. Parker. (2000); Healthy People 2010 and Healthy People 2020 Health Literacy = finding, understanding, evaluating, communicating, and using information to make decisions.* Applies to both public and health professionals *Calgary Chapter on Health Literacy It is an emerging public health issue that effects all ages, race and income levels*. *National Patient Safety Foundation

5. Why is health literacy important in managing chronic illness? • To understand health-related instructions • To follow discharge instructions • To identify signs or symptoms • To keep appointments • To understand insurance coverage • To fill out a patient information forms • To sign consent forms

6. “Costs” of low health literacy • Low health literacy costs the U.S. more than $58 billion annually. • 50% of the U.S. adult population (90 million) fall into the low or basic health literacy category.

7. The Literacy Problem

8. National Assessment of Adult Literacy (NAAL)http://nces.ed.gov/NAAL • Conducted in 2003 • More than 19,000 adults >16yr. • One-on-one administration • Goal: assess literacy in English

9. Results of NAAL: Literacy Statistics • Functionally illiterate = 23% of adults • Marginal literacy skills = 28% of adults • Proficient = Only 13% of adults • 66% of adults over age 60 have inadequate or marginal literacy skills • Average reading level in the U.S. is 8th grade; 20% read at 5th grade level or below

10. National Assessment of Adult Literacy(NAAL)Health Literacy

11. Graph of % of adults in each literacy Level Comparison of 1992 and 2003

12. Three Types of LiteracyProse Document Quantitative Requires ability to search, comprehend, and use continuous text • Non-continuous text • Requires ability to search, comprehend, & use information Requires ability to identify & perform computations, using numbers within printed materials

13. Prose LiteracyExample of a surgical consent form

14. Document Literacy • Non-continuous text • Requires ability to search, comprehend, and use information

15. Document Literacy

16. Quantitative Literacy • Requires ability to identify and perform computations, using numbers within printed materials.

17. Factors affecting learning ability • Stress • Illness • Age • Cultural Barriers • Language Barriers

18. You can’t tell by looking

19. What it is like to be a patient who doesn’t understand*? *AMA Foundation Health Literacy Help Patients Understand 2nd ed. 2007 (short version) www.amafoundation.org/go/healthliteracyt Version

20. Testing for Readability

21. Overview • Method • Word count • Syllables • Sentence length • Readability of Materials • Fry • SMOG • Patient Literacy (REALM, TOFHLA, Newest Vital Sign) • Computer software

22. SMOG Simple Measure Of Gobbledygook • Count off 10 sentences near the beginning, 10 in the middle and 10 at the end of text. • Circle every word containing 3 or more syllables and total the number of words circled • Estimate the square root of the total number of words counted • Add three to the square root. SMOG grade = 3 + Square Root of Polysyllable Count http://www.readabilityformulas.com/smog-readability- formula.php

23. REALM Rapid Estimate of Adult Literacy in Medicine • Asks patients to pronounce 66 words ranging from “fat” to “impetigo” • Test provides grade level scores for people who read below a ninth grade level • May be better suited for research • Realm SF – Form http://www.lsuhscshreveport.edu/HealthLiteracy/HealthLiteracyInfoFAQ.aspx Terry C. Davis, Ph.D.

24. What is the Newest Vital Sign? • Also know as NVS • New tool for rapid assessment of health literacy skills • First published Dec. 2005 Annals of Family Medicine Quick Assessment of Literacy in Primary Care: The Newest Vital Sign by Barry D. Weiss, MD. Professor of family and community medicine at University of Arizona College of Medicine • 3 minute assessment- Ice cream label • English & Spanish

25. Newest Vital Sign

26. Interpretation of Scores • Number of correct answers Score : 0-1 suggest likelihood (50% or more ) of limited literacy Score: 2-3 indicated the possibility of limited literacy Score: 4-6 almost always indicates adequate literacy

27. Functional Health Literacy “The ability to read and comprehend prescription bottles, appointment slips, and the other essential health related materials required to successfully function as a patient”* *AMA Council of Scientific Affairs

28. Red Flags • Forms incomplete or incorrectly filled out • Non-adherence to medication instructions • Can’t name medications, purpose, or how to take (color) • Frequently missed appointments • “I forgot my glasses” • Anger • My wife, friend etc. usually takes care of ……. AMA Foundation 2007

29. Task: Appointment Slip • Locate information in a simple document. • When is your next appointment? Where? CLINIC APPOINTMENT CLINIC: Diabetic DAY: Thursday DATE: April 2nd HOUR: 6:45 YOU MUST BRING YOUR PLASTIC CARD WITH YOU

30. Task: Prescription Label • Example of a prescription Label Bouvier, Patricia FF9418262 Dr. Hibbert, Julius DOXYCYCLINE 100 MG Take medication on empty stomach one hour before or two to three hours after a meal unless otherwise directed by your doctor.

31. What’s “plenty” of water? “Take twice a day “Don’t take medicine if you’ve been in the sun too long.” Medication Safety and Health LiteracyOnly about 50% of patients take meds as directed

32. Do your patients know what sodium is? Note: We rarely say, “Pass the sodium, please.”

33. Dosage using a spoon • Kitchen spoons • Medication dispensing spoons

34. Reading a thermometer

35. Reading ability vs. Listening ability She may be able to read but does she understand what she is reading? You may be able to read the written word but do you understand the spoken word?

36. Medical studies indicate most people suffer a 68% hearing loss when naked.

37. And, furthermore… • Up to 80% of patients forget what a doctor told them as soon as they leave the office! • Nearly 50% of what they do remember is remembered incorrectly!

38. Improving Oral Communication • Communication is two-way • Use “teach back” instructions • Avoid medical jargon • Use commonly understood words • Limit information • Include visual aids- models, pictograms, • Videos

39. Invite questions We usually say – Do you have any questions? • Better to say: What questions do you have? Implies you are expecting questions. • Or…. Let me answer any questions you may have. Assess understanding If we ask - Do you understand? Easy to say yes. We are implying the patient understands or should understand what we just said to them. • Better to use “teach back” technique http://www.youtube.com/watch?v=_Vo9Q_EfBX8

40. Summary • Assess patients’ needs • Focus on 1-3 key “need-to-know” items • Use “plain language” • Use visual aids • Ask ”what questions do you have” • Use “teach back” to validate understanding http://healthliteracymn.org/sites/default/files/images/files/Teach-Back%20Program%20Guide.pdf

41. Tools and Resources Internet Resources

42. Tools & Resources • Health Literacy Universal Precautions Toolkit • Plain Language • Teach Back NLM Resources • MedlinePlus • SeniorHealth • DailyMed

43. http://medlineplus.gov • Easy-to-Read materials • Medical Dictionary • Understanding Medical Words tutorial • Interactive tutorials • How to write easy-to-read materials: http://www.nlm.nih.gov/medlineplus/etr.html

44. Senior Health • Developed with the National Institute on Aging • Senior-friendly features: • Text Size • Contrast • Short segments of information http://nihseniorhealth.gov/

45. NLM Mobile http://www.nlm.nih.gov/mobile/ • MyMedList

46. Plain English/Plain Language http://www.plainlanguage.gov • Promote the use of plain language for all government communications • Examples, word suggestions, thesaurus • Separate section for health literacy

47. Health Literacy Universal Precautions Toolkithttp://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/ • Experts recommend assuming everyone may have difficulty understanding • Systems are needed to be in place to promote better understanding not only to those we think may need help • Promoting health literacy improves health outcomes • Areas that are important to address • Improve spoken communication • Improve written communication • Improve self-management & empowerment • Improve supportive systems Tools to address these areas are included in the toolkit

48. Key Players • Partnership for Clear Health Communication/AskMe3 Initiative http://www.npsf.org/askme3/ • Centers for Disease Control and Prevention – Simply Put http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf • U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion http://www.health.gov/communication/literacy • “Health Literacy Online: A Guide to Writing and Designing Easy-to-Use Health Web Sites” (U.S. Dept. HHS) http://www.health.gov/healthliteracyonline/index.htm

49. More Key Players • Hablamos Juntos – “Universal Symbols in Health Care Workbook” http://www.rwjf.org/pr/product.jsp?id=15864 • Clear Health Communications (Pfizer) http://www.pfizerhealthliteracy.com/ • Health Literacy Consulting http://www.healthliteracy.com • Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/browse/hlitix.htm • National Center for the Study of Adult Learning & Literacy ( end federal funding 2007 but all resources are online-training, teaching materials etc. http://www.ncsall.net/index.html@id=1.html

50. National Network of Libraries of Medicine Middle Atlantic Region About the Middle Atlantic Region (MAR)http://nnlm.gov/mar/ • The University of Pittsburgh Health Sciences Library System (HSLS) serves as the Regional Medical Library (RML) for the National Network of Libraries of Medicine, Middle Atlantic Region (NN/LM, MAR) under a 5-year contract with the National Library of Medicine.  The MAR is one of eight regions in the National Network of Libraries of Medicine (NN/LM) and includes Delaware, New Jersey, New York and Pennsylvania.