Health literacy workshop: Understanding and improving

health literacy Londonwide LMC Conference

April 2016 Gill Rowlands, Professor, University of Newcastle and

Aarhus University 1

There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know.

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This workshop • Known Knowns:

– What is health literacy? – Why is it important? – Health literacy and General Practice

• Known unknowns – Who are the key stakeholders in addressing the problems of low HL? – How can we as practitioners improve the HL environment in General

Practice? – How can we as commissioners improve HL in hospital and specialist

services? – How can patient HL skills be improved?

• Unknown unknowns from a GP perspective? • Suggestions for action - GP level, LMC level 3

Known knowns: The evidence. Is health literacy a serous problem?

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They: • Die earlier1,2 • Find it more difficult to take their medication as instructed1

• Are more likely to have one or more long-term conditions (LTCs)3

• LTCs more likely to be limiting3

• Are less likely to engage with disease prevention e.g. cancer screening, immunisation1

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1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacy interventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012 3. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study British Medical Journal 2012;344:e1602

Are people with lower health literacy Sicker? Yes!

They have • More unhealthy behaviours; alcohol, poor diet/obesity, smoking2,3 • Fewer healthy behaviours; good diet/normal weight2,3

• Lower levels of self-rated health1,2 • Lower response to public healthy living campaigns3

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1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacy interventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012 3. Buck D, Frosini F. Clustering of unhealthy behaviours over time. Implications for policy and practice London: King's Fund Aug 2012

Are people with lower health literacy less healthy? Yes!

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Is low health literacy a common problem? Yes

HLS-EU Consortium: Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012

In Europe

1.8% 10.3% 10.2%

13.9% 11.0% 12.4%

18.2% 7.5%

26.9%

26.9% 29.7%

34.4% 30.9% 35.3% 35.2%

38.2% 50.8%

35.2%

46.3% 38.7%

35.9% 39.6%

34.1% 36.0%

33.7% 32.6% 26.6%

25.1% 21.3% 19.5%

15.6% 19.6%

16.5% 9.9% 9.1%

11.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NetherlandsIrelandPolandGreece

GermanyTOTALAustriaSpain

Bulgaria

inadequate comp.-HL problematic comp.-HL sufficient comp.-HL excellent comp.-HL

In England

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% of the adult working age population unable to fully read,

understand, and act on health information in common

circulation.

National average 61%

Rowlands G, Protheroe J, Richardson M, et al. The health information gap: the mismatch between population health literacy and the complexity of health information; an observational study. BJGP 2015: http://bjgp org/content/65/635/e379

Gender Age Ethnicity

Birthplace First language Qualifications

Employment status Job grade Income

Home owner Area

deprivation level

Is low health literacy associated with other social determinants of health? Yes!

Male (literacy) Female

(numeracy) Aged 45+ BME

Born outside of the UK

English not first language

Below expected by

age 16

Unemployed Lowest job grade

Income less than £10,000

Not a home owner

Top 5 most deprived areas

Not statistically significant when considered together

In England

Health literacy is important because 1. People with lower health literacy are less healthy, and sicker,

than people with higher health literacy 2. This is associated, in part, with less healthier lifestyle choices 3. There is a social gradient; people already disadvantaged

through adverse social determinants face a further barrier to health

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Health literacy and General Practice

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Why are GPs crucial in addressing the issue of low health literacy

• Over 90% of patient:NHS contacts take place in General Practice

• We provide holistic patient-centred care • We provide longitudinal care • We care for patients as part of families and communities • We are part of the community ourselves

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RCGP workshop calls for action

• To work with the Health Literacy Group UK to ensure that national health literacy policy recommendations include those arising from the July 2013 workshop and this report.

• To develop GP training so that all GPs recognise the issues brought through low health literacy and learn to develop consultation techniques to improve the clarity of their communication with patients with low health literacy and support patients to develop their health literacy skills.

• To develop recommendations for Clinical Commissioning Groups (CCGs) to consider health literacy approaches by NHS service providers when commissioning services 14

RCGP workshop calls for action

• To develop pilot sites where CCGs can commission health literacy training for patients from adult learning providers, with assessment of the impact of these pilots on patient skills, patient satisfaction with NHS services and their use of NHS services

• To work with NHS England to ensure that those aspects of the Digital Inclusion Strategy relevant to General Practice are adopted by GPs.

• NHS England to work with The Information Standard to develop a health literacy guide to be circulated to all NHS Trusts.

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Working groups • Who are the key stakeholders in addressing the problems of low

HL? • How can we as practitioners improve the HL environment in

General Practice? • How can we as commissioners improve HL in hospital and

specialist services? • How can patient HL skills be improved?

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Outcomes from working groups • What actions can we take ourselves and in our practices? • Are there any London-wide actions the LMC could take forward? • Have we identified any unknown unknowns?

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Additional slides

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National Qualifications level: Literacy level 1 / Numeracy level 1 Key Stage Skill Equivalent Ages:

Literacy 11-14 years, Numeracy 11-14 years Number (%) English adults 16-65 yrs. UNABLE to understand and use this:

21 illi l (61%)

Example: Bowel Cancer Screening Kit

NQF level

Key stage equivalent

At this LITERACY level an adult understands

Entry level 1

5-7 years Short texts with repeated language patterns on familiar topics

Entry level 2

7-9 years Short straightforward texts on familiar topics and from familiar sources

Entry level 3

9-11 years Short straightforward texts on familiar topics accurately and independently Information from everyday sources

Level 1 11-14 years Short straightforward texts of varying length on a variety of topics accurately and Independently

Level 2 14-16 years A range of texts of varying complexity accurately and independently Information of varying length and detail Material level

Population level

Skills Qualification Framework

Literacy

NQF level

Key stage equivalent

At this NUMERACY level an adult understands

Entry level 1

5-7 years Numbers and symbols in a simple format

Entry level 2

7-9 years Numbers, symbols, simple diagrams and charts in a simple format

Entry level 3

9-11 years Numbers, symbols, diagrams and charts used for different purposes and in different ways

Level 1 11-14 years Straightforward mathematical information, can independently select relevant information

Level 2 14-16 years Mathematical information used for different purposes, can independently select and compare relevant information from a variety of sources

Material level

Population level

Skills Qualification Framework Numeracy

National and regional picture: % of adults aged 16-65 years for whom health information is too complex

52

35

35 38

40 41

44 44

46

National average 43%

Text (literacy) component of health materials