Health Literacy:Helping Patients Get the Message

Professor Pamela Zarkowski, JD, MPHUniversity of Detroit Mercy

Dental Continuing Education June 19. 2013

P. Zarkowski 2013

P. Zarkowski 2013

Take two tablets on an empty stomach Take a tablet by mouth twice each day Two tablets twice daily- (two tablets a day)

P. Zarkowski 2013

Misunderstood

Consider Literacy

Literacy in Context Time and Place Circumstances Background

◦ Speaker/writer◦ Listener/reader

Culture◦ Speaker/writer◦ Listener/reader

5 Core Skills ofLiteracy

◦ Reading◦ Prose◦ Documents◦ Writing◦ Numeracy◦ The Oral Exchange

Speaking Listening

P. Zarkowski 2013

Literacy influences one’s ability to access information and to navigate the highly literate environments of modern society

P. Zarkowski 2013

Literacy Skills for the 21st Century

Most health care materials are written at a 10th-grade level or higher.

Most adults read between the 8th and 9th grade level. Approximately one half of adults are unable to understand

printed health care material, and approximately 90 million adults have fair to poor literacy.

Twenty-one to 23 percent of adults read at the lowest reading level, approximately fifth-grade or lower.

For patients whose primary language is not English, the problem is compounded.◦ A survey of patients at two hospitals revealed that 35 percent of

English-speaking patients and 62 percent of Spanish-speaking patients had fair to poor health literacy.

P. Zarkowski 2013

Epidemiology

At first, health literacy was considered to be a characteristic of the individual. Increasingly, researchers and practitioners are looking at both sides of the coin – the provider and the patient.◦ Health literacy is a shared function of social and

individual factors. Health and Human Services, Communicating Health,

2003. Institute of Medicine Health Literacy: A Prescription to End Confusion, 2004

◦ Health Literacy is an interaction Institute of Medicine Health Literacy: A Prescription to End

Confusion, 2004

P. Zarkowski 2013

Changing Concept

Change the Skill Side:◦ Improve literacy skills of the public◦ Improve communication skills of professionals

Change the Demand Side:◦ Recalibrate the norm and identify literacy barriers◦ Lower demands◦ Remove barriers

P. Zarkowski 2013

What Can we Do?

Health Literacy in Dentistry: Strategic Action Plan

2010-2015Vision

◦ The Council and its ad hoc advisory committee on health literacy in dentistry share a vision that dentists and dental team members, and the ADA and related health organizations, will use and promote clear, accurate and interactive communication with colleagues, patients and policy makers to achieve optimal oral health for all. This vision may be realized when the following promising and best practices are used.

American Dental Association (ADA), Council on Prevention and Interdisciplinary Relations

P. Zarkowski 2013

Professional Concern

Create a respectful and “shame-free” environment and use a universal standards approach, where all patients are offered assistance to better understand and use printed and written communications.◦ Periodically assess office/clinic for ways to improve communication. ◦ Use clear and plain language in talking and writing.◦ Encourage question-asking and dialogue.

◦ Use “teach-back” or “teach-to-goal” method to check on successful communication by asking patients to repeat their interpretation of instructions and other information that has been provided.

◦ Offer take-home tools designed for easy use with clear directions. American Dental Association, Council on Prevention and Interdisciplinary

Relations

P. Zarkowski 2013

Health Literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Health People 2010, http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf

The capacity of an individual to obtain, interpret, and understand basic health information and services and the competence to use such information and services in ways which are health-enhancing.

Health Education Standards

P. Zarkowski 2013

Health Literacy

Patients are often faced with complex information and treatment decisions. Some of the specific tasks patients are required to carry out may include:◦ evaluating information for credibility and quality,◦ analyzing relative risks and benefits,◦ calculating dosages,◦ interpreting test results, or◦ locating health information.

P. Zarkowski 2013

Health Literacy

In order to accomplish these tasks, individuals may need to be:◦ visually literate (able to understand graphs or

other visual information),◦ computer literate (able to operate a computer),◦ information literate (able to obtain and apply

relevant information), and◦ numerically or computationally literate (able to

calculate or reason numerically).

P. Zarkowski 2013

Health Literacy

Count the number of polysyllabic (more than three syllables) words in the chain of 30 sentences and look up the approximate grade level on the SMOG conversion table.◦ Professional literature◦ Patient education pamphlet

P. Zarkowski 2013

Reading Level – A Test

P. Zarkowski 2013

Reading LevelTotal polysyllabic word counts

Approximate grade level (+/- 1.5 grades)

0-2 4

3-6 5

7-12 6

13-20 7

21-30 8

31-42 9

43-56 10

57-72 11

73-90 12

91-110 13

111-132 14

133-156 15

157-182 16

183-210 17

211-240 18

P. Zarkowski 2013

Health Literacy

At Risk: Vulnerable Populations Minority populations Immigrant populations Low income -

Approximately half of Medicare/Medicaid recipients read below the fifth-grade level http://www.medicarerights.org/maincon

tentstatsdemographics.html) People with chronic

mental and/or physical health conditions

Vulnerable populations include:◦ Elderly (age 65+)

Two thirds of U.S. adults age 60 and over have inadequate or marginal literacy skills, and 81% of patients age 60 and older at a public hospital could not read or understand basic materials such as prescription labels (Williams, MV. JAMA, December 6, 1995).

P. Zarkowski 2013

Influencing Factors

Cultural, social, and family influences shape attitudes and beliefs and therefore influence health literacy.

Lack of educational opportunity - people with a high school education or lower.

Learning disabilities. Cognitive declines in older

adults.◦ Use it or lose it

Reading abilities are typically three to five grade levels below the last year of school completed. Therefore, people with a high school diploma, typically read at a seventh or eighth grade reading level.

P. Zarkowski 2013

Native language, socioeconomic status, gender, race, and ethnicity along with mass culture as represented by news publishing, advertising, marketing, and the plethora of health information sources available through electronic channels are also integral to the social–cultural landscape of health literacy.

P. Zarkowski 2013

Influencing Factors

Health Literacy and Health Outcomes Health Status:

◦ Report their health as “poor”

Healthcare costs: ◦ Use services to treat

complications of disease more; less use of services to prevent complications,

Stigma and shame: ◦ Psychological effects

Use of Preventive Services: more likely to skip important preventive measures, e.g. Pap smear and flu shots.

Knowledge about medical conditions and treatment: more likely to have chronic conditions.

Rates of hospitalization: higher rates of hospitalization and use of emergency services.

P. Zarkowski 2013

If you eat the entire container, how many calories will you eat?

If you are allowed to eat 60 g of carbohydrates as a snack, how much ice cream could you have?

Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes 1 serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day?

If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?

Pretend that you are allergic to the following substances: Penicillin, peanuts, latex gloves, and bee stings. Is it safe to eat this ice cream? Why or why not?

P. Zarkowski 2013

Literacy: NVS-Ice Cream Label

• Patient registration forms that are incomplete or inaccurately completed.

• Asking staff for help.• Bringing along someone who can read• Inability to keep appointments.• Making excuses (“I forgot my

glasses.”)• Noncompliance with medication.

P. Zarkowski 2013

Behaviors Indicating Low Literacy

Poor adherence to recommended interventions Postponing decision making (“May I take the

instructions home?” or “I’ll read through this when I get home.”).

Watching others (mimicking behavior). Lack of follow-through with laboratory tests or

referrals to consultants. Patients say they are taking their medication,

but laboratory tests or physiological parameters do not change in the expected fashion.

P. Zarkowski 2013

Behaviors Indicating Low Literacy

Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.

P. Zarkowski 2013

What is feels like…..

Tools to Evaluate Low Literacy REALD-99 after

REALM, where words on the instrument are ranked in order of increasing difficulty and the score is based on the number of words the subject pronounces correctly.

REALM: Rapid Estimate of Adult Literacy in Medicine

REALD: Rapid Estimate of Adult Literacy in Dentistry

TAFHLAL: Test of Functional Health Literacy in Adults

P. Zarkowski 2013

P. Zarkowski 2013

Answers to Label Quiz

P. Zarkowski 2013

Culture affects how people communicate, understand, and respond to health information. Cultural and linguistic competency of health professionals can contribute to health literacy. Cultural competence is the ability of health organizations and practitioners to recognize the cultural beliefs, values, attitudes, traditions, language preferences, and health practices of diverse populations, and to apply that knowledge to produce a positive health outcome. Competency includes communicating in a manner that is linguistically and culturally appropriate.

P. Zarkowski 2013

Cultural and Linguistic Competency

Cultural competence has been variously defined by different organizations. Cultural awareness: A deliberate, cognitive process in which

health-care providers become appreciative and sensitive to values, beliefs, lifestyles, practices, and problem-solving strategies of clients’ cultures.

Cultural knowledge: The process of seeking and obtaining a sound educational foundation concerning worldviews of various cultures; goal is to understand clients’ world views, or the way individuals or groups of people view the universe to form values about their lives and the world around them.◦ Speaking of Health (IOM, 2002)

P. Zarkowski 2013

Influencing Factors: Cultural Competence

• Cultural skill: The ability to collect relevant cultural data regarding clients’ health histories and presenting problems, as well as accurately perform culturally sensitive physical histories.

• Cultural encounter: A process that encourages health-care providers to engage directly in cross-cultural interactions with clients from culturally diverse backgrounds (IOM, 2002).

P. Zarkowski 2013

Cultural Competence

Slow down, and take time to assess the patients’ health literacy skills.

Use “living room” language instead of medical terminology. Show or draw pictures to enhance understanding and subsequent

recall. Limit information given at each interaction, and repeat instructions. Use a “teach back” or “show me” approach to confirm

understanding. This approach involves having physicians take responsibility for adequate teaching by asking patients to demonstrate what they have been told (e.g., repeat how to take their medication) to ensure that education has been adequate.

Be respectful, caring, and sensitive, thereby empowering patients to participate in their own health care.

P. Zarkowski 2013

Six Steps to Enhance Understanding Among Patients with Low Health Literacy

Improve the Usability of Health Information Limit the number of

messages, use plain language and focus on action.

Supplement instruction with visuals

Make written communication look easy to read.

Improve the usability of information on the Internet.

Identify the intended users of the health information and services

Evaluate users’ understanding before, during and after the introduction of the information and services

Acknowledge cultural differences and practice respect◦ Accepted roles of men and

women◦ Tradition medicine vs. Western

medicine◦ Favorite and forbidden foods◦ Manner of dress◦ Body language

P. Zarkowski 2013

Costco Warning 1: "If you drink alcohol,

discuss the safe use of alcohol while taking this this medication with your healthcare professional“ ◦ NOTE: This warning appears inconsistent

with the approved FDA prescriber information that states: "Avoid alcohol consumption."

Warning 2: "Do not take aspirin products without doctor approval. Continue taking low-dose aspirin to prevent heart attack/stroke unless doctor tells you to stop"

P. Zarkowski 2013

Confusion in Labeling

Take your pills 2 times each day (once in the morning and once in the evening). Take the medicine every day for 10 days—

even if you feel better before then. Stopping the pills before 10 days can result

inserious heart problems.

(43 words; 6th-grade reading level)

P. Zarkowski 2013

Treating Strep Throat

P. Zarkowski 2013

Ask open ended questions Check for understanding

◦ Summarize what you want the patient to do.◦ Check for understanding: I want to be sure I didn’t

leave anything out out that I should have told you. Would you tell me what you are to do so that I can be sure you know what is important?

Source: Doak CC, Doak LG, Root JH 1996 Teaching Patients with Low Literacy

P. Zarkowski 2013

Are you speaking clearly and listening carefully?

Plain language is a strategy for making written and oral information easier to understand. It is one important tool for improving health literacy.◦ Plain language is

communication that users can understand the first time they read or hear it. With reasonable time and effort, a plain language document is one in which people can find what they need, understand what they find, and act appropriately on that understanding.

P. Zarkowski 2013

Use Plain Language

Words/Phrases

Keep metaphors to a minimum, for example the phrase "Make like a tree and leave" is understood as (an attempt) at a pun by native English-language speakers.

Examples:◦ “My dogs are killing

me”◦ “That smarts”◦ “It went up in smoke”

Current communication techniques eg. Texting

Inappropriate language/phrases/slang

Some phrases can be confusing:For instance, when you say "I give up," you mean "I surrender," "I quit," or "I yield." But the newcomer to the English language may be puzzled. What does it mean to make a gift in an upward direction?

Idiomatic expressions:◦ What’s up?◦ Can you work the graveyard

shift?

P. Zarkowski 2013

Teach Back Method

The “teach-back” method enhances communication. The person receiving the health information is asked to restate it in their own words—not just repeat it—to ensure that the message is understood and remembered. When understanding is not accurate or complete, the sender repeats the process until the receiver is able to restate the information needed. Consumers also can be asked to act out a medication regimen.

I want to be sure I went over everything. Tell me how you will take this medicine.

Just to check if I’ve covered everything: Tell me what you will say to your wife when you return home.

Just to be sure I was clear: Show me how you will use this peak flow meter.

P. Zarkowski 2013

Revise forms to ensure clarity and simplicity Test forms with intended users and revise as

needed. Provide plain language and in multiple

languages Provide clear information for assistance Train staff to give assistance in completing

forms.

P. Zarkowski 2013

Usability of Health Forms and Instructions

eHealth - the use of interactive technologies to improve health behavior and disease management

Examples◦ http://www.colgateprofessional.com/patienteducation

P. Zarkowski 2013

eHealth

Resources

Ask Me 3 http://www.npsf.org/askme3/ Sponsored by the

Partnership for Clear Health Communication at the National Patient Safety Foundation.

Ask Me 3 promotes three simple but essential questions that patients should ask their providers in every health care interaction: ◦ What is my main problem?◦ What do I need to do?◦ Why is it important for me to

do this?

◦ Office of Minority Health http://www.omhrc.gov/

◦ Pfizer Clear Health Communication Initiative http://

www.pfizerhealthliteracy.com/

◦ National Institute for Literacy http://www.nifl.gov/

◦ Health Literacy: AMA http://www.ama-assn.org/

ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program.shtml

P. Zarkowski 2013

Plainlanguage.gov◦ Designed to improve communication from the Federal

Government to the public, this Web site contains excellent tools and examples of plain language.

◦ Visit http://www.plainlanguage.gov Health Literacy: A Prescription to End Confusion

◦ Released in 2004 by the Institute of Medicine (IOM), this report examines the body of knowledge that applies to the field of health literacy and recommends actions to promote a health-literate society.

◦ Available at: www.iom.edu/report.asp?id=19723

P. Zarkowski 2013

Resources

CDC Health Literacy for Public Health Professionals. Available at www2a.cdc.gov/TCEOnline/registration/detailpage.asp?res_id=2074

Improving Health Literacy: Training Resources. University of Michigan Library. Available at: guides.lib.umich.edu/healthliteracyU.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health Literacy online: A guide to writing and designing easy –to-use health Websites. Washing, D.C. : Available at www.health.gov/healthliteracyonline/index.htm

P. Zarkowski 2013

Online Resources

Thank you!

W: 313.993.1585pamela.zarkowski@udmercy.edu

P. Zarkowski 2013