“Normal communication in lives that are anything but…

Renee L. McCune, PhD, RN

University of Detroit Mercy

McAuley School of Nursing

mccunere@udmercy.edu

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

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

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)

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.

MICHIGAN

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

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)

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)

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)

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

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

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

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

• Print

• Interpersonal

• Audio/Video

• Interactive Multimedia

• Health Message Content

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

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

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.

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)

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)

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)

CONCLUSION

He

Health Literacy: A Prescription to End Confusion (pg. 34)

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?

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

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.

• 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

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/

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/