Transcript Health Literacy - Arkansas Sophe

Health Literacy
Laura Owens, PhD, RN
Debra Walden, MNSc,RN
Arkansas State University
1
The National Literacy Act
defines literacy
• The ability to read, write, and speak
English, and compute and solve problems
at levels of proficiency necessary to
function on the job and in society, to
achieve one’s goals, and develop one’s
knowledge and potential.
2
Literacy
• Using printed and written information to
function in society, to achieve one’s goals,
and to develop one’s knowledge and
potential.
– National Adult Literacy Survey (2003) US
Department of Education
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NAAL
• The National Assessment of Adult Literacy
(NAAL) 2003
• Conducted by the National Center for
Education Statistics
• Sample of more than 19,000 adults
• Instruments that directly measured literacy
tasks
4
NAAL
• Three types of literacy were
measured in the NAAL
–Prose literacy
–Document literacy
–Quantitative literacy
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Prose Literacy
• The knowledge and skills needed to
search, comprehend, & use information
from continuous texts.
• Editorials, news stories, brochures, and
instructional materials.
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Document Literacy
• The knowledge and skills needed to
search, comprehend, & use information
from noncontinuous texts.
• job applications, payroll forms,
transportation schedules, maps, tables, &
drug and food labels.
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Quantitative literacy
• The knowledge and skills needed to
identify and perform computations using
numbers that are embedded in printed
materials.
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Quantitative Literacy
balancing a checkbook
figuring out a tip
completing an order form
determining the amount of interest on
a loan
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Four literacy levels
• Assessment results were reported at four
levels
• Below Basic
• Basic
• Intermediate
• Proficient
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Below Basic
• No more than the most simple and
concrete literacy skills
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Basic
• Can perform simple and everyday literacy
activities
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Intermediate
• Can perform moderately challenging literacy
activities
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Proficient
• Can perform complex and challenging literacy
activities
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Literacy Results
• 11 millions adults are could not even be
tested!
• 7 million adults could not answer simple
test questions
• 4 millions adults could not test because of
a language barrier
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Average scores of
participants
• Prose literacy – low intermediate literacy
• Document literacy – low intermediate
literacy
• Quantitative literacy – high basic literacy
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Results: Prose Literacy
•
•
•
•
Below Basic 14% or 30 million
Basic 29% or 63 million
Intermediate 44% or 95 million
Proficient 13% or 28 million
• 43% of adult Americans cannot
perform moderately challenging
prose literacy activities
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Who Has the Lowest Literacy
Level?
Those who:
Have not graduated from high school
Did not speak English in the home before
starting school
Are Hispanic or black
Are over the age of 65
Have multiple disabilities
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Interested in learning more?
• Other significant correlations were found in
the NAAL related to employment, income,
family and community. These can all be
found at the National Center for Education
Statistics website.
• http://nces.ed.gov
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Literacy in Arkansas
• More than 20% of Arkansas adults read at
or below a fifth-grade level
• 25% do not have a high school diploma
• 35% of those who didn’t complete high
school have only an 8th grade education
• Lack of a high school diploma correlates
with lower literacy
– Arkansas Literacy Council
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So what does this mean for
Healthcare?
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It means….
• Adults ages 65 and older have the lowest
average literacy scores of all age groups
• Average literacy increased with each
increasing level of education
• White adults had higher prose literacy
scores than Black and Hispanic adults for
all levels of education
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Health Literacy
• The degree to which individuals have the
capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions.
• Healthy People 2010
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Health Literacy
• Health literacy is the ability to apply the literacy
skills needed to function fully and effectively as
a patient.
• Davis et. al, 1996.
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Health literacy affects people’s
ability to read:
•
•
•
•
-patient education information
-prescription labels
-appointment cards
-consent forms
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Low health literacy affects people’s
ability to:
– Navigate the healthcare system,
following signs and reading maps
– Share personal information with health
care providers
– Understand mathematical concepts such
as risk/benefit ratios
– Calculating medication dosages
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Literacy is:
• The single best predictor of health
status
– More than
• Age
• Income
• Employment status
• Education level
• Racial or ethnic group
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Noncompliance…
• May be due to low literacy
– Low literate persons may not take their
medications correctly or at all
– Might miss appointments
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Reading Level
• Reading level is often lower than stated years of
education
• Most health education materials are written at a
reading level of 10th grade or above
• The average reading level of Americans is at the 7th
or 8th grade level
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National Assessment of Adult
Literacy: NAAL 2003
– Health literacy of adults measured for first
time
– Health literacy measured by tasks usually
required of adults in the healthcare system
– The health tasks measured by three NAAL
scales: prose, document, and quantitative
literacy
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NAAL 2003
• Tasks used to measure health literacy were
organized around three domains of health –
– Clinical
– Prevention
– Navigation of the healthcare system
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NAAL 2003
• Background questionnaire
– General demographic and background questions
– Specific health related questions
•
•
•
•
Health status
Preventative health practices
Health insurance coverage
Sources of information about health issues
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NAAL 2003
• Scores for health literacy were grouped in the
same levels as for the general literacy
–
–
–
–
Below basic
Basic
Intermediate
Proficient
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Examples of Health Literacy Tasks:
2003
Below basic
– “Circle the date of a medical appointment on a
hospital appointment slip”
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Examples of Health Literacy Tasks:
2003
Basic
- “Give two reasons a person with no symptoms
of a disease should be tested for a disease, based
on information in a clearly written pamphlet.
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Examples of Health Literacy Tasks:
2003
• Intermediate
– “Find the age range during which children should
receive a particular vaccine, using a chart that shows
all the childhood vaccines and the ages the children
should receive them.”
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Examples of Health Literacy Tasks:
2003
• Proficient
– “Calculate an employee’s share of health insurance
costs for a year using a table that shows how the
employee’s monthly cost varies depending upon
income and family size.”
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Demographic Findings Related to
Health Literacy
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Gender
• Women had higher health literacy scores than
men
• More men (16%) had Below Basic health literacy
than women (12%)
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Race and Ethnicity
• White and Asian/Pacific Islander adults had higher
health literacy than Black, Hispanic, American
Indian and Multiracial adults.
• Hispanic adults had lower health literacy than any
other group. Black adults had the next lowest
scores.
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Age
• Adults aged 65 and older had lower health
literacy than any other age group.
• Fewer adults over 65 were in the intermediate
and proficient categories when compared to
adults from younger age groups
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Educational Attainment
• Starting with high school graduates, health
literacy increased with each higher level of
educational attainment.
• Never completing or attending high school is a
strong predictor of below basic health literacy
scores
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Poverty Threshold
• Adults living below the poverty level had lower
health literacy than adults living above the
poverty level.
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Overall Health
• Adults with higher literacy reported better
overall health as reflected by higher scores on
the “self report of health”
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Health Insurance Coverage
• Those who received health insurance coverage
through their employer, the military or private
insurance had higher average health literacy than
those who received Medicare, Medicaid or had
no health insurance.
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How People Get Health Information
• Adults with lower literacy were more likely to
receive health information through radio or
television than through written sources.
• Adults with higher health literacy were more
likely to receive health information through
written sources such as newspapers, magazines,
books, brochures, or the internet.
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NAAL 2003
Average Literacy Scores
• 12% had Proficient health literacy
• 53 % of adults had Intermediate health literacy
• 22% had Basic health literacy
• 14% had Below Basic health literacy
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Other Current Research Findings…
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Health Literacy & Age
• Health literacy decreases with advancing age
– After age 65 studies show a decrease in health
literacy with marked declines after age 85
– These studies controlled for health status, education
level, and various behavioral factors
– So….older adults have poorer health
literacy
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Self-reported Poor Health
• Persons with inadequate functional health
literacy were consistently more likely to report
poor health than patients with adequate reading
skills.
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Health Literacy & Preventative Care
• Poor health literacy is a barrier to:
–
–
–
–
–
Immunizations
Colorectal screening
Mammography
Digital rectal examinations
Pap smears
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Knowledge of Chronic Diseases &
Other Health Issues
– Those with poorer health literacy
• have significantly less knowledge of their
chronic diseases, such as hypertension,
diabetes, asthma, HIV
• And less knowledge about smoking,
postoperative care, contraception
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Health Literacy & Health Behaviors
• Many studies show an inverse relationship
between health literacy and smoking
• Mothers with higher literacy are more likely to
breastfeed
• Many studies show a relationship between health
literacy and adherence to HIV regimens and
control of the disease
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• Diabetic patients with higher health literacy are
more likely to have better glycemic control and
have fewer complications of diabetes
• Mother’s literacy predicts child’s diabetic control
• Low literacy negatively effects cancer incidence,
mortality, and quality of life
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Health Literacy & The Health Care
System
• Patients with low literacy
– Have more emergency room visits
– Make more clinic visits
– Are hospitalized more often
– A documented financial burden on the system
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In Summary…
• Low health literacy affects all areas of health
– Prevention and screening activities
– Treatment of illness
– Management of chronic disease
– Knowledge of chronic disease
* So the lower the literacy level, the poorer the
outcome…
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Assessment and Interventions
• We know there is a
problem….so
• How do we find
these people? And…
• How do we help
them?
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Screening Tools for Clinical Practice
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The REALM
• Rapid Estimation of Adult Literacy in Medicine
(REALM)
• Instrument that utilizes word recognition and
pronunciation to assess health literacy
• Quick and reliable method to estimate grade
level reading ability
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Newest Vital Sign (NVS)
• Three minute instrument
• Nutrition label that is accompanied by six
questions
• Patients with four correct responses are unlikely
to have low literacy
• Reliable and accurate measure of literacy in the
clinical setting
• Available in both Spanish and English versions.
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Identifying Persons with Low
Literacy
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What You Might See…
• Non-compliance with medications or
treatment regimen
• Missed appointments and lack of followthrough with tests or referrals
• Filling out forms incompletely or
incorrectly
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What You Might See….
• Difficulty navigating their environment
• Unable to name medications or explain
their purpose
• Identifying medications by color or shape
rather than by name
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How To Begin The Discussion…
Be compassionate and empathetic
Be aware of the shame of low literacy
Avoid closed ended questions such as:
“Can you read this?” or “Do you have difficulty
reading?”
Instead ask:
“How happy are you with the way that you
read?”
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Things to Remember
• Asking about grade completed in school only
gives a limited picture of literacy
• Offer assistance with reading or completing
forms by saying:
“Filling out these forms is difficult for
many people, would you like some help?”
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Improving Communication with
Patients with Low Health Literacy
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How to Improve Written
Communication with Low Literacy
Patients
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Instructions: Making Them Easy to
Read
• Use conversational tone
– You and we
– Use plain language not jargon
• “Drugs to treat cancer” vs. Chemotherapy
• “Pain killer” vs. Analgesic
• “Get bigger” vs. Enlarge
• “Not cancer” vs. Benign
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Instructions: Making Them Easier
• Demonstrate how to take needed action
• Provide visual step-by-step diagrams
• Be specific in instructions
– Take two pills each day, once in the morning, once in
the evening.
• 6th grade reading level
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Instructions: Making Them Easier
•
•
•
•
Evaluate the patient’s level of understanding
‘Can you tell me what you are supposed to do?’
Provide in multiple languages
Train staff to provide assistance when
completing forms
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General Principles Related to Written
Material
• Limit message to a few key points
• Present information concretely
– Put pills in a pill box…
• Repeat most important points
• Content should be age and culturally appropriate
• No higher than 5th grade reading level
– 3rd for limited literacy populations
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General Principles
• Add simple line drawings to illustrate a point
• Avoid complex diagrams with unnecessary detail
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General Principles: Fonts
• Use large type font
– At least 12pt
• Limit the number of font styles used
– Use a font with serifs to improve readability
• Avoid ALL
CAPITOL LETTERS
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General Principles: Layout
•
•
•
•
Use headings and bullets
Avoid long sentences
Leave white space
Use captions to highlight information
Key
Information
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for noloc recnac. It sevlovni gnitresni a
elbixelf gniweiv epocs into your mutcer.
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noloc.
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How to Improve Verbal
Communication with Low Literacy
Patients
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Verbal Communication
•
•
•
•
Listen to the client
Speak slowly
Sit during the meeting rather than stand
Ask patient to explain their understanding of the
medical condition and treatment
– Use the “teach back” method
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Verbal Communication
• Create opportunities for discussion
• Encourage a list of questions and concerns
– Many older adults will not question a health
professional
– Ask, “What questions do you have?” not “Do
you have any questions?”
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Verbal Communication
• Use plain language
– “‘Living room” language
• Use orienting statements
– “‘Now we will talk about your high blood pressure”
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Verbal Communication
• Limit information at each meeting
• Stress the most important point
– “Your blood pressure is too high and you need to
start taking medicine to lower your blood pressure”
– Information about hypertension physiology,
complications…should be discussed later.
• Always review important points!
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Verbal Communication
• Use or draw a picture to illustrate a point
– Simple line drawing is best
– Avoid adding details that are irrelevant
• Use with verbal and written explanation not as a
substitute
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Verbal Communication
• Verify understanding of material
– “Some people get dizzy taking this medicine. If that
happens to you what will you do?”
– Ask patient to explain or demonstrate what they
have learned.
• Summarize the points made during the teaching
session
• Conclude with what the patient can expect next
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Strategies Helpful for Older
Adults with Low Literacy
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Teaching Strategies for Older Adults
• Scheduling issues
– Timed when energy level is high
– Brief ‘mini-sessions’ as opposed to 1 hour
• Relate new information to past experience
– Use stories to connect information in a personal way
• Present information 1 step at a time
– Omit unnecessary information
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Strategies for Working with Older
Adults
• Create a supportive environment
– Welcome patients with attitude of helpfulness
– Provide assistance with paperwork and insurance
issues
– Provide a quiet place to talk and ask questions
– Use straight back chairs
– Have a person, not a machine answer the phone
– Ask them to bring in all medicines to the first visit
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Strategies for Working With Older
Adults
Supportive Environments:
– Use large, easy to follow signs
– Provide directions or guide to find unfamiliar
locations
– Provide assistance with scheduling return or referral
appointments
– Consider visual and hearing impairment in addition
to literacy concern
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Alternative Teaching Methods
•
•
•
•
Audiotapes and CD
CD-ROM instruction
Interactive CD-ROM and Internet
www.usability.gov for resources
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Thank You!
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