Transcript Health_Literacy_June__10x

Costs, Consequences,
and Clinical Implications
Peggy Sissel-Phelan, Ed.D.
Community Health Centers of Arkansas
Annual Conference
June 14 – 15, 2010
Defining Literacy
An individual’s 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.
Workforce Investment Act (1998)
The ability to use printed and written information to
function in society, to achieve one’s goals, and to
develop one’s knowledge and potential.
National Assessment of Adult Literacy (2003)
Literacy Needs in Context

Historic Perspectives
 Multiple meanings
 Changing measures

20th Century Changes





1900 –
1960’s
1970’s
1980’s
1990’s
1950’s
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Industrialization
Space race
International development
Technological advancement
Globalization
Assessing Literacy
1992
National Adult
Literacy Survey
(NALS)
2003
National
Assessment of
Adult Literacy
(NAAL)
 16,000 adults ages 16+
 19,000 adults ages 16+
 1,000 incarcerated
 107 incarcerated
Methodology

NALS

NAAL
 Tested literacy tasks
 Prose, Document, and
Quantitative
 Tested literacy tasks
 Prose, Document, and
Quantitative
 5 reading skill levels
 5 reading skill levels
 Level 1 – approx. 1st grade
 Below Basic
 Level 2 – approx. 4th grade
 Basic
 Level 3 – approx. 8th grade
 Intermediate
 Level 4 – approx 12th grade
 Proficient
 Level 5 - College
 Not literate in English
 Health Literacy Component
Results

1992 NALS

2003 NAAL
 23% Level 1
 14% Below Basic
 28% Level 2
 29% Basic
 51% at Level 1 or 2
 43% at Basic or Below
plus
 5% not literate in English
=
=
 90 million U.S. adults  97 million U.S. adults
NALS and Communities
State by State Extrapolation

1992 NALS results synthesized with 1990
census data

Late 90’s Findings Released
 State
 Congressional District
 County
 City

Arkansas
Note:
Level 1
equates to
about 1st
grade
reading
skills
Estimated Adults at Level 2
Literacy Skills or Below
Number of
Counties
n=3
n=8
n = 19
n = 29
Note:
Level 2
equates to
about 4th
grade
reading
skills
n = 12
n=3
43-45%
46-51%
52-59%
60-69%
70-79%
80-89%
Percentage of Adults in Arkansas
Towns at Level 2 or Below Fayetteville
Sherwood
Arkadelphia
Bentonville
Conway
Fort Smith
Jacksonville
Jonesboro
Benton
Magnolia
N. Little Rock
Paragould
Van Buren
30-39%
Little Rock
Rogers
Russellville
Searcy
Springdale
50-59%
Blytheville Stuttgart
Texarkana
Camden
W. Memphis
El Dorado
Hot Springs
Forrest City
Pine Bluff
40-49%
70-79%
60-69%
Literacy Across Generations:
Arkansas
Below or Below Basic Literacy Skills
Percent
100
90
80
70
60
50
40
30
20
10
0
Children whose parents have low literacy skills are more likely to
become adults with low literacy skills than children whose parents
are good readers.
Thomas Sticht, 2002
Children
Parents/
Adults
Literacy Across Generations:
Arkansas
Basic or Below Basic
Parents/Adults
32%
44%
48%
42%
44%
42%
46 %
50 %
49 %
8th Graders
34%
37%
40%
46%
50%
57%
55%
58%
61%
City
Fayetteville
Bentonville
Springdale
Conway
Jonesboro
Rogers
Searcy
Benton
Arkadelphia
Note: Parents data derived from National Adult Literacy Survey, 1992
Students data derived from National Assessment of Educational Progress, 2002
Literacy Across Generations:
Arkansas
Basic or Below Basic
Parents/Adults
46 %
59%
58%
54%
63%
64%
62%
71%
78%
8th Graders
70%
58%
68%
77%
69%
70%
83%
92%
90%
City
Little Rock
Magnolia
Paragould
North Little Rock
El Dorado
Blytheville
Texarkana
Pine Bluff
Forrest City
Practical Implications

Almost half of U.S. adults lack the basic skills
needed to function successfully in society.

These Adults Can Not:


Find which foods contain a specific vitamin

Identify a specific location on a map

Use fractions

Interpret a growth chart or table
Functional illiteracy impedes health and
economic well-being.
Perspectives of
Health Literacy

Levels of Literacy Skills & Health?

Levels of Understanding & Health?
 Chronic
 Systemic
 Acute
 Preventative
Perspectives of
Health Literacy

Levels of Literacy Skills & Health?
 Chronic – persistent in daily living
 Systemic – resistance and culture of medical
settings

Levels of Understanding & Health?
 Acute – situational
 Preventative - cultural
Defining Health Literacy
ROLE
LEVEL
ACTION
EXPECTATION
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, 2000)
The degree to which individuals have the capacity to obtain,
process, and understand basic health information and
services needed to make appropriate health decisions.
(Ratzan and Parker, 2000)
Defining Health Literacy
ROLE
LEVEL
ACTION
EXPECTATION
The ability to read, understand, and act on health care
information.
(Healthy People 2010, US Department of Health and Human Services,
Office of Disease Prevention and Health Promotion, 2000, )
The ability to use printed and written information associated
with a broad range of health-related tasks to accomplish one’s
goals at home, in the workplace, and in the community (including
health care settings).
(NAAL, 2003)
Defining Health Literacy
ROLE
ROLE
LEVEL
ACTION
EXPECTATION
Health literacy allows the public and personnel working in all
health-related contexts to find, understand, evaluate,
communicate, and use information. Health literacy is the use of a
wide range of skills that improve the ability of people to act on
information in order to live healthier lives. These skills include
reading, writing, listening, speaking, numeracy, and critical
analysis, as well as communication and interaction skills.
(Calgary Charter on Health Literacy, 2008)
Defining Health Literacy
ROLE
ROLE
LEVEL
ACTION
EXPECTATION
Health literacy allows the public and personnel working in all
health-related contexts to find, understand, evaluate,
communicate, and use information. Health literacy is the use of a
wide range of skills that improve the ability of people to act on
information in order to live healthier lives. These skills include
reading, writing, listening, speaking, numeracy, and critical
analysis, as well as communication and interaction skills.
(Calgary Charter on Health Literacy, 2008)
* The interconnected expectation of improving ability to act as a result of being health
literate does not address key resource and access issues (distance, price, cultural
norms, living conditions, personal constraints)
Defining Health Literacy
ROLE
ROLE
LEVEL
ACTION
EXPECTATION
Health literacy allows the public and personnel working in all
health-related contexts to find, understand, evaluate,
communicate, and use information. Health literacy is the use of a
wide range of skills that improve the ability of people to act on
information in order to live healthier lives. These skills include
reading, writing, listening, speaking, numeracy, and critical
analysis, as well as communication and interaction skills.
(Calgary Charter on Health Literacy, 2008)
* Not simply being acted upon as the subject of care, but empowering individuals to
address their own, and others’ health as a “partner” with health care providers and
systems.
Health Literacy Needs
in Context
Changes in Care
35 yrs. ago
Today
Treatment of Acute
Myocardial Infarction
4 - 6 weeks bed
rest in hospital
2-4 days
in hospital
# Prescription Drugs
on the market
650
10,000 +
Treatment of new
onset Diabetes
3 weeks
in hospital
2 hours a day of
diabetic classes
+/- outpatient
classes 0-3 hrs.
Source: Balydon, Glusman, and Sharkey-Asner, 2009
For Reach Out and Read Illinois
Health Literacy Component
 NAAL
Health Literacy Component
 Health literacy and relationship to prose,
document, and quantitative skill.
 Address deficiencies in health literacy skills
○ Policies
○ Programs
○ Development of appropriate health information
Health Literacy Component
 NAAL
 Data on target audiences
 Relationship between health literacy and
○ educational attainment
○ age
○ race/ethnicity
○ where adults get information about health
issues, and
○ health insurance coverage
Health Literacy Component

Question types
 Clinical
 Navigation
 Preventive

Assessment Methods




Perform a task (circle word)
Decode words (read instructions)
Locate words or section (review and respond)
Interpret (infer applicability)
Elements of Health Literacy









Accessing health care system
Levels of existing health information
Locating information
Understanding rights/responsibilities
Decoding information
Making inferences about care needs
Carrying out directives
Formulating questions
Interpreting Oral information
NAAL Results
Low Health Literacy: Social
Characteristics






Reports poor health
1 or more disabilities
No health insurance or Medicaid
Fewer preventive health measures
Lower Educational Achievement
Gets no health information from the Internet
NAAL Results
Low Health Literacy: Social
Characteristics






Poverty
Racial and ethnic minorities
English as a Second Language
Single Parent Families
Older adults
Prison inmates
Consequences
of Low Literacy
 Access
 Misunderstanding
 Unable
Diagnosis
to Read Patient Education Materials
 Understanding
and Following Health Related
Instructions, compliance issues
Low Literacy Affects Access
 Locating,
obtaining, navigating
 ie: 84% of Medicaid patients do not understand rules
and regulations of the application form
 Adhering
to and accepting care
 While still in the clinic 26% did not understand
when return appointment was scheduled
 Cultural and beliefs stress no need for care
 Feelings of rejection, abuse, by health care staff
Consequences
of Low Literacy
 Medication
 Poor
2
Errors
Outcomes
x more likely to be hospitalized
 Higher
 Link:
rates of medication and treatment errors
Low literacy, poor health, and early death
 Related factors: housing, diet, addiction, violence
Costs

$38 -53 billion in unnecessary
costs annually
(Center for Health Care Strategies, Inc, 2001)

$73 billion

$106-$236 billion
 Medical
(Friedland, Georgetown University, 2003)
(Vernon, University of Connecticut, 2007)
costs for adults with low
literacy skills are four times the
national average - $21,760.
You Can’t Always Tell
In the Below Basic Literacy Group
37% have a HS or some college education
 52% speak only English
 54% have no physical or mental disabilities

Kutner M et al, Nat Center for Educ Statistics 2005
The Stigma
Patients who have never told:
%
 Supervisor
 Spouse
 Children
 Anyone
91%
68%
53%
19%
Parikh N, et al., Patient Educ Couns, 1996.
How Does It Feel?
The following passage simulates what a reader
with below basic general literacy sees on the
printed page.

Read the entire passage out loud.

You have 1 minute to read.

Hint: The words are written backwards and
the first word is “cleaning”
How Does It Feel?
GNINAELC – Ot erussa hgih ecnamrofrep,
yllacidoirep naelc eht epat sdaeh dna
natspac revenehw uoy eciton na
noitalumucca fo tsud dna nworb-red
edixo selcitrap. Esu a nottoc baws
denetsiom htiw lyporposi lohocla. Eb
erus on lohocla sehcuot eht rebbur
strap, sa ti sdnet ot yrd dna yllautneve
kcarc eht rebbur. Esu a pmad tholc ro
egnops ot naelc eht tenibac. A dlim
paos, ekil gnihsawhsid tnegreted, lliw
pleh evomer esaerg ro lio.
How Does It Feel?
 How
do you clean the capstan?
Red Flags: What to Look for
Unable to name medications, or explain
purpose or timing of administration
 Difficulty explaining medical concerns
 Detour, letting doctor miss the concern
 Have no questions

 Incomplete
registration forms
 Frequently missed appointments
 Skipped tests and referrals
 Non-compliant with meds
Red Flags: What to Look for
Seeking help only when illness is advanced
 Walking out of the waiting room
 Becoming angry, demanding
 Clowning around, using humor
 Being quiet, passive
 Making excuses
 Pretending they can read

Or . .
 “I
forgot my glasses. I’ll read this when I
get home.”
 “Let
me bring this home so I can discuss it
with my husband.”
Strategies: Make Changes






Lessen stigma: Approach all patients the same
way
Be non-judgmental.
There is no one correct way to ask
There are natural times in the history during
which you can bring this up
Never ask “do you have questions”
Use, what kind of questions do you have?
Strategies: Enhance
Communication
Attitude of helpfulness, caring and
respect by all staff
 Conduct patient-centered visits
 Explain things clearly in plain language
 Focus on key messages and repeat
 Use a “teach back” or “show me”
technique to check for understanding
 Use patient-friendly educational
materials to enhance interaction

Strategies: Use Plain
Language:
Examples
 Anti-inflammatory
 Benign
 Contraception
 Hypertension
 Oral
 Echocardiogram
Stops Swelling
Not Cancer
Birth Control
High BP
By Mouth
Picture of the heart
Plain Language:
It’s not just medical terms!
We are disseminating information about….
We are giving out information about…
How do you administer the medication?
How do you give the medicine?
Have you ever purchased generic medications?
Do you ever buy store brand medicine?
This product has an extensive list of symptoms that it treats…
This medicine can help with many things like fever, or
pain, etc….
Strategies: Use Patients’ Social
History
 How
far did you go in school?
 Did you ever have any difficulty in school?
 Has reading ever been a problem for you?
Other possible ways to ask:
 Have you ever had difficulty reading
materials the doctor gave you?
 Has a doctor ever been unclear
when they explained things to you?
D.I.R.E.C.T.
D- Do you have any Difficulty reading
IAre you interested in Improving
R- We have Referrals/resources available
E- Ask Everyone
C- This is a Common problem
T- Take down the barriers to obtaining the
resources and take down current barriers to
providing effective care
Source: Balydon, Glusman, and Sharkey-Asner, 2009
For Reach Out and Read Illinois
Strategies: Written materials
 Simple
words (1-2 syllables)
 Short
sentences (4-6 words)
 Short
paragraphs (2-3 sentences)
 No
medical jargon
 Headings
 Lots
and bullets
of white space
Strategies: Teach Back

Ask patient to demonstrate understanding

“What will you tell your spouse about your child’s
condition?”

“I want to be sure I explained everything clearly, so
can you please explain it back to me so I can be sure I
did.”

Academic settings can use the resident or
student/attending interaction to do this

Do not ask,
 “Do you understand?”
Strategies: Use Visuals






Show or draw simple pictures
Focus only on key points
Emphasize what the patient should do
Minimize information about anatomy
and physiology
Be sensitive to cultural preferences
Visual aids can include handouts,
pictures, models etc.
System Change




Identify patients
Identify the barriers faced by both patients
and clinicians
Identify and implement strategies to
enhance health literacy
Advocate for system change
Resources
Pfizer Clear Health Communication Initiative
http://www.pfizerhealthliteracy.com
NYU Patient and Family
Resource Center
http://www.nyupatientlibrary.org/medcenter/build-skills
Center for Health Care Strategies
Health Literacy Fact Sheets
http://www.chcs.org/publications3960/publications_show.htm?doc_id=291711
Resources
Institute for Healthcare Advancement
www.iha4health.org
Michael Villaire, MSLM
Director, Programs and Operations
[email protected]
(800) 434-4633 x202
American Medical Association
Health Literacy Program and Kit
www. ama-assn.org
Resources
Communicating Health Information. Editorial.
Critical Care Nurse. 2004;24: 8-13
http://ccn.aacnjournals.org/cgi/content/full/24/4/8
Assessing the Nation’s Health Literacy:
Key Concepts and Findings of the National Assessment of
Adult Literacy (NAAL)
Sheida White, PhD
National Center for Education Statistics
A Publication of the American Medical Association Foundation
“Help Your Patients Understand.”
Video Available from AMA Foundation
http://www.ama-assn.org/ama/pub/category/8035.html