Health Literacy: can your patients be healthy without it

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Health Literacy can your patients be healthy
without it?

• Christina Zarcadoolas, PhD
• Mount Sinai School of Medicine
• Dept. of Community and Preventive Medicine

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What is health literacy?

• The wide range of skills, and competencies that
  people develop over their lifetimes to seek out,
  comprehend, evaluate, and use health and
  information and concepts to make informed
  choices, reduce health risks, and increase
  quality of life.
• (Zarcadoolas, Pleasant Greer, 2003 2006)

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Approximately half of the adults in the US
read at 8th grade level and lower.Half have Low
Health Literacy.(1993 2003)
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Fundamental Literacy

• Reading
• Writing
• Speaking
• Numeracy

The Language of Health Environment
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Boldface type indicates chronic disease or
condition.Source National Center for Health
Statistics, Mortality Report. Hyattsville, MD
U.S. Department of Healthand Human Services,
2002. (From DHHS The Power of Prevention Steps
to a Healthier US Program and Policy Perspective
2003http//www.healthierus.gov/steps/summit/prevpo
rtfolio/power/index.htmlwe
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Who are they ? (Kirshner et al. National Adult
Literacy Study. 1993.)

• From all socio-economic groups
• Low-income and ethnic minority
• 45 of all functionally illiterate adults live
  below the poverty line.
• eg., ½ adults in Central Harlem have not
  completed HS
• Elderly
• 66 of U.S. adults aged 60 and over have either
  inadequate or marginal literacy skills. ( note
  doesnt include hearing loss/cognitive def. )

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One Third Of Medicare Managed Care Enrollees Had
Low Literacy

Gazmarian et al. JAMA 99.
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Implications Public health

• A study of Medicaid participants found that those
  reading at the lowest grade levels had average
  annual health care costs of roughly 13,000
  compared with the average for the population
  studied of 3,000 (Weiss, 1999).
• The National Academy on an Aging Society (1998)
  estimated that excess health care costs generated
  by patients with inadequate health literacy
  (primarily from extra and longer
  hospitalizations) is 73 billion dollars per year.

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Changing health literacy environment

• Complex health system
• Complex and changing science
• increased need for self-management
• conflicting media reports about health hazards
• misconceptions about communicable diseases such
  as smallpox, anthrax, and SARS
• direct-to-consumer advertising about new drugs
  and
• vast amounts of health information available on
  the Internet.

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Implications of Low Health Literacy

• Report poorer overall health
• Less likely to make use of screening and
  preventive services
• Present in later stages of disease
• Are more likely to be hospitalized
• Have poorer understanding of treatment and their
  own health
• Have lower adherence to medical regimens

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The Cost

• 1.5 million people in the United States are
  harmed by preventable drug errors each year
• Treatment of drug-related injuries adds at least
  3.5 billion annually, not counting indirect
  costs such as lost income and ancillary health
  and home care services. (IOM 2006)
• Low Health Literacy 70 billion yrly. (The
  National Academy on an Aging Society 1998)

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Not Generally Readable/Useable by many US adults
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Prescription Errors

• 5 common prescriptions - 2/3 mostly low-income
  patients of mixed literacy could read the
  wording, but only 1/3 knew what to do next
• patients with the highest literacy levels erred
  from 5 to 27 of the time
• 70.7 of patients with low literacy correctly
  stated the instructions Take two tablets by
  mouth twice daily,' only 34.7 could demonstrate
  the number of pills to take
• (Davis, et.al., Dec. 19,2006 Annals of
  Internal Medicine)

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The problem with much health outreach /
education/ communications

• Often top down deficit model
• Rarely starts with where people are at
• Seldom mindful of fundamental literacy
• Not mindful of health environmental literacy
  principles

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A central solution fix the language and
cultural mismatch between patients and providers/
patients publics

• Easy to read
• Easy to navigate
• Linguistically appropriate
• Culturally appropriate
• Relevant

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Simplifying
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Clear language is necessary.

• But it is NOT sufficient.
• It will not solve the low health literacy
  problems in the US

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Simplifying does not necessarily lead to
improved health literacy

• A notice from a health insurer
• Due to the fact that this drug is not on our
  formulary we are denying your claim for
  reimbursement.

• Simplified
• We deny (will not pay) your claim. We are
  denying your claim because this drug is not on
  our list of approved medications.

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Health literacy demands of previous message

• The insurance company has the authority to pay or
  not pay bills they do not automatically pay for
  any service or medication, even if the doctor
  recommends it.
• Insurers use a finite (and often changing) list
  of allowable medications that they will and will
  not pay for.
• Not all medicines are the same.
• To greater or lesser degree, consumers must
  understand that they can
• request an appeal,
• speak to their doctor about an alternative
  medication and treatment options,
• think about changing health plans, or even
• become an advocate for health care reform.

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What does this important health message demand of
the consumer/reader?
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Being health literate means much more than
understanding the words and sentences of health
and environmental information.

• Fundamental literacy
• Science Literacy
• Civic Literacy
• Cultural Literacy

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NSF, Public Understanding of Science

• Between 5 and 15 of the public qualify as
  scientifically literate. 
• 18 can be considered an attentive science
  public.

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Science Literacy

• Between 5 and 15 of the public qualify as
  scientifically literate. 
• 18 can be considered an attentive science
  public.
• fundamental scientific concepts, scientific
  process
• Technology technical complexity,
• scientific uncertainty and that rapid change in
  the accepted science is possible.

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Science Literacy

• fundamental scientific concepts, scientific
  process
• Technology technical complexity,
• scientific uncertainty and that rapid change in
  the accepted science is possible.

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Science Literacy

• Between 5 and 15 of the public qualify as
  scientifically literate. 
• 18 can be considered an attentive science
  public.
• fundamental scientific concepts, scientific
  process
• Technology technical complexity,
• scientific uncertainty and that rapid change in
  the accepted science is possible.

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Civic Literacy
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Civic Literacy

• judging the source of information
• media literacy skills
• knowledge of civic and governmental systems and
  processes
• knowledge of power, inequity
• knowledge that personal behaviors and choices
  affect others in a larger community and society

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photo caption reads Two residents wade through
chest-deep water after finding bread and soda
from a local grocery store after Hurricane
Katrina came through the area in New Orleans,
Louisiana.(AFP)
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photo caption reads A young man walks through
chest deep flood water after looting a grocery
store in New Orleans on Tuesday, Aug. 30, 2005.
Flood waters continue to rise in New Orleans
after Hurricane Katrina did extensive damage when
it made landfall on Monday. (AP )
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Cultural Literacy

• Ability to recognize, understand and use the
  collective beliefs, customs, world-view, and
  social identity
• Bilateral - experts should understand aspects of
  the culture of the recipient and visa versa.

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Percent Distribution of Foreign Bornby World
Region of Birth 2000
Other Regions 8.1
Europe 15.3
Latin America 51.0
Asia 25.5
Source Current Population Survey, March 2000,
PGP-3
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• The Sioux San Hospital of Rapid City, South
  Dakota, is an Indian Health Service (IHS)
  hospital. (Kibbe Conti,working with Lakota Indians

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Current focus of my work

• Health literacy of chronic disease
• Medication taking ( adherence)
• Health literacy and emergency preparedness
• Health literacy and technology
• Internet
• Electronic medical records

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Creating information that is matched to the
health literacy needs of your population

• Identify the complexity/opportunity for health
  education using model of health literacy
• Collaborate with target audiences on designing
  needed information/approaches
• Qualitatively field test material/communication
• Revise, contextualize, reinforce messages using
  combination of communication models diffusion,
  social marketing, decision making, etc.
• Evaluate and be ready to revise on an ongoing
  basis

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Health Literacy Load Analysis

• Is the message/material to inform and/or educate?
• Is it intended to produce action or change of
  behavior?
• Will it be used with mediation?
• What medium/technology will be used?
• How culturally appropriate is this message?
• Who is it tailored to?
• What does it require the target audience to
  understand about health / health concepts?
• Is the message reinforced?
• Are the action steps clear?

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1.Know your audience

• the audience you have (or might)
• the audience you want
• collaborate with them to develop messages
  and materials

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2. Know your material

• the text you have
• the text you need

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3. Conduct a Health Literacy Load Analysis

• What does the material/message assume/require of
  the patient
• Fundamental literacy
• Science literacy
• Civic literacy
• Cultural literacy

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What are the demands on a patients health
literacy ( Health Literacy Load)?

• Where to read whats most important
• 3X daily (all 3 at once)
• Can this be stopped before all 30 are taken?
• Perception of medication and medication taking
• When to contact physician and why?
• What to say

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Health Literacy Load redux?

• HOW does the patient understand as directed.
• Dose/response
• Does the patient trust believe this scientific
  perspective?

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No.

• Patients cant be healthy without it.

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• Forgive me for not writing a shorter letter for I
  did not have the time.
• (Poe)

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christina.zarcadoolas_at_mssm.edu

• 212-824-7061
• Mount Sinai School of Medicine
• Dept. of Community and Preventive Medicine
• Health and Environmental Literacy Initiative