1. Health Literacy 101 Pamela Kavanaugh, RN, CDE & Alejandra Gomez, MHSM, MBA Brownsville Community Health Center (BCHC)

2. OBJECTIVES Defining health literacy and gain awareness with its impact and relationship to quality care, Identify & discuss challenges and barriers patients and their families face that impact wellness, and Learn innovative tools and techniques to address low literacy and overcome barriers and challenges.

3. “As a former nurse, trauma surgeon, and public health director [I realized] there was a wall between us and the people we were trying to serve. Health care professionals do not recognize that patients do not understand the health information we are trying to communicate. We must close the gap between what health care professionals know and what the rest of America understands.” Dr. Richard Carmona, U.S. Surgeon General 2002-2006

4. Health Literacy “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Healthy People 2010

5. Health Literacy & Quality of Care “Good quality means providing patients with appropriate services, in a technically competent manner, with good communication, shared decision-making, and cultural sensitivity. * * From IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. Shared decision-making includes encouraging active participation by patients in visits with their health care providers.

6. Cultural Sensitivity Cultural sensitivity is the ability of health organizations and practitioners to recognize the following in diverse populations to produce a positive health outcome: Cultural beliefs Values Attitudes Traditions Language preferences Health practices

7. Health Literacy & Shame Often report feeling a sense of shame about their skill level. Often uncomfortable about being unable to read well, and they develop strategies to compensate, or they often do not ask questions at all. Children often are expected to translate for parents and providers.

8. A Demonstration Exercise The following paragraph of instructions simulates what a reader with low literacy sees on the printed page Read the paragraph out loud. You have 15 seconds to read. HINT: The first word is “cleaning”

9. GNINAELC – Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-der edixo selcitrap. Esu a nottoc baws denetsiom htiw lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.

10. Cleaning – to assure high performance, periodically clean the tape heads and capstan whenever you notice an accumulation of dust and brown-red oxide particles. Use a cotton swab moistened with isopropyl alcohol. Be sure no alcohol touches the rubber parts as it tends to dry and eventually crack the rubber. Use a damp cloth or sponge to clean the cabinet. A mild soap like dishwasher detergent will help remove grease or oil.

11. Test your Comprehension… You are not alone if… You did not get past the first line. You were not able to understand the instructions on how to clean the equipment. How many of your patients are struggling just to ‘de-code’ words?

12. CHALLENGES AND BARRIERS

13. 2003 Nat’l Assessment of Adult Literacy Intermediate Basic Below Basic Proficient 14% 13% 44% % 29% % 93 Million Adults have Basic or Below Basic Literacy

14. Literacy and Spanish Language 11 million US residents do not speak English well or at all 8 million of these speak Spanish Functional Health Literacy in Adults at two Public Hospitals LanguagePercent Low Literacy (in preferred language) English35% Spanish62% Williams et al. JAMA 1995

16. Who Is at Risk? The problem of limited health literacy is greater among: –Older adults –Those who are poor –People with limited education –Minority populations –Persons with limited English proficiency (LEP)

17. Barriers between Literacy and Health Outcomes

18. Health Literacy: Knowledge About Medical Conditions & Treatment Persons with limited health literacy skills: Are more likely to have chronic conditions and less likely to manage them effectively. Have less knowledge of their illness (e.g., diabetes, asthma, HIV/AIDS, high blood pressure) and its management.

19. Outcomes Associated with Literacy Health Outcomes/Health Services General health status Hospitalization Prostate cancer stage Depression Asthma Diabetes control HIV control Mammography Pap smear Pneumococcal & Influenza immunizations STD screening Behaviors Only Substance abuse Breastfeeding Behavioral problems Adherence to medication Smoking Knowledge Only Birth control knowledge Cervical cancer screening Emergency department instructions Asthma knowledge Hypertension knowledge DeWalt, et al. JGIM 2004;19:1228-1239

20. “How would you take this medicine?” 46% did not understand instructions ≥ 1 labels 38% with adequate literacy missed at least 1 label Davis TC, et al. Annals Int Med 2006, slide by T Davis

21. “Show Me How Many Pills You Would Take in 1 Day” John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill Slide by Terry Davis

22. Can Patients Comprehend Rx Drug Warning Labels? Davis et al. JGIM 2006; 21: 847-851

23. Simple Familiar Wording Understood by Most Patients 84% (1 st grade.) Slide by Terry Davis

24. More Complex Message Limited Comprehension 59% (10 th -12 th grade.) Slide by Terry Davis

25. Unfamiliar Multi-step Instructions Rarely Understood 8% ( 12 th -13 th grade) Slide by Terry Davis

26. Innovative Tools and Techniques

27. Make it easier… Raise awareness among all staff and providers; Literacy training / patient education Improve health forms and instructions; develop easier to read materials. Improve the physical environment; may include practice re-design. Establish a People Relations or Patient Navigator Program team via Promotoras and/or greeters. Improve communication skills

28. Improve Health Forms & Instructions Revise forms to ensure clarity and simplicity. Test forms with intended users and revise as needed. Provide forms in multiple languages. Have staff offer assistance with completing forms and scheduling follow-up care.

29. Improve Access to Accurate & Appropriate Health Information Work with the media to increase awareness of health literacy issues. Work with providers to ensure that the health information they share is accurate, current, and reliable. Form partnerships with civic and faith- based organizations trusted in the community.

30. Improve the Physical Environment Settings with lots of signs and postings have a high literacy demand: Include universal symbols and clear signage in multiple languages. Promote easy flow through healthcare facilities Create a respectful and shame-free environment.

31. Establish a Patient Navigator Program / Use your Promotoras Promotoras are community health workers who help patients: - Evaluate their treatment options. –Obtain referrals. –Through local University, find clinical trials. –Apply for financial assistance. Greeters are individuals hired to guide patients through our clinics.

32. Speak Clearly & Listen Carefully Use a medically trained interpreter if necessary: –For those who do not speak English well, plain English will not help. –Ensure that all language access services, including translation, are in plain language. –Refer to Cultural & Linguistically Appropriate Services (CLAS) standards. Ask open-ended questions: –Elicit cultural beliefs and attitudes: “Tell me about the problem and what may have caused it.” Check for understanding: Use the “teach-back” method: Have the person restate the information in his or her own words.

33. Internet Make it User Friendly. People cannot find the information they seek on Web sites 60% of the time. Many elements that improve written and oral communication can be applied to information on the Web: — Plain language — Large font — White space — Simple graphics

34. Patient Education Co-develop adult basic education lessons on health topics: Adult learners want information that is relevant to their lives; health content is likely to engage them. Construct lessons in which students use health-related texts, forms, and content from the Internet.

35. Use Patient-Friendly Educational Materials Simple wording, short sentences –4 th -6 th grade level Picture based Focus only on key points Emphasize patient concerns –What the patient may experience –What the patient should do Minimize information about disease statistics, anatomy, and physiology Be sensitive to cultural preferences

36. Understanding Clarify Assess Explain Teach-back

37. Summary Low literacy is common and is associated with adverse health outcomes Interventions to mitigate the impact of literacy on health continued to be studied. Some evidence suggests awareness and understanding of health literacy can improve outcomes

38. Resources Darren DeWalt, MD, MPH, & Michael Pignone, MD, MPH University of North Carolina-Chapel Hill, Department of Medicine AHRQ Report—Literacy and Health Outcomes (2004): www.ahrq.gov/clinic/epcsums/litsum.htm www.ahrq.gov/clinic/epcsums/litsum.htm Healthy People 2010 (2000): www.healthypeople.govwww.healthypeople.gov Healthy People 2010 Health Literacy Action Plan—Communicating Health: Priorities and Strategies for Progress (2003): http://odphp.osophs.dhhs.gov/projects/healthcomm/ objective2.htm http://odphp.osophs.dhhs.gov/projects/healthcomm/ objective2.htm NIH Improving Health Literacy Web page: www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm

39. Questions ? ? ? ? ?