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Health Literacy Internal Medicine

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    • 1. An Introduction to Ycaretil Htlaeh Mary J. Markland MA, AHIP UND SE Clinical Campus Librarian February 15, 2008
    • 2.
      • "Not knowing how to read feels like being blind, ignorant, not able to understand or ask people. I feel embarrassed to tell the doctor I cannot understand."
      • Anonymous Patient
    • 3. AMA Video Health Literacy: Help Your Patients Understand
    • 4. Do you know?
      • Which of the following is the strongest predictors of an individual’s health status?
      • A) Age
      • B) Income
      • C) Literacy skills
      • D) Education level
      • E) Racial or ethnic group
    • 5. True or False?
      • Most people with limited literacy are poor, immigrants or minorities.
      • Most people with limited literacy have low IQs.
      • People will tell you if they have trouble reading.
      • The number of years of schooling is a good general guide to determine literacy level
    • 6. What is Health Literacy
      • Healthy People 2010 defines health literacy as the ability to obtain, process and understand health information and services to make appropriate health decisions.
    • 7. Another Definition:
      • Health literacy is the degree to which people can understand basic health information and services they need to make appropriate health decisions, including:
        • Reading an appointment slip
        • Interpreting prescription information
        • Understanding recommendations for health care
        • Completing health insurance applications
        • Understanding informed consent
    • 8. Health Literacy is Math too
      • Cholesterol and blood sugar levels
      • Measuring medications
      • Understanding nutrition labels
      • Choosing between health plans or comparing prescription drug coverage requires calculating premiums, copays, and deductibles.
    • 9. The Literacy Problem
      • Nearly half of the U.S. adult population (90 million people) have low functional health literacy (National Adult Literacy Survey (NALS) data)
      • 11 million adults are non-literate in English (2003 National Assessment of Adult Literacy (NAAL) data)
      • 7.8 million seniors can only perform the most simple and concrete literacy skills (Below Basic) (2003 National Assessment of Adult Literacy (NAAL) data)
    • 10. Literacy Levels of Adults in America 2003 National Assessment of Adult Literacy (NAAL) *Estimates Reading Ability NAAL Level *Approx Grade Level % of Pop. Below Basic Basic 1 2 0-5 6-8 14 (30 mil) 29 (47 mil) Intermediate 3 9-12 44 (114 mil) Proficient 4 College 15 (12 mil)
    • 11. Literacy Levels of Adults in America: Sample of Tasks Typical of Level (NAAL)
      • Below Basic
      • Searching a short, simple text to find out what a patient is allowed to drink before a medical test
      • Signing a form
      • Adding amounts on a deposit slip
      • Can’t use bus schedule, find intersection on map
      • Can’t fill out social security application
      • Basic
      • Using a television guide to find out what programs are on
      • Comparing the ticket prices for two events
      • Can’t use bus schedule
      • Can’t read a bar graph
      • Can’t write a letter of complaint
      • Intermediate
      • Consulting reference materials to find out which foods contain a certain vitamin
      • Identifying a specific location on a map
      • Calculating the total cost of ordering office supplies from a catalog
      • Proficient
      • Comparing viewpoints in two editorials
      • Interpreting a table about blood pressure, age and physical activity
      • Computing and comparing the cost per ounce of food items
    • 12.
      • The average reading level in the U.S. is 8th grade, and 20 percent read at the 5th grade level or below. (NALS data)
      • 40 percent of seniors read at or below the 5th grade level (Doak, Doak, and Root)
      • 50 percent of African Americans and Hispanics read at or below the 5th grade reading level (Center for Health Care Strategies)
        • Welfare recipients
        • Chronic physical and/or mental health conditions
        • Native Americans
      • Most health-related material is written at the 10th grade reading level or higher (Institute of Medicine)
      • Literacy skills are a stronger predictor of health status than age, income, employment status, education level or racial/ethnic group (Partnership for Clear Health Communication)
      • http://askmethree.com/health-literacy.aspx
    • 13. People with low functional health literacy have:
      • Poorer health status
      • Less treatment adherence and a greater number of medication/treatment errors
      • Higher rates of health services utilization, including 29 - 69 percent higher hospitalization rates
      • Higher health care costs:
        • $50 - $73 billion in additional health expenditures annually
        • $7,500 more in annual health care costs for a person with limited health literacy, versus a person with higher health literacy skills
      Partnership for Clear Communication http://askmethree.com/health-literacy.aspx
    • 14. Implications for HealthCare
      • Misread prescriptions and OTC instructions
      • Can’t read or understand appointment slips, letters or informed consent
      • Can’t read or understand directions for procedures like colonoscopies
      • Patients are noncompliant
      • Risk management issues
      • Diagnoses are made at later stages
    • 15. Literacy in North Dakota
      • North Dakota
        • Level 1 15%
        • Level 1 or 2 39%
      • Cass County
        • Level 1 or 2 27%
      • Grand Forks County
        • Level 1 or 2 30%
      • Burleigh County
        • Level 1 or 2 32%
      • Pembina County
        • Level 1 or 2 45%
      • Mercer County
        • Level 1 or 2 44%
      Data based on 1992 National Adult Literacy Survey and the 1990 Census Data from Synthetic Estimates of Literacy/National Institute for Literacy http://www.nifl.gov/reders/reder.htm
    • 16. How to Identify a Patient
      • Common phrases
        • I can’t read this now. I forgot/broke my glasses.
        • I’m in a hurry. Can I read this at home?
        • My eyes are tired. Could you read this for me?
        • I’m not feeling very good. Could you read this for me?
        • Do you have a videotape on this?
    • 17. How to Identify a Patient
      • Behaviors
        • Clarification – individual asks a lot of questions about written information
        • Visual clues – individual may be holding paper upside down while trying to read it
        • Inability to please – none of the materials are “right” or “fit their needs” or “it’s just not what I was looking for”
        • Indifference – individual hands written materials to an accompanying family member
        • Can’t read directions on their prescription bottles
    • 18. Screening Tools
    • 19. REALM Rapid Estimate of Adult Literacy in Medicine Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, Bairnsfather LE. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991 Aug;23(6):433-5.
    • 20. Abbreviated REALM Directions
      • The survey only takes 2 to 3 minutes to do
      • I want to hear you read as many words as you can from this list. Begin with the first word on List 1 and read aloud. When you come to a word you cannot read, do the best you can or say “blank” and go on to the next word
      • If the patient takes more than five seconds on a word say “blank” and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word; have him/her pronounce only known words.
      • Count as an error any word not attempted or mispronounced. Count the number of correct words for each list and record the numbers in the “SCORE box.
      • Total the numbers and match the total score with its grade equivalent in the table below:
    • 21.
      • Newest Vital Sign
      • Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22. Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83.
      • Assesses general literacy and numeracy skills
      • Quick to administer (three minutes)
      • Available in both English and Spanish.
      Ice Cream Label
    • 22.  
    • 23. Quick Screening Questions
      • 1. How often do you have problems learning about your medical condition because of difficulty understanding written information?
      • 2. How often do you have someone help you read hospital materials?
      • 3. How confident are you filling out medical forms by yourself?
      • Possible answers are: always, often, sometimes, occasionally, never
      • Most effective question was the “filling out medical forms.” An answer of “sometimes” was indicative of literacy issues.
      Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006 Aug;21(8):874-7.
    • 24. What to do about handouts
    • 25. Basic information about a colonoscopy, as perceived by a patient with limited literacy skills
    • 26. What Makes a Handout Easy-to-Read
      • Limit major points to 3-5 “need-to-know”
      • Sections are short, distinct, labeled with subheadings
      • Key messages are action-focused, up front and repeated
      • Bulleted lists
      • Conversational, active voice, friendly tone
      • Use pictures
      • Lots of white space, make sure there is good contrast between the print and the paper.
      • 12pt. Font
      • Only use capital letters when grammatically needed
    • 27. Watch Your Words and Numbers
      • Words that have multiple meanings
        • Stool, dressing, gait
      • No Acronyms
        • HDL, CAT, MRI, PCI, CBT
      • Put Health Measurements in a context
        • Give a healthy cholesterol number and then their number
      • Idioms don’t always work
          • Are you feeling blue? Try using sad instead.
      • Once means 11 in Spanish
    • 28. Where Can You Find Easy-To-Read Handouts?
      • MedlinePlus
        • http://medlineplus.gov
      • AAFP Family Doctor
        • http://www.familydoctor.org/
      • Commercial Publishers
        • Journeyworks Publishing
        • Channing-Bete Company
        • Krames
      • Health and Literacy Compendium – an annotated bibliography of print and web-based health materials for use with limited-literacy adults
        • http://healthliteracy.worlded.org/docs/comp/
        • http://healthliteracy.worlded.org/teacher-2.htm
    • 29. How Readable are Your Handouts?
      • Use the SMOG readability test
        • http://www.med.utah.edu/pated/authors/readability.html
      • Flesch-Kincaid Grade Level Index
        • Computes readability based on the average number of syllables per word and the average number of words per sentence. The score in this case indicates a grade-school level.
        • Found in Microsoft Word under Tools/Options/Spelling and Grammar
        • Computer typically gives a score of 2-3 grade levels below what a document calculated by hand would have scored.
        • To improve the accuracy have appropriate sample size of at least 30 sentences or 300-500 words.
        • Remove all headings, lists with bullets, sentence fragments, abbreviations, etc.
    • 30. Problems with Screening Tools
      • Do not account for the organization of the text including design and layout.
      • Do not measure complexity and difficulty of concepts.
      • Do not determine if the text is culturally appropriate or relevant.
      • Do not calculate the readers’ previous background on the content of the text.
      • Do not account for the readers’ interest to learn the information.
    • 31.  
    • 32. Flesch Reading Level Grade 6.3 Flesch Reading Ease 66.8/100 – 65 is the plain English score Is it easy to read?
    • 33. Flesch Grade Level 6.8 Flesch Ease of Reading Level 64.5/100 Flesch Grade Level 6.6 Flesch Ease of Reading level 66.8/100
    • 34. What Can You Do?
      • Be respectful and caring
      • Slow down
      • Offer audio or video options
      • Have the patient repeat back your instructions
      • Use pictures and models
      • Make sure your printed materials are written at
      • < 5 th grade level
      • No Jargon
      • Focus on “need-to-know” information. Most people can only remember 3-5 items at one time.
    • 35. How Can You Encourage Reading Skills in Your Patients?
      • Encourage children and parents to read together
        • Reach Out and Read Program
          • http://www.reachoutandread.org/
        • Imagination Library
          • http://www.dollywoodfoundation.com
      • Learn about literacy programs in your community
        • National Institute for Literacy
          • http://www.literacydirectory.org
        • ProLiteracy Worldwide
          • http://www.proliteracy.org/locator
    • 36. Organizations Working on Health Literacy
    • 37. Council of State Governments http://www.healthystates.csg.org/Public+Health+Issues/Wellness+and+Prevention
    • 38. Partnership for Clear Health Communication at the National Patient Safety Foundation http://askmethree.com/
    • 39.
      • What is my main problem?
      • What do I need to do?
      • Why is it important for me to do this?
      http://askmethree.org/
    • 40. http://www.plainlanguage.gov/
    • 41.  
    • 42.  
    • 43. More info available on my web site: http://del.icio.us/seundlibrary Look under Health Literacy
    • 44. Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/QuestionsAreTheAnswer