Health Literacy What is it and what can we do about it

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Health LiteracyWhat is it and what can we do
about it?

• Paul D. Smith, MD, Associate Professor
• UW Department of Family Medicine
• Paul.Smith_at_fammed.wisc.edu

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Topics today

• Literacy and Health Literacy
• Impact on Health and Healthcare
• Social Marketing and Readable Text Documents

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Literacy skills
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What is Literacy?

• National Adult Literacy Survey (NALS 1992)
• National Assessment of Adult Literacy (NAAL 2003)
• Using printed and written information to
  function in society, to achieve one's goals, and
  to develop one's knowledge and potential.

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More than just reading grade level

• Prose Literacy
• Written text like instructions or newspaper
  article
• Document literacy
• Short forms or graphically displayed information
  found in everyday life
• Quantitative Literacy
• Arithmetic using numbers imbedded in print

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What is Health Literacy?

• The Institute of Medicine 2004
• The degree to which individuals have the
  capacity to obtain, process, and understand basic
  information and services needed to make
  appropriate decisions regarding their health.

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What is Health Literacy?

• The Institute of Medicine 2004
• The degree to which individuals have the
  capacity to obtain, process, and understand basic
  information and services needed to make
  appropriate decisions regarding their health.

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What is Health Literacy?

• The Institute of Medicine 2004
• The degree to which individuals have the
  capacity to obtain, process, and understand basic
  information and services needed to make
  appropriate decisions regarding their health.

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In Their Own Words

• Insert video clip here

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National Adult Literacy Survey

• Federal survey conducted in 1992
• 26,000 people over age 15
• Living in households and prisons
• Divided into 5 levels

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National Adult Literacy Survey

• Level 1 find one piece of information
• Level 2 find two related pieces of information
• Level 3 integrate multiple pieces of
  information
• Level 4 respond
• Level 5 analyze, formulate

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National Adult Literacy Survey

• Level 1 find one piece of information
• Can
• Sign name on a document
• Identify a country in a short article
• Total a bank deposit slip

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National Adult Literacy Survey

• Level 1 find one piece of information
• Cannot
• Enter information on a social security card
  application
• Locate an intersection on street map
• Calculate the total cost on an order form

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National Adult Literacy Survey

• Level 2 Find two related pieces of information
• Can
• Identify YTD gross pay on a paycheck
• Determine price difference between tickets for 2
  shows

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National Adult Literacy Survey

• Level 2 Find two related pieces of information
• Cannot
• Use a bus schedule
• Balance a check book
• Write a short letter explaining error on a credit
  card bill

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National Adult Literacy Survey
47-51 of Americans in Levels 1 and 2
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How Age Effects NALS Data

• Adults age 60 and over
• Living in households or prisons
• 68-80 are in Level 1 and 2
• More in Level 1 and 2 with advancing age
• 89-99 Level 1 and 2 age 80 and over

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Literacy Levels Change with Age

• BUT, they do not recognize their problem
• Age 60 and older
• 91 Read well or very well
• 88 Write well or very well
• 83 Do arithmetic well or very well

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2003 National Assessment of Adult Literacy

• Data released 12/05
• 17,000 people participated
• Changed reporting methodology

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New Reporting Method

• 80 correct responses moved down to 67
• 4 categories
• Below basic
• Basic
• Intermediate
• Proficient

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2003 National Assessment of Adult Literacy
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2003 National Assessment of Adult Literacy

• NAAL health literacy assessment
• 28 questions specifically related to health
• 3 clinical
• 14 prevention
• 11 system navigation

Kutner, M., Greenberg, E., Jin,Y., and Paulsen,
C. (2006). The Health Literacy of Americas
Adults Results From the 2003 National Assessment
of Adult Literacy (NCES 2006483).
U.S.Department of Education.Washington, DC
National Center for Education Statistics.
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NAAL Health Literacy Assessment

• Background questions
• Self-rated health status
• Health insurance
• Sources of health information

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NAAL Health Literacy Assessment

• Entire population
• Below basic 14
• Basic 22
• Intermediate 53
• Proficient 12

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NAAL Health Literacy Assessment

• Basic and Below Basic Health Literacy
• White 28
• Native Americans 48
• Blacks 58
• Hispanics 66

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NAAL Health Literacy Assessment

• Basic and Below Basic Health Literacy
• Age16-64 28-34
• Age 65 59

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NAAL Health Literacy Assessment

• Basic and Below Basic by education level
• In High School, GED or HS grad 34-37
• Less than/some High School 76

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NAAL Health Literacy Assessment

• Basic and Below Basic by Self-reported health
  status
• Excellent 25
• Very Good 28
• Good 43
• Fair 63
• Poor 69

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Sources of Health Information

• TV and radio
• Family and Friends
• Health Care Professionals

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Sources of Health Information

• Text Media
• Newspaper
• Magazines
• Books or brochures
• Internet

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Sources of Health Information

• Percent of people that NEVER obtain health
  information from the internet
• Proficient 12
• Intermediate 14
• Basic 58
• Below Basic 80

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The Impact of Low Literacy on Health

• Poorer health knowledge
• Poorer health status
• Higher mortality
• More hospitalizations
• Higher health care costs

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Poorer Health Knowledge

• Understanding prescription labels
• 395 patients
• 19 low literacy (6th grade or less)
• 29 marginal literacy (7-8th grade)
• 52 adequate literacy (9th grade and over)
• 5 prescription bottles

Literacy and Misunderstanding Prescription
Labels. Davis et al. Ann Intern Med
2006145887-894
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Poorer Health Knowledge

• At least one incorrect
• 63 low literacy
• 51 marginal literacy
• 38 adequate literacy

Literacy and Misunderstanding Prescription
Labels. Davis et al. Ann Intern Med
2006145887-894
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Poorer Health Knowledge

• Take two tablets twice daily
• Stated correctly Demonstrated
  correctly
• 71 low literacy 35
• 84 marginal literacy 63
• 89 adequate literacy 80

Show me how many pills you would take in one
day. Counted out 4 tablets-correct
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Poorer Health Status

• 2923 new Medicare enrollees
• Inadequate literacy had increased frequency of
• Diabetes
• Hypertension
• Heart failure
• Arthritis

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Poorer Health Status

• Medical Outcomes Study (SF-36)
• Inadequate literacy had
• Decreased
• Physical function
• Mental health
• Increased
• Limitations in activity due to physical health
• Pain that interferes with normal work activities

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Poorer Health Status
Diabetics with retinopathy
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Increased Mortality

• Age 70-79
• Reading level 8th grade or less
• Five Year Prospective Study

Sudore R, et al. Limited Literacy and Mortality
in the Elderly. J Gen Intern Med 2006 21806-812.
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Increased Mortality

• Risk of Death Hazard ratio 1.75

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More Hospitalizations
2 year hospitalization rate for patients visiting
ED
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Increased Health Care Costs

• Data
• 2003 Medical Expenditure Panel Survey
• 2003 National Assessment of Adult Literacy
• Low Health Literacy Implications for National
  Health Policy. Vernon, J, Trujillo, A, Rosenbaum,
  S, DeBuono, B. Oct. 2007

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Increased Health Care Costs

• Annual cost today
• Future costs based on todays actions
• (or lack of action)
• Low Health Literacy Implications for National
  Health Policy. Vernon, J, Trujillo, A, Rosenbaum,
  S, DeBuono, B. Oct. 2007

106-238 Billion
1.6-3.6 Trillion
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Low Literacy is Overlooked

• Patients do not volunteer their literacy problem
• Many are ashamed
• Some do not recognize their inadequate literacy
• Lack of trust

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The Big Secret

• of low literate adults that have not told their

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More likely to have Low Literacy

• Older
• Less education
• Non-white
• Immigrants

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More likely to have Low Literacy

• Low-income
• Medical Assistance
• Incarceration

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You Cant Tell by Looking

• Many Level 1 people dont fit the stereotypes
• 75 born in USA
• 50 are white
• 40 hold full or part time jobs

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Other Issues Effecting Literacy

• Visual Impairments
• 60 and older 17
• 80 and older 36

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Other Issues Effecting Literacy

• Cognitive impairment
• Learning disability
• 65 and older
• 6 severe dementia
• 10-15 mild-moderate
• Increases with advancing age

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Another Cause for Non-Compliance?

• Medications
• Testing
• Consultations

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How do we fix this problem?

• Education
• Change the system

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Education

• K-12
• Everyone graduates functionally literate
• Address the social and other issues that
  influence HS drop out rates.

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Education

• Adult education
• More money for effective literacy programs.
• Community-based
• Family
• Workforce
• Corrections

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Education Will Not Solve Everything

• The healthcare system has to change.
• Universal Design
• If it works for people with low literacy or low
  English skills, it will work for everyone.

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Getting the Message to Clinicians

• Clinicians
• Everyone wants our time or attention
• Stand out in the crowd
• Keep it short and sweet

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Social Marketing

• Other Stakeholders
• Adapt message to the stakeholder
• Top down vs bottom up
• Policy starts at the top

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Social Marketing

• Medicare Beneficiaries
• Multiple approaches
• Family has significant influence
• Consistent message about what to DO

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Medicare Beneficiaries

• Understanding is the key.
• Self-efficacy/empowerment.
• Text materials that are understandable.

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Reading Levels

• 20 of American adults read at or below the 5th
  grade level.
• Most health care materials are written above the
  10th grade level.

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Readability

• Review materials for reading level
• 5th 6th grade reading level
• Flesch-Kincaid grade level
• 12-14 point font

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Written Materials- Common Mistakes

• Too much detail
• Hard words are not explained
• Pictures do not reinforce the message
• No examples

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Center for Medicare and Medicaid Services

• All documents written in Plain Language
• http//www.plainlanguage.gov/
• Page 23 QIO Communications Handbook

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Plain Language

• CMS
• Regulations
• Web content
• Forms and consents

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Low Tech/Low Cost Methods

• Dont recreate the wheel
• Communications Clearinghouse
• Many other sources on internet
• Partner with adult educators
• National Coalition for Literacy

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Low Tech/Low Cost Methods

• Critically evaluate for readability
• Rewrite as necessary
• Test with target audience
• Share your results

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Summary

• Low literacy is a common problem
• Low literacy affects health

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Summary

• Most of our documents are written
• at a reading level that is too high.
• The System has to change

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What can YOU do?

• Learn more about health literacy
• IOM A Prescription to End Confusion
• Health literacy resource list
• Google health literacy toolkit

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What can YOU do?

• Be a catalyst for change
• Raise awareness
• QIO leadership and staff
• Healthcare stakeholders

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What can YOU do?

• Be a patient.
• Review processes
• Review documents

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What can YOU do?

• Universal Design
• Health Literacy Definition
• The degree to which individuals have the capacity
  to obtain, process, and understand basic
  information and services needed to make
  appropriate decisions regarding their health.

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• Action expresses priorities.
• ---Mohandas Gandhi
  

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Learn more about writing

• Health Literacy Making Your Health Materials
  Understandable for All
• 230-4 pm C3 Bayview B, Bay Level
• Paul.Smith_at_fammed.wisc.edu

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