Improving Health Literacy: Building the Skills We Need to Manage Our Own Health

1. Improving Health Literacy: Building the Skills We Need to Manage Our Own Health Jennifer Dillaha, MD Director, Center for Health Advancement, Arkansas Department of Health; Assistant Professor, UAMS College of Public Health and College of Medicine

2. What is 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.

3. Predictor of Health Status Although low health literacy can affect everyone regardless of background or educational level, studies on the issue show that limited literacy skills are a stronger predictor of an individual's health status than age, income, employment status, education level, and racial or ethnic group.  "Health Literacy: Report of the Council on Scientific Affairs." JAMA 1999:281:552-557. �

4. Health Literacy Includes a variety of components beyond reading and writing, including Numeracy Listening Speaking Relies on cultural and conceptual knowledge

5. Scope of Health Literacy Health-related activities are a part of the daily life of adults, whether sick or well. Many health-related decisions are made in the workplace and in the marketplace. The presentation of health information is often unnecessarily complex. Current evidence reveals a mismatch between people�s skills and the demands of health systems.

6. Health Systems Health systems in the US are complex and often confusing. An adult�s ability to navigate these health systems may reflect the system complexity in addition to individual skill levels. Even highly skilled individuals may find the systems too complicated to understand, especially when they are made more vulnerable by poor health or stress.

7. Health Systems Demands for reading, writing, and numeracy skills are intensified due to systems� complexities, advancements in discoveries, and new technologies These demands exceed the health literacy skills of most adults in the US Health literacy is fundamental to quality care

8. Changes in the health care system 4 - 6 weeks bed rest in hospital 650 3 weeks in hospital 2 hours a day of diabetic education classes 2-4 days in hospital 10,000 + Outpatient 0-3 hours diabetic education classes written materials internet telemedicine Purpose: To describe changes in our health care system that exacerbate the problem of low health literacy. Our health system has evolved over the last 35 years to a place where it demands that patients carry out their own complex medical care. Note to facilitator: Choose one or two examples from the information below to paint a picture of the differences in health care today versus 35 years ago. It is not necessary to cover all the information. 35 years ago a patient with a heart attack was immediately hospitalized for 6 weeks, flat in bed for several weeks and not even let up to go to the commode! If they survived, by the time they left the hospital, they knew everything they needed to know about how to care for themselves, the drugs they were on (we only had 3 or 4 available), the side effects, etc. Nowadays the same patient will be in and out of the hospital in 2-4 days, on 7 or 8 different drugs at every hour of the day or night, long lists of instructions, life style changes, diet changes (not only low fat, but avoiding such things as a grapefruit because it interacts with the drugs they are on), many different physician appointments, tests, etc. And they are still in shock, having come face to face with their own mortality! 35 years ago there were only 650 drugs, so that a primary care physician could know all of them. Today there are over 10,000 drugs, so no one individual can be familiar with all! In terms of patient education, 35 years ago a new diabetic patient would be hospitalized for 3 weeks. In addition to all the tests and insulin adjustments, they had 2 hours of patient education per day. (weekdays only, nothing happened on Sat. or Sun). So before they left the hospital, they had had 15 classes or 30 hours of instruction. Because patients came and left during the 3 weeks there was lots of repetition. Nowadays, new diabetics are treated outpatient, signed up for the next diabetes lectures � perhaps next month � perhaps only 1-3 hours worth � perhaps have a one-on-one 30 minutes with a dietician � and primarily need to read through several brochures and teach themselves. Today�s health care system puts a tremendous burden on the patient to teach themselves what they need to care for themselves. We give them written and verbal instructions and expect them to understand and know how to translate that information into the routine of their everyday lives. The questions are �Are our expectations unrealistic?� and �How many can actually do this with the information we provide?� Transition: There are many factors that contribute to low health literacy ��� Purpose: To describe changes in our health care system that exacerbate the problem of low health literacy. Our health system has evolved over the last 35 years to a place where it demands that patients carry out their own complex medical care. Note to facilitator: Choose one or two examples from the information below to paint a picture of the differences in health care today versus 35 years ago. It is not necessary to cover all the information. 35 years ago a patient with a heart attack was immediately hospitalized for 6 weeks, flat in bed for several weeks and not even let up to go to the commode! If they survived, by the time they left the hospital, they knew everything they needed to know about how to care for themselves, the drugs they were on (we only had 3 or 4 available), the side effects, etc. Nowadays the same patient will be in and out of the hospital in 2-4 days, on 7 or 8 different drugs at every hour of the day or night, long lists of instructions, life style changes, diet changes (not only low fat, but avoiding such things as a grapefruit because it interacts with the drugs they are on), many different physician appointments, tests, etc. And they are still in shock, having come face to face with their own mortality! 35 years ago there were only 650 drugs, so that a primary care physician could know all of them. Today there are over 10,000 drugs, so no one individual can be familiar with all! In terms of patient education, 35 years ago a new diabetic patient would be hospitalized for 3 weeks. In addition to all the tests and insulin adjustments, they had 2 hours of patient education per day. (weekdays only, nothing happened on Sat. or Sun). So before they left the hospital, they had had 15 classes or 30 hours of instruction. Because patients came and left during the 3 weeks there was lots of repetition. Nowadays, new diabetics are treated outpatient, signed up for the next diabetes lectures � perhaps next month � perhaps only 1-3 hours worth � perhaps have a one-on-one 30 minutes with a dietician � and primarily need to read through several brochures and teach themselves. Today�s health care system puts a tremendous burden on the patient to teach themselves what they need to care for themselves. We give them written and verbal instructions and expect them to understand and know how to translate that information into the routine of their everyday lives. The questions are �Are our expectations unrealistic?� and �How many can actually do this with the information we provide?� Transition: There are many factors that contribute to low health literacy ���

10. A Hidden Problem Low health literacy is often undetected People may have trouble understanding both printed materials and the meaning of discussions with providers People who are confused about health information may feel ashamed They may mask their shame to maintain their dignity

11. National Adult Literacy Survey 26,000 adults First portrait of literacy in U.S. Scored on 5 levels Result: 48% of US population have inadequate or marginal literacy skills (0:04) Purpose: To describe the study that showed that � of the population is at risk. The National Adult Literacy Survey was conducted in 1992 and published in 1993. This study was conducted by the Department of Education. 26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US. The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy) Based on this study we know that almost 50% of the US population falls in the first two levels, inadequate or marginal literacy. There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which is included in the AMA Foundation Health Literacy: Help Your Patients Understand kit. Transition: The full results for the 5 levels are represented in the following chart��.. (0:04) Purpose: To describe the study that showed that � of the population is at risk. The National Adult Literacy Survey was conducted in 1992 and published in 1993. This study was conducted by the Department of Education. 26,000 US adults were interviewed for the study and it paints the most accurate portrait available on literacy in the US. The survey was scored on five levels from Level 1 (inadequate) to Level 5 (high-level literacy) Based on this study we know that almost 50% of the US population falls in the first two levels, inadequate or marginal literacy. There is much more information on this study in the manual, Health Literacy: A Manual for Clinicians, which is included in the AMA Foundation Health Literacy: Help Your Patients Understand kit. Transition: The full results for the 5 levels are represented in the following chart��..

12. 1993 National Adult Literacy Survey Purpose: To describe the 5 levels in NALS. (There are 2 additional slides in the Appendix on NALS Level 1 and Level 2.) Level 1: The red section of the diagram represents the lowest level, those that have inadequate literacy. Although they can perform some reading and writing tasks, their limited literacy skills prevent full functioning in today�s society. Level 1 represents 21% of the population. Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the �gist� of the content of the article. They usually (with 80% reliability) can sign their name and total a bank deposit entry They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form. Level 2: The yellow section of the diagram represents those with marginal literacy skills. Individuals in this level have somewhat more advanced skills than those in Level 1, but they are still substantially limited in their ability to read and understand text. Level 2 represents 27% of the population. Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. They also struggle with writing a simple letter explaining an error on a bill. What is the impact? All health care directions are words and numbers. Take one of our oldest directions �Take one teaspoon four times a day�. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 3 1/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once? Another example: �Take 2/3 of your insulin dosage before surgery.� We should be translating this into the exact amount�.e.g. if they normally take 15 units, they should take only 10 units before surgery. Together, Level 1 and Level 2 include 48% of the population, almost half of the US adult population. Levels 3, 4 and 5: In contrast, persons at NALS levels 3, 4 and 5 have sufficient literacy skills to permit full functioning in society Additional information for discussion if time permits: Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school. There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with �functionally illiterate� people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently. Transition: Let�s look at the literacy data available for our city/region��..Purpose: To describe the 5 levels in NALS. (There are 2 additional slides in the Appendix on NALS Level 1 and Level 2.) Level 1: The red section of the diagram represents the lowest level, those that have inadequate literacy. Although they can perform some reading and writing tasks, their limited literacy skills prevent full functioning in today�s society. Level 1 represents 21% of the population. Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the �gist� of the content of the article. They usually (with 80% reliability) can sign their name and total a bank deposit entry They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form. Level 2: The yellow section of the diagram represents those with marginal literacy skills. Individuals in this level have somewhat more advanced skills than those in Level 1, but they are still substantially limited in their ability to read and understand text. Level 2 represents 27% of the population. Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. They also struggle with writing a simple letter explaining an error on a bill. What is the impact? All health care directions are words and numbers. Take one of our oldest directions �Take one teaspoon four times a day�. How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 3 1/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once? Another example: �Take 2/3 of your insulin dosage before surgery.� We should be translating this into the exact amount�.e.g. if they normally take 15 units, they should take only 10 units before surgery. Together, Level 1 and Level 2 include 48% of the population, almost half of the US adult population. Levels 3, 4 and 5: In contrast, persons at NALS levels 3, 4 and 5 have sufficient literacy skills to permit full functioning in society Additional information for discussion if time permits: Of the NALS Level 1 people, 66% were 65 years or older, 25% were immigrants, and 62% had not finished high school. There are very few Americans who are totally illiterate. Some third world countries may have 25% of the population that has never seen a printed page or learned an alphabet. That is not the problem with �functionally illiterate� people in the US and around the developed world. The % of the population in Levels 1 & 2 are very similar in England, Germany, Canada, Australia, etc. Around the world in countries with universal education, 1 out of 5 never gets to the point of reading fluently. Transition: Let�s look at the literacy data available for our city/region��..

13. �Volumes To Go Before We Rest�The Crisis of Low Literacy in Arkansas� Peggy Sissel-Phelan, Ed.D 56% of adult Arkansans (1.1 million adults) are functionally and/or marginally illiterate When broken down by county, 85% exceed national figures Local data can be found at www.nifl.gov/reders/reder.html To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

16. 2003 National Assessmentof Adult Literacy* Most recent assessment of English Literacy N = 19,000 adults (>16 years) 500 everyday literacy tasks First large scale national assessment of Health Literacy Four new Literacy Levels *http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid+2006483 To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

17. Health Literacy Levels Below Basic�circle date on appt slip Basic�read pamphlet and determine symptoms of a disease Intermediate�vaccine schedule Proficient�calculate share of health insurance cost from table To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

18. Health Literacy Levels Below Basic�14 percent Basic�22 percent Intermediate�53 percent Proficient�12 percent To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

19. Demographics Women > Men White and Asian > Black and Native Americans Hispanic lowest skills among minorities Persons 65 years and older had lowest Majority are white, native-born American To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

20. Other Factors Higher level of educational attainment correlated with increased Health Literacy 49% who never attended or did not complete HS had below basic health literacy Adults living in poverty had lower health literacy People on Medicare, Medicaid, or no insurance are more likely to be at below basic and basic levels To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�.. To find literacy data on your specific region, state, county or town, you can go to the National Institute for Literacy (NIFL) website listed on this slide. This is the information for our area�� Transition: It is hard for us to imagine what it must be like to have a serious problem reading and interpreting information. In the following activity we will try to simulate for you what it is like to have low general literacy�..

21. Inadequate health literacy increases with age� The prevalence of inadequate health literacy steadily increases with age. Of note, patients were screened for dementia in this study and those with any signs of dementia excluded. We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a �use it or lose it� phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV. While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy. Transition: There has been a substantial amount of research on literacy in the last decade�� Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51. The prevalence of inadequate health literacy steadily increases with age. Of note, patients were screened for dementia in this study and those with any signs of dementia excluded. We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a �use it or lose it� phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV. While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy. Transition: There has been a substantial amount of research on literacy in the last decade�� Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281: 545-51.

22. What do we know from a decade of research? Low health literacy leads to: Lower health knowledge and less healthy behaviors Poorer health outcomes Greater health costs Specific communication techniques may enhance health literacy. AHRQ, 2004; IOM, 2004; Schwartzberg, 2005 (0:50) Purpose: To provide an overview of research on the implications of low health literacy and strategies to address low health literacy. Note: This slide �builds.� We�ve learned a lot over the last decade about the implications of low health literacy. You will find more on this body of research in your �Manual for Clinicians� (or summarized in your Participant Guide). Data from numerous studies shows that low health literacy leads to: Lower health knowledge and less healthy behaviors. Poorer health outcomes Greater costs There is also research on communication techniques that enhance health literacy. Transition: Literacy level is also a good predictor of health status��. References: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015. Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64. Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30. Schillinger D, et al. Closing the Loop. Arch Intern Med. 2003; 163: AHRQ, 2001 Report on Making Health Care Safer. Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding health literacy: implications for medicine and public health. Chicago: AMA Press 2005. Health Literacy: A prescription to end confusion. Report of the Institute of Medicine. Washington DC: The National Academies Press 2004. Literacy and health outcomes: final evidence report. Rockville, MD: Agency for Healthcare Research and Quality 2004. (0:50) Purpose: To provide an overview of research on the implications of low health literacy and strategies to address low health literacy. Note: This slide �builds.� We�ve learned a lot over the last decade about the implications of low health literacy. You will find more on this body of research in your �Manual for Clinicians� (or summarized in your Participant Guide). Data from numerous studies shows that low health literacy leads to: Lower health knowledge and less healthy behaviors. Poorer health outcomes Greater costs There is also research on communication techniques that enhance health literacy. Transition: Literacy level is also a good predictor of health status��. References: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114:1008-1015. Weiss BD, Hart G, McGee D, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. Journal of the American Board of Family Practice. 1992; 5:257-64. Baker D, Parker R, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997; 87:1027-30. Schillinger D, et al. Closing the Loop. Arch Intern Med. 2003; 163: AHRQ, 2001 Report on Making Health Care Safer. Schwartzberg JG, VanGeest JB, Wang CC, eds. Understanding health literacy: implications for medicine and public health. Chicago: AMA Press 2005. Health Literacy: A prescription to end confusion. Report of the Institute of Medicine. Washington DC: The National Academies Press 2004. Literacy and health outcomes: final evidence report. Rockville, MD: Agency for Healthcare Research and Quality 2004.

23. Low literate diabetic patients less likelyto know correct management�. In one study of diabetic patients, those with low literacy were less likely to know correct management of hypoglycemic symptoms. Patients who attended diabetes education classes were tested with the TOHFLA to determine their health literacy level before starting the classes, and then tested on knowledge after the class. While 95% of those with adequate literacy (green) knew the symptoms of hypoglecemia, only 48% of those with inadequate literacy (red) sitting side by side in the classes, got this key message. What is of equally great concern, is that when it comes to knowing what to do about this life-threatening major adverse drug event, only 75% of those with adequate literacy knew what to do. So even in the best of circumstances, we don�t know how to get crucial messages understood. We need to learn a great deal more about how to make our health care communication more effective. Transition: It is not surprising that diabetic patients with low literacy have poorer health outcomes�. Reference: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients� knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.In one study of diabetic patients, those with low literacy were less likely to know correct management of hypoglycemic symptoms. Patients who attended diabetes education classes were tested with the TOHFLA to determine their health literacy level before starting the classes, and then tested on knowledge after the class. While 95% of those with adequate literacy (green) knew the symptoms of hypoglecemia, only 48% of those with inadequate literacy (red) sitting side by side in the classes, got this key message. What is of equally great concern, is that when it comes to knowing what to do about this life-threatening major adverse drug event, only 75% of those with adequate literacy knew what to do. So even in the best of circumstances, we don�t know how to get crucial messages understood. We need to learn a great deal more about how to make our health care communication more effective. Transition: It is not surprising that diabetic patients with low literacy have poorer health outcomes�. Reference: Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients� knowledge of their chronic disease: a study of patients with hypertension or diabetes. Arch Int Med. 1998; 158:166-172.

24. Poor health outcomes for diabetic patients�� Diabetic patients with low health literacy have poorer glucose control than patients with adequate literacy. (Schillinger D, et al. JAMA. 2002.) Diabetic children (ages 5-17) had poorer glucose control if their parents had lower literacy skills. (Ross LA, et al. Diabetic Med. 2001.) Read these examples. Transition: These examples provide strong scientific evidence that low literacy leads to poorer health outcomes�. References: Schillinger D, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-82. Ross LA, Frier BM, Kelnar CJ, Deary IJ. Child and parental mental ability and glycemic control in children with Type 1 diabetes. Diabetic Med. 2001;18:364-9. Read these examples. Transition: These examples provide strong scientific evidence that low literacy leads to poorer health outcomes�. References: Schillinger D, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-82. Ross LA, Frier BM, Kelnar CJ, Deary IJ. Child and parental mental ability and glycemic control in children with Type 1 diabetes. Diabetic Med. 2001;18:364-9.

25. Patients with low literacy more likely to be hospitalized In a study that followed more than 1000 patients at a public hospital for 2 years, patients with inadequate health literacy were twice as likely to be hospitalized. Even after controlling for age, gender, socioeconomic status, health status, and regular source of care, inadequate health literacy was associated with a 52% increased odds of hospitalization. Transition: And all of this adds up to BIG COSTS!!!� Reference: Baker DW, Parker RM, Williams MV. Health literacy and the risk of hospital admission. JGIM. 1998; 13: 791-8.In a study that followed more than 1000 patients at a public hospital for 2 years, patients with inadequate health literacy were twice as likely to be hospitalized. Even after controlling for age, gender, socioeconomic status, health status, and regular source of care, inadequate health literacy was associated with a 52% increased odds of hospitalization. Transition: And all of this adds up to BIG COSTS!!!� Reference: Baker DW, Parker RM, Williams MV. Health literacy and the risk of hospital admission. JGIM. 1998; 13: 791-8.

26. Institute of Medicine20 Priorities Areas for National Action to Transform Health Care Quality Health literacy is important to improving the health of individuals and populations Self-management/health literacy was identified as one of two cross-cutting priorities for health care quality improvement

27. Potential Intervention Points

28. Addressing the Problemof Low Health Literacy Health literacy is based on the interaction of individuals� skills with health contexts, the health-care system, the education system, and broad social and cultural factors at home, at work, and in the community. The responsibility for health literacy improvement must be shared by these sectors.

29. Arkansas Literacy Councils Referrals for low literate patients to literacy programs Community-based Literacy Organizations in 65 of 75 Arkansas counties Basic literacy skills, ESL, Workplace and Family Literacy, Math; some with Health Literacy Initiatives Over 10,000 Arkansans served 1-800-264-7323 www.arkansasliteracy.org

30. Coordinated School Health

31. Stanford Chronic DiseaseSelf-management Program Grant from Administration on Aging Implement Program in two Area Agencies on Aging regions Involves statewide aging network Interest in statewide expansion Not just for older adults

32. The Arkansas Aging Initiative Stanford Chronic Disease Self-Management Program 26 AAI staff and volunteers from all over the state These 26 individuals will become �master trainers� for additional trainers Partnership with ADH funded through a federal grant from Administration on Aging Chronic Care Model Medical Home

33. BAPTIST HEALTH Home Health NetworkAddressing Health Literacy Through the Home-Based Chronic Care Model Home-Based Chronic Care certification course Low literacy red flags and common cues Verbal communication strategies to improve understanding Selecting and designing appropriate educational materials Use of visual sources of medical information Emphasis on understanding literacy issues during weekly care conferences Results: Patients demonstrating improved disease self-management

34. Creating a Patient-Centered Medical Home with a Shame-Free Environment

35. Low Health Literacy as an Economic Drain A major source of inefficiency in the US health care system Cost to the US economy: $106 billion to $238 billion annually 7% to 17% of all personal health care expenditures Future costs from current actions (or lack of action): $1.6 trillion to $3.6 trillion

36. A health-literate Arkansasis an achievable goal.

37. Jennifer Dillaha, MDArkansas Dept. of Health4815 W Markham, Slot 41Little Rock, AR 72205Office: 501-661-2199Email: Jennifer.Dillaha@Arkansas.gov