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Health Literacy June 10

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  • 1. Health Literacy:
    Costs, Consequences,
    and Clinical Implications
    Peggy Sissel-Phelan, Ed.D.
    Community Health Centers of Arkansas
    Annual Conference
    June 14 – 15, 2010
  • 2. 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)
  • 3. Literacy Needs in Context
    Historic Perspectives
    Multiple meanings
    Changing measures
    20th Century Changes
    1900 – 1950’s . . . . . . . . Industrialization
    1960’s . . . . . . . . . . . . . . Space race
    1970’s . . . . . . . . . . . . . . International development
    1980’s . . . . . . . . . . . . . . Technological advancement
    1990’s . . . . . . . . . . . . . . Globalization
  • 4. Assessing Literacy
    2003
    National Assessment of Adult Literacy
    (NAAL)
    19,000 adults ages 16+
    107 incarcerated
    1992
    National Adult Literacy Survey
    (NALS)
    16,000 adults ages 16+
    1,000 incarcerated
  • 5. Methodology
    NAAL
    Tested literacy tasks
    Prose, Document, and Quantitative
    5 reading skill levels
    Below Basic
    Basic
    Intermediate
    Proficient
    Not literate in English
    Health Literacy Component
    NALS
    Tested literacy tasks
    Prose, Document, and Quantitative
    5 reading skill levels
    Level 1 – approx. 1st grade
    Level 2 – approx. 4th grade
    Level 3 – approx. 8th grade
    Level 4 – approx 12th grade
    Level 5 - College
  • 6. Results
    2003 NAAL
    14% Below Basic
    29% Basic
    43% at Basic or Below
    plus
    5% not literate in English
    =
    97 million U.S. adults
    1992 NALS
    23% Level 1
    28% Level 2
    51% at Level 1 or 2
    =
    90 million U.S. adults
  • 7. 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
  • 8. Note:
    Level 1 equates to about 1st grade reading skills
  • 9. Estimated Adults at Level 2 Literacy Skills or Below
    Number of Counties
    Note:
    Level 2 equates to about 4th grade reading skills
    n = 3
    n = 8
    n = 19
    n = 29
    n = 12
    n = 3
     
     
    43-45% 46-51% 52-59% 60-69% 70-79% 80-89%
  • 10. 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
     
    Blytheville
    Camden
    El Dorado
    Hot Springs
     
    Forrest City
    Pine Bluff
    30-39%
    40-49%
    50-59%
    60-69%
    70-79%
    Little Rock
    Rogers Russellville
    Searcy
    Springdale
     
     
    Stuttgart
    Texarkana
    W. Memphis
     
  • 11. Literacy Across Generations: Arkansas
    Below or Below Basic Literacy Skills
    Percent
    100
    90
    80
    70
    60
    50
    40
    30
    20
    10
    0
    Children
    Parents/Adults
    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
  • 12. Literacy Across Generations: Arkansas
    Basic or Below Basic
    Parents/Adults 8th Graders City
    32% 34% Fayetteville
    44% 37% Bentonville
    48% 40% Springdale
    42% 46% Conway
    44% 50% Jonesboro
    42% 57% Rogers
    46 % 55% Searcy
    50 % 58% Benton
    49 % 61% Arkadelphia
    Note: Parents data derived from National Adult Literacy Survey, 1992
    Students data derived from National Assessment of Educational Progress, 2002
  • 13. Basic or Below Basic
    Parents/Adults 8th Graders City
    46 % 70% Little Rock
    59% 58% Magnolia
    58% 68% Paragould
    54% 77% North Little Rock
    63% 69% El Dorado
    64% 70% Blytheville
    62% 83% Texarkana
    71% 92% Pine Bluff
    78% 90% Forrest City
    Literacy Across Generations: Arkansas
  • 14. 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
    • 15. Identify a specific location on a map
    • 16. Use fractions
    • 17. Interpret a growth chart or table
    Functional illiteracy impedes health and
    economic well-being.
    Practical Implications
  • 18. Perspectives ofHealth Literacy
    Levels of Literacy Skills & Health?
    Levels of Understanding & Health?
    Chronic
    Acute
    • Systemic
    • 19. Preventative
  • Perspectives ofHealth 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
  • 20. 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 individualshave the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
    (Ratzan and Parker, 2000)
  • 21. 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 accomplishone’s
    goals at home, in the workplace, and in the community (including
    health care settings).
    (NAAL, 2003)
  • 22. Defining Health Literacy
    ROLE ROLE
    LEVEL
    ACTION
    EXPECTATION
    Health literacy allows the public andpersonnel working in all health-related contextsto find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improvethe ability of people to act on informationin order tolive 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)
  • 23. Defining Health Literacy
    ROLE ROLE
    LEVEL
    ACTION
    EXPECTATION
    Health literacy allows the public andpersonnel working in all health-related contextsto find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improvethe ability of peopleto act on informationin 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)
  • 24. Defining Health Literacy
    ROLE ROLE
    LEVEL
    ACTION
    EXPECTATION
    Health literacy allows the public andpersonnel working in all health-related contextsto find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improvethe ability of peopleto 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.
  • 25. Health Literacy Needs
    in Context
    Changes in Care35 yrs. ago Today
    Treatment of Acute 4 - 6 weeks bed 2-4days Myocardial Infarction rest in hospital in hospital
    # Prescription Drugs 650 10,000 +
    on the market
    Treatment of new 3 weeks +/- outpatient
    onset Diabetes in hospital classes 0-3 hrs.
    2 hours a day of
    diabetic classes
    Source: Balydon, Glusman, and Sharkey-Asner, 2009
    For Reach Out and Read Illinois
  • 26. 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
  • 27. 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
  • 28. 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)
  • 29. 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
  • 30. 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
  • 31. NAAL Results
    Low Health Literacy: Social Characteristics
    Poverty
    Racial and ethnic minorities
    English as a Second Language
    Single Parent Families
    Older adults
    Prison inmates
  • 32. Consequences of Low Literacy
    Access
    Misunderstanding Diagnosis
    Unable to Read Patient Education Materials
    Understanding and Following Health Related Instructions, compliance issues
  • 33. 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
  • 34. Consequences of Low Literacy
    Medication Errors
    Poor Outcomes
    2 x more likely to be hospitalized
    Higher rates of medication and treatment errors
    Link: Low literacy, poor health, and early death
    Related factors: housing, diet, addiction, violence
  • 35. Costs
    $38 -53 billion in unnecessary costs annually (Center for Health Care Strategies, Inc, 2001)
    $73 billion (Friedland, Georgetown University, 2003)
    $106-$236 billion (Vernon, University of Connecticut, 2007)
    Medical costs for adults with low literacy skills are four times the national average - $21,760.
  • 36. 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
  • 37. The Stigma
    Patients who have never told:
    %
    Supervisor 91%
    Spouse 68%
    Children 53%
    Anyone 19%
    Parikh N, et al., Patient EducCouns, 1996.
  • 38. 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”
  • 39. How Does It Feel?
    GNINAELC – Oterussahgihecnamrofrep, yllacidoirepnaelcehtepatsdaehdnanatspacrevenehwuoyecitonnanoitalumuccafotsuddnanworb-red edixoselcitrap. Esu a nottocbawsdenetsiomhtiwlyporposilohocla. Eberus on lohoclasehcuotehtrebbur strap, satisdnetotyrddnayllautnevekcarcehtrebbur. Esu a pmadtholcroegnopsotnaelcehttenibac. A dlimpaos, ekilgnihsawhsidtnegreted, lliwplehevomeresaergrolio.
  • 40. How Does It Feel?
    How do you clean the capstan?
  • 41. 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
  • 42. 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
  • 43. 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.”
  • 44. 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?
  • 45. 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
  • 46. Strategies: Use Plain Language:
    Examples
    Stops Swelling
    Not Cancer
    Birth Control
    High BP
    By Mouth
    Picture of the heart
    Anti-inflammatory
    Benign
    Contraception
    Hypertension
    Oral
    Echocardiogram
  • 47. Plain Language: It’s not just medical terms!
    We are disseminating information about….
    We are giving outinformation about…
    How do you administer the medication?
    How do you givethe medicine?
    Have you ever purchased generic medications?
    Do you ever buystore brand medicine?
    This product has an extensive list of symptoms that it treats…
    Thismedicinecan help with many thingslike fever, or pain, etc….
  • 48. 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?
  • 49. D.I.R.E.C.T.
    D- Do you have any Difficulty reading
    I- Are 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
  • 50. Strategies: Written materials
    Simple words (1-2 syllables)
    Short sentences (4-6 words)
    Short paragraphs (2-3 sentences)
    No medical jargon
    Headings and bullets
    Lots of white space
  • 51. 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?”
  • 52. 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.
  • 53. 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
  • 54. 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
  • 55. Resources
    Institute for Healthcare Advancement
    www.iha4health.org
    Michael Villaire, MSLM
    Director, Programs and Operations
    mvillaire@iha4health.org
    (800) 434-4633 x202
    American Medical Association
    Health Literacy Program and Kit
    www. ama-assn.org
  • 56. 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

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