11/5/2013
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Health Literacy
Maureen George PhD RN AE-C FAAN
University of Pennsylvania
School of Nursing
Conflict of interest statement
Speaker’s Bureau
Novartis
Merck
Consultant
Novartis
Objectives
• Distinguish literacy from health literacy
• Compare and contrast health literacy assessment tools used in research from clinical tools
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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The United Nations Educational, Scientific and Cultural Organization (UNESCO) "Literacy is the ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts. Literacy involves a continuum of learning to enable an individual to achieve his or her goals, to develop his or her knowledge and potential, and to participate fully in the wider society."
Prose-Document-Numeracy (quantitative literacy)
Literacy
Global Literacy Rates
1900 2011
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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Components of Literacy
Institute of Medicine, Health Literacy: A Prescription to End Confusion, 2004
Reading Ability NAAL *Approx % ofLevel Grade Pop.
Level
- Below Basic 1 0-5 14- Basic 2 6-8 29
- Intermediate 3 9-12 43
- Proficient 4 College 14
2003 National Assessment of Adult Literacy (NAAL)* Estimates
Literacy Levels of Adults in America
Health Communication
J O Frempong & Assoc
NALS % of % of % of % of % of % of % of Level Pop. 16-18 19-24 25-39 40-49 50-64 65+
1 14 11 11 12 11 13 232 29 37 29 25 27 27 38
Totals 43 48 40 37 38 40 61
Literacy and Age
Health Communication
2003 National Assessment of Adult Literacy (NAAL)J O Frempong & Assoc
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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Berkman, Sheridan, Donahue, Halpern & CrottyLow health literacy and health outcomes: an updated
systematic review.Ann Intern Med. 2011 Jul 19;155(2):97-107.
• Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. Poor health literacy partially explains racial disparities in some outcomes.
Literacy is
• Location specific• Varies city-to-city; state-to-state
• Lower in those with ESL
• Lower in those receiving Medicare/Medicaid or being uninsured
Common myths about learning
• That low literacy groups will never be able to manage complex diseases or grasp sophisticated concepts
• That there are distinct groups of visual, auditory and kinesthetic learners
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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How do we learn best?
• Defines health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.
• Specific tasks :
• evaluating information for credibility and quality,
• analyzing relative risks and benefits,
• calculating dosages,
• interpreting test results, or
• locating health information
• Low health literacy skills increase annual health care expenditures by $73 billion
• National Academy on an Aging Society
The Patient Protection and Affordable Care Act of 2010, Title V
Health literacy
• Cannot be reliably predicted by
• Educational attainment
• Occupation
• How well a person speaks (oral literacy)
• How well a person presents themselves
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Health Literacy in America
Proficient: Define medical term from complex document, Calculate share of employee’s health insurance costs
Intermediate: Determine healthy weight from BMI chart, Interpret prescription and over-the-counter drug labels
Basic: Understand simple patient education handout
Below Basic: Circle date on appointment slip,Understand simple pamphlet about pre-test instructions
0%10%20%30%40%50%60%70%80%90%
100%12%
14%
22%
53%
Kutner et al 2006
Kumar, Sanders, Perrin, Lokker, Patterson, Gunn, Finkle, Franco, Choi & Rothman. Parental understanding of infant health information:
Health literacy, numeracy and the Parental Health Literacy Activities Test (PHLAT). Academic Pediatrics, 2010;10:309-316.
Results
• 182 English-speaking parents enrolled from academic pediatric clinics; 85% had > high school degree• Only 68% of total items answered correctly
• 31% could not properly prepare prescription medication doses or read a digital thermometer
• 47% could not correctly prepare OTC medication doses
Sample PHLAT question
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Sample PHLAT question
Health literacy tools
• Research Tools• Rapid Estimate of Adult Literacy in Medicine
(REALM)
• (Short)Test of Functional Health Literacy in Adults (s)TOFHLA
• The IOM has concluded that the REALM and the TOFHLA assess reading ability and are therefore inadequate measures of health literacy
• IOM Health Literacy: A Prescription to End Confusion (2004)
• Clinical Screening Tools• Newest Vital Sign
Newest Vital Sign
• Available in English and Spanish
• Patients typically complete it in about 3 minutes
• 6 questions based on reading an ice cream label
• 98% of patients find it acceptable assessment during a routine office visit.
• The NVS can be obtained online at no cost from
http://www.pfizerhealthly.com/
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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Wood, Price, Dake, Telljohann & Khuder SA.African American parents’/guardians’ health literacy and
self efficacy and their child’s level of asthma control. Journal of Pediatric Nursing, 2010;25:418-427.
Results
• 196 caregivers of African American children with asthma completed an investigator-developed 17-item efficacy and outcome expectancy questionnaire• 56% of parents had an Asthma Action Plan
• 80% were highly confident in their ability to identify triggers, use asthma devices and follow physician advice
• 65% of parents characterized as having inadequate health literacy, using modified NVS
Wood MR, Price JH, Dake JA, Telljohann SK, Khuder SA.African American parents’/guardians’ health literacy and self efficacy
and their child’s level of asthma control. Journal of Pediatric Nursing, 2010;25:418-427.
• Parental efficacy increased with parental health literacy levels; parental efficacy was significantly related to the child’s level of asthma control
• Parental health literacy did not predict child’s level of asthma control, the frequency of physician visits, acute health care utilization or outcome expectations
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Teach back
• Ask the patient to repeat back, in their own words, what they need to do
• It is not a test of the patient but of the effectiveness of your communication skills
• Take responsibility for any inability of the patient
• Start with a permissive stem • We’ve gone over a lot of information today. No one is going to
remember it all.
• Then move to the teach back• I want to be certain I did a good job explaining your allergy
medicines because I know it can be confusing.“ • “What will you tell your partner about the changes we made to
your asthma medications?”• “What do you think were the most important points?”
Ask Me 3 National Patient Safety Foundation
• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?
Goal is to facilitate the patient’s tipping the balance in favor of the health behavior 27
Status Quo
“a collaborative, person--‐centered form of guiding to elicit and strengthen motivation for change.”
Establish rapportRaise the subjectExplore the pros and consExplore discrepanciesAssess readiness to change
Motivational interviewing
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Learning
• Is a transaction
• How information is provided influences what is learned
• Most effective if education builds on information already known
• Quality patient care requires quality patient education
Characteristics of adult learners
• Self-directed
• Have a lifetime of experiences and real-world knowledge to draw upon
• Practical
• Goal oriented
• Relevancy oriented
• Need to be shown respect
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Adult learning
• Use card sorting to help start the conversation
• Limit each session to no more than three new words or concepts• Say the word and show the patient the printed word
• Is content culturally-sensitive/relevant?
• Does content persuade people that they can learn how to manage this condition? (self-efficacy)
• Does the material make people feel like they want to manage their condition? (persuasive)
Adult learning
• Find out what is already known
• I need to give you some information but I don’t want to take up your time if you have the most recent information. Can you tell me what you know about asthma?
• Be prepared to ask open-ended prompt• What is asthma?
• What is the best way to treat asthma?
• What do you do when you have an attack?
• How do you know when you’re sick enough to call the doctor?
Enhance written and verbal communication
• Strategies to improve written materials• Assess the reading levels of your practice
materials (history forms, informed consent, patient education materials…)
• Print materials : Fry, SMOG• Electronic materials: Flesch-Kincaid• Websites: ATS Best of the Web
• Strategies to enhance oral communication• Use natural frequencies and qualitative
descriptives of quantitative data• Avoid ambiguous language• Avoid framing bias
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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• Quantitative data delivered qualitatively (natural frequencies)
WRONG: If a person has IDDM, he or she has a 95% probability of a positive result on a genetic test
RIGHT: If a person has DIABETES, 95 of every 100 people will have a positive genetic test for diabetes
• Avoid ambiguous language (Sutherland et al., 1991)
• “Rare” Quantified by patients as meaning 24%
• “Rare” Quantified by physicians as meaning 5%
• Framing differences (Tversky & Kahneman, 1974)
• 90% chance it won’t help
• 10% chance it will help• If I give this medicine to 100 people, it will help 10
of them but it won’t be effective for the other 90
Design and content
• Use plain language; use clear conversational writing
• Write at a 4th-6th grade level• Avoid polysyllabic words
• Use Active voice• We will ask you questions about your asthma
• Avoid Passive voice • You will be asked about your asthma
• Write in the first person using pronouns, such as “I,” “we,” and “you”
• Chunk• Write in short sentences
• Limit paragraphs to one main idea
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Design and content-the 5 what’s common to health education
• Education must be organized into “chunks”
• What is the diagnosis
• What tests are needed
• What will happen (at the test, after treatment)
• What treatment is needed
• What other things should be done to stay healthy
Chunk and check
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Design and content
• Visuals should be interesting
• Pictograms (icon arrays) are easiest to understand; avoid tables, graph and pie charts
Design and content
Anatomical pictures should be placed within the human body
• WRONG • RIGHT
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
11/5/2013
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Design and content
• Limit pamphlet to “need to know” information only
• Adequate white space and margins provide visual breaks that encourage the reader to keep going
• Top and bottom margins should be at least 1 inch, and side margins should be at least 1.25 inches
• Avoid decreasing margins to force text to fit on one page
Design and content
• Headers
• Are road signs; should be specific and descriptive; aiding reading and comprehension
• What will happen if I take part in this study?
• Emphasize important information using bold or larger font, borders, or other graphical elements.
• Avoid putting sentences in italics or all capital letters
• 1 or 2 words in italics or CAPS is OK
Design and content
• Use a clear topic sentence at the beginning of each paragraph
• Follow with details and examples• Proper use of asthma inhalers helps you
breathe better. Here are reasons why.
• Then give reasons
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Design and content• Avoid using justified margins
• WRONGAn asthma attack is a sudden worsening of asthma symptoms caused by the tightening ofmuscles around your airways (bronchospasm). During the asthma attack, the lining of theairways also becomes swollen or inflamed and thicker mucus -- more than normal -- isproduced. All of these factors -- bronchospasm, inflammation, and mucus production --cause symptoms of an asthma attack such as difficulty breathing, wheezing, coughing,shortness of breath, and difficulty performing normal daily activities.
• RIGHT
An asthma attack is a sudden worsening of asthma symptoms caused by the tightening of muscles around your airways (bronchospasm). During the asthma attack, the lining of the airways also becomes swollen or inflamed and thicker mucus -- more than normal -- is produced. All of these factors -- bronchospasm, inflammation, and mucus production -- cause symptoms of an asthma attack such as difficulty breathing, wheezing, coughing, shortness of breath, and difficulty performing normal daily activities.
Before printing in bulk…
• Pilot test your pamphlet with patients, staff and adults who do not have the condition• Is jargon used?
• Are there any word(s) that you did not understand?
• Did you find anything offensive?
• Check reading level (Microsoft word-FleschKincaid)
Common mistakes made in creating materials for low literacy or diverse communities
• Use of materials not intended for the population
• Use of materials created for children
• Fail to use graphics that show people that look like them
• Fail to adequately translate and back translate
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore
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Summary
• Literacy and health literacy are not the same thing
• The Newest Vital Sign is the best studied clinical tool to assess health literacy
• You can communicate information verbally and in written form more clearly if you follow some simple rules
ACAAI Annual MeetingNov. 7 - 11 2013, Baltimore