Addressing Cross-Cultural Health Literacy Challenges in Clinical Practice

4. Who Is Responsible for Improving Health Literacy? A health literate America is a society in which health systems and institutions take responsibility for providing clear communication and adequate support to facilitate health-promoting actions based on understanding. —Institute of Medicine, 2004 http://www.health.gov/communication/literacy/powerpoint

5. What Is Health Literacy? Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is dependent on both individual and systemic factors: Communication skills of lay people and professionals Knowledge of lay people and professionals of health topics Culture Demands of the healthcare and public health systems Demands of the situation/context http://www.health.gov/communication/literacy/powerpoint Note on #3 Culture: Culture is broadly defined to encompass the values, norms, symbols, ways of living, traditions, history, and institutions shared by a groups of people (this definition is from the Pink Book Making Health Communication Programs Work). Demographic factors are discussed in greater detail in the “Improving the Usability of Health Information” section.Note on #3 Culture: Culture is broadly defined to encompass the values, norms, symbols, ways of living, traditions, history, and institutions shared by a groups of people (this definition is from the Pink Book Making Health Communication Programs Work). Demographic factors are discussed in greater detail in the “Improving the Usability of Health Information” section.

6. How Big Is the Problem?

7. National Assessment of Adult Literacy Levels - 2003 Below Basic - no more than the most simple and concrete literacy skills Basic can perform simple everyday literacy activities Intermediate - can perform moderately challenging literacy activities Proficient - can perform complex and challenging literacy activities http://nces.ed.gov/naal/ file:///C:/Documents%20and%20Settings/like.CORE/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/W3ATUDWR/439,17,Description of literacy levels People were classified in one of 5 categories. To make it more personal - Think about how you felt a few weeks ago when you were trying to figure out which new dental and/or vision benefit was best for you and your family. Where do you think questions about that info would fall? If asked, sample questions are on page 6 of the NAAL HL ComponentPeople were classified in one of 5 categories. To make it more personal - Think about how you felt a few weeks ago when you were trying to figure out which new dental and/or vision benefit was best for you and your family. Where do you think questions about that info would fall? If asked, sample questions are on page 6 of the NAAL HL Component

8. Measuring health literacy Number & Percentage of Adults in Each Health Literacy Level: 2003 Here are the results. The population breakdown is based on a total of 216 million adults - Which category do you think someone would have to be in in order to figure out Part D Medicare benefits? - What about a person trying to understand enough to give truly informed consent to enrolling in a clinical trial?Here are the results. The population breakdown is based on a total of 216 million adults - Which category do you think someone would have to be in in order to figure out Part D Medicare benefits? - What about a person trying to understand enough to give truly informed consent to enrolling in a clinical trial?

9. Percentage of adults in each literacy level: 2003 Here is the chart you just saw (at the top) compared with scores on the general NAAL. Note: An additional 2% of the population (4 million adults) could not take the assessment at all because they could not understand either English or Spanish. The brings the total number of adults with Basic or Below Basic health literacy to over 80 million. Here is the chart you just saw (at the top) compared with scores on the general NAAL. Note: An additional 2% of the population (4 million adults) could not take the assessment at all because they could not understand either English or Spanish. The brings the total number of adults with Basic or Below Basic health literacy to over 80 million.

10. Percentage of adults in each health literacy level, by age: 2003 Note that nearly 60% of adults 65 and over score Basic or Below BasicNote that nearly 60% of adults 65 and over score Basic or Below Basic

11. Who Is at Risk for Low Health Literacy?

12. Low Health Literacy Impacts a Patient’s Ability to Fully Engage in the Healthcare System

13. Implications of Low Health Literacy Poor Health Outcomes Under-utilization of preventive services Over-utilization of health services Unnecessary health care expenditures Limited effectiveness of treatment Needless patient suffering Higher patient dissatisfaction Higher provider frustration

14. Video Presentation Health Literacy: Help Your Patients Understand American Medical Association American Medical Association Foundation http://www.ama-assn.org/ama/pub/category/8115.html

15. CASE STUDIES AND SMALL GROUP DISCUSSION Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians, 2nd edition. Chicago, IL: American Medical Association Foundation, 2007 http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

18. Brief Health Literacy Screening Questions

19. Health Literacy Screening Tools Wide Range Achievement Test (WRAT) reading subtest Rapid Estimate of Adult Literacy in Medicine (REALM) Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA) The Newest Vital Sign Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) Wide Range Inc. Wide Range Achievement Test (WRAT 3). Wilmington, DE: Wide Range Inc., 1993. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993;25:391-5. Parker RM, Baker DW, Williams MV, et al. The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10:537-41. Weiss BD, Mays MZ, Martz W, et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign Ann Fam Med 2005; 3:514-522. Shoou-Yih DL, Bender DE, Ruiz RE, and Cho YI. Development of an easy-to-use Spanish health literacy test. Health Services Research 2006; 41(4):1392-1412.

20. SPEAK: A Mnemonic for Addressing Health Literacy Issues S : Speech - How will the healthcare provider’s speech be received by the patient and/or caregiver? P : Perception - How will the patient and/or caregiver perceive both the verbal and written content during the communication with the health care provider? E : Education - What is the education level of the patient and/or caregiver? A : Access – How will the patient and/or caregiver access the health care system? K : Knowledge – How will assessment of health literacy be carried out, and what tools will be used? Kobylarz FA, Pomidor A, Heath JM. “Speak – A Mnemonic Tool for Addressing Health Literacy Concerns in Geriatric Clinical Encounters.” Geriatrics 2006; 71(7):20-26.

21. Reaching a Solution The Partnership for Clear Health Communication is a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomes

22. Written Communication 87% report reading Rx information

23. Example of Health Communication That May Not Reach a Broad Consumer Audience

24. Example of Clear Health Communication – That Reaches a Broad Consumer Audience Common visual used to explain concept Uses action captions that clarify the point of the visual Creates interaction with the reader

25. Verbal Communication Patients experience shame around the issue Only 14% of patients say they feel awkward admitting they don’t understand; yet 79% feel others don’t understand Providers experience time challenges Providers interrupt patients 30 seconds after they start speaking; if not interrupted, patients will speak less than two minutes

26. Clear Health Communication in Action

27. Ask Me 3 – Creates Shared Responsibility for Clear Health Communication Ask Me 3 is a new patient education program designed to promote communication between health care providers and patients, in order to improve health outcomes. The program promotes these three questions that patients should ask their providers in every health care interaction and that providers should always encourage their patients to understand the answers to. Ask Me 3 is a new patient education program designed to promote communication between health care providers and patients, in order to improve health outcomes. The program promotes these three questions that patients should ask their providers in every health care interaction and that providers should always encourage their patients to understand the answers to.

28. What Is Ask Me 3 Promotes three simple, but essential, questions and answers for every healthcare interaction: Ask Me 3 is a new patient education program designed to promote communication between health care providers and patients, in order to improve health outcomes. The program promotes these three questions that patients should ask their providers in every health care interaction and that providers should always encourage their patients to understand the answers to. Ask Me 3 is a new patient education program designed to promote communication between health care providers and patients, in order to improve health outcomes. The program promotes these three questions that patients should ask their providers in every health care interaction and that providers should always encourage their patients to understand the answers to.

29. What Else Can You Do?

30. What Else Can You Do?

31. What Else Can You Do?

32. What Else Can You Do?

33. What Should We Do? Raise professional and public awareness about health literacy Need for activated, informed, and empowered patients/consumers, families, and caregivers Implement a “universal precautions” approach in screening for low health literacy Create “shame-free” and “blame-free” environments

34. What Should We Do? Develop health education programs and materials that are appropriately targeted and tailored for diverse populations Provide culturally and linguistically appropriate services (OMH CLAS Standards - www.omhrc.gov/CLAS) Monitor for disparities in access to care, service utilization, quality, safety, and health outcomes Address ethical issues and concerns in health literacy improvement efforts

38. Joint Commission

40. Selected Health Literacy Resources Nielsen-Bohlman L, Panzer AM, Kindig, DA, eds. Committee on Health Literacy. Health Literacy - A Prescription to End Confusion. Institute of Medicine, Washington, DC: National Academies Press, 2004. http://www.nap.edu/catalog/10883.html Andrulis DB, Brach C. “Integrating Literacy, Culture, and Language to Improve Health Care Quality for Diverse Populations. American Journal of Health Behavior 2007; 31 (Suppl 1):S122-S133. Johnston Lloyd LL, Ammar NJ, Epstein LG, Johnson R, Rhee K. A Transdisciplinary Approach to Improve Health Literacy and Reduce Disparities. Health Promotion Practice 2006; 7(3):331-335.http://hpp.sagepub.com/cgi/content/abstract/7/3/331 DHHS Office of Disease Prevention and Health Promotion Health Literacy Improvement Website http://www.health.gov/communication/literacy/powerpoint http://www.health.gov/communication/literacy/quickguide DHHS Administration on Aging. Communicating with Older Adults http://www.aoa.gov/prof/communicating/communicating.asp AHRQ Health Literacy and Cultural Competency Website http://www.ahrq.gov/browse/hlitix.htm Partnership for Clear Health Communication/Ask Me 3 “Advancing Clear Health Communication to Positively Impact Health Outcomes” Presentation http://www.askme3.org/PFCHC/professional_presentation.ppt

41. Selected Health Literacy Resources Health Resources and Services Administration. Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency http://www.hrsa.gov/healthliteracy/training.htm AMA/AMA Foundation’s Health Literacy Toolkits, Videos, Partnerships Video - Health Literacy: Help Your Patients Understand http://www.ama-assn.org/ama/pub/category/8115.html Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians, 2nd edition. Chicago, IL: American Medical Association Foundation, 2007 http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf Allen CE, Kindig, DA, Parker RM, Roter DL. Assuring Quality Care for People With Limited Health Literacy CME/CE Medscape Family Medicine, January 25, 2008. http://www.medscape.com/viewprogram/8603 American College of Physicians Foundation Health Literacy Resources and CD Health Literacy: A Silent Epidemic. http://foundation.acponline.org/healthcom/hli/resources.htm American Academy of Family Physicians. Play It Safe with Medicine! (Toolkit) http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20061122playitsafe.html