Education and Literacy

1. Education and Literacy Presenter Tool – revised summer 2013

2. Education and Literacy (prezi) OUTLINE • Objectives • TED Talk • Definitions • Global Context • Local Context • Role of Primary Care • Discussion / Activities

3. Objectives • Be able to describe how education & literacy influences 3 other social determinants of health • Be able to describe 3 direct effects of literacy on health • Be able to identify 3 areas in primary care management where incorporation of education plays an important role in patient care

5. Ted Talk • Joseph Lekuton tells a parable for Kenya (5:24) • Joseph Lekuton, a member of parliament in Kenya, starts with the story of his remarkable education, then offers a parable of how Africa can grow. His message of hope has never been more relevant. OR • Bunker Roy: Learning from a barefoot movement (19:08) • In Rajasthan, India, an extraordinary school teaches rural women and men -- many of them illiterate -- to become solar engineers, artisans, dentists and doctors in their own villages. It's called the Barefoot College, and its founder, Bunker Roy, explains how it works.

6. Joseph Lekuton tells a parable for Kenya • When listening, pay attention to: • Barriers to education • Opportunities to access/improve education • How educations relates to other SDOH

7. After the Ted Talk… group questions to consider… • How does education improve the life of: the individual, their family, their community? • What are some challenges that people in village face in terms of their health? no clean drinking water, lack of transportation to hospital, distance from health facilities • How does a better education influence other determinants of health? poverty, food security, housing, access to health care

8. Bunker Roy: Learning from a barefoot movement • When listening, pay attention to: • Different meanings / definitions of education • Impact of education on the individual and community, and on the other SDOH • Education strategies utilized when faced with illiteracy

9. After the Ted Talk… group questions to consider… • What are some examples of the impact of education on this community's inhabitants? • How does education effect other SDOH? At the individual level, the community level?  • What are some examples of education strategies they utilized when faced with illiteracy?

10. Key facts • Better education is fundamental to economic and social development, and the end of world poverty. • More than 100 million children of primary school age are not in school. • Girls are disproportionately affected, particularly in Sub-Saharan Africa, South Asia, and East Asia and the Pacific, where 83 percent of all out-of-school girls live. • Completion of schooling is a significant problem.

11. Key facts • Education = key ingredient for social change • Education is closely tied to socioeconomic status • Effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. • Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving, and helps provide a sense of control and mastery over life circumstances. • Education increases opportunities for job and income security, and job satisfaction • Education improves people's ability to access and understand information to help keep them healthy.

12. What does it mean to be illiterate? • "Literacy means more than knowing how to read, write or calculate. It involves understanding and being able to use the information required to function effectively." • Literacy is a major factor underlying most other determinants of health

13. What does it mean to be illiterate? • “it is a set of tangible skills — particularly the cognitive skills of reading and writing" UNESCO • “Scholars have suggested that a useful concept would be that of multiple literacies – that is, ways of ‘reading the world’ in specific contexts: technological, health, information, media, visual, scientific, and so on.” UNESCO

15. Group questions • How does literacy influence health? • How does literacy influence the determinants of health?

16. Social determinants of health

18. Global context (MDG) • MDG Goal 2: Achieve Universal Primary Education • Ensure that by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling. http://www.telegraph.co.uk/news/worldnews/asia/afghanistan/8258146/Taliban-abandons-opposition-to-girls-education.html

19. Global context group discussion:How education affects achievement of the Millennium Development Goals

20. Global context group discussion:How education affects achievement of the MillenniumDevelopment Goals How education affects achievement of the Millennium Development Goals • Poverty reduction: • No country has ever achieved continuous and rapid growth without achieving an adult literacy rate of at least 40 percent. • The higher productivity these income gains reflect can contribute to national economic growth. • HIV/AIDS: • Women are now the principal victims of HIV/AIDS in poor countries. • Education helps women protect themselves. • Young people (15–24 years) who have completed primary education are less than half as likely to contract HIV as those with little or no schooling. • Maternal mortality: • Women with six or more years of education are more likely to seek prenatal care, assisted childbirth, and postnatal care, reducing the risk of maternal and child mortality and illness. • Child health: • Educated mothers are 50 percent more likely to immunize their children than mothers with no schooling. • Hunger: • Most farmers in the developing world are women. Educating girls and women leads to more productive farming and accounted for more than 40 percent of the decline in malnutrition achieved between 1970 and 1995.

21. Possible global context discussion (extra) How can the international community reach the global goal of universal primary education and gender parity at all levels of education by 2015? • Institutional problems prevent many children who do attend school from actually learning • Countries with weak educational systems can learn from the many developing countries that have made progress • Examples of successful interventions: • Be pragmatic to reduce costs: • introducing contract teachers, • shifting to low-cost school construction methods, • resisting pressures to reduce class size much below 40 until universal coverage is achieved, • providing free primary education and recovering a larger share of costs at other levels, and • shortening the preservice teacher training cycle. • All of these actions lower the unit costs of primary schooling and promote faster achievement of universal coverage.

22. Possible global context discussion (continued) How can developing countries get out-of-school children into school? • Encourage children to attend school. • Support mothers – through maternal education • Enhance postprimary education.

23. local context (prezi) "Literacy means more than knowing how to read, write or calculate. It involves understanding and being able to use the information required to function effectively."

24. SDOH –local context (continued) • About 22 percent of adult Canadians fall into the lowest level of literacy • For example, they are unable to look at a medicine label and determine the correct amount of medicine to give to a child. • Individuals at this level are limited in their ability to deal with much of the written material they would encounter in everyday life. • A further 26 percent are at Level 2. • Individuals at this level can read. But they can only deal with material that is simple, clearly laid out, and in familiar contexts. • They would have difficulty understanding information which is more complex or in a context different from what they are familiar with. • Thus nearly half of Canadians have difficulty with reading materials encountered in everyday life. • They avoid reading except for materials which are relatively simple and familiar to them.

25. Who’s at risk? • Poor children are less likely to attend school… …as are children in rural areas, …as are children from ethnic and linguistic minorities, …as are children with disabilities, and …as are children affected by armed conflict

26. Group discussion How do low literacy skills impact on Canadians? What barriers and challenges will your patients with low literacy skills encounter?

27. Impact of low literacy • Canadians with low literacy skills are more likely than those with high levels of literacy: • To be unemployed and poor, • to suffer poorer health and • to die earlier • People with higher levels of education: • have better access to healthy physical environments and • are better able to prepare their children for school. • tend to smoke less, • Tend to be more physically active and • tend to have access to healthier foods. http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#income

28. Supplementary information (extra) 1996-97 National Population Health Survey (NPHS): • Only 19% of respondents with less than a high school education rated their health as "excellent" • Whereas 30% of university graduates rated their health as “excellent” 1990 Canada Health Promotion Survey: • Number of lost workdays decreases with increasing education. • People with elementary schooling lose 7work days per year due to illness, injury or disability, while those with university education lose fewer than 4days per year. 

29. Discussion / Activity (prezi) • Research shows that physicians commonly overestimate patients' level of literacy, education or understanding, and they rarely consider limited literacy skills in their assessment of whether patients understand what they need to do • In pairs of two, share an example, taken from your clinical practice, where you feel you either demonstrated strength or weakness in assuring patient or patient’s family education/literacy level. How did this or could this impact patient health? • My example: • Mrs. D presented to her follow-up with high blood pressure measurement (BP 160/100). Interestingly, at our last encounter, her Meet and Greet, her blood pressure was well controlled (BP 128/78). • In response to this high readings, she states: “But last time you told me my BP was normal. So I stopped taking my medications because I thought I had been cured”. • The chronicity of HTN was not reviewed at the last visit, nor was the importance of continuing treatment as previously prescribed. This led to poor BP control, and thus putting the patient at risk of potential health consequences related to suboptimal BP such as CVS disease. • Lessons learned: Patient understanding of their acute and chronic health conditions lead to improved health and medication compliance. As a primary care physician, it is my role to assure this education is provided.

30. Role of Primary Care Primary health care services often include: • prevention and treatment of common diseases and injuries • basic emergency services • referrals to/coordination with other levels of care (such as hospitals and specialist care) • primary mental health care • palliative and end-of-life care • health promotion • healthy child development • primary maternity care • rehabilitation services Patient / Family / Community level of education, understanding will influence all of the above • Patient education is the process of influencing patient behavior and producing the changes in knowledge, attitudes and skills necessary to maintain or improve health.

31. Role of Primary Care (continued) Direct Effects of Literacy on Health • Failure to understand information about medications, health practices, and safety risks can result in health problems. • Incorrect use of medications: errors in the use of over-the-counter and prescription medications as a result of literacy difficulties • example of a woman with diabetes: "...She needs to follow a restricted diet and take several medications prescribed by her family physician at regular intervals each day. But [she] is unable to read food labels or the instructions that come with her prescription medicines. [Her] literacy problems are a hazard to her health!" • Failure to comply with medical directions: due to an inability to read written instructions or because verbal instructions were not presented in a way in which they could be understood • Impede the ability to understand the risks of medical procedures. • Errors in administration of infant formula: instances where infant formula was misused, placing babies at risk. • example, a number of nurses reported that some mothers were not diluting concentrated formulas, and others were diluting ready-to-feed formulas.

32. Role of Primary Care (continued) • Safety risks in the workplace, the community and at home: literacy difficulties resulted in accidents, including inability to understand safety instructions when handling chemicals and "a pictorial instruction material demonstrating 'how not to' carry out a task was interpreted as a 'how to' instruction and the result was an increase in accidents." Indirect Effects • Five major determinants of health: Living and Working Conditions Personal Health Practices and Coping Skills Physical Environment Health Services Biology and Genetic Endowment • Of these, "Biology and Genetic Endowment" is the only one which is not affected, at least to some degree, by literacy

33. What role can you play in terms of education as a family doctor? • Family physicians are uniquely suited to take a leadership role in patient education. • Family physicians build long-term, trusting relationships with patients, providing opportunities to encourage and reinforce changes in health behavior. • Patient education is an essential component of residency training for family physicians. • Patient education is critically important because it is clear that the leading causes of (i.e., heart disease, cancer, stroke, lung disease and injuries) are closely associated with unhealthy lifestyles. • Strong evidence to suggest that counseling and patient education provides substantial benefits.

34. Role of Primary Care (continued) • Providing patients with complete and current information: • helps create an atmosphere of trust, • enhances the doctor-patient relationship and • empowers patients to participate in their own health care. • Effective patient education also ensures that patients have a sufficient level of knowledge and understanding, which allows them to make informed decisions regarding their care. • To provide effective patient education depends on: • ascertaining patients' educational needs, • identifying barriers to learning, • incorporating education into routine office visits and • counseling concisely • Patient education materials.

36. Group discussion ACTION PLAN • After today’s workshop, make a list of tangible action plans to implement in your respective practices.

37. Supplementary information (extra) One of the most commonly used indicators of health is self-rated health status • "Self-rated health status is a good predictor of the presence of more 'objectively' measured health problems as well as health care utilization.” • % of Canadians who rated their health as "excellent”: • 19 percent of Canadians with less than high school education, • 23 percent who have completed high school, • 27 percent of college graduates and • 39 percent of university graduates.

38. Supplementary information (extra) Behavioural measure of health is long-term activity limitation at home, work or school: • % of Canadians reporting an activity limitation: • 23 percent of people who have not completed high school • 19 percent of high school and college graduates, • 15 percent of university graduates.

39. Supplementary information (extra) • Education is negatively associated with poorer health, whether the measures used are subjective (such at self reported health), behavioral (e.g. activity limitation), or objective (e.g. high blood pressure and the presence of other risk factors, or the presence of disease). • Many different sources of information have repeatedly documented the negative effect of low literacy on virtually all aspects of health, including: • overall levels of morbidity and mortality, • accidents, and • a wide range of diseases, e.g., diabetes, cardiovascular disease, and rheumatoid arthritis.

40. Supplementary information (extra) How the Health Care Field can address this: • Recognition is needed at a broader societal level. • Service providers need to be sensitive to the importance of literacy and create a respectful environment when dealing with individuals, families, and groups. • Few people will readily acknowledge that they have a problem in reading or in understanding what they are being told. • To do so would require them to declare their own inadequacies or limitations. When health practitioners are sensitive to the potential role of literacy in comprehension, they are more likely to check that what they are saying is indeed being understood and to use simpler or alternative explanations as necessary to ensure that their message actually is being received. Anumber of medical practitioners have indicated that they eventually came to realize that what they initially thought was lack of compliance by their patients was instead a lack of understanding.