1. Health Impact of Low Literacy & Partnering to Address Solutions Paul D. Smith, MD, Associate Professor UW Department of Family Medicine Paul.Smith@fammed.wisc.edu

2. Topics today Social determinants of health Impact of literacy on health and health care Collaboration in Wisconsin Policy issues to consider

3. Social Determinants of Health Social determinants of health Impact of literacy on health and health care Collaboration in Wisconsin Policy issues to consider

4. In Their Own Words Insert video clip here

5. How Age Effects NALS Data Adults age 60 and over Living in households or prisons 68-80% are in Level 1 and 2 More in Level 1 and 2 with advancing age 89-99% Level 1 and 2 age 80 and over

6. Literacy Levels Change with Age BUT, they do not recognize their problem Age 60 and older 91% Read well or very well 88% Write well or very well 83% Do arithmetic well or very well

7. NAAL Health Literacy Assessment Basic and Below Basic by education level In High School, GED or HS grad 34-37% Less than/some High School 76%

8. NAAL Health Literacy Assessment Basic and Below Basic by Self-reported health status Excellent 25% Very Good 28% Good 43% Fair 63% Poor 69%

9. The Impact of Low Literacy on Health Poorer health knowledge Poorer health status Higher mortality More hospitalizations Higher health care costs

10. Poorer Health Knowledge Understanding prescription labels 395 patients 19% low literacy (6 th grade or less) 29% marginal literacy (7-8 th grade) 52% adequate literacy (9 th grade and over) 5 prescription bottles Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

11. Poorer Health Knowledge At least one incorrect 63% low literacy 51% marginal literacy 38% adequate literacy Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

12. Poorer Health Knowledge Take two tablets twice daily Stated correctly Demonstrated correctly 71% low literacy 35% 84% marginal literacy 63% 89% adequate literacy 80% Show me how many pills you would take in one day. Counted out 4 tablets-correct

13. Poorer Health Status 2923 new Medicare enrollees Inadequate literacy had increased frequency of: Diabetes Hypertension Heart failure Arthritis

14. Poorer Health Status Medical Outcomes Study (SF-36) Inadequate literacy had Decreased: Physical function Mental health Increased Limitations in activity due to physical health Pain that interferes with normal work activities

15. Poorer Health Status Diabetics with retinopathy 36% 19%

16. Increased Mortality Age 70-79 Reading level 8 th grade or less Five Year Prospective Study Sudore R, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.

17. Increased Mortality Risk of Death Hazard ratio: 1.75

18. More Hospitalizations 2 year hospitalization rate for patients visiting ED 31% 14%

19. Increased Health Care Costs Data 2003 Medical Expenditure Panel Survey 2003 National Assessment of Adult Literacy Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007

20. Increased Health Care Costs Annual cost today: Future costs based on todays actions (or lack of action): Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007 $106-238 Billion $1.6-3.6 Trillion

21. Low Literacy is Overlooked Patients do not volunteer their literacy problem Many are ashamed Some do not recognize their inadequate literacy Lack of trust

22. The Big Secret % of low literate adults that have not told their: Children52% Friends62% Spouse68% Health care providers75% Co-workers85%

23. More likely to have Low Literacy Older Less education Non-white

24. More likely to have Low Literacy Immigrants Immigrate after age 12 >50% NALS Level 1

25. More likely to have Low Literacy Low-income Medical Assistance Incarceration

26. You Cant Tell by Looking Many Level 1 people dont fit the stereotypes 75 % born in USA 50% are white 40% hold full or part time jobs

27. Other Issues Effecting Literacy Visual Impairments 60 and older 17% 80 and older 36%

28. Other Issues Effecting Literacy Cognitive impairment Learning disability 65 and older 6% severe dementia 10-15 % mild-moderate Increases with advancing age

29. Screening for Low Literacy Upside-down test Rapid Estimate of Adult Literacy in Medicine REALM Test of Functional Health Literacy in Adults TOFHLA Newest Vital Sign NVS

30. Common Clues of Low Literacy Patients say things like: I lost my glasses I dont need to read this through now, Ill read it when I get home Id like to discuss this with my family I have a headache now and cant focus

31. Common Clues of Low Literacy Medication review Looking vs reading Unable to name med Do not know why taking med Do not know medication timing

32. Common Clues of Low Literacy Non-compliance Medications Testing Consultations

33. How do we fix this problem? Universal Design If it works for people with low literacy or low English skills, it will work for everyone.

34. Barriers to Effective Communication Environmental factors Noise Lack of privacy Distractions Time constraints

35. Barriers to Effective Communication Health care provider factors Jargon Lack of rapport Ambiguous wording Incomplete message Too much information

36. Barriers to Effective Communication Patient factors Language Cultural issues Lack of trust Hearing impairment Visual impairment

37. Summary Low literacy is a common problem Low literacy affects health

38. Summary Low literacy is hard to identify Most of our documents are written at a reading level that is too high.

39. Policy Issues to Consider Healthcare Social Marketing ABE ELL, family, workforce and corrections programs.

40. What can YOU do? Raise awareness American Medical Association Foundation Low Health Literacy: You Can't Tell By Looking Health Literacy: Help Your Patients Understand Institute of Medicine Prescription to End Confusion

41. What can YOU do? Be a patient. Review processes Review documents

42. What can YOU do? Universal Design Health Literacy Definition The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.

43. Understandable Consent Forms A consent process that checks understanding Documents written at 5 th grade reading level Procedures Research Billing/insurance

44. Informed Consent Who are We Really Protecting? Institutions Researchers Sponsors Patients?

45. Other Consenting Methods Script with verbal consent Computer consent Video/DVD

46. What can YOU do? Partner with your local Literacy Council Connie Solsrud Executive Director Marathon County Literacy Council 300 N. 1st Street, Wausau 715-261-7292

47. What can YOU do? Partner with your local Literacy Council Jennifer Lund Director The Neighbors Place 745 Scott Street, Wausau 715-845-1966

48. Wisconsin Literacy Coordinating organization for community- based adult literacy organizations. 52 Organizations scattered around the state. Four Regional Literacy Consultants.

49. Wisconsin Literacy www.wisconsinliteracy.org Michele Erikson, director 608-257-1655 michele@wisconsinliteracy.org

50. Health Literacy Regional Meetings Steering Committee volunteers needed Sponsors needed

51. What can YOU do? Partner with your local Regional Literacy Consultant Connie Turbiville connie@wisconsinliteracy.org 435-2474 Office in Green Bay

52. Donate Time Be a tutor Donate Wisconsin Literacy Your local Literacy Council

53. Action expresses priorities. Be the change that you want to see in the world. ---Mohandas Gandhi