North Bay Literacy Council – Literacy and Health Presentation

1. North Bay Literacy Council – Literacy and Health Presentation Recognition and Treatment of a Hidden Problem

2. Funding for the Literacy & Health Project • This project is funded by the Ontario Trillium Foundation, from the Ministry of Culture • The project provides funding for one year (December 2006-2007) • One person for three days per week

3. Do you know? Which of the following is the strongest predictors of an individual’s health status? A) Age B) Income C) Literacy skills D) Education level E) Racial or ethnic group F) Average Beer Intake at Metro

4. Do you know? Which of the following is the strongest predictors of an individual’s health status? A) Age B) Income C) Literacy skills D) Education level E) Racial or ethnic group F) Average Beer Intake at Metro

5. True or False? • Most people with limited literacy have low IQs. • People will tell you if they have trouble reading. • The number of years of schooling is a good general guide to determine literacy level • Most people with low literacy skills are poor, immigrants or minorities.

6. Goals of the Presentation • Recognize the scope and implications of health literacy issues. • Identify and implement strategies to enhance patient understanding. • Learn to evaluate health care literature and documentation • Referral process for clients who want help in the community.

7. Health Literacy Health literacy is the degree to which people are able to access, understand, appraise and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course.

8. Types of Illiteracy • Functional illiteracy • Sensory/physical illiteracy • Cultural/language illiteracy • Psychological illiteracy • Computational illiteracy

9. Functional Literacy • Ability to read, write and speak in English • Compute and solve problems at levels of proficiency necessary to function in society • Ability to achieve one’s goals and develop one’s knowledge and potential

10. Physical Literacy • Sensory • Visual • Hearing • Neurological • Psychological / Mental Health • Other physical • Metabolic • Endocrine

11. Cultural/Language • Non-English speaking • Immigrant status • Ethnic interpretation of illness • Spiritual and religious beliefs • Majority of the lowest level readers are white and native born

12. Computational – Health Numeracy • The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions

13. Computational Numeracy • The ability to count, quantify, compute, and otherwise use simple manipulation of numbers, quantities, items, or visual elements in a health context so as to function in everyday situations. An example would be using nutritional labels correctly

14. Analytical Numeracy • This involves the ability to make sense of information, as well as higher functions like inference, estimation, proportions, percentages, frequencies, and equivalent situations. Information may be from multiple sources, and an example would be determining whether an analytical result was within the normal range, or understanding graphs

15. Statistical Numeracy • An understanding of basic biostatistics involving probability statements, skills to compare different scales (Probability, proportion, percent), to critically analyze quantitative information like life expectancy or risk, and understanding concepts like randomization and blinding. An example would be making choices between treatments based on standard outcomes of relative or absolute risk

16. Scope of the Problem • LBS (Literacy Basic Skills)- Level 1 • 22% of adult Canadians are so limited that they are unable to determine the correct dosage from reading the medicine label. • LBS (Literacy Basic Skills)- Level 2 • A further 26% can read provided that the materials are simple and presented in a familiar context.

17. LBS – Literacy Basic Skills • There are five levels • The levels provide a summary of skills for each level of written, verbal innumeracy outcomes • It offers a common language to describe learner levels and outcomes

18. LBS- Level 1 • Indicates very low literacy skills where the individual may, for example have difficulty identifying the correct amount of medicine to give a child from the information found on the package. These individuals are generally aware they have a problem

19. LBS Level One Grade 1-2 • Can • Sign name • Find expiration date on license • Total bank deposit entry • Can’t • Use bus schedule, find intersection on map • Fill out health history form • Total costs on an order form • Can’t read a simple story to a child

20. LBS Level 2 • Respondents can deal with material that is simple, clearly laid out and in which the tasks involved are not too complex. This is significant because it identifies people who may have adapted to everyday life, but would have difficulty learning new health related material and making informed decisions. These individuals often do not recognize their own limitations.

21. LBS Level Two Grade 2-3 • Can • Find intersection on map • Locate info in news article • Tell difference in two ticket prices (compare and contrast) • Can’t • Use bus schedule • Read a bar graph • Write a letter of complaint

22. What Happens? • Problems with: • Navigating from one clinic to another • Completing forms • Following medication instructions • Interactions with providers • Coping strategies in general

23. What Happens? • Limited general knowledge (Health promotion & prevention) • Do not ask for clarification • Focus on details, hard to get them to prioritize • Don’t understand Likert scales, math • Deal in literal/concrete concepts, not abstract • Essential vocabulary only • Check answers without understanding

24. Why worry? • Not keeping appointments—26% • Unable to find clinic/office • Failure to take meds correctly—42% did not understand “empty stomach” • Incomplete history • Overuse of emergency room • Lack of informed consent • Diagnosis made at later stages • Unhealthy/risky behaviors

25. More reasons • More than 80% of Canadians over 65 have low literacy skills and are unable to cope with the demands of everyday life and work. • Seniors with low literacy are more likely to have health problems than seniors with high literacy abilities • Non compliance can be life threatening

26. The elderly • Fewer years of schooling, poorer—fixed incomes • > 50% do not take meds as directed • 68% cannot interpret blood sugar value • 76% cannot follow Upper GI instructions • 2 billion dollars spent per year on hospital admission for medication errors

27. Oh, I can tell…Oh no you can't • If you can tell which patients are illiterate, you are doing better than trained physicians • Shame and stigma therefore… • 67% have never told their spouses and 19% never told anyone

28. More on Identifying • Forgot their glasses • Eyes wandering over page, very slow to finish, sounding out words, look confused • NEVER ask “How well do you read.” • Response will be: • Feign anger • Walk out rather than admit it. • If a person acts out, be curious.

29. More on Identifying • 98% will bring someone with them who read. • 88% will watch others or copy. • 90% will ask for help from the staff (front desk person) • 80% will ask for help from other patients. • Take forms home to complete

30. More on Identifying • Read too slowly or too quickly • Ask a lot of questions or none • Frequently use health care system • Routinely miss scheduled appointments • Never refer to written information they have received • Non-compliance with directions

31. Who Are They? • Not stupid • All social classes • No racial/ethnic bias • Amazing ability to function

32. Literacy Tests • Always assume and ask in sensitive way—”How do you like to get your information?” or “What things do you like to read?” or “How satisfied are you with how you read?” Treat all the same.

33. So, do I test them? • Time/place/training • Confidentiality and ethics • Cost • Reliability and validity • Timing re: patient • Age, sight, hearing, cognitive • Language

34. What to do • Whole staff must be aware and sensitive • Speak slowly and start with context • Quiet room with minimal distractions • Use monosyllabic and colloquial terms—avoid technical terms. Be concrete and use active voice. • Start with the most important information first and limit new information • No more than one or two instructions at a time—and check on each as you go: “Chunks and Checks”

35. More hints • Use repetition • Have the patient repeat the information • Use the “teach back” method • Never ask “Do you understand?” • Use models, sketches, pictures, symbols demonstrations • Consider follow up phone calls • Give instructions to several of family members • If you are rushed, get someone else to do it

36. More interventions • Know what languages and cultures you will encounter in your community-know what resources you will need • Check the reading level of materials you give to patients • Consider referring your patient to the North Bay Literacy Council • Develop partnerships between the health and literacy sectors • Work with your schools to get health education into the K—12 curriculum

37. Printed Materials (Secondary to Verbal) • Use pictures, photos, videos and other visuals—including med charts • Monosyllabic and simple language • Read over the instructions—highlight important parts with color • Lots of white space • Review materials for literacy level—rewrite as necessary, ask patients for help • Writing style should be clear, concise, organized, and jargon-free

38. Assessing level of literature • Most pamphlets at 10-12th grade level • Informed consents at 14.3—16th grade level • Internet health resources at similar grade levels • SMOG

42. Speaking Plainly • Request and respect patients prior knowledge, opinion and experience • Speaking plainly is as important as writing plainly • Avoid jargon • Use everyday examples to explain technical or medical terms • Teach in an organized manner • Use the “interactive communication loop”

43. Legal issues • Informed consent and living wills need post-college level comprehension • Must explain verbally as well as give written—just handing them the form to sign is not informed consent • Legal right to understand alternatives for care and risk of care • Avoid legal jargon/keep short

44. It is all of these things that have made them what they are and these are the things that you cannot come to know by hearsay; you can only know them if you have lived them.” Somerset Maughan, The Razor’s Edge (Introduction), 1944.

45. To Conclude “ …follow the counsel of Aristotle, to speak as the common people do, to think as wise men do; and so should every man understand him, and the judgment of wise men follow him.”— Roger Ascham (1515-1568)