Do You Know Which Critical Public Health Issue…

1. 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 Answer: Low Health Literacy Do You Know Which Critical Public Health Issue…

2. Which One of These People Has Low Health Literacy?

3. The Issue: Low Health Literacy • What is health literacy? • The ability to read, understand and acton health information • Practical applications: • Learn how to take medications properly • Understand an informed consent form • Follow dietary and therapeutic recommendations • Navigate the health care system

4. The Problem: Low Health Literacy – Scope and Impact AMA Video – Helping your Patients Understand Finding a Solution Written Communication Verbal Communication Ask Me 3 Additional Resources Today’s Presentation Sections

5. 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 Sources: 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

6. 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

7. 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

8. 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.

9. 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.

10. Health Literacy: Helping your Patients Understand -

11. 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

12. 87% report reading Rx information Written Communication Making Health Information Understandable Written • 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

13. Mix upper and lower case letters ALL CAPITAL letters are harder to read for low-literacy Avoid Fancy or italic lettering Avoid boldface or underlining Use clear captions Emphasize desired behavior not medical facts Provide Ample White Space Use “living room” language Limit to 2-3 main points Use active voice – not passive Creating & Using Patient Friendly Materials Test reading level of materials 6th – 8th grade level lower for high risk groups.

14. Clear Health Communication in Action • Assess Reading Level of Patient Education Materials • By hand – SMOG Test – example in your packet • Less than 30 sentences, see worksheet • Computer Programs – Readability Calculations • Avoid using the Microsoft Word readability tool known to tests 2-3 grades lower than other formulas, stops at 12th grade • Field Test Materials with members of the target audience to ensure comprehension & cultural appropriateness

15. Written Communication – Using SMOG • Scientific Measure of Gobbledygook • Analysis of text by hand • Choose 30 sentences from your text • Ten consecutive sentences from 3 different areas of your text • 10 from the beginning, 10 in the middle and 10 from the end • Look at sample and instructions in packet

16. SMOG Readability Formula • Count any string of words ending in a period, exclamation point, or question mark as a sentence. • Now circle all the words which have more than two syllables (multisyllabic words) • If in doubt about # of syllables, place finger under your chin, say the word aloud, and count # of times your chin drops. Each drop is a syllable.

17. SMOG Readability Formula • Count proper nouns such as Ann or Peoria • Read abbreviations out in long form to decide if they are multisyllabic such as M.D. which has five syllables (med i cal doc tor) • Count hyphenated words as one word (pre-existing) • Numbers such as 67 are multisyllabic but 16 is not (sixty-seven vs sixteen)

18. Sample of Different Reading Levels • College Reading Level With the onset of nausea, diarrhea or other gastrointestinal disturbances, consult your physician immediately. • 12th Grade Reading Level If you experience nausea, diarrhea or other stomach or bowel problems, call your physician immediately.

19. Sample of Different Reading Levels • 8th Grade Reading Level If you start having nausea, loose bowel movements or other stomach or bowel problems, call your doctor immediately. • 4th Grade Reading Level If you start having an upset stomach, loose bowel movements or other problems, call your doctor right away.

20. Finding a Solution

21. 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

22. 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!

23. 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 Patient Provider

24. 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 Patient Provider De-stigmatize andReduce Embarrassmentof Low Health Literacy RecognizePatient Coping Mechanisms

25. 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? Diagnosis Treatment Context What Is Ask Me 3

26. Element: Patient brochure Description: Educates patients about the Ask Me 3 Motivates patients to ask their healthcare provider questions Implementation: 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

27. Element: Organization brochure Description: Explains the scope and impact of low health literacy Provides ideas and complementary roles in advancing health literacy Implementation: Distribute to partner/affiliate organizations Ask Me 3 – For Providers

28. 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?

29. 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

30. 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 Time Place Our Telephone Number: Do not eat or drink for 6 hours before the day and time on this card.

31. 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

32. 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

33. 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

34. 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

35. A Community Collaboration for Health Literacy Common Place Adult Literacy

36. Common Place of Peoria • To help adults achieve the literacy skills they need to function effectively and independently in the home, in the community,and on the job – empowering them to achieve their personal literacy, education, and employment goals • Call (309) 674-3315 to make a referral • See the “Making Referrals to Literacy Programs: Guidelines for Providers” handout

37. AskMe3 brochures and materials AMA Video – Helping Your Patients Understand for staff education Health Literacy Page on the OSF Libraries Web Site OSF Resources for Health Literacy