Health Literacy Internal Medicine

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Information about Health Literacy Internal Medicine

Published on February 15, 2008

Author: mjmarkland

Source: slideshare.net

An Introduction to Ycaretil Htlaeh Mary J. Markland MA, AHIP UND SE Clinical Campus Librarian February 15, 2008

"Not knowing how to read feels like being blind, ignorant, not able to understand or ask people. I feel embarrassed to tell the doctor I cannot understand." Anonymous Patient

"Not knowing how to read feels like being blind, ignorant, not able to understand or ask people. I feel embarrassed to tell the doctor I cannot understand."

Anonymous Patient

AMA Video Health Literacy: Help Your Patients Understand

Do you know? Which of the following is the strongest predictors of an individual’s health status? A) Age B) Income C) Literacy skills D) Education level E) Racial or ethnic group

Which of the following is the strongest predictors of an individual’s health status?

A) Age

B) Income

C) Literacy skills

D) Education level

E) Racial or ethnic group

True or False? Most people with limited literacy are poor, immigrants or minorities. Most people with limited literacy have low IQs. People will tell you if they have trouble reading. The number of years of schooling is a good general guide to determine literacy level

Most people with limited literacy are poor, immigrants or minorities.

Most people with limited literacy have low IQs.

People will tell you if they have trouble reading.

The number of years of schooling is a good general guide to determine literacy level

What is Health Literacy Healthy People 2010 defines health literacy as the ability to obtain, process and understand health information and services to make appropriate health decisions.

Healthy People 2010 defines health literacy as the ability to obtain, process and understand health information and services to make appropriate health decisions.

Another Definition: Health literacy is the degree to which people can understand basic health information and services they need to make appropriate health decisions, including: Reading an appointment slip Interpreting prescription information Understanding recommendations for health care Completing health insurance applications Understanding informed consent

Health literacy is the degree to which people can understand basic health information and services they need to make appropriate health decisions, including:

Reading an appointment slip

Interpreting prescription information

Understanding recommendations for health care

Completing health insurance applications

Understanding informed consent

Health Literacy is Math too Cholesterol and blood sugar levels Measuring medications Understanding nutrition labels Choosing between health plans or comparing prescription drug coverage requires calculating premiums, copays, and deductibles.

Cholesterol and blood sugar levels

Measuring medications

Understanding nutrition labels

Choosing between health plans or comparing prescription drug coverage requires calculating premiums, copays, and deductibles.

The Literacy Problem Nearly half of the U.S. adult population (90 million people) have low functional health literacy (National Adult Literacy Survey (NALS) data) 11 million adults are non-literate in English (2003 National Assessment of Adult Literacy (NAAL) data) 7.8 million seniors can only perform the most simple and concrete literacy skills (Below Basic) (2003 National Assessment of Adult Literacy (NAAL) data)

Nearly half of the U.S. adult population (90 million people) have low functional health literacy (National Adult Literacy Survey (NALS) data)

11 million adults are non-literate in English (2003 National Assessment of Adult Literacy (NAAL) data)

7.8 million seniors can only perform the most simple and concrete literacy skills (Below Basic) (2003 National Assessment of Adult Literacy (NAAL) data)

Literacy Levels of Adults in America 2003 National Assessment of Adult Literacy (NAAL) *Estimates Reading Ability NAAL Level *Approx Grade Level % of Pop. Below Basic Basic 1 2 0-5 6-8 14 (30 mil) 29 (47 mil) Intermediate 3 9-12 44 (114 mil) Proficient 4 College 15 (12 mil)

Literacy Levels of Adults in America: Sample of Tasks Typical of Level (NAAL) Below Basic Searching a short, simple text to find out what a patient is allowed to drink before a medical test Signing a form Adding amounts on a deposit slip Can’t use bus schedule, find intersection on map Can’t fill out social security application Basic Using a television guide to find out what programs are on Comparing the ticket prices for two events Can’t use bus schedule Can’t read a bar graph Can’t write a letter of complaint Intermediate Consulting reference materials to find out which foods contain a certain vitamin Identifying a specific location on a map Calculating the total cost of ordering office supplies from a catalog Proficient Comparing viewpoints in two editorials Interpreting a table about blood pressure, age and physical activity Computing and comparing the cost per ounce of food items

Below Basic

Searching a short, simple text to find out what a patient is allowed to drink before a medical test

Signing a form

Adding amounts on a deposit slip

Can’t use bus schedule, find intersection on map

Can’t fill out social security application

Basic

Using a television guide to find out what programs are on

Comparing the ticket prices for two events

Can’t use bus schedule

Can’t read a bar graph

Can’t write a letter of complaint

Intermediate

Consulting reference materials to find out which foods contain a certain vitamin

Identifying a specific location on a map

Calculating the total cost of ordering office supplies from a catalog

Proficient

Comparing viewpoints in two editorials

Interpreting a table about blood pressure, age and physical activity

Computing and comparing the cost per ounce of food items

The average reading level in the U.S. is 8th grade, and 20 percent read at the 5th grade level or below. (NALS data) 40 percent of seniors read at or below the 5th grade level (Doak, Doak, and Root) 50 percent of African Americans and Hispanics read at or below the 5th grade reading level (Center for Health Care Strategies) Welfare recipients Chronic physical and/or mental health conditions Native Americans Most health-related material is written at the 10th grade reading level or higher (Institute of Medicine) Literacy skills are a stronger predictor of health status than age, income, employment status, education level or racial/ethnic group (Partnership for Clear Health Communication) http://askmethree.com/health-literacy.aspx

The average reading level in the U.S. is 8th grade, and 20 percent read at the 5th grade level or below. (NALS data)

40 percent of seniors read at or below the 5th grade level (Doak, Doak, and Root)

50 percent of African Americans and Hispanics read at or below the 5th grade reading level (Center for Health Care Strategies)

Welfare recipients

Chronic physical and/or mental health conditions

Native Americans

Most health-related material is written at the 10th grade reading level or higher (Institute of Medicine)

Literacy skills are a stronger predictor of health status than age, income, employment status, education level or racial/ethnic group (Partnership for Clear Health Communication)

http://askmethree.com/health-literacy.aspx

People with low functional health literacy have: Poorer health status Less treatment adherence and a greater number of medication/treatment errors Higher rates of health services utilization, including 29 - 69 percent higher hospitalization rates Higher health care costs: $50 - $73 billion in additional health expenditures annually $7,500 more in annual health care costs for a person with limited health literacy, versus a person with higher health literacy skills Partnership for Clear Communication http://askmethree.com/health-literacy.aspx

Poorer health status

Less treatment adherence and a greater number of medication/treatment errors

Higher rates of health services utilization, including 29 - 69 percent higher hospitalization rates

Higher health care costs:

$50 - $73 billion in additional health expenditures annually

$7,500 more in annual health care costs for a person with limited health literacy, versus a person with higher health literacy skills

Implications for HealthCare Misread prescriptions and OTC instructions Can’t read or understand appointment slips, letters or informed consent Can’t read or understand directions for procedures like colonoscopies Patients are noncompliant Risk management issues Diagnoses are made at later stages

Misread prescriptions and OTC instructions

Can’t read or understand appointment slips, letters or informed consent

Can’t read or understand directions for procedures like colonoscopies

Patients are noncompliant

Risk management issues

Diagnoses are made at later stages

Literacy in North Dakota North Dakota Level 1 15% Level 1 or 2 39% Cass County Level 1 or 2 27% Grand Forks County Level 1 or 2 30% Burleigh County Level 1 or 2 32% Pembina County Level 1 or 2 45% Mercer County Level 1 or 2 44% Data based on 1992 National Adult Literacy Survey and the 1990 Census Data from Synthetic Estimates of Literacy/National Institute for Literacy http://www.nifl.gov/reders/reder.htm

North Dakota

Level 1 15%

Level 1 or 2 39%

Cass County

Level 1 or 2 27%

Grand Forks County

Level 1 or 2 30%

Burleigh County

Level 1 or 2 32%

Pembina County

Level 1 or 2 45%

Mercer County

Level 1 or 2 44%

How to Identify a Patient Common phrases I can’t read this now. I forgot/broke my glasses. I’m in a hurry. Can I read this at home? My eyes are tired. Could you read this for me? I’m not feeling very good. Could you read this for me? Do you have a videotape on this?

Common phrases

I can’t read this now. I forgot/broke my glasses.

I’m in a hurry. Can I read this at home?

My eyes are tired. Could you read this for me?

I’m not feeling very good. Could you read this for me?

Do you have a videotape on this?

How to Identify a Patient Behaviors Clarification – individual asks a lot of questions about written information Visual clues – individual may be holding paper upside down while trying to read it Inability to please – none of the materials are “right” or “fit their needs” or “it’s just not what I was looking for” Indifference – individual hands written materials to an accompanying family member Can’t read directions on their prescription bottles

Behaviors

Clarification – individual asks a lot of questions about written information

Visual clues – individual may be holding paper upside down while trying to read it

Inability to please – none of the materials are “right” or “fit their needs” or “it’s just not what I was looking for”

Indifference – individual hands written materials to an accompanying family member

Can’t read directions on their prescription bottles

Screening Tools

REALM Rapid Estimate of Adult Literacy in Medicine Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, Bairnsfather LE. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991 Aug;23(6):433-5.

Abbreviated REALM Directions The survey only takes 2 to 3 minutes to do I want to hear you read as many words as you can from this list. Begin with the first word on List 1 and read aloud. When you come to a word you cannot read, do the best you can or say “blank” and go on to the next word If the patient takes more than five seconds on a word say “blank” and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word; have him/her pronounce only known words. Count as an error any word not attempted or mispronounced. Count the number of correct words for each list and record the numbers in the “SCORE box. Total the numbers and match the total score with its grade equivalent in the table below:

The survey only takes 2 to 3 minutes to do

I want to hear you read as many words as you can from this list. Begin with the first word on List 1 and read aloud. When you come to a word you cannot read, do the best you can or say “blank” and go on to the next word

If the patient takes more than five seconds on a word say “blank” and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word; have him/her pronounce only known words.

Count as an error any word not attempted or mispronounced. Count the number of correct words for each list and record the numbers in the “SCORE box.

Total the numbers and match the total score with its grade equivalent in the table below:

Newest Vital Sign Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22. Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83. Assesses general literacy and numeracy skills Quick to administer (three minutes) Available in both English and Spanish. Ice Cream Label

Newest Vital Sign

Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22. Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83.

Assesses general literacy and numeracy skills

Quick to administer (three minutes)

Available in both English and Spanish.

 

Quick Screening Questions 1. How often do you have problems learning about your medical condition because of difficulty understanding written information? 2. How often do you have someone help you read hospital materials? 3. How confident are you filling out medical forms by yourself? Possible answers are: always, often, sometimes, occasionally, never Most effective question was the “filling out medical forms.” An answer of “sometimes” was indicative of literacy issues. Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006 Aug;21(8):874-7.

1. How often do you have problems learning about your medical condition because of difficulty understanding written information?

2. How often do you have someone help you read hospital materials?

3. How confident are you filling out medical forms by yourself?

Possible answers are: always, often, sometimes, occasionally, never

Most effective question was the “filling out medical forms.” An answer of “sometimes” was indicative of literacy issues.

What to do about handouts

Basic information about a colonoscopy, as perceived by a patient with limited literacy skills

What Makes a Handout Easy-to-Read Limit major points to 3-5 “need-to-know” Sections are short, distinct, labeled with subheadings Key messages are action-focused, up front and repeated Bulleted lists Conversational, active voice, friendly tone Use pictures Lots of white space, make sure there is good contrast between the print and the paper. 12pt. Font Only use capital letters when grammatically needed

Limit major points to 3-5 “need-to-know”

Sections are short, distinct, labeled with subheadings

Key messages are action-focused, up front and repeated

Bulleted lists

Conversational, active voice, friendly tone

Use pictures

Lots of white space, make sure there is good contrast between the print and the paper.

12pt. Font

Only use capital letters when grammatically needed

Watch Your Words and Numbers Words that have multiple meanings Stool, dressing, gait No Acronyms HDL, CAT, MRI, PCI, CBT Put Health Measurements in a context Give a healthy cholesterol number and then their number Idioms don’t always work Are you feeling blue? Try using sad instead. Once means 11 in Spanish

Words that have multiple meanings

Stool, dressing, gait

No Acronyms

HDL, CAT, MRI, PCI, CBT

Put Health Measurements in a context

Give a healthy cholesterol number and then their number

Idioms don’t always work

Are you feeling blue? Try using sad instead.

Once means 11 in Spanish

Where Can You Find Easy-To-Read Handouts? MedlinePlus http://medlineplus.gov AAFP Family Doctor http://www.familydoctor.org/ Commercial Publishers Journeyworks Publishing Channing-Bete Company Krames Health and Literacy Compendium – an annotated bibliography of print and web-based health materials for use with limited-literacy adults http://healthliteracy.worlded.org/docs/comp/ http://healthliteracy.worlded.org/teacher-2.htm

MedlinePlus

http://medlineplus.gov

AAFP Family Doctor

http://www.familydoctor.org/

Commercial Publishers

Journeyworks Publishing

Channing-Bete Company

Krames

Health and Literacy Compendium – an annotated bibliography of print and web-based health materials for use with limited-literacy adults

http://healthliteracy.worlded.org/docs/comp/

http://healthliteracy.worlded.org/teacher-2.htm

How Readable are Your Handouts? Use the SMOG readability test http://www.med.utah.edu/pated/authors/readability.html Flesch-Kincaid Grade Level Index Computes readability based on the average number of syllables per word and the average number of words per sentence. The score in this case indicates a grade-school level. Found in Microsoft Word under Tools/Options/Spelling and Grammar Computer typically gives a score of 2-3 grade levels below what a document calculated by hand would have scored. To improve the accuracy have appropriate sample size of at least 30 sentences or 300-500 words. Remove all headings, lists with bullets, sentence fragments, abbreviations, etc.

Use the SMOG readability test

http://www.med.utah.edu/pated/authors/readability.html

Flesch-Kincaid Grade Level Index

Computes readability based on the average number of syllables per word and the average number of words per sentence. The score in this case indicates a grade-school level.

Found in Microsoft Word under Tools/Options/Spelling and Grammar

Computer typically gives a score of 2-3 grade levels below what a document calculated by hand would have scored.

To improve the accuracy have appropriate sample size of at least 30 sentences or 300-500 words.

Remove all headings, lists with bullets, sentence fragments, abbreviations, etc.

Problems with Screening Tools Do not account for the organization of the text including design and layout. Do not measure complexity and difficulty of concepts. Do not determine if the text is culturally appropriate or relevant. Do not calculate the readers’ previous background on the content of the text. Do not account for the readers’ interest to learn the information.

Do not account for the organization of the text including design and layout.

Do not measure complexity and difficulty of concepts.

Do not determine if the text is culturally appropriate or relevant.

Do not calculate the readers’ previous background on the content of the text.

Do not account for the readers’ interest to learn the information.

 

Flesch Reading Level Grade 6.3 Flesch Reading Ease 66.8/100 – 65 is the plain English score Is it easy to read?

Flesch Grade Level 6.8 Flesch Ease of Reading Level 64.5/100 Flesch Grade Level 6.6 Flesch Ease of Reading level 66.8/100

What Can You Do? Be respectful and caring Slow down Offer audio or video options Have the patient repeat back your instructions Use pictures and models Make sure your printed materials are written at < 5 th grade level No Jargon Focus on “need-to-know” information. Most people can only remember 3-5 items at one time.

Be respectful and caring

Slow down

Offer audio or video options

Have the patient repeat back your instructions

Use pictures and models

Make sure your printed materials are written at

< 5 th grade level

No Jargon

Focus on “need-to-know” information. Most people can only remember 3-5 items at one time.

How Can You Encourage Reading Skills in Your Patients? Encourage children and parents to read together Reach Out and Read Program http://www.reachoutandread.org/ Imagination Library http://www.dollywoodfoundation.com Learn about literacy programs in your community National Institute for Literacy http://www.literacydirectory.org ProLiteracy Worldwide http://www.proliteracy.org/locator

Encourage children and parents to read together

Reach Out and Read Program

http://www.reachoutandread.org/

Imagination Library

http://www.dollywoodfoundation.com

Learn about literacy programs in your community

National Institute for Literacy

http://www.literacydirectory.org

ProLiteracy Worldwide

http://www.proliteracy.org/locator

Organizations Working on Health Literacy

Council of State Governments http://www.healthystates.csg.org/Public+Health+Issues/Wellness+and+Prevention

Partnership for Clear Health Communication at the National Patient Safety Foundation http://askmethree.com/

What is my main problem? What do I need to do? Why is it important for me to do this? http://askmethree.org/

What is my main problem?

What do I need to do?

Why is it important for me to do this?

http://www.plainlanguage.gov/

 

 

More info available on my web site: http://del.icio.us/seundlibrary Look under Health Literacy

Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/QuestionsAreTheAnswer

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