Julie Miller-Cribbs, Ph.D., MSWAssociate Professor, Assistant Director, Anne & Henry Zarrow

School of Social Work

Michael Miller, RPh, DrPHAssociate Professor, College of Pharmacy

SUMMER INSTITUTE ANCHORING LECTURE

August 4, 2011

Education Matters: Education and Health Outcomes

ObjectivesExamine the connection between

education and health literacyReview the concept of health literacy

and its relationship to health outcomes

Raise awareness of national standards for health literacy

Discuss literacy based tools and interventions that can be integrated into clinical practice

BackgroundMost patient/health education materials are

developed by HIGHLY educated individuals.Patient understanding/ comprehension of

materials are RARELY assessed or considered

Most American adults have NEVER had a human anatomy/biology course (including those with a college degree).

Most students take ONE health/wellness class during high school (usually taught by a teacher with a limited health background).

Credit: Wallace

How Does Education Influence Health?

Three interrelated pathways

① Health Knowledge and Behavior

② Employment and Income

③ Social and Psychological Factors

How does education influence health?

How does education influence health?

PATHWAY ONE:HEALTH KNOWLEDGE, LITERACY &

BEHAVIORS

Education and Health Behaviors

Health Behaviors Continued

Education and Health Outcomes

Education and Health Calculatorhttp://www.commissiononhealth.org/Calcula

tor.aspx

Parent’s education is linked to children’s health

Education, Income & Children’s Health

From http://www.commissiononhealth.org/Documents/ChildrensHealth_Chartbook.pdf

How does education influence health?

PATHWAY TWO:EMPLOYMENT AND INCOME

Income & Health

Income & Children’s Health

Gaps in Infant Mortality Rates by Mother’s Education

Working Conditions & ResourcesWorking long hours has been linked with

cardiovascular disease, diabetes, subjective health complaints, fatigue, and depression

Safety and Health hazards: Hotel cleanersErgonomic hazards (bending, pushing carts,

and making beds)Trauma hazards that include slips, trips, and

fallsRespiratory, dermal, and possibly

carcinogenic hazards from chemicals in cleaning products

Mold and microbial contaminants Infectious agentsOccupational stress due to heavy workloads,

lack of adequate supplies, job insecurity, low pay, and discrimination

Part time, seasonal, and temporary employment & insurance coverage

Percent of Nonelderly Women Reporting No Doctor Visit in Past Year Due to Cost, by Race/Ethnicity

Hispanic

American Indian/ Alaska Native

Black

White

Asian and NHPI

28.1%

23%

27%

14.7%

12.7%

Data: BRFSS, 2006-2008.Note: Data reflect the U.S. average and the states with the highest and lowest percentages.Source: The Kaiser Family Foundation, Putting Women’s Health Care Disparities on the Map, available at: www.kff.org/womensdisparities/.

12%38.5%

43.3%11.9%

33.7%12.4%

22.7%6.9%

22.5%6.1%

OKHI

ARSC

IARI

WVMA

GACT

US

US

US

US

US

How does education influence health?

PATHWAY THREE:SOCIAL AND PSYCHOLOGICAL

FACTORS

Work, Stress and Control

Social Support

•Sense of belonging•Increased sense of self-worth•Security•Increased access to resources through network (emotional, instrumental)

Focus: Health Literacy

“…the constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment.”

Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, AMA, 1999

“…the ability to understand and use health-related printed information in daily activities at home, at work, and in the community to achieve one's goals and to develop one's knowledge and potential”

National Assessment of Adult Literacy, 2006

Demographic Correlates of Health Literacy

Health LiteracyAge

Minority Race/

Ethnicity

Higher Socioeconomic Status

Education

English as a second language

The Health Literacy of America’s Adults. Results from the 2003 National Assessment of Adult Literacy. 2006.http://nces.ed.gov/pubs2006/2006483.pdf

Recognized Priority Populations

Racial/Ethnic MinoritiesLow Income GroupsWomenAge <18 yearsAge ≥ 65 yearsResidents of rural areasIndividuals with disabilities or special

health care needs

USDHS. 2009 National Healthcare Disparities Report 2009. AHRQ Publication No. 10-0004. March 2010. www.ahrq.gov/qual/qrdr09.htm

Components of Health Literacy – Skills Vs Demands

Cultural Knowled

ge Conceptual

Knowledge

Listening Skills

Speaking Skills

Writing Skills

Reading Skills

Numeracy Skills

Skills Demands

Provider Instructions

Medical Forms

Drug Labels

Complex Systems

Individual Capability

Interpreting Literacy Levels

Below BasicCircle date on appointment slip, Identify what is permissible to drink before a medical test, based on a set of short instructions.

BasicUnderstand simple patient education handout.

IntermediateDetermine healthy weight from BMI chart; Interpret prescription and over-the-counter drug labels.

ProficientDefine medical term from complex document; Calculate share of employee’s health insurance costs

Literacy Proficiency Level

The Health Literacy of America’s Adults. Results from the 2003 National Assessment of Adult Literacy. 2006.http://nces.ed.gov/pubs2006/2006483.pdf

The Health Literacy Problem

14%

22%

53%

12%

Health Literacy Proficiency

Below BasicBasicIntermediateProficient

The Health Literacy of America’s Adults. Results from the 2003 National Assessment of Adult Literacy. 2006.http://nces.ed.gov/pubs2006/2006483.pdf

How many polio vaccinations should children have received by the time they are 7 years old?

Health Literacy

Level

% Correct

Below Basic 5

Basic 22

Intermediate 78

Proficient 100

Credit: Wallace

What does the label say a person should do in case of an overdose?

Credit: Wallace

Common Misunderstanding of Warning Labels

“Chew pill and crush before swallowing.”“Just for your stomach.”

“Use extreme caution in how you take it.”“Medicine will make you feel dizzy.”“Take only if you need it.”

“Don’t take medicine if you’ve been in the sunlight too long.”“Don’t leave medicine in the sun.”“Don’t leave [medicine] in sunlight but a cool place.”

Davis et al. (2006). J Gen Intern Med.

What messages do we send to our patients with varying literacy?

Higher Literacy“ I love these

sheets…they tell me exactly

what is happening in my body.”

Lower Literacy“I think they make

my baby look ugly.”

Credit: Wallace

Readability of AAFP and ACOG Patient Education

Materials

Wallace et al. (2004). Fam Med. Freda. (1999). Obstet Gynecol.

Average reading level

of materials=9.4

Average reading level

of materials=≈9.0

800+ published studies confirm these findings.

Are Home Blood Glucose and Pressure Monitor Guides Readable?

Blood Glucose Monitors•Average reading grade level was 10th grade.•Font and graphic size were small throughout.

Blood Pressure Monitors•Average reading grade level was 9th grade.•Most instructions did NOT emphasize key points.

Wallace et al. (2008). Diabetes Techn Ther. Wallace et al. (in press). Blood Pressure Monit.

Survey of Sooner Care Parents

Belo

w 8

th G

rade

Som

e Hig

h Sc

hool

HS/GED

Som

e Col

lege

Colle

ge D

egre

e

Post

Col

lege

0

0.51

1.52

2.53

Health Literacy Score

Health Literacy Score

Survey of Young OklahomansHigh School or Less

Some College & Above

Health Literacy Score

3.34 4.02Medical Debt

NO YES

Health Literacy Score

3.86

3.31

N=519, Young Oklahomans 18-34

Young Oklahomans with High Health Literacy

Completed more educationValued Health insurance covered more

Rated the quality of their health care services higher

Had fewer health worriesHad less medical debt

As compared to those with lower levels of health literacy

41% report medical

debt39 % report

using pay day lender for medical costs/debt

Examples from Oklahoma Data: Tulsa Photovoice (preliminary)CATEGORY EXAMPLE QUOTE(S)

Knowledge without action

’’I’m very poor at getting like follow ups and check ups for myself. And I just got into the habit of telling myself, you go to the to the doctor more.”“Well my father’s husband died from emphysema from smoking. I thought that would teach him right there but he hasn’t done a thing. So, I don’t know.”

Medical Term Confusion

“Last year one of the kids got sick and passed away from swing flu.”“My nephew has, uh, it called sharka syndrome.”“I have an uncle that died from what they call scoliosis to liver. Oh is scerosis..”“I don’t really know, I actually only learned about that after he had atherosclerosis, so its kind of similar to Alzheimer’s…”“No I think she has rudimentary arthritis or something. It’s the one that eats out your bone marrow.”“Actually, it’s a new pill. Kipper, Kippa, something like that. I take 6 of those and then four of the generic tegratol.”

Health behavior/disease state confusion

“The cancer was making my sugar go up.”“But when you bake it is still greasy even though fried is greasy is too. I think flour soaks up most of the grease.”“I had cancer and they didn’t catch it, because I have an Asian gene that doesn’t detect cancer, throws it off”“Well they told me that the whole thing, [autism] maybe he can grow out of it.”“He’ got a lot of problems, the front part of his heart doesn’t beat. No, it’s the back part, the back part doesn’t beat like the front part. They told me at anytime he could just go to sleep and not wake up..”

DATA CATEGORY

EXAMPLE QUOTE(S)

Communi-cation breakdown

“I kept telling them I wasn’t diabetic. Instead of them finding out what was causing it, they just kept giving me medicine. … and my sugar would drop to 40……..And I was having to eat a bowl of sugar just to get it brought back up and that would go on 3 or 4 times a month”“And they gave me, I don’t know some kind of medicine they shot me with. Like to increase, I guess, my sugar because I had a low blood pressure?”“He said something, but he said that they way, that the rating I was having with my sugar being so low and my blood pressure. He told me I really need to lay off for a while. Until I get back on track. And I was like, whatever that means, but I don’t know what he meant by that. But I was like, whatever that means.”

Medical Dis/Mistrust

“Because we people, I think, are bad at that. Like, as far as when it comes to the hospital, we think about oh my god they’re going to poke me…I don’t want nothing going in my mouth…”“I don’t like all these doctors because every time I go to a new one they add another medication. And then another test and more tests and you know it just gets expensive..”“I don’t trust a flu shot”. “This right here I have like a very personal vendetta against any kind of what you call it, pharmaceuticals and stuff…”

PhotoVoice: Communication Errorsfinishing participants’ sentences upon asking a question, answer it

themselves without giving the participant time to answer

correcting the respondenttalking over the respondentbecoming sidetracked during the

interviewjudgmental

ReferencesAmerica’s Health Starts with Health Children From

http://www.commissiononhealth.org/Documents/ChildrensHealth_Chartbook.pdf

Oklahoma data RWF http://www.commissiononhealth.org/State.aspx?State=54348

National Poverty Center, Education and Health Policy Brief http://www.npc.umich.edu/publications/policy_briefs/brief9/

Work Hazards resources: http://www.cdc.gov/niosh/docs/2004-143/table3(large).html