HEALTH LITERACY

Linda J Weinberg, MBA, MSW, LCSW

Workshop Overview

Define Health Literacy

Learn what it mean to be health literate

Learn the impact of health numeracy

What is plain language

How health literacy impacts health

outcomes

Learn what to do

What is Health Literacy?

“The ability to understand and use health-

related printed information in daily

activities at home, at work, and in the

community to achieve one’s goals and to

develop one’s knowledge and potential” (National Assessment of Adult Literacy)

Health Literacy

Healthy People 2020 – National Action

Plan Improve Health Literacy

Patient and Affordable Care Act of 2010,

Title V

Healthy People 2010 - Improve health

communication/health literacy

Joint Commission (1993) - Patients must

be given information they understand

Health Literacy

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.”

•Terry Davis, PhD

Dr. Richard Carmona

Health Literacy

https://www.youtube.com/watch?v=39A9o

U-gOOA

Health Literacy

Skills needed for health care

professionals:

Help people find information and services

Communicate about health and healthcare

Process what people are explicitly and implicitly asking for

Understand how to provide useful information and services

Decide which information and services work best for different situations and people so they can act

Health literacy skills are needed to:

Find information and services

Communicate their needs and preferences and respond to information and services

Process the meaning and usefulness of the information and services

Understand the choices, consequences and context of the information and services

Decide which information and services match their needs and preferences so they can act

Health Literacy

12% of the adults

have proficient health

literacy

9 out of 10 people

lack the skills needed

to manage their

health and prevent

disease

14% of adults have

below basic health

literacy

Literacy Levels*

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

*Institute for Healthcare Advancement, 2017

https://www.youtube.com/watch?v=xCIFSUFC_mQ

Defining Health Literacy part 1

https://www.youtube.com/watch?v=xCIFS

UFC_mQ

Health Literacy

Reading and writing

Listening and verbal communication

Numeracy - computation, interpreting risks

Self efficacy

Additional Facts

Mismatch between provider demand and

patient skill level

Mismatch reading level / materials

Relationship to health disparities

Strong relation to safety and quality

Cultural Factors/Values

Accepted roles of men and women

Recognize roles

How you introduce yourself / titles / pronouns

Value of traditional medicine vs. Western medicine

Favorite or forbidden foods

Manner of dress - cover tattoos, simple jewelry

Pause speech/speech patterns

Be mindful of holidays, daily patterns

Body language

Health Literacy Myths*

If you cannot read, you cannot learn

If someone cannot read, and I give them written instructions, they will tell me they cannot read

I can tell if someone will understand my instructions by their education level

Most people who are illiterate are poor, immigrants or minorities**

*Institute for Healthcare Advancement, 2017

**Teaching Patients with Low Literacy, 2012

Incorporate Diverse Adult Learning Styles

Visual - simple, easy-to-process diagrams, pictures, graphs or the written word

Aural - auditory so that it can be processed

Print - written word

Tactile - touch, manipulate

Interactive - hands-on, uses technology, whole body movement

Kinesthetic - multisensory, touch, hear, see

Olfactory - smell, taste

Low Literacy Impact

Higher risk of death

More emergency room visits and

hospitalizations

Increased medical visits

Poor self-management skills for chronic

health conditions

Medication errors

Less use of preventative services

Increased healthcare costs

The cost of limited health literacy

Major source of economic inefficiency in

the U.S. healthcare system

Costs range $106 billion - $238 billion

• (7% - 17% of all personal healthcare expenditures)

According to the Institute of Healthcare

Advancement

1 in 2 Americans cannot read above a 5th

grade reading level (Kirsch, 2003)

Most patient education materials written beyond individuals’ ability to understand (IOM, 2004)

26% could not understand when their next appointment was

42% could not understand “take on empty stomach”

60% could not understand consent form (JAMA,

1995)

“

• 46% did not understand instructions ≥ 1 labels

• 38% with adequate literacy missed at least 1 label

“How would you take this medicine?”

395 primary care patients in 3 states

Davis TC , et al. Annals Int Med 2006

Patient Safety: Medication Errors

Terry Davis, PhD

Sample Label:

Numeracy

“The ability to locate numbers within

graphs, charts, prose texts and

documents; to integrate quantitative

information from texts; and to perform

appropriate arithmetic operations on text-

based quantitative data.”

(Schwartzberg, VanGeest, & Wang, 2005, p. 6)

Numeracy

Ability to understand and work with

numbers

May also be known as “mathematical

literacy”

Being able to reason with numbers and

other mathematical concepts

Health Numeracy

“The degree to which individuals have the

capacity to access, process, interpret,

communicate, and act on numerical,

quantitative, graphical, bio statistical, and

probabilistic health information needed to

make effective health decisions.”

(Golbecket al., 2005)

Easy to Difficult Numeracy

(Golbeck, Ahlers-Schmidt, Paschal, & Dismuke, 2005, p. 375)

Health Numeracy

Dosing medication

Monitoring weight

Checking temperature (F or C)

BMI

Cholesterol

Using nutrition labels - serving sizes, carbs, calories, fat, sodium, etc.

Selecting insurance plans

Co-pays

Deductibles

Understanding lab work

Managing diabetes - insulin, carbs, glucose, hemoglobin A1c

Monitoring blood pressure

Interpreting risk - disease risk, treatment risk/benefit

Appointment times

Appointment Times

Quarter to 8

7:45

¼ to 8

Bus schedules

Transportation

Laboratory Results

Medication Measurements

Nutrition Labels

What can I do?

Ask: “What questions do you have?”

Teach back: Have the patient explain or show what they learned

Use plain language

Slow down

Limit, but repeat information at every visit

Avoid medical jargon

Avoid acronyms

Know your population

Ask Me 3

Become a health literate organization

Tips on what to do

https://www.youtube.com/watch?v=VdjQE

SS4SxM

Ask Me 3

What is my main

problem?

What do I need to do?

Why is it important for

me to do that?

Ask Me 3 - trademark licensed to the National Patient Safety Foundation

Smartphone ownership exhibits greater variation based on

age, household income and educational attainment (January 12, 2017)

Any

cellphoneSmartphone

Cellphone, but

not smartphone

Total 95% 77% 18%

Men 96% 78% 18%

Women 94% 75% 19%

White 94% 77% 17%

Black 94% 72% 23%

Hispanic 98% 75% 23%

Ages 18-29 100% 92% 8%

30-49 99% 88% 11%

50-64 97% 74% 23%

65+ 80% 42% 38%

Less than high

school graduate92% 54% 39%

High school graduate 92% 69% 23%

Some college 96% 80% 16%

College graduate 97% 89% 8%

Less than $30,000 92% 64% 29%

$30,000-$49,999 95% 74% 21%

$50,000-$74,999 96% 83% 13%

$75,000+ 99% 93% 6%

Urban 95% 77% 17%

Suburban 96% 79% 16%

Rural 94% 67% 27%

www.pewinternet.org/fact-sheet/mobile/,

Plain language

Know your audience

Write for your audience.

Use language your audience knows and feels comfortable with

Take your audience's current level of knowledge into account. Don't write for an 8th grade class if your audience is composed of PhD candidates, small business owners, working parents or immigrants. Only write for 8th graders if your audience is, in fact, an 8th grade class

Make sure you know who your audience is - don't guess or assume

Do NOT dummy-down

Organize

Organization is key

Start by stating the document's purpose and its bottom line

Eliminate filler and unnecessary content

Put the most important information at the beginning and include background information (when necessary) toward the end

plainlanguage.gov

Plain language

Address One Person, Not a Group

Write as if it is for an

individual

Singular nouns and verbs

are easier to understand

Avoid confusion by using

“you” rather than using

“he or she” or “his or her”

Use Headings to

structure document

Question headings - this

is what your audience is

asking

Statement headings -

specific

Topic headings - can be

too vague

plainlanguage.gov

Plain language

Short sentences

Be precise and concise

Action verbs

Use nouns - adjectives can be confusing

No jargon

No abbreviations

Use words your audience recognizes

Plain language

When adding a point: also, and, in addition, besides, what is more, similarly, further

When giving an example: for instance, for example, for one thing, for another thing

When restating: in other words, that is, in short, put differently, again

When introducing a result: so, as a result, thus, therefore, accordingly, then

When contrasting: but, however, on the other hand, still, nevertheless, conversely

When summing up: to summarize, to sum up, to conclude, in conclusion, in short

When sequencing ideas: First,…Second,…Third,…Finally,…

Plain language

Short paragraphs

One topic

Start with topic

sentence about the

paragraph

Pictures, illustrations,

simple charts

Use examples for

complex information

Design for easy

reading

Fonts, colors

Understandability

Easy to read

Charts

Materials and Messages

Reflect:

• Age

• Social and cultural diversity

• Language

• Literacy skills

• Economic contexts

• Access to services/resources

• Life experiences

Tips

Evaluate understanding before, during, and

after introducing materials and services

Before designing materials and services talk

to target group to determine what information

they need to know and how it will be used

Pre-test messages and services for feedback

• Test messages again, assess effectiveness, refine

if necessary. Use post-test to evaluate

effectiveness

More Tips

Use active voice

Limit the number of messages - no more

than 4 main messages

Keep it simple

Clearly state the actions/behaviors needed

Tips for Messaging/Printed Materials

Fonts - Serif fonts, such as Century Schoolbook, Century Expanded, Times New Roman, Georgia, or Palatino;

12 point font size or larger - avoid font sizes that are smaller and more difficult to read;

Do not use all CAPITAL letters, italics, or fancy script;

Use headings and bullets to break up text;

Spacing between lines / plenty of white space in margins and between sections;

Set off photo captions in bold, to create contrast;

Vary the font size of individual parts of the brochure according to their importance, but be consistent throughout with each part;

Reserve larger type sizes for the most important headlines;

Coloring - no red and green;

Bullet information; and

Use pictures / icons

Brochure

Tips for Clinicians

Use plain language

Limit information (3-5 key points)

Be specific and concrete, not general

Demonstrate, draw pictures, use models

Repeat / Summarize

Teach-back (confirm understanding)

Be positive, hopeful, empowering

What can be done?

Establish formal mechanisms to review and address literacy levels, quality of translations, and cultural appropriateness / congruency of all written materials for patients;

Establish programs for health navigators, promatoras / community health workers to help patients access healthcare services;

Integrate health literacy and CLAS audit tools, standards, and score cards in reviewing materials;

Include target population and new readers to review materials and process to access care, organizational assessments and health literacy efforts;

Provide patient support services - previsit, hospitalization reminders and post/visit and discharge follow-up calls; and

Text-to-read software

Health Literate Organization1. Has leadership that makes health literacy integral to its mission, structure, and

operations.

2. Integrates health literacy into planning, evaluation measures, patient safety and quality improvement.

3. Prepares the workforce to be health literate and monitors progress.

4. Includes populations served in the design, implementation, and evaluation of health information and services.

5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization.

6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.

7. Provides easy access to health information and services and navigation assistance.

8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on.

9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines.

10. Communicates clearly what health plans cover and what individuals will have to pay for services.

Brach C, et al. IOM Roundtable, 2012

Resources

www.Plainlanguage.gov

www.cdc.gov Centers for Disease Control

https://www.iha4health.org/ Institute for Healthcare Advancement

https://cccm.thinkculturalhealth.org/ A Family Physician's Practical Guide to Culturally Competent Care

http://www.cahealthliteracy.org/resource_center.html California Health Care Literacy Initiative

Usability.gov - information, guidelines, and checklists for conducting usability testing and user-centered design

www.Nationalacademies.org

https://healthliteracy.bu.edu/ Health Literacy Tool Shedu/ ://healthliteracy.bu.edu/.usability.gov

tps://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53

Activity

Read the chronic disease or health

information

Using the plain language handout and

your notes develop educational materials

and your presentation to an individual with

low literacy skills