Taking Action on Health Literacy

Taking Action on Health Literacy CPD Session 5th December 2011 Alastair Pringle, Head of Patient Focus & Equalities, SG Kate Burton, Public Health Practitioner, NHS Lothian Catriona Carson, Health Improvement Lead for Literacies, NHS Greater Glasgow and Clyde

today • Background • The theory - Catriona • The practice - Kate • What next?

background • Health Improvement & Patient Focus get our heads together – we know there is a problem…. • Scoping Study 2008/9 recommends ‘focus on the practical integration of the ideas underpinning health literacy into existing programmes, projects and initiatives’ • 2 Seminars • Quality Strategy 2010 commitment to ‘Improve resources to support better health literacy’. • Resources on Medicines, TeachBack & (NES) Workforce Development • Self-Management • Establishment of National Literacy Action Group

“ The impact of limited literacy skills on health has been well documented, giving rise to a new field of study termed health literacy.” – Wolf (2008) Health literacyTheory, models, approaches

What is health literacy? In short: “the ability to access, understand, and use information for health” Nutbeam (2000)

Unpacking this: • What is the relationship between literacy and health literacy? • What is the focus of research in related fields? • What approaches are employed in tackling health literacy?

Greatest application in clinical care - a risk to be assessed and managed through adapted communication/ environmental modification Greatest application in public health - an asset to be developed, as an outcome to health education and communication Understanding literacy Nutbeam: • Literacy can be measured in absolute terms (distinguishing between those who can read and write basic texts and those who can’t); • In relative terms by assessing the skill differences between adults who are able to perform relatively challenging literacy tasks and those who are not. • Literacies are context and content specific e.g. health literacy What is the relationship between literacy and health literacy?

Nutbeam’s model of health literacy • Functional literacy: basic literacy skills to function effectively with regards to health and knowledge • Interactive health literacy: independently obtain relevant health information, derive meaning, and apply information to health circumstances. • Critical health literacy: ability to use information to exert greater control over life events and situations What is the relationship between literacy and health literacy?

What is the focus of research in related fields? • Links between literacy and health outcomes: • Demands of the healthcare system including self-management • Inequalities: the lives of those with limited literacy skills • Health literacy as a public health outcome i.e. education approaches

Health literacy population surveys • National Consumer Council survey among 2,000 adults (2004). • One in five people had problems with the basic skills needed to understand simple information that could lead to better health. • Poorer sections of the community were less likely to seek information or help for health problems. Focus of research in related fields: The evidence

Literacy population surveys Findings from the Scottish Survey of Adult Literacies 2009: • 26.7 per cent may face occasional challenges and constrained opportunities. • Within this, 3.6 per cent face serious challenges in their literacy practices. • People who score lowest in all three categories are considerably more likely to be 56-65. • People from the 15% most deprived areas tend to have lower scores. Focus of research in related fields: The evidence

Self-management of long term conditions Schillinger et al (2002) found: • Diabetic retinopathy • 36% of patients with low health literacy • 19% of those with adequate skills. • Optimal blood sugar control • 20% of patients with low health literacy • 33% of those with adequate skills. Focus of research in related fields: The evidence

Self-management of long term conditions Omachi et al (paper in preparation): • Independent of race, income, and educational attainment, poor health literacy is associated with greater COPD severity and general health status... • Attention to health literacy has the potential to improve COPD self-management. Focus of research in related fields: The evidence

Self-reported health and health-related behaviour • Poor physical and mental well-being is associated with poor literacy and/or numeracy. • Men with lower literacy levels who drank alcohol were also more likely to consume a higher number of units than those with good skills. • They were more likely to smoke cigarettes. New Light on Literacy and Numeracy in Scotland Focus of research in related fields: The evidence

Health improvement interventions Huizinga (2009): • Lower literacy skills were associated with less accuracy with poor portion-size estimation skills. • Opportunities may exist to improve portion-size estimation by addressing literacy. Focus of research in related fields: The evidence

Medicine and adherence • Wolf et al (2007) found that 46% of patients misunderstood one or more dosage instructions. • Patients with low literacy were less able to understand instructions compared to those with adequate literacy. Focus of research in related fields: The evidence

Measuring low literacy and low health literacy • Health literacy-related test instruments e.g Newest Vital Sign, REALM, s-TOFHLA • Testing of literacy skills • Assessment/self-assessment based on literacy-related practices e.g. the single item screener: How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Focus of research in related fields: The evidence

The impact of communication interventions • For example, Ask Me 3 What is my main problem? What do I need to do? Why is it important for me to do this? • Galliher et al 2010: no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. • No evidence of better adherence to prescription medications or lifestyle recommendations. Focus of research in related fields: The evidence

What approaches are adopted in tackling the issue? • Programmes of work to address inequalities • Rudd: • Improve the literacy skills of the public • Improve the communications skills of health care staff • Recalibrate the norm and identify literacy barriers • Lower demands • Remove barriers What approaches are adopted in tackling the issue?

Health literacy as an outcome • Education programmes incl. patient education for long term conditions • Public information and campaigns • Accessible information policy and practice • Communication interventions What approaches are adopted in tackling the issue?

A dual focus Weiss et al (2006) • RCT with patients assigned either to • an intervention group that receiving standard depression treatment plus literacy education • control group received standard depression treatment • At final follow up depression severity was lower in intervention group • Literacy skills improved and their depression severity lessened. What approaches are adopted in tackling the issue?

“ I never knew help was out there until I was asked… no one had ever asked me before” Woman aged 57, referred to adult literacy learning through Keep Well programme

Health Literacy is.... ‘A critical empowerment strategy to increase people’s control over their health, their ability to seek out information and their ability to take responsibility.’

Bumpstart Aim - to improve health outcomes for pregnant women and their families Target – pregnant women in North Edinburgh Development – partnership, funding, time and assessment

Health Literacy Interventions Parent education classes Tier 1 – Mums Pregnancy Planner Mums Clubs Tier 2 – Pregnancy Cafe Tier 3 – 1:1 literacy support

Health Literacy Interventions Parent education classes Tier 1 – Mums Clubs Mums Pregnancy Planner Tier 2 – Pregnancy Cafe Tier 3 – 1:1 literacy support

How can you identify who has low health literacy? ‘Sorry I forgot my glasses’ ‘I’ll take it home to read’ Forms incorrectly completed Frequently missed appointments Non-compliance with treatment or medication regimes

Kate’s experience of Bumpstart

Communication & Health Literacy ‘The biggest problem in communication is the illusion that it has taken place.’ George Bernard Shaw

Communication strategies for improving health literacy Ask if they understand Draw pictures Go over and repeat the information several times Write it down for them Give them a leaflet or suggest a useful website

Teach-back technique The only way to know for sure is to ask! Asking patients to explain or demonstrate in their own words what they need to know or do Not a test for the patient Chance to check for understanding and re-teaching if necessary

Teach–back evidence Patient safety Surgical informed consent Chronic disease management Asthma

Edinburgh GP using teach-back ‘I told a patient to have a blood test in 1 week and phone 3 days later for the test results. I said if the blood results were worse, I would see him that week, if not, I would see him in a month. He told me he understood, but when I did teach-back he thought he had to see me in a week and get the blood test in a month.’

‘Teach-back saves time in the longer term as it reduces unnecessary follow up appointments, medication and treatment errors. I’ve recommended it to all my GP colleagues in the practice.’

Thank you! Kate Burton Kate.burton@nhslothian.scot.nhs.uk

What next • National Health Literacy Group – high impact interventions • What do you think will make the biggest difference?

Taking Action on Health Literacy