Health Literacy: A Clinician

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Health LiteracyA Clinicians Point of View

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

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Topics today

• Social determinants of health.
• Health literacy.
• Impact of literacy on health and health care.
• What can we do about this?

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Determinants of Health

• Gender
• Age
• Race/ethnicity
• Co-morbidities

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Social Determinants of Health

• Employment status
• Income level
• Health insurance status
• Marital status

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Social Determinants of Health

• Education level
• High school diploma or equivalent
• Literacy level

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Question?

• What would happen to Wisconsins overall health,
  if we were able to eliminate health disparities?

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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
Men (367)
Suburban (247)
Women (225)
Milwaukee County (424)
Some college (212)
High school or less (459)
College graduates (188)
Native Americans (592)
African Americans (624)
Asians (170)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
Men (367)
Suburban (247)
Women (225)
Milwaukee County (424)
Some college (212)
High school or less (459)
College graduates (188)
Native Americans (592)
(279)
Asians (170)
African Americans (624)
(279)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
(277)
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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
Men (367)
Suburban (247)
Women (225)
Milwaukee County (424)
Some college (212)
High school or less (459)
College graduates (188)
Native Americans (592)
African Americans (624)
Asians (170)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
(275)
Men (367)
Suburban (247)
Women (225)
Milwaukee County (424)
(275)
Some college (212)
High school or less (459)
College graduates (188)
Native Americans (592)
African Americans (624)
Asians (170)
Worst state Mississippi (519)
Wisconsin (296)
Best state Minnesota (257)
(266)
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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
Men (367)
Suburban (247)
(225)
Women (225)
Milwaukee County (424)
Some college (212)
High school or less (459)
College graduates (188)
Native Americans (592)
African Americans (624)
Asians (170)
Worst state Mississippi (519)
Best state Minnesota (257)
Wisconsin (296)
(225)
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Wisconsin Working-Age Adult Mortality Rates (Ages
25-64, rates per 100,000 population)
Whites (279)
Rural (319)
Non-urban (275)
Men (367)
Suburban (247)
Women (225)
Milwaukee County (424)
Some college (212)
High school or less (459)
(212)
College graduates (188)
Native Americans (592)
African Americans (624)
Asians (170)
Worst state Mississippi (519)
Best state Minnesota (257)
Wisconsin (296)
(206)
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Effect of Eliminating Disparity by

• Race 296 ? 277
• Geography 296 ? 266
• Gender 296 ? 225
• Education 296 ? 206
• Wisconsin becomes the healthiest state in the
  U.S.

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Answer

• Eliminating health disparities in any category
  improves Wisconsins overall health.
• The greatest potential gain is in the elimination
  of disparities by education.

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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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In Their Own Words

• Insert video clip here

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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
31
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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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In Their Own Words

• Focus group project
• Three community-based literacy programs
• Six groups
• Fifty-one adults
• Limited reading skills- Adult Basic Education
• Limited English skills- English Language Learners

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Focus Groups Major Themes

• Communication and understanding.
• Completing/understanding forms including consents.

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Focus Groups Major Themes

• Difficulty in accessing healthcare
• Medication errors
• Anxiety and shame

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The System is Broken

• Pre-school
• Children learn to read on the laps of their
  parents.
• K-12 education
• Third-fourth grade watershed.
• HS graduation rates.
• Almost 20 functionally illiterate HS graduates.

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The System is Broken

• Adult education
• Lack of funding for literacy programs
• Family
• Workforce
• Corrections

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The System is Broken

• Health Care
• Highly educated clinicians and support staff.
• Medical terminology.
• Documents written at a high reading level.
• Increasing complexity of medical care.

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How do we fix this problem?

• Multi-faceted approach
• Funding one aspect and ignoring the other issues
  will not address the problems today.
• Education
• Change the health care system

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How do we fix this problem?

• Pre-school
• Effective programs
• Reach Out and Read
• Refer parents to family literacy programs

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How do we fix this problem?

• Pre-school
• Similar programs in non-traditional settings
• Women Infants and Children
• Prenatal care
• Ethnic community groups
• Faith based

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How do we fix this problem?

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

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How do we fix this problem?

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

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How do we fix this problem?

• Health content in literacy curriculum
• Susan Levy, Ph.D.
• Breakout at 345

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Education Will Not Solve Everything

• Health Care
• Continuing Medical Education (CME) for clinicians
• Medical education is stuck in the 60s

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Education Will Not Solve Everything

• Universal Design
• If it works for people with low literacy or low
  English skills, it will work for everyone.

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The Healthcare System Has to Change

• Communication strategies
• Improve oral communication
• Easier to read written documents
• Effective informed consent process
• Check understanding

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The Healthcare System Has to Change

• Commonwealth Fund Report
• A team effort, beginning at the front desk.
• Use of standardized communication tools
• Clinicians partner with patients to achieve goals

Barrett S, et al. Health Literacy Practices in
Primary Care Settings Examples from the Field,
January 2008 http//www.commonwealthfund.org/publi
cations/publications_show.htm?doc_id645961
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The Healthcare System Has to Change

• Use of
• Plain language
• Face-to-face communication
• Pictorials
• Educational materials

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The Healthcare System Has to Change

• Organizational commitment to create an
  environment where health literacy is not assumed.

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More Research is Needed

• Effective preschool and K-12 programs.
• Effective adult literacy programs.
• Effective health literacy interventions.

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Summary

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

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Summary

• 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

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Raising Awareness

• Your own local, state and national organizations.
• Health care organizations.
• State and federal legislators.
• Medical Education.

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What can YOU do?

• Add health content to curricula.

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What can YOU do?

• Collaborate with health care groups
• Hospitals
• Large medical groups
• Health care insurers

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• Action expresses priorities.
• Be the change that you want to see in the
  world.
• ---Mohandas Gandhi
  

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• Paul D. Smith M.D.
• paul.smith_at_fammed.wisc.edu
• 608-265-4477

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