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Health Literacy
Paul D. Smith, MD, Associate Professor
University of Wisconsin
Department of Family [email protected]
Topics today
General health literacy information
Results of WAFP Health Literacy Survey
Communication Issues
What can you do?
Literacy skills
What is Literacy?
National Adult Literacy Survey 1992
“Using printed and written information to
function in society, to achieve one's goals,
and to develop one's knowledge and
potential.”
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
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.”
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.”
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.”
Real People with Real Problems
Insert video clip here
National Adult Literacy Survey
Federal survey conducted in 1992
26,000 people over age 15
Living in households and prisons
Divided into 5 levels
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
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
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
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
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
National Adult Literacy Survey
0
5
10
15
20
25
30
35
%
Level 1 Level 2 Level 3 Level 4 Level 5
47-51% of Americans in Levels 1 and 2
National Adult Literacy Survey
39% of Wisconsin adults in Levels 1 and 2
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
Literacy Levels Change with Age
Level1
Level2
Level3
Level4
Level5
60-69
80 and over0
10
20
30
40
50
60
70
80Document Literacy
Literacy Levels Change with Age
Level1
Level2
Level3
Level4
Level5
60-69
80 and over0
10
20
30
40
50
60
70
80Document Literacy
80 and over
Level 1 + 2
89%
Literacy Levels Change with Age
BUT, they do not recognize their problemAge 60 and older
91% Read well or very well
88% Write well or very well
83% Do arithmetic well or very well
2003 National Assessment of Adult Literacy
Data released 12/05
~17,000 people participated
Changed reporting methodology
New Reporting Method
80% correct responses moved down to 67%
4 categories
Below basic
Basic
Intermediate
Proficient
2003 National Assessment of Adult Literacy
1992 and 2003 National Literacy data
0%10%20%30%40%50%60%70%80%90%
100%
Prose
Docum
ent
Quant
itativ
e
Proficient
Intermediate
Basic
Below Basic
2003 National Assessment of Adult Literacy
The Bottom Line
Not much change
Prose a bit worse
Document a bit better
Quantitative a bit better
Clinician Survey
16 question email survey
Sent to 411 Wisconsin family physicians
28% response rate
Impact on Quality and OutcomesImpact on Quality and OutcomesN
um
ber
of
Res
po
nd
ents
Impact Health OutcomesImpact Health Outcomes
Impact Quality of Impact Quality of CareCare
>87%>87%
Results : PrevalenceResults : Prevalence
0
10
20
30
40
>5% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Percent of Patients with Low LiteracyNu
mb
er o
f R
esp
on
ses Mean = 17.4%
NALS = 47-51%
ResultsResults
Does your clinic screen patients?
The Bottom Line
Physicians are aware of literacy impacting on health and health care
They underestimate the extent of the problem
The Impact of Low Literacy on Health
Poorer health knowledge
Poorer health status
More hospitalizations
Higher health care costs
Poorer Health Knowledge
Diabetics that know low glucose symptoms
0
20
40
60
80
100
%
inadequate adequate
50%
94%
Poorer Health Knowledge
Hypertensives that know exercise lowers BP
0
10
20
30
40
50
60
70
%
inadequate adequate
40%
68%
Poorer Health Status
Diabetics with retinopathy
0
5
10
15
20
25
30
35
40
%
inadequate adequate
36%
19%
Poorer Health Status
2923 new Medicare enrollees
Inadequate literacy had increased frequency of:
Diabetes
Hypertension
Heart failure
Arthritis
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
More Hospitalizations
2 year hospitalization rate for patients visiting ED
0
5
10
15
20
25
30
35
%
low adequate
31%
14%
Increased Health Care Costs
Total annual Medicaid charges
0
2,000
4,000
6,000
8,000
10,000
12,000
low higher
$10,688
$2,890
Increased Health Care Costs
Based on NALS data
Majority from increased hospitalizations1998 - $73 Billion
Medicare, 28.3
Employers, 12.1
Patients, 11.5
Medicaid, 10.3
Other public, 7.6
Other private, 3.2
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.
Low Literacy is Overlooked
Clinicians don’t ask about literacy
Some are not aware of the problem
Not sure how to ask
Not sure how to respond
Do not want to open the can of worms
Low Literacy is Overlooked
Patients do not volunteer their literacy problem
Many are ashamed
Some do not recognize their inadequate literacy
Lack of trust
The Big Secret
% of low literate adults that have not told their:
Children 52%
Friends 62%
Spouse 68%
Health care providers 75%
Co-workers 85%
More likely to have Low Literacy
Older
Immigrants
Less education
Incarceration
More likely to have Low Literacy
Non-white
Low-income
Medical Assistance
Low Literacy is Overlooked
Many Level 1 people don’t fit the stereotypes
75 % born in USA
50% are white
40% hold full or part-time jobs
Common Clues of Low Literacy
Patients say things like:
“I lost my glasses”
“I’d like to discuss this with my family”
“I have a headache now and can’t focus”
Common Clues of Low Literacy
Medication review
Looking vs reading
Unable to name med
Do not know why taking med
Do not know medication timing
Common Clues of Low Literacy
Non-compliance
Medications
Testing
Consultations
Patient Communication Processes
Patient-physician communication
Patient history
Informed consent
Medical instructions
Patient Communication Processes
Patient education materials
Prescription labeling
Patient Communication Processes
Responding to medical and insurance forms
Navigating the clinic or hospital
Verbal Communication Strategies
Whole staff must be aware and sensitive
Create a culture of helpfulness
Quiet room with minimal distractions
Front Desk/Registration
Always offer to help complete forms
Simplify registration forms
Only ask for information that you need
Verbal Communication Strategies
SLOW DOWN Simple terms
Use monosyllabic and colloquial terms Avoid or explain the medical jargon.
Begin with important information first
and limit new information.
Repeat the information/instructions
Verbal Communication Strategies
Have the patient repeat the information, use the “teach back” method.
No more than one or two instructions at a time—and check each time: “Chunks and Checks”.
Write it down.
Verbal Communication Strategies
Use models, sketches, pictures.
Give instructions to several of family members.
Consider follow up phone calls.
Written Materials- Common Mistakes
Readability level is too high
Too much detail
Hard words are not explained
Written Materials- Common Mistakes
Pictures do not reinforce the message
No examples
Written Materials
Review materials for reading level
5th – 6th grade reading level
Flesch-Kincaid grade level
Objectives
Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.
Identify people at increased risk of low literacy Acquire an understanding of specific activities they
can do to improve verbal communication with all patients, especially low literacy adults
Identify the important issues to address when developing educational documents for low literate adults
Flesch-Kincaid Grade Scale: 12
Objectives
Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin.
Identify people at increased risk of low literacy Acquire an understanding of specific activities they
can do to improve verbal communication with all patients, especially low literacy adults
Identify the important issues to address when developing educational documents for low literate adults
Flesch-Kincaid Grade Scale: 12
Topics today
General health literacy information
How to recognize people with low literacy
How to improve communication
Factors to consider when creating documents
Flesch-Kincaid Grade Scale: 12
Topics today
Health literacy.
Finding people with low literacy.
How to improve communication.
How to make things easier to read.
Flesch-Kincaid Grade Scale: 7.1 (talking for communication = 5.1)
Beyond handouts
Pictures and models
Audiotapes and CDs
Videotapes and DVDs
CD-ROM
Internet
What can be done?
Raise awareness
American Medical Association Foundation
Low Health Literacy: You Can't Tell By Looking
Health Literacy: Help Your Patients Understand
Institute of Medicine
Prescription to End Confusion
What can be done?
Distribute the handouts about health literacy
resources.
Consider partnering with a local Community-
based adult literacy organization.
What can be done?
Be a patient.
Review processes
Review documents
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.
Summary
Low literacy is a common problem.
Low literacy affects health.
Summary
Low literacy is hard to identify.
Most of our documents are written
at a reading level that is too high.
Wisconsin Literacy
Coordinating organization for community-
based adult literacy organizations
44 Organizations scattered around the state
New funding for regional facilitators
Wisconsin Literacy
www.wisconsinliteracy.org
Michele Erikson, director
608-257-1655
“Action expresses priorities.”
---Mohandas Gandhi
