Techniques for Improving Health Literacy Among Low-Income and Immigrant Populations

1. Techniques for Improving Health Literacy Among Low-Income and Immigrant Populations March 26, 2013 Michael Villaire, MSLM Chief Operating Officer Institute for Healthcare Advancement www.iha4health.org mvillaire@iha4health.org (800) 434-4633 x202

2. What You’ll Learn By the time you’re done with this webinar, you should be able to: • Define health literacy   • Describe the importance of improving health literacy • Explain the relationship between health literacy and health disparities • Identify strategies to improve health literacy among low-income and immigrant populations • Discuss the Institute for Healthcare Advancement’s “What to do for Health” book series

3. Definitions Literacy • “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)

4. Definitions Health Literacy • “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)

5. Definitions

6. 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

7. 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

8. You know what you mean…But do they?

9. 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.

10. 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

11. 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.

12. Which of the following is the strongest predictor of an individual’s health status? Age Income Literacy skills Employment status Education level Racial or ethnic group

13. Which of the following is the strongest predictor of an individual’s health status? • Age • Income • Literacy skills (75% who self reported poor health in Below Basic HL category) • Employment status • Education level • Racial or ethnic group • --National Patient Safety Foundation

14. 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

15. Health Disparities andHealth Literacy

16. Health Disparities -Definitions- • “[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)

17. 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

18. 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

19. 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

20. Literacy / Health Literacy StatisticsData Sources • 1992 NALS (National Adult Literacy Survey) • 2003 NAAL (National Assessment of Adult Literacy) Added Health Literacy Module

21. 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

22. NAAL Literacy Findings Percent of U.S. adult population with Below Basic or Basic skills in: • Prose Literacy – 44% • Document Literacy – 34% • Quantitative Literacy – 55%

23. 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)

24. 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

25. 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)

26. 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”

27. 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.

28. How Patients Hide Illiteracy May 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

29. 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

30. Why Does Health Literacy Matter? 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)

31. Toward Solutions

32. 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

33. Tools and Techniques • Design Considerations • Large type size (12-14 point) and double-spaced • Standard font (no italics or ALL CAPS) • Two type faces (Arial-headings, Times NR-body) • Simple headings • White space • Usable, appropriate, explanatory graphics

34. 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

35. 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

36. Real-life Examples From “What To Do When Your Child Gets Sick” Institute for Healthcare Advancement www.iha4health.org

37. 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

38. 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

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

40. “The Bible” • Available from: • http://www.hsph.harvard.edu/healthliteracy/resources/doak-book/ • IHA Health Literacy Conference

41. 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

42. 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

43. Don’t Use Medical Jargon Consider these words: vomiting insomnia formulary urine unconscious acne oral CVA analgesic benign umbilicus terminal contraception negative

44. Don’t Use Medical Jargon 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)

46. 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

47. 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?”

48. 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

49. 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?

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