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“Normal communication in lives that are anything but…
Renee L. McCune, PhD, RN
University of Detroit Mercy
McAuley School of Nursing
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OBJECTIVES
The participant will:
• Identify similarities between historical literacy promotion and current health literacy
• Examine the definition(s) of health literacy in relation to professional practice
• Identify low literacy characteristics and health management challenges
• Formulate a professional health literacy plan
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BRIEF HISTORY
• 3100 BC - writing developed
• 650-550 BC - Greeks invent
the alphabet
• 500-400 BC - 1st schools and
the beginning of literacy for
civic purposes
• 800-900 AD -Carolingian
language & writing
• 1200 - literacy for commercial
expansion and the
development of vernacular
• 1450 – advent of printing
• 1600 – Swedes national
literacy campaign
• 1800 – mass literacy through
school development and
compulsory education
• 20th century – many literacies
identified: technological
(computers), cultural, health,
etc.
Graff, 1987
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IDENTIFYING LITERACY
• 1600-1900: document signature = literacy (Western Europe)
• 1860 &1870 U.S.: self report of literacy 20% & 8.3%
respectively
• 1918 & 1945 U.S. significant number of military recruits unable
to read basic instructions
• 1992 National Adult Literacy Survey (NALS): 21-23% Level I
(rudimentary skills) & 25-28% Level II (general literacy
measures: Prose, Document, & Quantitative)
• 2003 National Assessment of Adult Literacy (NAAL): Minimal
change in scores from 1992
Kaestle et al. (1991)Kunter, Greenberg, Jin, & Paulsen (2006)
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1992 & 2003 NATIONAL ASSESSMENT OF ADULT LITERACY
(NAAL)
U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 1992 National Adult Literacy Survey and 2003 National Assessment of Adult Literacy.
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MICHIGAN
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MICHIGAN BASIC PROSE LITERACY STATISTICS
County Average Range
• Houghton 8% 3.7 – 15.%
• Genesee 10% 6.5 – 15.9%
• Grand Traverse 5% 2.5% - 9.9%
• Ingham 6% 3.0 – 11.3%
• Kalamazoo 6% 2.9 – 11.6%
• Mackinaw 8% 3.8 - 14.8%
• Muskegon 8% 4.0 – 11.3%
• Oakland 7% 4.2 – 11.3%
• Saginaw 10% 4.6 – 17.2%
• St. Clair 7% 3.1 – 12.5%
• Wayne 12% 5.5 – 21.2%U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy
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HEALTH LITERACY DEFINED
• “Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”
(Ratzan & Parker, 2000, p. vi).
• The degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions.
Berkman, Davis & McCormack (2010)
• “Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course”.
European Health Literacy Consortium (Sørensen et al., 2012)
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HEALTH EQUITY
• “Equity in healthcare can mean: equal utilization, distribution, according to need, equal access, equal health outcomes” (Culyer & Wagstaff, 1993)
• “A health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies; it is a difference in which disadvantaged social groups (such as the poor, racial/ethnic minorities, women or other groups that have persistently experienced social disadvantage or discrimination) systematically experience worse health or greater health risks than more advantaged groups. (Braveman & Gruskin, 2003, pg. 13)
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HEALTH LITERACY STATISTICS
• Using the measurement categories of prose, document and quantitative, the 2003 NAAL added 28 health related questions.
• Six states participated in the survey containing these questions and the aggregate health literacy results are as follows:• 53% Intermediate• 12% Proficient• 22% Basic• 14% Below Basic
Kutner, Greenberg, Jin, & Paulsen (2006)
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INDIVIDUALS EXPERIENCING HEALTH LITERACY CHALLENGES
INCLUDE:• Anyone receiving
healthcare!
• Those who may require added support:• The very young or very
old• Individuals speaking
another language• Individuals under stress• Persons who have been
incarcerated
• Those suffering chronic health conditions
• The unemployed
• Individuals with lower educational backgrounds or poor experiences
• Persons who are poor and /or homeless
• Mispronounces medications or medical terms
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CONSIDER CULTURE, CUSTOMS AND BELIEFS
An individual’s religion, culture, beliefs, and ethnic
customs can influence:
• Understanding of health concepts
• how personal health care is undertaken
• how healthcare decisions are decided
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HOW DO WE RECOGNIZE THE LOW LITERATE?
• Many times you cannot identify individuals with low literacy.
• Some clues are the patient may:• state “I’ll have to take this home to read, as I don’t
have my glasses.• ask to have information repeated• become angry when asked questions, rather than
answer• demonstrate poor follow through with discharge
instructions• not complete paperwork• bring another family member or friend to the health
visit
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NECESSARY HEALTH LITERACY: COMMUNICATION MATRIX
ATTRIBUTES
• Quantitative literacy
• Physical/mental impairments
• External assistance
• Prose and document literacy
• Two-way communication
• Media literacy
• Computer literacy
• Motivation (culture and relevance)
• CHANNELS
• While all Attributes intersect the Channels, some are more specific based on format and content. These intersections are color coded below
• Interpersonal
• Audio/Video
• Interactive Multimedia
• Health Message Content
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COMMUNICATION TOOLS
• Speak directly to the individual slowly and clearly
• Use videos when teaching self care tecniques
• Teach new information in small pieces and if possible, spread across visits
• Focus on concrete behaviors
• Use visuals in handouts, increase white space and keep to 1 sheet
• Write at a 4th to 6th grade reading level
• Involve patients in the creation of educational tools
• Use “Plain” language (also known as “living room” language). Avoid medical jargon and large words• High blood pressure vs. hypertension• Pee vs. void• Walk or exercise vs. ambulate• Bad vs. adverse
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ASK ME THREE
Encourage people to ask their caregivers:
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
https://npsf.site-ym.com/default.asp?page=askme3
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TEACH BACK (CLOSING THE LOOP)
The teach - back method is a way to check patient understanding and comprehension through a non-threatening approach.
1. Using a loop process, the provider asks the patient to repeat back the new information just given.
2. If the response is unclear, the process is repeated until a clear understanding is obtained.
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HEALTH LITERACY MEASUREMENTS
TOFHLA (Test of Functional Health Literacy in Adults )• widely used in health literacy research• assesses reading comprehension and numeracy• scores patients as having:
• low, marginal, or adequate health literacy skills • available in English and Spanish• Two versions: long takes about 22 minutes to administer
and short 10 minutes
Nurss, Parker & Baker (1995)
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REALM ( Rapid Estimate of Adult Literacy in Medicine)
• The 66-item REALM takes 2-3 minutes to administer and score
• Word recognition test increasing in complexity and read out loud
• Translates into three grade levels:• 6th grade (low literacy)• 7-8th grade (marginal literacy)• 9th grade (adequate literacy)
• available in English
Davis et al. (1991)
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NVS (Newest Vital Sign)
• Uses an ice cream label to assess reading, numeracy and problem solving asking 6 questions
• Takes 3-5 minutes to administer
• Available in English and Spanish
• Scores patients outcomes as:• Low health literacy likely• Possibility of low health literacy• Adequate health literacy
Weiss et al. (2005)
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CONCLUSION
He
Health Literacy: A Prescription to End Confusion (pg. 34)
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YOUR TURN• Does your organization support health literacy?
• How will you use the information from today in your work, within your family’s healthcare, in your community and for your own health?
• What will be your first step in creating a health literacy plan?
• How will you evaluate your success?
• Who will you include in your plan? Will this make you more accountable?
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PARTING THOUGHT
The illiterate of the future are not those that can not read or write. They are those that can not learn, unlearn, relearn.
Alvin Toffler 1928- American Author & Futurist
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REFERENCES
• Braveman, P. (2006). Health disparities and health equity. Annual Review Public Health, 27: 167-94.
• Davis, T.C., Crouch, M.A., Long, S.W., Jackson, R.H., Bates, P, George, R.B. et al. (1991). Rapid estimate of adult literacy in medicine: a shortened screening
instrument. Family Medicine, 23(6), 391-395
• Greenberg, E. and Jin, Y. (2007). 2003 National Assessment of Adult Literacy:Public-Use Data File User’s Guide (NCES 2007-464). U.S. Department of Education. Washington, DC: National Center for Education Statistics.
• Kaestle, C.F., Damon-Moore, H., Stedman, L.C., Tinsley, K., & Trollinger, W.V. (1991). Literacy in the United States: Readers and reading since 1880. New Haven: Yale University Press
• Kutner, M., Greenberg, E., Jin, Y., & Paulson, C. (2006). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy. National Center for Educational Statistics. Retrieved from: http://nces.ed.gov/pubs93/93275.pdf
• Nielsen-Bohlman, L., Panzer, A.M., and Kindig, D.A. (Eds.) (2004). Health literacy: a prescription to end confusion. Washington, DC: The National Academies Press.
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• Nurss, J.R., Parker, R.M., & Baker, D.W. (1995). TOFHLA – test of functional health literacy in adults. Peppercorn Books & Press: Snow Camp,
NC.
• Ratzan, S.C. & Parker, R.M. (1999). Introduction. In: National library of medicine current bibliographies in medicine: Health literacy. NLM Pub. No. CBM 2000-1.
• Schwartzberg, J.G., VanGeest, J.B., & Wang, C.C. (2005). Understanding health literacy: Implications for medicine and public health. AMA Press: United States.
• Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Keong-Grotz, K., Castro, C., and Bindman, A.B. (2003). Closing the loop. Archives of Internal Medicine, 163, 83-90.
• Weiss, B.D., Mays, M.Z., Martz, W., Merriam-Castro, K., DeWalt, D.A., Pignone, M.P. et al. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3(6), 514-522. doi: 10.1370/afm.405
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USEFUL WEBSITES• AHRQ Health Literacy Universal Precautions Toolkit:
http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
• Centers for Disease Control and Prevention: Health Literacy: http://www.cdc.gov/healthliteracy/index.html
• Center for Plain Language: http://centerforplainlanguage.org/
• CMS.gov (Centers for Medicare & Medicaid Services):
https://www.cms.gov/site-search/search-results.html?q=health%20literacy
• Doak, C.C., Doak, L. G,., & Root, J.H. (1996) Teaching patients with low health literacy. J. B. Lippincott; Philadelphia.
http://www.hsph.harvard.edu/healthliteracy/resources/teaching-patients-with-low-literacy-skills/
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USEFUL WEBSITES
• Harvard School of Public Health:
http://www.hsph.harvard.edu/healthliteracy/resources/
• Health Literacy Special Collection: http://healthliteracy.worlded.org/
• National Network of Libraries of Medicine: http://nnlm.gov/outreach/consumer/hlthlit.html
• Plain Language: http://www.plainlanguage.gov/populartopics/health_literacy/index.cfm
• U.S. Department of Health and Human Services:
http://www.hrsa.gov/publichealth/healthliteracy/