Introduction to
Health Literacy
UAB GEC Faculty Scholars Program
July 26, 2013
Gabriel Rios, MLIS
Health Literacy Consultant
Objectives
Define health literacy
Discuss how low health literacy impacts health
Identify tools to assess health literacy levels
Practice interventions for clients with low health
literacy
• Discuss strategies and resources for improving
health literacy
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Teaching Tool:
LEP Exercise
Define health literacy
What is Health Literacy?
• IOM – “Health literacy is the degree to which
individuals have the capacity to obtain, process,
and understand basic health information and
services needed to make appropriate health
decisions.”
• NLM - “Health literacy is the ability to read,
understand, and act on health information.”
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colonoscopy, as perceived…
National Assessment of
Adult Literacy (NAAL) 2003
• Most up to date portrait of literacy in U.S.
• Scored on 4 levels
• Lowest 2 levels cannot:
o Use a bus schedule or bar graph
o Explain the difference in two types of employee benefits
o Write a simple letter explaining an error on a bill
National Center for Education Statistics, U.S. Department of Education
78 Million Adults have Basic
or Below Basic Literacy
2003 National Assessment of Adult Literacy
14%
12%
22%
Proficient
53%
Intermediate
Basic
Below Basic
Trends in Literacy Over
Time
• A comparison of National Adult Literacy Survey
(1992) and the National Assessment of Adult
Literacy (2003)
o The percentage of adults with below basic levels of literacy remained
constant
o The percentage of adults with proficient levels of literacy has declined
Types of illiteracy
• Functional illiteracy
• Sensory/physical illiteracy
o Blindness
o Deafness
o Neurological impairments
• Cultural/language illiteracy
• Psychological illiteracy
• Computational literacy
Health Literacy in Older Adults
Barriers to Self Care
• Economic
• Language - limited English proficiency
• Healthcare system - insurance, appointment,
signage
• Activities of daily living
• Access to information
• Provider/patient Communication
• Other barriers?
Why Is Health Literacy
Important?
• Health literacy is important because it affects a
person’s ability to:
Navigate the healthcare system
Share personal and health information with providers
Engage in self-care and chronic disease management
Adopt health-promoting behaviors, such as exercising and eating a
healthy diet
o Act on health-related news and announcements (media literacy)
o
o
o
o
14
Review - What is Health
Literacy?
Not only reading skill….BUT ALSO
• Writing
• Speaking
• Listening
• Numeracy
• Cultural and Conceptual knowledge
Discuss how low health
literacy impacts health
Limited Health Literacy
Leads to…
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Underutilization of services
Poor understanding of health
Increased hospitalizations
Poor health outcomes
Increased healthcare costs
Increased medication errors
Increased Medication
Errors
• Labels are seemingly
simple but not
necessarily clear.
• Mistakes are more likely
the more medication a
patient takes.
• Ability to read a Rx
label does not
guarantee ability to
understand and act.
Medication Errors Industry Standards
Inconsistent labeling
Branding trumps all
Confusing numbers
Poor color
combinations
• Curved shape is hard
to read
• Tiny type
• Older Adults fill 30
Rx/year, see 8 clinicians
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Medication Errors ClearRx
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Easy I.D.
Code Red
Information hierarchy
Upside down to save
paper
Green is for Grandma
An info card that’s
hard to lose
Take “daily”
Clear warnings.
Medication Errors Instructions
Medication Errors Instructions
Navigational Errors Signage
Ambulatory
Entrance
Ambulatory
Entrance
Hospital XYZ
 Some people become
confused about whether
this entry was intended for
ambulances or for patients
 The use of visuals clarify
the message
 Contrast in color makes
it easy to read
 Try to be consistent when
hanging signs
Teaching Tool:
Navigational Errors
• What are the tasks a patient needs to accomplish in
a health care visit?
• Diabetes patient
o Pre-visit
o Visit
o Post-visit
Teaching Tool:
Health Care Navigation and Self-Care Tasks
What can we do?
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Raise awareness among providers
Develop easier to read materials
Improve communication skills
Practice-redesign
Literacy training / adult education
Identify tools to assess
health literacy levels
Less effective methods of
health literacy assessment
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Years of education (except at extremes)
Race
Income
Age
Reliance on self-disclosure
Methods of Assessing
Health Literacy
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Informal
Word pronunciation tests
Cloze method
Newest Vital Sign
Davis TC, Kennan E, Gazmararian J, Williams MV. Literacy Testing in Health Care Research.
Understanding Health Literacy: Implications for Medicine and Public Health. Chicago: AMA Press; 2004.
Identify Low Health
Literacy: (Informal)
• Fills out intake forms incompletely
o “I forgot my glasses”
o “Let me bring this home so I can discuss it with my children.”
o “My hand hurts too much to write”
• Misspelling many words
• Gets angry about forms
• Identifies medication by looking at pill rather than
reading the label
• Other means?
Weiss BD. Health literacy: a manual for clinicians. 2003
Teaching Tool: Newest Vital
Sign
Exercise
Newest Vital Sign
Word Pronunciation Tests
• Rapid Estimate of Adult Literacy in Medicine
(REALM)
o Word recognition and pronunciation
• Wide Range Achievement Test
(WRAT)
o Word recognition and pronunciation
Cloze Method
• Test of Functional Health Literacy in Adults (TOFHLA)
• Allows students to "intelligently guess" and fill in
missing words from a written passage.
• Tests reading comprehension using skills like:
o
o
o
o
o
o
Background knowledge
Context cues
Semantics
Syntax
General understanding of material
Grammar skills
TOFHLA (Cloze method)
Your doctor has sent you to have a _________ X-ray.
a. stomach
b. diabetes
c. stitches
d. germs
You must have an ________ stomach when you come in for ___.
a. asthma
b. empty
c. incest
d. anemia
a. is
b. am
c. if
d. it
Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)
Problems with Measuring
Literacy
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Sensitive topic
May offend some
If it is seen as a “test” it can be threatening
Patients hide low literacy
Inappropriate labeling
Time
Three Screening
Questions
• “How often do you have someone help you read
hospital materials?”
• “How confident are you filling out medical forms by
yourself?” and
• “How often do you have problems learning about
your medical condition because of difficulty
understanding written information?”
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with
inadequate health literacy. Family Medicine. 2004; 36(8)588–94.
Discuss strategies and
resources for improving
health literacy
Strategies: Providers and
Staff
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Whole staff must be aware and sensitive
Assess baseline understanding
Explain things clearly using plain language
Start with most important information first and limit
new information
Effectively encourage patients to ask questions
Use teach-back to confirm understanding
Provide useful educational materials
Repeat important points
Teach back
Explain
Assess
Clarify
Understanding
Strategies: Clear
Communication
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Assess baseline understanding
Explain things clearly using plain language
Emphasize 1-3 points
Effectively encourage patients to ask questions
Use teach-back to confirm understanding
Write down important instructions
Provide useful educational materials
Helpful phrases
• “I want you to explain to me how you will take your
medication, so I can be sure I have explained
everything correctly,” or
• “Please show me how you will use the asthma
inhaler, so I can be sure I have given you clear
instructions,” or
• “When you get home your spouse will ask you what
the doctor said—what will you tell your spouse?”
• “We don’t always do a great job of explaining our
care plan. Can you tell me in your words how you
understand the plan?”
More on teach-back
• Do not ask a patient, “Do you understand?”
• Ask patients to explain or demonstrate
• Ask questions that begin with “how” and “what,”
rather than closed-ended yes/no questions
• Organize information so that the most important
points stand out and repeat this information
• Ensure agreement and understanding about the
care plan. This is essential to achieving adherence
Teaching Tool: Plain
Language Exercise
Resources: AMA Health
Literacy Videos
• Health Literacy Toolkit from AMA Foundation
o http://bit.ly/fZjvex
o http://www.youtube.com/watch?v=FlGDn1r2RwY
Resources: AHRQ Toolkit
• AHRQ Health Literacy Universal Precautions Toolkit
o http://www.ahrq.gov/qual/literacy/
• Quick start guide
• Path to improvement (6 steps to take)
• 20 Tools
Strategies: Standards
• JCAHO RI.01.01.03
• “For communication to be effective, the
information provided must be:
o
o
o
o
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Complete
Accurate
Timely
Unambiguous
And understood by the patient.”
• Affordable Care Act: Health Literacy Implications
• National Action Plan to Improve Health Literacy
o http://www.health.gov/communication/hlactionplan/
Introduction to Standard RI.01.01.03, CAMH Update 2, October 2009
Strategies: Educational
Materials
• Good health information is often
hard to come by
• Most health information written at too
high of a reading level
• Few health care systems have comprehensively
integrated educational materials in their overall
care plans
Strategies: Use Patient-Friendly
Educational Materials
• Simple wording, short sentences
o 4th-6th grade level
• Picture based
• Focus only on key points
• Emphasize patient concerns
o What the patient may experience
o What the patient should do
• Minimize information about disease statistics,
anatomy, and physiology
• Be sensitive to cultural preferences
Resources: NIH Senior
Health
• http://nihseniorhealth.gov
• Health information for older adults
• Partnership of National Institute on
Aging and National Library of Medicine
• Information comes from
National Institutes of Health
• Older Adult-friendly features (large text, sound,
contrast)
• Information in bite-sized pieces
Resources: MedlinePlus
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http://www.medlineplus.gov
Launched in 1998
Free
Health information for patients and consumers
Quality filtered credible sources
Spanish language
Low literacy materials
Review
Define health literacy
Discuss how low health literacy impacts health
Identify tools to assess health literacy levels
Practice interventions for clients with low health
literacy
• Discuss strategies and resources for improving
health literacy
•
•
•
•
Resources
• AMA Foundation Health Literacy Toolkit
o http://bit.ly/fZjvex
• AHRQ Health Literacy Universal Precautions Toolkit
o http://www.ahrq.gov/qual/literacy/
• AHRQ Health Literacy Interventions and Outcomes
(SR)
o http://www.ahrq.gov/clinic/epcsums/litupsum.htm
• MedlinePlus
o http://www.medlineplus.gov
Questions?
Gabriel R. Rios
grios@uab.edu