Techniques for Improving Health Literacy Among

Low-Income and Immigrant Populations

March 26, 2013

Michael Villaire, MSLMChief Operating Officer

Institute for Healthcare Advancementwww.iha4health.org

mvillaire@iha4health.org(800) 434-4633 x202

What You’ll LearnBy the time you’re done with this webinar, you should be able

to:1. Define health literacy  2. Describe the importance of improving health literacy 3. Explain the relationship between health literacy and health

disparities4. Identify strategies to improve health literacy among low-

income and immigrant populations 5. Discuss the Institute for Healthcare Advancement’s “What

to do for Health” book series

• “Using printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential” (Kirsch et al, 1993)

DefinitionsLiteracy

• “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 and Parker, 2000)

• “Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that … include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills.” (Calgary Charter on Health Literacy, 2008)

DefinitionsHealth Literacy

Definitions

Health Literacy Components• Reading and writing• Listening and verbal communication (patient

and provider)• Numeracy

Computation skills Interpreting / evaluating risk (%)

• Self-efficacy--Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004

Other Considerations• Culture / belief systems• Mismatch between provider demand and

patient skill level• Mismatch of reading level / materials• Strong relation to health disparities• Strong relation to safety and quality

You know what you mean…But do they?

This happens…

An 89-year-old man with dementia is diagnosed with an ear infection and is prescribed an oral liquid antibiotic. His wife understands that he must take one teaspoon twice a day. After carefully studying the bottle’s label and not finding administration instructions, she fills a teaspoon and pours it into his painful ear.

Parker, R. et al. J Health Comm, 2003.

This happens, too…

Mr. G, 45, an Hispanic immigrant, native Spanish language speaker, has a job health screening. He is told his BP is high, can’t work until it’s controlled. Given β-blocker, diuretic, instructed to take each “once a day.” 1 week later, presents @ ED, BP very low, dizzy. Docs can’t figure out. Spanish speaker asks him how many pills he took each day. “22,” says Mr. G. (In Spanish, once means 11.)

Nielsen-Bohlman et al. IoM “A Prescription to End Confusion” 2004

Who’s to Blame?

At a teaching hospital, an intern writes in a “Patient’s problems” section of the medical chart, “Speaks no English.” The attending physician writes a note back in response, “Your problem, not his.”

Clancy C. AHRQ. Comments at Institute of MedicineHealth Literacy Roundtable 2/09.

Which of the following is the strongest predictor

of an individual’s health status?A. Age B. Income C. Literacy skillsD. Employment statusE. Education levelF. Racial or ethnic group

Which of the following is the strongest predictor

of an individual’s health status?A. Age B. Income C. Literacy skills (75% who self reported poor health in Below Basic HL

category)

D. Employment statusE. Education levelF. Racial or ethnic group

--National Patient Safety Foundation

Health Literacy Myths• People who can’t read, can’t learn. • Most people who are illiterate are immigrants

or minorities.• If someone can’t read and I give them written

instructions, they’ll tell me they can’t read.• I can tell how well someone can read by the

number of years they attended school.From: Health Literacy Myths, Misperceptions and Reality

http://www.idph.state.ia.us/fsbupdate/common/pdf/110804.pdf

Health Disparities andHealth Literacy

• “[D]ifferences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the U.S.” (NIH, 1999)

• “… a population-specific difference in disease, health outcomes, or access to care.” (HRSA, 2000)

• “…difference in health status between a defined portion of the population and the majority. Disparities can exist because of SES, age, … gender, race/ethnicity, language, customs or other cultural factors, [or] disability… .” (Minnesota Dept. Health, 2002)

Health Disparities-Definitions-

Health Disparities Components

• Restricted access to healthcare services• Includes unjust / preventable inequities• Disproportionately affects minorities /

poverty / low educational attainment• Shared responsibility among system,

providers, patients

Connections: Health Literacy / Health Disparities

• Low systemic awareness of the problem• ↓ access to usable health promotion materials• Disproportionate by poverty / language

barriers / education / disability• Lower rates of insured / less access • Victims of poor cultural competency / lack of

racial/ethnic diversity in HC system

Connections: Health Literacy / Health Disparities

• Higher hospital admission rates• Receive poorer quality healthcare• Poorer outcomes• Inadequate language access services• Perception of unequal treatment• Poor self-efficacy• Preventable

Literacy / Health Literacy Statistics

Data Sources• 1992 NALS (National Adult Literacy

Survey)

• 2003 NAAL (National Assessment of Adult Literacy) Added Health Literacy Module

Literacy Levels• Below Basic—no more than the most simple

& concrete literacy skills• Basic—skills needed to perform simple,

everyday literacy activities• Intermediate—skills needed to perform

moderately challenging activities• Proficient—skills needed for more complex &

challenging literacy activities

NAAL Literacy FindingsPercent of U.S. adult population with Below

Basic or Basic skills in:

• Prose Literacy – 44%• Document Literacy – 34%• Quantitative Literacy – 55%

NAAL Health Literacy Findings:• 36% have limited health literacy skills

(22% Basic, 14% Below Basic)• About 12% considered Proficient• Includes 3% who did poorly on basic screening tasks,

routed to alternative assessment • Does not include 2% who knew no English or Spanish• Majority (53%) had intermediate HL levels• Women’s avg. HL score 6 pts. higher (4% more men

in Below Basic)

Who has poor health literacy?

• Nearly 60% of 65+ in Basic/Below Basic• Health ins. from employer ↑ HL,

Medicare/Medicaid/No ins ↓ HL• Hispanics (12% of adult pop.) represent

35% of those in Below Basic HL category• Below poverty level (17% adult pop.)

represent 43% of those in Below Basic HL• 75% who self-reported poor health in Below

Basic HL

Health Literacy Statistics• 1 in 2 Americans can’t read above a 5th grade

level (Kirsch 2003)

• Most patient education materials written beyond recipients’ ability to understand (IoM 2004)

• 26% couldn’t understand when next appt.• 42% couldn’t understand “take on empty

stomach”• 60% couldn’t understand consent form (JAMA 1995)

Stir In…

• 381 languages spoken/signed in U.S.• 40 million foreign-born people live in the

United States (2010) • 60 million Americans speak a language other

than English at home• 24 million Americans have LEP • 75-90% of patients in the 2 lowest reading

levels describe themselves as being able to read/write English “well” or “very well”

Oh, and then there’s…• Cognitive impairment• Hearing / visual impairment• Medications• Stress (most forget at least 50% of what

healthcare provider told them)• Shame re Illiteracy:

78% thought they should hide it/cope 77% never told their doctor 67% never told their spouse 19% never told anyone

Parikh, N.S., et al. Patient Educ Couns, 1996.

How Patients Hide IlliteracyMay say things like:

• “I forgot my glasses”• “I don’t need to read this through now; I’ll read it

when I get home”• “I’d like to discuss this with my family”• “I have a headache now and can’t focus”• “I’ll just take this with me and read it later”• Don’t ask questions• Believe they understand but don’t

Why Does Health Literacy Matter?Those with limited literacy skills:

• Report poorer overall health• Have poorer ability to manage chronic diseases• Have poorer outcomes• Less likely to understand their diagnosis• Less likely to have screening / preventive care• Present in later stages of disease• Are more likely to be hospitalized / rehospitalized

Cost of Poor Health Literacy:• $73 billion in unnecessary costs annually

(Friedland, Georgetown University, 2003)

• $106-$238 billion in unnecessary costs annually (Vernon, University of Connecticut, 2007)

Cost of Chronic Disease:• $1.7 trillion (75% of HC expenditures)• Nearly 1 in 2 Americans live with a chronic disease• 90% >65 have a chronic disease;

77% have 2+• 70% of annual US deaths (CDC 2008)

Why Does Health Literacy Matter?

Toward Solutions

Tools and Techniques• Design Considerations• Universal Precautions• Plain language• Teach-back method• Brown-bag test• Ask Me 3 / Questions Are the Answer• Easy to Use Materials

Tools and Techniques

• Design Considerations Large type size (12-14 point) and double-spacedStandard font (no italics or ALL CAPS)Two type faces (Arial-headings, Times NR-body)Simple headingsWhite space Usable, appropriate, explanatory graphics

Tools and Techniques

• Design Considerations Short sentences (8-10 words each) Use columns Bulleted list/text or “chunking” (keep to 7-8 max) “How to” or “Need to do” in active voice

Design• White space • Large type size (12-14 point) and double-spaced• Standard font (no italics or ALL CAPS)• Two type faces (Arial-headings; Times New Roman-

body)• Simple headings• Usable, appropriate, explanatory graphics (no abstract

graphics)• Short sentences (8-10 words each)• Use columns • Bulleted lists (keep to 7-8 max)• Color / Navigation

Real-life Examples

From “What To Do When Your Child Gets Sick” Institute for Healthcare Advancement www.iha4health.org

Real-life Examples

From “Living With Diabetes: An Everyday Guide for You and Your Family” American College of Physicians Foundation foundation.acponline.org/hl/hlresources.htm

Real-life Examples:Photonovela

From “From Junk Food to Healthy Eating: Tanya's Journey to a Better Life” Inter-Cultural Association of Greater Victoria www.photonovel.ca/photonovels.htm

Design critique • What’s good?• What’s not so good?

“The Bible”

Available from:

•http://www.hsph.harvard.edu/healthliteracy/resources/doak-book/

•IHA Health Literacy Conference

Tools and Techniques

• Universal Precautions Assume 5th grade reading level for all pts. Include all stakeholders in planning/

implementation Limit key messages to no more than 3 “need to

do,” not “nice to know” Elicit questions. “What questions do you have?”

Strike the phrase, “Do you have any questions?” from your vocabulary!

www.ahrq.gov UP toolkit

Tools and Techniques

• Plain language Do not use medical jargon Slow down Use “living room language” Test results: What is benign? Negative? At-risk? More likely your message will be understood Lower chance of misunderstanding instructions

Don’t UseMedical Jargon

Consider these words:

vomiting insomniaformulary urineunconscious acneoral CVAanalgesic benignumbilicus terminalcontraception negative

Do these “living room language” alternatives work?

vomiting (throwing up) insomnia (can’t sleep)formulary (list of drugs) urine (pee)unconscious (out, not awake) acne (pimples)oral (by mouth) CVA (stroke)analgesic (pain med) benign (no cancer)umbilicus (belly button) terminal (end of life)contraception (birth control) negative (don’t have)

Don’t UseMedical Jargon

Tools and Techniques• Teach-back method

Toward assuring patient comprehension Shared learning burden – include clinician role Iterative process – teach to goal:

Introduce new concept / technique Demonstrate using multiple teaching modalities Ask pt. to demonstrate / explain in their own words Assess – review – tailor approach Repeat to patient mastery

Tools and Techniques• Brown-bag test

A form of literacy screening Look at pill or label?Ask patient to bring in all their meds (in a brown

bag) (Drug interaction opportunity) Test for comprehension of what med is / how to

take it / why they take it “When was the last time you took this pill?”

Tools and Techniques• Ask Me 3 / Questions Are the Answer

Ask Me 3 What is my main problem? What do I need to do? Why is it important for me to do this?

www.npsf.org/askme3

Tools and Techniques• Ask Me 3 / Questions Are the Answer (www.ahrq.gov/questions)

Questions Are the Answer What is the test for? How many times have you done this procedure? When will I get the results? Why do I need this treatment? Are there any alternatives? What are the possible complications? Which hospital is best for my needs? How do you spell the name of that drug? Are there any side effects? Will this medicine interact with medicines that I'm already taking?

Tools and Techniques• Easy to Read, Easy to Use Books

Tools and Techniques“What To Do For Health” Books

• Written at a 3rd-5th grade reading level         • Effective in-home solutions for most health issues         • Liberally illustrated with useful diagrams and

images         • No medical jargon        • Available in multiple languages       • Indexed for quick and easy use

Tools and Techniques“What To Do For Health” Books

• 57-61% reduction in ER Visits• 39-56% decrease in doctors/clinic

visits• 29-60% fewer missed school days

by children due to illness or injury• 41-47% fewer missed work days by

parents due to child's illnessContact: books@iha4health.org

Explore…• www.ihahealthliteracy.org• nnlm.gov/outreach/consumer/hlthlit.html• nces.ed.gov/naal• www.health.gov/communication• www.ahrq.gov/browse/hlitix.htm• medlineplus.gov• healthfinder.gov• www.hsph.harvard.edu/healthliteracy• www.iha4health.org• plainlanguage.gov

Explore…• www.healthliteracy.com• www.healthliteracymissouri.org• http://lincs.ed.gov/mailman/listinfo/Healthliteracy/

(join listserv) • ama-assn.org (Foundation/Health Literacy)• foundation.acponline.org/hl/hlresources.htm• www.iom.edu (health literacy)

Thank you!

What questions do you have?