Health literacy: Making It easy Angela Shepherd NES Nursing & Midwifery Practice Educator

Functional Literacy The basic skills of reading, writing and numeracy taking context into account

Low Literacy – not confined to developing countries 1 in 5 adults in Scotland could not locate the page for plumbers in the Yellow Pages directory

Literacy Levels In Scotland Results of International Adult Literacy Survey (Scotland)    23% Very poor skills. May not be able to determine the amount of medicine to take     32% Weak skills. Can only deal with well laid out simple material and tasks that are not complex    45% Skills at or above level required for coping with demands of everyday life

Consequences of low literacy Higher unemployment Low skill jobs Social exclusion More likely to live in areas of deprivation Women more likely to be teenage mothers Increased health problems and disabilities Higher rates of depression Higher proportions self-reporting poor health Less physical activity Higher smoking rates

Medicines/Health Screening Trouble adhering to medication regimes Poor understanding of labelling 3-4 times more likely to misinterpret prescription labels 43% working age adults – unable to calculate childhood Paracetamol dose 49% unable to understand instructions for using the National Bowel Cancer screening kit

Low literacy can hamper self-care activities  Information leaflets difficult to read, often discarded  Medication instructions - too much text, writing too small  Dosage - frequency not understood  Difficulties buying OTC medicines I don’t know what I’m buying normally, do you know if it’s got Calpol on it, then I’m like that ‘That’s Calpol, that’s fine’…. but then if it’s Cal.. is it Calbrufen? I’m not allowed that, because I’ve got asthma so (son)’s not allowed that…..So you have to watch the colours of the packets and stuff … to tell the difference

Self Management People with low literacy more likely to be more unwell, have lower knowledge, not use inhalers properly and more likely to go to an emergency department (Williams, MV et al. Arch Int Med 1998;158: ) Less diabetes knowledge, less likely to understand and act on diabetes monitoring, less likely to control their blood glucose and more likely to have eye problems (Schillinger, D et al. JAMA 2002;288: )

Stigma Research participants anticipated that disclosure would not change clinical treatment but staff would judge them, be patronising, think badly of them, look down on them, compromising relationships with healthcare staff they speak to you like you’re three. Then they wouldn’t leave you alone and then they’re kinda like as if you can’t do nothing for yourself (Katy, female, 20s)

Hid their literacy problems Pretended to understand Did not ask questions Did not ask for help.... they never explain anything properly. It’s always their own big words and I just say, uh hmm, yeah, okay and I go home and I’m like, ‘I don’t know what that meant.’ (Megan, female, teens) People with low literacy who had attended clinics said that they…

Red Flags for Low/Poor Literacy Frequently missed appointments Incomplete forms Non-compliance with medication Unable to name medications, explain purpose or dosing Identifies pills by looking at them, not reading label Unable to give coherent, sequential history Asks fewer questions Lack of follow-through on tests or referrals

Recommendations from people with low literacy Don’t assume that people can read or write Use a variety of media to share information Oral explanation in simple terms Keep forms simple and explain them Offer to help without labelling Don’t put people on the spot Send forms out before appointments

Health Literacy “Health literacy is based on general literacy and entails people’s knowledge, motivation and competences to access, understand, appraise and apply health information to make judgments and take decisions in terms of healthcare, disease prevention and health promotion to maintain and improve quality of life throughout the life course” (HLS-EU Project - the European Health Literacy Project) “The term ‘health literacy’ refers to people having the appropriate skills, knowledge, understanding and confidence to access, understand, evaluate, use and navigate health and social care information and services” (Making it Easy, NHS Scotland, 2014)

Findings from various surveys Recent UK study- estimated 33%of people aged over 52 have limited health literacy Survey of 8 European countries - 47% estimated to have inadequate health literacy

The Scale of Limited Health Literacy 42% working age individuals – unable to understand & make use of everyday health information 61% find health materials too complex to understand 43% - unable to calculate childhood Paracetamol dose (Improving Health Literacy to Reduce Health Inequalities: Public Health England, 2015)

People with Low Health Literacy: times more likely to experience increased hospitalisation or death More likely to have depression More likely to struggle with managing their and their family’s health and wellbeing Increased risk of developing multiple health problems Use fewer preventive and health promotion services, such as cancer screening and flu vaccinations Have less recall and adherence to medical instructions and healthcare regimes Find it more difficult to access appropriate health services Make more use of accident and emergency services and have longer in-patient stays Have less effective communication with health and social care practitioners Less likely to engage in active discussions about their health options, potentially leading to their health needs being hidden (Improving Health Literacy to Reduce Health Inequalities: Public Health England, 2015)

Improving Health Literacy Increases health knowledge Builds resilience Encourages positive lifestyle change Empowers people to manage long-term health conditions Reduces the burden on health and social care services

Low Health literacy: not just a problem for patients with limited education or reading ability - can also be found in individuals who may be highly literate in other areas but have difficulty understanding medical terminology and jargon. Patients may be embarrassed to admit their lack of understanding and sometimes matters can be further complicated by anxiety or confusion associated with pain or drug treatments. The use of Teach Back will ensure that patients understand what is being explained to them.

Teach-Back A way to confirm that you have explained to the patient what they need to know in a manner that the patient understands

Teach-Back is Supported by Research “Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on the strength of scientific evidence.” AHRQ, 2001 Report, Making Health Care Safer “Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.” Schillinger, Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop”

Teach-Back Not a test of the patient’s knowledge A test of how well you have explained the concept Should be used by everyone with everyone Avoids use of ‘closed’ questions Takes time to learn, requires practice Can save time in the long run Person centred approach Can improve patient safety and patient outcomes

Laws of Remembering Recently Frequently Impact Application

Listening Dilemma We speak at a rate of about 150 words per minute (wpm) But we can hear at a rate of about 1,000 wpm This gives us a lot of extra time! What do we do with this time? (Gaber, 2008)

Listening Exercise

Hearing is a passive process, like breathing. We do it without thinking. Listening, however, is a learnt skill and an active process. Our brains have to work harder to process the information that we hear and see in order to understand the meaning of the message. Understanding is the goal of listening.

Talking with Patients & Families Always: Use Plain Language. Slow down. Break it down into short statements. Focus on the 2 or 3 most important concepts. Check for understanding using teach-back

Teach-Back Asking patients to demonstrate understanding using their own words: “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?” “What will you tell your husband about the changes we made to your blood pressure medicines today?” “We’ve gone over a lot of information about your diabetes tablets, In your own words, can you tell me what we talked about?” From Health Literacy: Universal Precautions Toolkit (AHRQ)

Teach-back… Creates an opportunity for dialogue in which the provider gives information, then asks the patient to respond and confirm understanding before adding any new information Re-phrase if a patient is not able to repeat the information accurately Ask the patient to teach back the information again, using their own words, until you are comfortable they really understand it If they still do not understand, consider other strategies.

Questions to Consider What are specific topics or directions you commonly discuss with your patients that you can use the teach-back method with? Ideas: Insulin injections, inhalers, medication changes, chronic disease self-care, colonoscopy prep How can you phrase your teach-back questions?

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