Health Literacy - Digital Publishing Platform Demo | Digital

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

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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


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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


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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


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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


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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


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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/


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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


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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


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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


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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


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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


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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


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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


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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


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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


Health Literacy - Digital Publishing Platform Demo | Digital

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