Techniques for Improving
Health Literacy Among
Low-Income and Immigrant
Populations
March 26, 2013
Michael Villaire, MSLM
Chief Operating Officer
Institute for Healthcare Advancement www.iha4health.org mvillaire@iha4health.org
(800) 434-4633 x202

By the time you’re done with this webinar, you should be able to:
1. Define health literacy
2. Describe the importance of improving health literacy
3. Explain the relationship between health literacy and health disparities
4. Identify strategies to improve health literacy among low-income and immigrant populations
5. Discuss the Institute for Healthcare Advancement’s
“What to do for Health” book series

• “Using printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential”
(Kirsch et al, 1993)

• “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”
(Ratzan and Parker, 2000)
• “Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that … include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills .”
(Calgary Charter on Health Literacy,
2008)

•
Reading and writing
•
Listening and verbal communication (patient and provider)
•
Numeracy

Computation skills

Interpreting / evaluating risk (%)
•
Self-efficacy
--Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004

•
Culture / belief systems
•
Mismatch between provider demand and patient skill level
•
Mismatch of reading level / materials
•
Strong relation to health disparities
•
Strong relation to safety and quality

An 89-year-old man with dementia is diagnosed with an ear infection and is prescribed an oral liquid antibiotic. His wife understands that he must take one teaspoon twice a day. After carefully studying the bottle’s label and not finding administration instructions, she fills a teaspoon and pours it into his painful ear.
Parker, R. et al. J Health Comm, 2003.

Mr. G, 45, an Hispanic immigrant, native Spanish language speaker, has a job health screening. He is told his BP is high, can’t work until it’s controlled. Given β-blocker, diuretic, instructed to take each “once a day.” 1 week later, presents @
ED, BP very low, dizzy. Docs can’t figure out.
Spanish speaker asks him how many pills he took each day. “22,” says Mr. G. (In Spanish, once means 11.)
Nielsen-Bohlman et al. IoM “A Prescription to End Confusion” 2004

At a teaching hospital, an intern writes in a
“Patient’s problems” section of the medical chart, “Speaks no English.”
The attending physician writes a note back in response, “Your problem, not his.”
Clancy C. AHRQ. Comments at Institute of Medicine
Health Literacy Roundtable 2/09.

Which of the following is the strongest predictor of an individual’s health status?
A. Age
B. Income
C. Literacy skills
D. Employment status
E. Education level
F. Racial or ethnic group

Which of the following is the strongest predictor of an individual’s health status?
A. Age
B. Income
C. Literacy skills
(75% who self reported poor health in Below Basic HL category)
D. Employment status
E. Education level
F. Racial or ethnic group
--National Patient Safety Foundation

• People who can’t read, can’t learn.
•
Most people who are illiterate are immigrants or minorities.
• If someone can’t read and I give them written instructions, they’ll tell me they can’t read.
•
I can tell how well someone can read by the number of years they attended school.
From: Health Literacy Myths, Misperceptions and Reality http://www.idph.state.ia.us/fsbupdate/common/pdf/110804.pdf

• “[D]ifferences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the U.S.” (NIH, 1999)
• “… a population-specific difference in disease, health outcomes, or access to care .” (HRSA, 2000)
• “…difference in health status between a defined portion of the population and the majority. Disparities can exist because of
SES, age, … gender, race/ethnicity, language, customs or other cultural factors, [or] disability… .” (Minnesota Dept. Health,
2002)

Health Disparities Components
•
Restricted access to healthcare services
•
Includes unjust / preventable inequities
•
Disproportionately affects minorities / poverty
/ low educational attainment
•
Shared responsibility among system, providers, patients

Connections: Health Literacy /
Health Disparities
•
Low systemic awareness of the problem
• ↓ access to usable health promotion materials
•
Disproportionate by poverty / language barriers / education / disability
•
Lower rates of insured / less access
•
Victims of poor cultural competency / lack of racial/ethnic diversity in HC system

Connections: Health Literacy /
Health Disparities
•
Higher hospital admission rates
•
Receive poorer quality healthcare
•
Poorer outcomes
•
Inadequate language access services
•
Perception of unequal treatment
•
Poor self-efficacy
•
Preventable

Literacy / Health Literacy Statistics
Data Sources
•
1992 NALS (National Adult Literacy
Survey)
•
2003 NAAL (National Assessment of
Adult Literacy)
Added Health Literacy Module

•
Below Basic—no more than the most simple
& concrete literacy skills
•
Basic—skills needed to perform simple, everyday literacy activities
•
Intermediate—skills needed to perform moderately challenging activities
•
Proficient—skills needed for more complex & challenging literacy activities

Percent of U.S. adult population with Below
Basic or Basic skills in:
•
Prose Literacy – 44%
•
Document Literacy – 34%
•
Quantitative Literacy – 55%

NAAL Health Literacy Findings:
•
36% have limited health literacy skills
(22% Basic, 14% Below Basic)
•
About 12% considered Proficient
•
Includes 3% who did poorly on basic screening tasks, routed to alternative assessment
•
Does not include 2% who knew no English or Spanish
•
Majority (53%) had intermediate HL levels
• Women’s avg. HL score 6 pts. higher (4% more men in Below Basic)

Who has poor health literacy?
•
Nearly 60% of 65+ in Basic/Below Basic
• Health ins. from employer ↑ HL,
Medicare/Medicaid/No ins ↓ HL
•
Hispanics (12% of adult pop.) represent 35% of those in Below Basic HL category
•
Below poverty level (17% adult pop.) represent 43% of those in Below Basic HL
•
75% who self-reported poor health in Below
Basic HL

• 1 in 2 Americans can’t read above a 5 th grade level
(Kirsch 2003)
•
Most patient education materials written beyond recipients’ ability to understand
(IoM 2004)
• 26% couldn’t understand when next appt.
• 42% couldn’t understand “take on empty stomach”
• 60% couldn’t understand consent form
( JAMA 1995)

•
381 languages spoken/signed in U.S.
•
40 million foreign-born people live in the
United States (2010)
•
60 million Americans speak a language other than English at home
•
24 million Americans have LEP
•
75-90% of patients in the 2 lowest reading levels describe themselves as being able to read/write English “well” or “very well”

•
Cognitive impairment
•
Hearing / visual impairment
•
Medications
•
Stress (most forget at least 50% of what healthcare provider told them)
•
Shame re Illiteracy:

78% thought they should hide it/cope

77% never told their doctor

67% never told their spouse

19% never told anyone
Parikh, N.S., et al. Patient Educ Couns, 1996.

How Patients Hide Illiteracy
May say things like:
• “I forgot my glasses”
• “I don’t need to read this through now; I’ll read it when I get home”
• “I’d like to discuss this with my family”
• “I have a headache now and can’t focus”
• “I’ll just take this with me and read it later”
• Don’t ask questions
• Believe they understand but don’t

Why Does Health Literacy Matter?
Those with limited literacy skills:
•
Report poorer overall health
•
Have poorer ability to manage chronic diseases
•
Have poorer outcomes
•
Less likely to understand their diagnosis
•
Less likely to have screening / preventive care
•
Present in later stages of disease
•
Are more likely to be hospitalized / rehospitalized

Why Does Health Literacy Matter?
Cost of Poor Health Literacy:
•
$73 billion in unnecessary costs annually
( Friedland, Georgetown University, 2003)
•
$106-$238 billion in unnecessary costs annually
( Vernon, University of Connecticut, 2007)
Cost of Chronic Disease:
•
$1.7 trillion (75% of HC expenditures)
•
Nearly 1 in 2 Americans live with a chronic disease
•
90% >65 have a chronic disease;
77% have 2+
•
70% of annual US deaths
(CDC 2008)

•
Design Considerations
•
Universal Precautions
•
Plain language
•
Teach-back method
•
Brown-bag test
•
Ask Me 3 / Questions Are the Answer
•
Easy to Use Materials

•
Design Considerations

Large type size (12-14 point) and double-spaced

Standard font (no italics or ALL CAPS)

Two type faces (Arial-headings, Times NR-body)

Simple headings

White space

Usable, appropriate, explanatory graphics

•
Design Considerations

Short sentences (8-10 words each)

Use columns
 Bulleted list/text or “chunking” (keep to 7-8 max)
 “How to” or “Need to do” in active voice

•
White space
•
Large type size (12-14 point) and double-spaced
•
Standard font (no italics or ALL CAPS)
•
Two type faces (Arial-headings; Times New Romanbody)
•
Simple headings
•
Usable, appropriate, explanatory graphics (no abstract graphics)
•
Short sentences (8-10 words each)
•
Use columns
•
Bulleted lists (keep to 7-8 max)
•
Color / Navigation

Real-life
Examples
From “What To Do When Your
Child Gets Sick” Institute for
Healthcare Advancement www.iha4health.org

Real-life
Examples
From “Living With Diabetes:
An Everyday Guide for You and Your Family”
American College of
Physicians Foundation foundation.acponline.org/hl/hlr esources.htm

Real-life
Examples:
Photonovela
From “From Junk Food to
Healthy Eating: Tanya's
Journey to a Better Life”
Inter-Cultural Association of
Greater Victoria www.photonovel.ca/photonove ls.htm

Design critique
• What’s good?
• What’s not so good?

Available from:
•http://www.hsph.
harvard.edu/ healthliteracy/ resources/doak-book/
•IHA Health Literacy
Conference

•
Universal Precautions

Assume 5 th grade reading level for all pts.

Include all stakeholders in planning/ implementation
 Limit key messages to no more than 3 “need to do,” not “nice to know”
 Elicit questions. “What questions do you have?”
Strike the phrase, “Do you have any questions?” from your vocabulary!
 www.ahrq.gov UP toolkit

•
Plain language

Do not use medical jargon

Slow down
 Use “living room language”

Test results: What is benign? Negative? At-risk?

More likely your message will be understood

Lower chance of misunderstanding instructions

Don’t Use
Medical Jargon vomiting formulary unconscious oral analgesic umbilicus contraception
Consider these words: insomnia urine acne
CVA benign terminal negative

Don’t Use
Medical Jargon
Do these “living room language” alternatives work?
vomiting (throwing up) formulary (list of drugs) unconscious (out, not awake) oral (by mouth) analgesic (pain med) umbilicus (belly button) contraception (birth control) insomnia (can’t sleep) urine (pee) acne (pimples)
CVA (stroke) benign (no cancer) terminal (end of life) negative (don’t have)

•
Teach-back method

Toward assuring patient comprehension

Shared learning burden – include clinician role

Iterative process – teach to goal:
 Introduce new concept / technique

Demonstrate using multiple teaching modalities

Ask pt. to demonstrate / explain in their own words

Assess – review – tailor approach

Repeat to patient mastery

•
Brown-bag test

A form of literacy screening

Look at pill or label?

Ask patient to bring in all their meds (in a brown bag) (Drug interaction opportunity)

Test for comprehension of what med is / how to take it / why they take it
 “When was the last time you took this pill?”

•
Ask Me 3 / Questions Are the Answer
Ask Me 3

What is my main problem?

What do I need to do?

Why is it important for me to do this?
www.npsf.org/askme3

•
Ask Me 3 / Questions Are the Answer (www.ahrq.gov/questions)
Questions Are the Answer
 What is the test for?

How many times have you done this procedure?

When will I get the results?

Why do I need this treatment?

Are there any alternatives?
 What are the possible complications?

Which hospital is best for my needs?

How do you spell the name of that drug?

Are there any side effects?

Will this medicine interact with medicines that I'm already taking?

•
Easy to Read, Easy to Use Books

“What To Do For Health” Books
•
Written at a 3rd-5th grade reading level
•
Effective in-home solutions for most health issues
•
Liberally illustrated with useful diagrams and images
•
No medical jargon
•
Available in multiple languages
•
Indexed for quick and easy use

“What To Do For Health” Books
•
57-61% reduction in ER Visits
•
39-56% decrease in doctors/clinic visits
•
29-60% fewer missed school days by children due to illness or injury
•
41-47% fewer missed work days by parents due to child's illness
Contact: books@iha4health.org

• www.ihahealthliteracy.org
• nnlm.gov/outreach/consumer/hlthlit.html
• nces.ed.gov/naal
• www.health.gov/communication
• www.ahrq.gov/browse/hlitix.htm
• medlineplus.gov
• healthfinder.gov
• www.hsph.harvard.edu/healthliteracy
• www.iha4health.org
• plainlanguage.gov

• www.healthliteracy.com
• www.healthliteracymissouri.org
• http://lincs.ed.gov/mailman/listinfo/Healthliteracy/
(join listserv)
• ama-assn.org (Foundation/Health Literacy)
• foundation.acponline.org/hl/hlresources.htm
• www.iom.edu (health literacy)