health literacy: a clinician’s point of view

Health Literacy:A Clinician’s Point of View

Paul D. Smith, MD, Associate ProfessorUW Department of Family Medicine

[email protected]

Topics today

Social determinants of health.

Health literacy.

Impact of literacy on health and health care.

What can we do about this?

Determinants of Health

Gender

Age

Race/ethnicity

Co-morbidities

Social Determinants of Health

Employment status

Income level

Health insurance status

Marital status

Social Determinants of Health

Education level

High school diploma or equivalent

Literacy level

Question?

What would happen to Wisconsin’s

overall health, if we were able to

eliminate health disparities?

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

High school or less (459)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Wisconsin (296)

Best state Minnesota (257)

Asians (170)

100 200 300 400 500 600 700


ABCDF

Some college (212)


Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)




Wisconsin (296)


Asians (170)


Native Americans (592)(279)

(279)

(277)

100 200 300 400 500 600 700


ABCDF

Some college (212)


Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)






Wisconsin (296)


Asians (170)

100 200 300 400 500 600 700


ABCDF

Some college (212)


Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)






Wisconsin (296)


Asians (170)

(275)

(275)

(266)

100 200 300 400 500 600 700


ABCDF

Some college (212)


Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)







Asians (170)

Men (367)(225)

Wisconsin (296)(225)

100 200 300 400 500 600 700


ABCDF

Some college (212)


Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)






Asians (170)

High school or less (459)(212)

Wisconsin (296)(206)

Effect of Eliminating Disparity by:

Race 296 277

Geography 296 266

Gender 296 225*

Education 296 206*

*Wisconsin becomes the healthiest state in the U.S.

Answer:

Eliminating health disparities in any category

improves Wisconsin’s overall health.

The greatest potential gain is in the elimination

of disparities by education.

2003 National Assessment of Adult Literacy

NAAL health literacy assessment

28 questions specifically related to health 3 clinical 14 prevention 11 system navigation

Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S.Department of Education.Washington, DC: National Center for Education Statistics.

NAAL Health Literacy Assessment

Background questions

Self-rated health status

Health insurance

Sources of health information


Entire population

Below basic 14%

Basic 22%

Intermediate 53%

Proficient 12%


Basic and Below Basic Health Literacy

White 28%

Native Americans 48%

Blacks 58%

Hispanics 66%


Basic and Below Basic Health Literacy

Age16-64 28-34%

Age 65+ 59%


Basic and Below Basic by education level

In High School, GED or HS grad 34-37%

Less than/some High School 76%


Basic and Below Basic by Self-reported health status

Excellent 25% Very Good 28% Good 43% Fair 63% Poor 69%

Sources of Health Information

TV and radio

Family and Friends

Health Care Professionals


Text Media

Newspaper

Magazines

Books or brochures

Internet


Percent of people that NEVER obtain health information from the internet

Proficient 12%

Intermediate 14%

Basic 58%

Below Basic 80%

In Their Own Words

Insert video clip here

The Impact of Low Literacy on Health

Poorer health knowledge

Poorer health status

Higher mortality

More hospitalizations

Higher health care costs

Poorer Health Knowledge

Understanding prescription labels

395 patients

19% low literacy (6th grade or less)

29% marginal literacy (7-8th grade)

52% adequate literacy (9th grade and over)

5 prescription bottles

Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894


At least one incorrect

63% low literacy

51% marginal literacy

38% adequate literacy

Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894


“Take two tablets twice daily”

Stated correctly Demonstrated correctly

71% low literacy 35%

84% marginal literacy 63%

89% adequate literacy 80%

“Show me how many pills you would take in one day.” Counted out 4 tablets-correct

Poorer Health Status

2923 new Medicare enrollees

Inadequate literacy had increased frequency of:

Diabetes

Hypertension

Heart failure

Arthritis


Medical Outcomes Study (SF-36)

Inadequate literacy had Decreased:

Physical function

Mental health

Increased Limitations in activity due to physical health

Pain that interferes with normal work activities


Diabetics with retinopathy

0

5

10

15

20

25

30

35

40

%

inadequate adequate

36%

19%

Increased Mortality

Age 70-79

Reading level 8th grade or less

Five Year Prospective Study

Sudore R, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.

Increased Mortality

Risk of Death Hazard ratio: 1.75

19.7

10.6

0

5

10

15

20

%

Low Literacy Higher Literacy

More Hospitalizations

2 year hospitalization rate for patients visiting ED

0

5

10

15

20

25

30

35

%

low adequate

31%

14%

Increased Health Care Costs

Data

2003 Medical Expenditure Panel Survey

2003 National Assessment of Adult Literacy

Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007

Increased Health Care Costs

Annual cost today:

Future costs based on today’s actions (or lack of action):

Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A,

Rosenbaum, S, DeBuono, B. Oct. 2007

$106-238 Billion

$1.6-3.6 Trillion

In Their Own Words

Focus group project

Three community-based literacy programs

Six groups

Fifty-one adults

Limited reading skills- Adult Basic Education

Limited English skills- English Language Learners

Focus Groups Major Themes

Communication and understanding.

Completing/understanding forms

including consents.

Focus Groups Major Themes

Difficulty in accessing healthcare

Medication errors

Anxiety and shame

The “System” is Broken

Pre-school

Children learn to read on the laps of their parents.

K-12 education

Third-fourth grade “watershed.”

HS graduation rates.

Almost 20% functionally illiterate HS graduates.


Adult education

Lack of funding for literacy programs

Family

Workforce

Corrections


Health Care

Highly educated clinicians and support staff.

Medical terminology.

Documents written at a high reading level.

Increasing complexity of medical care.

How do we fix this problem?

Multi-faceted approach

Funding one aspect and ignoring the other

issues will not address the problems today.

Education

Change the health care system


Pre-school

Effective programs

Reach Out and Read

Refer parents to family literacy programs


Pre-school

Similar programs in non-traditional settings

Women Infants and Children

Prenatal care

Ethnic community groups

Faith based


K-12

Everyone graduates functionally literate

Address the social and other issues that

influence HS drop out rates.


Adult education

More money for effective literacy programs.

Community-based

Family

Workforce

Corrections


Health content in literacy curriculum

Susan Levy, Ph.D.

Breakout at 3:45

Education Will Not Solve Everything

Health Care

Continuing Medical Education (CME) for

clinicians

Medical education is stuck in the 60’s

Education Will Not Solve Everything

Universal Design

If it works for people with low literacy or low

English skills, it will work for everyone.

The Healthcare System Has to Change

Communication strategies

Improve oral communication

Easier to read written documents

Effective informed consent process

Check understanding


Commonwealth Fund Report

A team effort, beginning at the front desk.

Use of standardized communication tools

Clinicians partner with patients to achieve goals

Barrett S, et al. Health Literacy Practices in Primary Care Settings: Examples from the Field, January 2008http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=645961


Use of:

Plain language

Face-to-face communication

Pictorials

Educational materials


Organizational commitment to create an

environment where health literacy is not

assumed.

More Research is Needed

Effective preschool and K-12 programs.

Effective adult literacy programs.

Effective health literacy interventions.

Summary

Low health literacy is a common problem

Low literacy affects health

Summary

The System has to change

What can YOU do?

Learn more about health literacy

IOM “A Prescription to End Confusion”

Health literacy resource list

Google “health literacy toolkit”

What can YOU do?

Be a catalyst for change

Raise awareness

Raising Awareness

Your own local, state and national organizations.

Health care organizations.

State and federal legislators.

Medical Education.

What can YOU do?

Add health content to curricula.

What can YOU do?

Collaborate with health care groups

Hospitals

Large medical groups

Health care insurers

“Action expresses priorities.”

“Be the change that you want to see in the world.”

---Mohandas Gandhi

Paul D. Smith [email protected]

608-265-4477

mailto:[email protected]

health literacy: a clinician’s point of view

Documents

african americans

native americans

college graduates

populationsome college

worst state mississippi

best state minnesota

healthiest state

health disparities