1. Top Tips for Good Health Literacy Practice
Angela Shepherd
NES Practice Educator
NHS Tayside Demonstrator site - won funding bid from SG to 2015 – set up programme - test & evaluate HL best practice in relation to transitions in care –
My role in HL demo programme – developing & delivering HL education & training for staff

2. It’s Simple.....
What seems simple for us....is often not so simple for service users/patients

3. Definitions - Health Literacy
“The term ‘health literacy’ refers to people having the appropriate skills, knowledge, understanding & confidence to access, understand, evaluate, use and navigate health and social care information and services”
(Making it Easy, NHS Scotland, )
“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 2015)
Making it Easier 2014 – 1st National HL action Plan – sets out ambition – Scotland to be a health literate society – enabling everyone to have the confidence, understanding, knowledge & skills to maintain good health.
Refreshed plan - Making it Easier – builds on this - includes learning from the NHST Demo programme – outlines next steps on improving HL practice across Scottish health & care systems
Realistic medicine annual report Health literacy is a key determinant of poor health outcomes & significant cause of health inequalities
Highlights the impact HL has on informed consent &shared decision making
Building our Personalised approach – taking time to listen & have truly shared conversation
Emphasises importance of HL as a priority issue for Scotland – work from the NHST demo site referred to as good practice that should be shared & embedded throughout NHS Scotland
Asserts - we need to make healthcare simpler and more engaging so that it’s responsive –particularly to those with greatest HL needs

4. Health Literacy & Practising Realistic Medicine
Building our personalised approach to care –attitudes of HC professionals impacts on pts inclination to ask questions – need to take the time to listen & have a truly shared conversations
Changing our style to shared decision making – effective communication skills lead to improved pt safety, symptom resolution and improvements in functional and psychological status - includes Sharing decisions about how our services are delivered - working creatively to improve the care we provide
Understanding & managing medico-legal risk – ensuring decisions are made in partnership with people – helping them to make choices about the care & treatment that’s best for them
Exploring risk as it’s relevant to the pt rather than the view of the HC professional – ensuring any consent is truly informed
Realising knowledge for a realistic era – information about managing health – must be user friendly – H&SC practitioners, local authorities and the voluntary sector - key role ensuring information is more accessible to the public. Includes ensuring staff are aware of HL

5. Be Aware The scale of the problem
The links between low functional literacy and health literacy
The effects of low functional or 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
Low literacy - directly correlated with low health literacy -
Literacy levels Scotland
23% Very poor skills. not able to determine the amount of medicine to take
32% - Weak skills- only deal with well laid out simple material and tasks that aren’t complex
45% - Skills at or above level required for coping with demands of everyday life
55% population poor or weak skills in literacy & therefore HL
One and a half to 3 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)

6. Know Who May Struggle English not first language Travelling community
Learning disabled
Cognitive impairment
Elderly
Sensory impairment
People who are ill / anxious / worried
Low functional literacy (often hidden)
Who might struggle ?
Ability to be health literate - important for all. All will face issues of health literacy. GP/hospital  appointment, dealing with your sick child, elderly relative. Deciding to take flu vaccine or not
HL - challenging regardless of your background, educational attainment or social status.
All may struggle at sometime
Added to this - demands our healthcare environments make of people -  admission to hospital - diagnosis of disease or illness - fear and anxiety - may be accompanied by physical pain or discomfort - seriously limits ability to understand information
 Many people will struggle with demands and expectations of health care
Some groups– may struggle even more –
particularly vulnerable groups:
Mental health problems
Low educational attainment
Low income families
Socially isolated
People in prison or been in prison
Homeless
Different cultures
People used to different health care systems

7. Think ‘Red Flags’ Failed appointments/no shows 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
People with low literacy are often a hidden population – don’t readily disclose
When we see these behaviours its worth considering if low literacy and HL is a factor

8. Take Responsibility Patients and service users Practitioners
Organisations
 individual and collective responsibilities in relation to HL
HL - not just the responsibility of pts and service users
Definitions of HL -  place issue with individuals rather than the complex & unfamiliar nature of health care environments. 
 Nothing about - ease of access and usability of those services or that information.
HL - not purely dependent on the skills or abilities of the individual or the organisation...
About relationship between the skills of the person receiving care/ treatment & the professionals and systems providing care and treatment
 • Patients and service users  have to be given information in ways that they can understand - that understanding must be checked and never assumed.
• Practitioners – focus should be on improving communication with patients, carers, relatives and others.
• Organisations  - focused on ensuring systems and processes as easy as possible for people to access , navigate and use.

9. Use Universal Precautions
Avoids labelling
Avoids making assumptions
Benefits everyone
Ensures everyone understands
Universal precautions for prevention and control of infection use this for everyone..... don’t test people / make assumptions before taking these precautions
Health literacy universal precautions - steps that practitioners & practices take when they assume all patients may have difficulty understanding health information and accessing health services.
Simplifying communication with & confirming understanding for all patients - risk of miscommunication is reduced.
info about managing health – must be available in a user friendly way – ensuring staff are aware of HL is part of this.

10. Always use Teach Back Benefits patients and care providers
Not a test of the patient’s knowledge
Avoids using closed questions
Takes time to learn/practice
Saves time in the long run
Improves patient safety/outcomes
Person centred approach
Should invite response in patients’ own words – not a repetition of what you have said
A way to confirm that you have explained to a patient what they need to know in a manner that they understand

11. Use Teach Back Effectively
Being ‘in the moment’
Practising consciously
Laws of remembering – impact & application
Simple instructions??
Importance of highlighting the important
Consistent use
Top tips:
Being ‘in the moment’, present with patients – prepare yourself, the patient, the environment, - suspend busyness – make time really listen– filter out the ‘noise’ .
Practice Consciously - Teach Back is often used in an unconscious way - when used in a conscious way - it becomes intentional and focused on specific outcomes
Impact & Application - why does the pt/service user need to know this - make explicit
simple instructions – can be more complex than we think and interpreted in many different ways
Importance of highlighting the important – tell people what the important bit is.....it may seem obvious, but not be obvious to them
Consistent use - used by everyone for everyone as far as possible

12. Asking the Right Questions Matters
To help you make the right decisions about your care, treatment or tests please ask your doctor or nurse:
Do I really need this test, treatment or procedure?
What are the benefits or risks?
What are the possible side effects?
Are there simpler, safer options?
What will happen if I do nothing?
‘People often want to be more involved in decisions about their care but may not know what questions to ask’ (Practicing Realistic Medicine, April 2018)
Effective communication skills lead to improved patient safety, symptom resolution & improvements in functional & psychological status.
People often need ‘permission’ and encouragement to ask questions about their care / treatment
Asking people ‘what questions do you have invites questions – but knowing what questions to ask can be confusing for patients
Delivering info on a specific condition/illness - tell people what other pts have asked /wanted to know more about – helps them to think about what they need to know or want to ask
Giving people the information they need – is professionally and morally ethical - it’s their ‘right’ to know
Doing this means that consent is truly informed – legal obligation
Give information in terms that people understand
Check understanding using Teach Back
Back up all verbal information with printed where possible
Use drawings, diagrams etc to get the message across

13. Ask Yourself: What discussions do you routinely have with patients?
What are the most important things that you want patients to know/be able to do after these discussions?
How will you know that your patients understand important information?
How can you make written/printed information easier to understand?
Why do we need to change?
Financial aspect - don’t have money to keep doing what we do
Ethical aspect - Health Literacy is an important empowerment tool - potential to reduce health inequalities
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
Think about the conversations you have with your patients
Are they complex/difficult?
Are you sure the patient understands what you’re telling them?
Do you make sure you back this up with written information?

14. Know How You Can Help Understand health literacy problems/consequences
Identify ‘at risk’ patients
Know how best to ‘reach’ those individuals
Provide education and support
Use teach-back
Use plain/simple language, short sentences, avoid jargon
Organise information – most important point first
Repeat information
Encourage questions
Ask “what questions do you have?”, rather than “do you have any questions?”
Supplement oral information with appropriate materials – leaflets, pictures, diagrams etc
Limit new concepts to a maximum of 3 per visit

15. Thank You Any Questions?