1. Health Literacy Paul D. Smith, MD, Associate Professor University of Wisconsin Department of Family Medicine Paul.Smith@fammed.wisc.edu

2. Topics today General health literacy information Results of WAFP Health Literacy Survey Communication Issues What can you do?

4. Literacy skills

5. What is Literacy? National Adult Literacy Survey 1992 “Using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential.”

6. More than just reading grade level Prose Literacy Written text like instructions or newspaper article Document literacy Short forms or graphically displayed information found in everyday life Quantitative Literacy Arithmetic using numbers imbedded in print

7. What is Health Literacy? The Institute of Medicine 2004 “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.”

8. What is Health Literacy? The Institute of Medicine 2004 “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.”

9. What is Health Literacy? The Institute of Medicine 2004 “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.”

10. Real People with Real Problems Insert video clip here

11. National Adult Literacy Survey Federal survey conducted in 1992 26,000 people over age 15 Living in households and prisons Divided into 5 levels

12. National Adult Literacy Survey Level 1 – find one piece of information Level 2 – find two related pieces of information Level 3 – integrate multiple pieces of information Level 4 – respond Level 5 – analyze, formulate

13. National Adult Literacy Survey Level 1 – find one piece of information Can: Sign name on a document Identify a country in a short article Total a bank deposit slip

14. National Adult Literacy Survey Level 1 – find one piece of information Cannot: Enter information on a social security card application Locate an intersection on street map Calculate the total cost on an order form

15. National Adult Literacy Survey Level 2 – Find two related pieces of information Can: Identify YTD gross pay on a paycheck Determine price difference between tickets for 2 shows

16. National Adult Literacy Survey Level 2 – Find two related pieces of information Cannot: Use a bus schedule Balance a check book Write a short letter explaining error on a credit card bill

17. National Adult Literacy Survey 47-51% of Americans in Levels 1 and 2

18. National Adult Literacy Survey 39% of Wisconsin adults in Levels 1 and 2

19. 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

20. Literacy Levels Change with Age Document Literacy

21. Literacy Levels Change with Age Document Literacy 80 and over Level 1 + 2 89%

22. 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

23. 2003 National Assessment of Adult Literacy Data released 12/05 ~17,000 people participated Changed reporting methodology

24. New Reporting Method 80% correct responses moved down to 67% 4 categories Below basic Basic Intermediate Proficient

25. 2003 National Assessment of Adult Literacy

26. The Bottom Line Not much change Prose a bit worse Document a bit better Quantitative a bit better

27. Clinician Survey 16 question email survey Sent to 411 Wisconsin family physicians 28% response rate

28. Impact on Quality and Outcomes Number of Respondents Impact Health Outcomes Impact Quality of Care >87%

29. Results : Prevalence Number of Responses Mean = 17.4% NALS = 47-51%

30. Results Does your clinic screen patients?

31. The Bottom Line Physicians are aware of literacy impacting on health and health care They underestimate the extent of the problem

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

33. Poorer Health Knowledge Diabetics that know low glucose symptoms 50% 94%

34. Poorer Health Knowledge Hypertensives that know exercise lowers BP 40% 68%

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

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

37. 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

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

39. Increased Health Care Costs Total annual Medicaid charges $10,688 $2,890

40. Increased Health Care Costs Based on NALS data Majority from increased hospitalizations

41. Reading Levels  20% of American adults read at or below the 5th grade level  Most health care materials are written above the 10th grade level.

42. Low Literacy is Overlooked Clinicians don’t ask about literacy Some are not aware of the problem Not sure how to ask Not sure how to respond Do not want to open the can of worms

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

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

45. More likely to have Low Literacy Older Immigrants Less education Incarceration

46. More likely to have Low Literacy Non-white Low-income Medical Assistance

47. Low Literacy is Overlooked Many Level 1 people don’t fit the stereotypes 75 % born in USA 50% are white 40% hold full or part-time jobs

48. Common Clues of Low Literacy Patients say things like: “I lost my glasses” “I’d like to discuss this with my family” “I have a headache now and can’t focus”

49. 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

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

51. Patient Communication Processes Patient-physician communication Patient history Informed consent Medical instructions

52. Patient Communication Processes Patient education materials Prescription labeling

53. Patient Communication Processes Responding to medical and insurance forms Navigating the clinic or hospital

54. Verbal Communication Strategies Whole staff must be aware and sensitive Create a culture of helpfulness Quiet room with minimal distractions

55. Front Desk/Registration Always offer to help complete forms Simplify registration forms Only ask for information that you need

56. Verbal Communication Strategies SLOW DOWN Simple terms Use monosyllabic and colloquial terms Avoid or explain the medical jargon. Begin with important information first and limit new information. Repeat the information/instructions

57. Verbal Communication Strategies Have the patient repeat the information, use the “teach back” method. No more than one or two instructions at a time—and check each time: “Chunks and Checks”. Write it down.

58. Verbal Communication Strategies Use models, sketches, pictures. Give instructions to several of family members. Consider follow up phone calls.

59. Written Materials- Common Mistakes Readability level is too high Too much detail Hard words are not explained

60. Written Materials- Common Mistakes Pictures do not reinforce the message No examples

61. Written Materials Review materials for reading level 5 th – 6 th grade reading level Flesch-Kincaid grade level

63. Objectives Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin. Identify people at increased risk of low literacy Acquire an understanding of specific activities they can do to improve verbal communication with all patients, especially low literacy adults Identify the important issues to address when developing educational documents for low literate adults Flesch-Kincaid Grade Scale: 12

64. Objectives Acquire an understanding of the definition of literacy, health literacy and the magnitude of the problem in Wisconsin. Identify people at increased risk of low literacy Acquire an understanding of specific activities they can do to improve verbal communication with all patients, especially low literacy adults Identify the important issues to address when developing educational documents for low literate adults Flesch-Kincaid Grade Scale: 12

65. Topics today General health literacy information How to recognize people with low literacy How to improve communication Factors to consider when creating documents Flesch-Kincaid Grade Scale: 12

66. Topics today Health literacy. Finding people with low literacy. How to improve communication. How to make things easier to read. Flesch-Kincaid Grade Scale: 7.1 (talking for communication = 5.1)

67. Beyond handouts Pictures and models Audiotapes and CDs Videotapes and DVDs CD-ROM Internet

68. What can be done? 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

69. What can be done? Distribute the handouts about health literacy resources. Consider partnering with a local Community- based adult literacy organization.

70. What can be done? Be a patient. Review processes Review documents 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.

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

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

73. Wisconsin Literacy Coordinating organization for community- based adult literacy organizations 44 Organizations scattered around the state New funding for regional facilitators

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

75. “Action expresses priorities.” ---Mohandas Gandhi