Health Literacy 101Health Literacy 101

Pamela Kavanaugh, RN, CDEPamela Kavanaugh, RN, CDE

& Alejandra Gomez, MHSM, MBA& Alejandra Gomez, MHSM, MBA

Brownsville Community Health Center Brownsville Community Health Center (BCHC)(BCHC)

OBJECTIVES

• Defining health literacy and gain awareness with its impact and relationship to quality care,

• Identify & discuss challenges and barriers patients and their families face that impact wellness, and

• Learn innovative tools and techniques to address low literacy and overcome barriers and challenges.

“As a former nurse, trauma surgeon, and public health director [I realized] there

was a wall between us and the people we were trying

to serve.

Health care professionals do not recognize that

patients do not understand the health

information we are trying to communicate.

We must close the gap between what health care

professionals know and what the rest of America

understands.”

Dr. Richard Carmona,

U.S. Surgeon General

2002-2006

Health Literacy

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Healthy People 2010

Health Literacy & Quality of Care“Good quality means providing patients withappropriate services, in a technically

competent manner, with good communication, shared decision-making, and cultural sensitivity . *

* From IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.

• Shared decision-making includes encouraging active participation by patients in visits with their health care providers.

Cultural SensitivityCultural sensitivity is the ability of health

organizations and practitioners to recognize the following in diverse populations to produce a positive health outcome:

•Cultural beliefs•Values•Attitudes•Traditions•Language preferences•Health practices

Health Literacy & Shame

• Often report feeling a sense of shame about their skill level.

• Often uncomfortable about being unable to read well, and they develop strategies to compensate, or they often do not ask questions at all.

• Children often are expected to translate for parents and providers.

A Demonstration Exercise

• The following paragraph of instructions simulates what a reader with low literacy sees on the printed page

• Read the paragraph out loud.

• You have 15 seconds to read.

• HINT: The first word is “cleaning”

• GNINAELC – Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-der edixo selcitrap. Esu a nottoc baws denetsiom htiw lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.

• Cleaning – to assure high performance, periodically clean the tape heads and capstan whenever you notice an accumulation of dust and brown-red oxide particles. Use a cotton swab moistened with isopropyl alcohol. Be sure no alcohol touches the rubber parts as it tends to dry and eventually crack the rubber. Use a damp cloth or sponge to clean the cabinet. A mild soap like dishwasher detergent will help remove grease or oil.

Test your Comprehension…

You are not alone if…

• You did not get past the first line.

• You were not able to understand the instructions

on how to clean the equipment.

How many of your patients are struggling

just to ‘de-code’ words?

CHALLENGES AND BARRIERS

2003 Nat’l Assessment of Adult Literacy

Intermediate

Basic

Below Basic

Proficient

14%

13%

44%%

29%%

93 Million Adults have Basic or Below Basic Literacy

Literacy and Spanish Language

• 11 million US residents do not speak English well or at all

• 8 million of these speak Spanish

Functional Health Literacy in Adults at two Public Hospitals

Language Percent Low Literacy (in preferred language)

English 35%

Spanish 62%Williams et al. JAMA 1995

Who Is at Risk?

• The problem of limited health literacy is greater among:

– Older adults– Those who are poor– People with limited education– Minority populations– Persons with limited English proficiency (LEP)

Barriers between LiteracyBarriers between Literacyand Health Outcomes and Health Outcomes

Health Literacy: Knowledge About Medical Conditions &

TreatmentPersons with limited health literacy

skills:

• Are more likely to have chronic conditions and less likely to manage them effectively.

• Have less knowledge of their illness (e.g., diabetes, asthma, HIV/AIDS, high blood pressure) and its management.

Outcomes Associated with Literacy

Health Outcomes/Health Services• General health status• Hospitalization• Prostate cancer stage• Depression• Asthma• Diabetes control• HIV control• Mammography• Pap smear• Pneumococcal & Influenza

immunizations• STD screening

Behaviors Only• Substance abuse• Breastfeeding• Behavioral problems• Adherence to medication• Smoking

Knowledge Only• Birth control knowledge• Cervical cancer screening• Emergency department

instructions• Asthma knowledge• Hypertension knowledge

DeWalt, et al. JGIM 2004;19:1228-1239

“How would you take this medicine?”

• 46% did not understand instructions ≥ 1 labels

• 38% with adequate literacy missed at least 1 label

Davis TC , et al. Annals Int Med 2006, slide by T Davis

“Show Me How Many Pills You Would Take in 1 Day”

John Smith Dr. Red

Take two tablets by mouth twice daily.

Humibid LA 600MG1 refill

Slide by Terry Davis

Can Patients Comprehend Rx Drug Warning Labels?

Davis et al. JGIM 2006; 21: 847-851

Simple Familiar Wording Understood by Most Patients

84%

(1st grade.)

Slide by Terry Davis

More Complex Message Limited Comprehension

59%

(10th-12th grade.)

Slide by Terry Davis

Unfamiliar Multi-step Instructions Rarely Understood

8%

(12th-13th grade)

Slide by Terry Davis

Innovative Tools and Techniques

Make it easier…• Raise awareness among all staff and

providers; Literacy training / patient education

• Improve health forms and instructions; develop easier to read materials.

• Improve the physical environment; may include practice re-design.

• Establish a People Relations or Patient Navigator Program team via Promotoras and/or greeters.

• Improve communication skills

Improve Health Forms & Instructions

• Revise forms to ensure clarity and simplicity.

• Test forms with intended users and revise as needed.

• Provide forms in multiple languages.

• Have staff offer assistance with completing forms and scheduling follow-up care.

Improve Access to Accurate & Appropriate Health

Information• Work with the media to increase

awareness of health literacy issues.

• Work with providers to ensure that the health information they share is accurate, current, and reliable.

• Form partnerships with civic and faith-based organizations trusted in the community.

Improve the Physical Environment

Settings with lots of signs and postings have a high literacy demand:

• Include universal symbols and clear signage in multiple languages.

• Promote easy flow through healthcare facilities

• Create a respectful and shame-free environment.

Establish a Patient Navigator Program / Use your

Promotoras• Promotoras are community health

workers who help patients: - Evaluate their treatment options.

– Obtain referrals.– Through local University, find clinical trials.– Apply for financial assistance.

• Greeters are individuals hired to guide patients through our clinics.

Speak Clearly & Listen Carefully

•Use a medically trained interpreter if necessary:– For those who do not speak English well, plain

English will not help.– Ensure that all language access services, including

translation, are in plain language. – Refer to Cultural & Linguistically Appropriate

Services (CLAS) standards.

•Ask open-ended questions:– Elicit cultural beliefs and attitudes: “Tell me about

the problem and what may have caused it.”

• Check for understanding:Use the “teach-back” method: Have the person restate the information in his or her own words.

Internet• Make it User Friendly. People cannot

find the information they seek on Web sites 60% of the time.

• Many elements that improve written and oral communication can be applied to information on the Web:

— Plain language— Large font— White space— Simple graphics

Patient EducationCo-develop adult basic education

lessons on health topics:

• Adult learners want information that is relevant to their lives; health content is likely to engage them.

• Construct lessons in which students use health-related texts, forms, and content from the Internet.

Use Patient-Friendly Educational Materials

• Simple wording, short sentences– 4th-6th grade level

• Picture based• Focus only on key points• Emphasize patient concerns

– What the patient may experience– What the patient should do

• Minimize information about disease statistics, anatomy, and physiology

• Be sensitive to cultural preferences

Understanding

Clarify

Assess

Explain

Teach-back

Summary• Low literacy is common and is

associated with adverse health outcomes

• Interventions to mitigate the impact of literacy on health continued to be studied.

• Some evidence suggests awareness and understanding of health literacy can improve outcomes

Resources• Darren DeWalt, MD, MPH, & Michael Pignone, MD, MPH

University of North Carolina-Chapel Hill, Department of Medicine

• AHRQ Report—Literacy and Health Outcomes (2004): www.ahrq.gov/clinic/epcsums/litsum.htm

• Healthy People 2010 (2000): www.healthypeople.gov

• Healthy People 2010 Health Literacy Action Plan—Communicating Health: Priorities and Strategies for Progress (2003): http://odphp.osophs.dhhs.gov/projects/healthcomm/objective2.htm

• NIH Improving Health Literacy Web page: www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm

Questions

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