1. In It Together: National Health Literacy Project for Black MSM Training of Trainers Module 1: Introduction to Health Literacy

2. Welcome Trainer: Daniel Driffin Email: hivhealthliteracy@jsi.comhivhealthliteracy@jsi.com Phone: 404.460.4790 This material was produced by John Snow Inc., under Contract #HHSH25020140037I with the Health Resources and Services Administration, U.S. Department of Health and Human Services.

3. Project overview  This project is designed to improve the capacity of health departments and community-based organizations to deliver health literate HIV services, with a particular focus on health services provided to Black/African American MSM.  The purpose of In it Together: National Health Literacy Project for Black MSM is to provide training-of-trainers (ToT) training to at least 100 Health Literacy Trainers in 34 communities across the U.S. that are highly affected by HIV/AIDS.  Upon completion of this ToT, each trainer will provide health literacy training to at least 5 health care professionals in his or her community. 3

4. Project overview Upon completion of the Training of Trainers, each trainer will provide health literacy training to at least 5 health care professionals in his or her community. 4

5. Trainers will increase their understanding of:  Populations affected by limited health literacy  Indicators that an individual may be experiencing limited health literacy  The use of the universal precautions approach to health literacy 5 Goals of this training module

6. At the end of this training, you will be able to:  Explain the importance of health literacy  Discuss at least 3 ways in which limited health literacy results in poorer health outcomes  List at least 5 indicators that a patient may have limited health literacy  Define the universal precautions approach to health literacy 6 Training objectives

7. What is Health Literacy?

8. Definition of 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.” 1  “The ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials required to successfully function as a patient.” 2 8 1 Ratzan and Parker, 2000 2 AMA Council of Scientific Affairs, 2000

9. Expanded definition of health literacy  Expanded definitions see health literacy more broadly: “More than just the ability to read and write, health literacy includes the ability to listen, follow directions, fill out forms, calculate using basic math, and interact with professionals and health care settings. It can also include making sense of jargon or unfamiliar cultural norms. Health literacy requires people to apply critical thinking skills to health-related matters.” 3  Recognizes health literacy is key to quality, safety, and equity in health care. 9 3 http://health.gov/communication/literacy

10. 1.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 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, 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 10 Institute of Medicine’s Attributes of a Health Literate organization

11. Who does limited health literacy affect? 11

12. Who does limited health literacy affect? 89 million adults, or 36% of the U.S. adult population have limited health literacy 12

13. Who does limited health literacy affect? All populations could be affected by limited health literacy Populations most affected by limited health literacy include:  Elderly  Low Socioeconomic Status (SES)  Unemployed  Did not finish high school  Members of minority groups  People who did not speak English during early childhood 13

14. Who does limited health literacy affect? 14

15. How does limited health literacy affect people? 15

16. How does limited health literacy affect people?  Limited knowledge of the body 16 U.S. Department of Education National Assessment of Adult Literacy

17. How does limited health literacy affect people?  Limited knowledge of the body  Difficulty understanding charts or ranges (such as healthy weight ranges or vaccine charts) 17 U.S. Department of Education National Assessment of Adult Literacy

18. How does limited health literacy affect people?  Limited knowledge of the body  Difficulty understanding charts or ranges (such as healthy weight ranges or vaccine charts)  Difficulty understanding when or how to take medication 18 U.S. Department of Education National Assessment of Adult Literacy

19. How does limited health literacy affect people?  Limited knowledge of the body  Difficulty understanding charts or ranges (such as healthy weight ranges or vaccine charts)  Difficulty understanding when or how to take medication  Difficulty using over-the-counter drug labels to identify potential risks such as side effects 19 U.S. Department of Education National Assessment of Adult Literacy

20. How does limited health literacy affect people?  Limited knowledge of the body  Difficulty understanding charts or ranges (such as healthy weight ranges or vaccine charts)  Difficulty understanding when or how to take medication  Difficulty using over-the-counter drug labels to identify potential risks such as side effects  Difficulty filling in health insurance applications  Unable to evaluate information for determining which legal document applies to a specific health care situation 20 U.S. Department of Education National Assessment of Adult Literacy

21. How does limited health literacy affect people? People with limited health literacy skills often have:  Limited knowledge of the nature and cause of a disease  Less than 50% of diabetic patients with limited health literacy knew the symptoms of hypoglycemia  Trouble understanding and applying health care information 21

22. How does limited health literacy affect people? People with limited health literacy skills often have:  Difficulty interacting with the health care system  86% could not understand Rights and Responsibilities section of a Medicaid application  26% did not understand when their next appointment was scheduled 22 White, S. (2008). Assessing the nation’s health literacy: Key concepts and findings of the National Assessment of Adult Literacy. American Medical Association Foundation.

23. How does limited health literacy affect people? People with limited health literacy skills often have:  Less awareness of preventive health measures  Less knowledge of their medical conditions and self-care instructions  42% did not understand instructions to “take medication on an empty stomach”  (up to) 78% misinterpret warnings on prescription labels  Limited health literacy is associated with increased mortality and hospitalizations 23

24. Those with limited literacy skills:  Report poorer overall health  Have poorer ability to manage chronic diseases  Have poorer outcomes  Less likely to understand their diagnosis  Less likely to have screening/ preventive care  Present in later stages of disease 24 How does limited health literacy affect people?

25. How does limited health literacy affect the health care system?  $106-$238 billion in unnecessary costs annually 4  Are more likely to be hospitalized/rehospitalized  Higher costs for emergency room and inpatient care  One study: $2,891 (annual health care cost for Medicaid enrollee) vs. $10,688 (cost for enrollee with limited health literacy) 5 25 4 Vernon, University of Connecticut, 2007 5 Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005; 118; 371-377.

26. RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH OUTCOMES 26

27. Relationship between health literacy and health outcomes People with limited health literacy are:  Less likely to use of preventive services 27

28. Relationship between health literacy and health outcomes People with limited health literacy are:  Less likely to use of preventive services  Less knowledgeable about medical conditions and treatment  More likely to use emergency services 28

29. Relationship between health literacy and health outcomes People with limited health literacy are:  Less likely to use of preventive services  Less knowledgeable about medical conditions and treatment  More likely to use emergency services  More likely to report their health as “poor” 29

30. Relationship between health literacy and health outcomes People with limited health literacy are:  Less likely to use of preventive services  Less knowledgeable about medical conditions and treatment  More likely to use emergency services  More likely to report their health as “poor”  Often ashamed about their literacy skill level 30

31.  Recognizing signs of limited health literacy  Responding to client needs  Employ the universal precautions approach 31 What is the response?

32. INDICATIONS THAT A CLIENT MAY HAVE LIMITED HEALTH LITERACY 32

33.  Does not take medications correctly 33 General indications

34.  Does not take medications correctly  Frequently misses appointments  Fails to follow through on tests or referrals 34 General indications

35.  Does not take medications correctly  Frequently misses appointments  Fails to follow through on tests or referrals  Does not complete intake forms  Unable to provide a detailed history of their illness or treatments 35 General indications

36.  Does not take medications correctly  Frequently misses appointments  Fails to follow through on tests or referrals  Does not complete intake forms  Unable to provide a detailed history of their illness or treatments  Does not complete intake forms  Asks few questions  Avoids reading tasks using commonly accepted reasons (e.g., “I forgot my glasses.”)  Does not remember information read earlier 36 General indications

37. Indications among people living with HIV/AIDS  Has a consistently high or unchanged viral load  Does not take antiretroviral therapies correctly  Has frequent hospitalizations  Falls out of care  Skips important preventive measures  Can not explain HIV or AIDS 37

38. UNIVERSAL PRECAUTIONS APPROACH 38

39. Universal precautions refers to taking specific actions that minimize risk for everyone when it is unclear which patients may be affected. 39 What is the universal precautions approach?

40.  Health literacy universal precautions allow health professionals to ensure that systems are in place to promote better understanding for all patients, not just those you think need extra assistance.  Improving patient understanding is beneficial for both the patient and health care provider. 40

41.  All clients benefit from easy-to-understand materials and simple spoken communication.  Medical care is complicated, and many people struggle with understanding medications, self-care, instructions, and follow-up plans. 41 Premise of the universal precautions approach

42. How could you implement universal precautions for health literacy? Give 3 examples. 42

43. Considerations when employing the universal precautions approach  Cultural, emotional, and situational factors may influence a client’s ability to process information.  Clients must feel safe to disclose personal and private information (judgment-free and confidential) and to ask questions.  Points of communication in the patient care process:  scheduling medical visits  reviewing medical history  communicating health information and treatment options  Each point is an opportunity to improve the clarity and quality of the exchanges between practice staff and patients of all literacy levels. 43

44. Questions? 44

45. Recap Today we covered the:  Importance of health literacy  Ways in which limited health literacy results in poorer health outcomes  Indicators that a patient may have limited health literacy  Health literacy universal precautions approach 45

46. Check your knowledge  Explain the importance of health literacy  Discuss at least 3 ways in which limited health literacy results in poorer health outcomes  List at least 5 indicators that a patient may have limited health literacy  Define the universal precautions approach to health literacy 46

47.  In Module 2, we are going to explore the cultural, emotional, and situational factors that may influence a client’s ability to process information, with a focus on the factors that influence Black MSM seeking treatment and care.  In later training modules, we will look at specific communication approaches and tools that can improve health literacy and increase your provision of health literate services. 47 Next steps

48. Take home Over the next week, consider what you have learned. Apply the universal precautions approach to health literacy at least 3 times. Come prepared to share your experiences. 48

49. Welcome Trainer: Daniel Driffin Email: hivhealthliteracy@jsi.comhivhealthliteracy@jsi.com Phone: 404.460.4790 This material was produced by John Snow Inc., under Contract #HHSH25020140037I with the Health Resources and Services Administration, U.S. Department of Health and Human Services.