Health Literacy: A Clinician’s Point of View Paul D. Smith, MD, Associate Professor UW Department of Family Medicine

Topics today Social determinants of health. Health literacy. Impact of literacy on health and health care. What can we do about this?

Determinants of Health Gender Age Race/ethnicity Co-morbidities

Social Determinants of Health Employment status Income level Health insurance status Marital status

Social Determinants of Health Education level High school diploma or equivalent Literacy level

Question? What would happen to Wisconsin’s overall health, if we were able to eliminate health disparities?

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170)

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170) African Americans (624) Native Americans (592) (279) (277)

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170)

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170) (275) (266)

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Best state Minnesota (257) Asians (170) Men (367) (225) Wisconsin (296) (225)

Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) Native Americans (592) African Americans (624) Worst state Mississippi (519) Best state Minnesota (257) Asians (170) High school or less (459) (212) Wisconsin (296) (206)

Effect of Eliminating Disparity by: Race 296  277 Geography 296  266 Gender 296  225* Education 296  206* *Wisconsin becomes the healthiest state in the U.S.

Answer: Eliminating health disparities in any category improves Wisconsin’s overall health. The greatest potential gain is in the elimination of disparities by education.

2003 National Assessment of Adult Literacy NAAL health literacy assessment 28 questions specifically related to health 3 clinical 14 prevention 11 system navigation Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S.Department of Education.Washington, DC: National Center for Education Statistics.

NAAL Health Literacy Assessment Background questions Self-rated health status Health insurance Sources of health information

NAAL Health Literacy Assessment Entire population Below basic 14% Basic 22% Intermediate53% Proficient 12%

NAAL Health Literacy Assessment Basic and Below Basic Health Literacy White 28% Native Americans 48% Blacks 58% Hispanics 66%

NAAL Health Literacy Assessment Basic and Below Basic Health Literacy Age % Age %

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%

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

Sources of Health Information TV and radio Family and Friends Health Care Professionals

Sources of Health Information Text Media Newspaper Magazines Books or brochures Internet

Sources of Health Information Percent of people that NEVER obtain health information from the internet Proficient 12% Intermediate 14% Basic 58% Below Basic 80%

In Their Own Words Insert video clip here

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

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:

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:

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

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

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

Poorer Health Status Diabetics with retinopathy 36% 19%

Increased Mortality  Age  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:

Increased Mortality Risk of Death Hazard ratio: 1.75

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

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

Increased Health Care Costs Annual cost today: Future costs based on today’s actions (or lack of action): Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct $ Billion $ Trillion

In Their Own Words Focus group project Three community-based literacy programs Six groups Fifty-one adults Limited reading skills- Adult Basic Education Limited English skills- English Language Learners

Focus Groups Major Themes Communication and understanding. Completing/understanding forms including consents.

Focus Groups Major Themes Difficulty in accessing healthcare Medication errors Anxiety and shame

The “System” is Broken Pre-school Children learn to read on the laps of their parents. K-12 education Third-fourth grade “watershed.” HS graduation rates. Almost 20% functionally illiterate HS graduates.

The “System” is Broken Adult education Lack of funding for literacy programs Family Workforce Corrections

The “System” is Broken Health Care Highly educated clinicians and support staff. Medical terminology. Documents written at a high reading level. Increasing complexity of medical care.

How do we fix this problem? Multi-faceted approach Funding one aspect and ignoring the other issues will not address the problems today. Education Change the health care system

How do we fix this problem? Pre-school Effective programs Reach Out and Read Refer parents to family literacy programs

How do we fix this problem? Pre-school Similar programs in non-traditional settings Women Infants and Children Prenatal care Ethnic community groups Faith based

How do we fix this problem? K-12 Everyone graduates functionally literate Address the social and other issues that influence HS drop out rates.

How do we fix this problem? Adult education More money for effective literacy programs. Community-based Family Workforce Corrections

How do we fix this problem? Health content in literacy curriculum Susan Levy, Ph.D. Breakout at 3:45

Education Will Not Solve Everything Health Care Continuing Medical Education (CME) for clinicians Medical education is stuck in the 60’s

Education Will Not Solve Everything Universal Design If it works for people with low literacy or low English skills, it will work for everyone.

The Healthcare System Has to Change Communication strategies Improve oral communication Easier to read written documents Effective informed consent process Check understanding

The Healthcare System Has to Change Commonwealth Fund Report A team effort, beginning at the front desk. Use of standardized communication tools Clinicians partner with patients to achieve goals Barrett S, et al. Health Literacy Practices in Primary Care Settings: Examples from the Field, January

The Healthcare System Has to Change Use of: Plain language Face-to-face communication Pictorials Educational materials

The Healthcare System Has to Change Organizational commitment to create an environment where health literacy is not assumed.

More Research is Needed Effective preschool and K-12 programs. Effective adult literacy programs. Effective health literacy interventions.

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

Summary The System has to change

What can YOU do? Learn more about health literacy IOM “A Prescription to End Confusion” Health literacy resource list Google “health literacy toolkit”

What can YOU do? Be a catalyst for change Raise awareness

Raising Awareness Your own local, state and national organizations. Health care organizations. State and federal legislators. Medical Education.

What can YOU do? Add health content to curricula.

What can YOU do? Collaborate with health care groups Hospitals Large medical groups Health care insurers

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

Paul D. Smith M.D