Health Literacy & Diabetes Management

1. Health Literacy & Diabetes Management Angela Brega, Colorado School of Public Health

2. Workshop Overview • Introduction to Health Literacy • What is it? • What is the prevalence of limitations in health literacy? • How is health literacy associated with health? • What can we do to address health literacy? • Improving communication • Written communication • Oral communication

3. Health Literacy Your experience

4. Introduction to Health Literacy

5. What is Health Literacy? The degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

6. What Does Health Literacy Include? Institute of Medicine (IOM) Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.

7. Are Limitations in Health Literacy Common? Kutner et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy.U.S. Department of Education. Washington, DC: National Center for Education Statistics; 2006. • 2003 National Assessment of Adult Literacy (NAAL) • Only national assessment of health literacy (N=19,258) • Performance categorized into 4 levels • Proficient • Intermediate • Basic • Below basic • Lowest 2 levels considered inadequate; they cannot: • Find the definition of a medical term in a written document • Adhere to a childhood immunization schedule using a chart • Follow directions on a medication bottle

8. Prevalence of Limited Health Literacy • 36% of U.S. adults age 16+ had basic or below basic skills (77 million people)

9. Race/Ethnicity & Health Literacy Limited health literacy affects all racial/ethnic groups Limitations are more common in some populations % with Basic or Below Basic Skills

10. Income & Health Literacy Health Literacy Score by Poverty Level As income increases, so does the health literacy score

11. Education & Health Literacy % with Basic or Below Basic Skills Health literacy is associated with education See limitations even among well-educated people

12. Age & Health Literacy % with Basic or Below Basic Skills Health literacy peaks in the late 20’s and 30’s Older adults show significantly lower health literacy

13. Overall Lessons from the NAAL • > 1/3 of U.S. adults have significant limitations • Some level of limitation in all groups • Some groups are more at risk than others • American Indians and Alaska Natives

14. SDPI-HH Health Literacy Data • Baseline Participant Questionnaire • 3 items – confidence in reading and writing • 4 items – numeracy • Medical risk information (i.e., 1 in 1000) • Relationship between proportions and percentages (i.e., 20 out of 100 = 20%) • Time to take medication • Identifying whether blood sugar is in the normal range • Significant limitations

15. Print Literacy: Reading & Writing • How often do you have a hard time understanding written information about your health that you get from your clinic…? • 65% said sometimes, often, or always • How often do you prefer that someone… help you read medical materials? • 47% said sometimes, often, or always • How confident are you in filling out medical forms by yourself? • 42% said somewhat, a little bit, or not at all

16. Numeracy: Understanding Numbers • Which of the following numbers represents the lowest risk…? Options: 1 in 10, 1in 100, 1 in 1000 • 52% correctly chose “1 in 1000” • If the chance of getting a health condition is 20 out of 100 people, this would be the same as having what percent (%) chance of getting the condition? • 70% correctly chose “20%”

17. Numeracy (cont.) • A prescription says “Take one tablet by mouth every 6 hours.” If you take your first tablet at 7 a.m., when should you take your second tablet? • 88% correctly chose “1 p.m.” • Normal fasting blood sugar is 70-100. If your blood sugar today is 140, is your blood sugar normal? • 69% correctly chose “no”

18. Reactions & Reflection

19. Implications of Poor Health Literacy

20. Health Literacy & Health Berkman et al. Low health literacy and health outcomes: an updated systematic review. Ann. Intern. Med. Jul 19 2011;155(2):97-107. Limited health literacy is associated with: Poor disease knowledge Increased use of hospital and emergency room care Poor medication management skills & compliance Poor comprehension of labels & instructions Worse health status and higher mortality rates Too few studies to draw conclusions about diabetes

21. SDPI-HH Baseline Data More limited health literacy associated with: Lower level of disease knowledge (diabetes, insulin use, cholesterol, blood pressure) Less frequent consumption of healthy foods and more frequent consumption of unhealthy foods Lower likelihood of blood glucose self-monitoring Higher A1c

22. Limited Health Literacy… It’s a problem!

23. What Can We Do to Address Health Literacy?

24. Balance Between Skills & Demands Demands of Health Care Context Individual’s Health Literacy Skills

25. Reducing the Demand on Patients Demands Health Literacy Skills Improve written communication Improve oral communication

26. Improving Written Communication

27. Factors Affecting Comprehension • Two main factors we want to address • Readability • How difficult is the text • Suitability • Other features that can make a document easier or harder to understand • Font • Density of the text • Medical jargon

28. Improving Readability • Recognizing limitations in reading ability • Average U.S. adult has a high school education • Average reading level of U.S. adults = 8th grade • Many U.S. adults with skills below that • Recommendation for health materials = 6th grade or below • ≈75% of U.S. adults can read at this level • >1000 studies show the reading level of health-related materials are beyond the average U.S. adult • typically 10thgrade level; college level is not uncommon

29. Tools to Assess Readability • Typically identify the reading skills one would need in order to understand a text (grade level) • Focus on word length and sentence length • Most common tools • Flesch-Kincaid Readability Test • Flesch Reading Ease • Fry Formula

30. Flesch Readability Tools • Flesch Measures • Available in MS Word - Turn on & run spell checker • Flesch-Kincaid Readability Test – grade level • Warning: Flesch-Kincaid underestimates grade level • Flesch Reading Ease – 100-point score (higher = better) • 90-100 – very easy – 4th grade • 80-89 – easy – 5th grade • 70-79 – fairly easy – 6th grade • 60-69 – standard – 7th or 8th grade • 50-59 – fairly difficult – some high school • 30-49 – difficult – high school or some college • 0-30 – very difficult – college

31. Fry Formula • Grade level required to read text • Scores are based on # syllables and sentences • Assess 3 passages of 100-words each • Adaptations for shorter docs (e.g., one 100-word passage) • How to calculate the Fry reading score • Identify one 100-word passage • Count # of syllables (average if using 3 passages) • Count # of sentences (average if using 3 passages) • Count the last (partial) sentence as a fraction (# words in the sentence that are in the 100-word passage / # words in the whole sentence) • Plot those values of the Fry Graph to identify grade level

32. Fry Graph – Identify Grade Level Average # of sentences per 100 words Average # of syllables per 100 words

33. Practice Assessing Readability • Practice using Fry Formula • Diabetes educational materials from 4 Websites • Centers for Disease Control and Prevention (CDC) • Mayo Clinic • National Institutes of Health (NIH) • WebMD

34. Overview of Readability Flesch-Kincaid is consistently lower All are beyond the average reading level Flesch Reading Ease – none are 70+ level Variation across measures – good to use >1 tool Some Websites are better than others

35. Online Readability Calculator • Flesch measures are available in MS Word • Fry Formula • http://www.readabilityformulas.com/free-fry-graph-test.php

36. Suitability of Written Documents • Suitability refers to other aspects of a document that can make it hard to read • Recommendations for ensuring documents are easy to read (beyond reading level) • Review some key recommendations • Comprehensive list at the end of the slides

37. Ensuring Suitability: Key Guidelines Limit content to a few key points – What should do Use everyday language Short words, short sentences, short paragraphs Minimum 12 point font - Don’t use ALL UPPERCASE Leave lots of white space Use headings Use bulleted lists

38. Communicating Numbers • Use frequencies rather than percentages • 30% chance of rain (35% don’t understand) • 10 out of 100 people (rather than 10%) • Consistent denominators – 1 out of 100 vs. 10 out of 100 • Use absolute risk rather than relative risk • 1995 pill scare in the UK • Dramatic increase in abortion and birth rates • A decrease from 4% to 2% (rather than a 50% decrease) • Use a time frame that is meaningful to people • Over the next 5 years (rather than lifetime risk)

39. Communicating Numbers (cont.) • Present numeric information visually • Bar graphs • Comparing risks • Icon arrays • 27 of 100 will get X • 73 of 100 will not • Framing effects • 10% chance of X • 90% chance of not X • Present both ways

40. Improving Oral Communication The single biggest problem in communication is the illusion that it has occurred. George Bernard Shaw

41. Improving Oral Communication • Patients remember 40-80% of what they are told during a clinical encounter • Almost 50% of the recalled information is incorrect • Communications are often beyond the health literacy skills of average folks

42. Guidelines for Improving Oral Communication • Slow down • Use everyday language • Use visuals – draw pictures, show models • Limit the information provided to a few key things • Focus on action steps • Repeat information • Encourage questions • “What questions do you have?”

43. Confirming Comprehension • Teach-Back Technique • Ask patients to explain in their own words • Confirm comprehension and reteach key points • Eye opener! Helps you improve your teaching • Put the onus on yourself – “I want to make sure I explained that well. Can you tell me (show me) how you are going to….” • YouTube Video • http://www.youtube.com/watch?v=90UYktrxClg

44. Practice Teach-Back • Practice the technique • FDA guidelines on drug disposal • CDC recommendations on shingles vaccination • Reactions • Barriers to using Teach-Back

45. Resources • CDC. Simply Put: A Guide for Creating Easy-to-Understand Materials. Atlanta, GA 2009. • Provides step-by-step instructions on readability formulas • Appendix A: Checklist for assessment of suitability • Teach-Back Instructions from: DeWalt DA et al. Health Literacy Universal Precautions Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; 2010. • Weiss BD. Health literacy and patient safety: Help patients understand: American Medical Association Foundation;2007. • Outlines recommendations for improving oral and written communication

46. After being diagnosed with recurrent aphthous stomatitis involving the epithelium of the buccal mucosa, Winston did what he thought was necessary… which was a funny thing to do for a canker sore.

47. Ensuring Suitability Comprehensive List of Recommendations

48. Ensuring Suitability • Content • Limit content to a few key points • Repeat them • Action Steps - Focus on what participant should do • Use everyday language, not medical terminology • Use the terms your participants use • Define medical terms • Medical thesaurus

49. Ensuring Suitability (cont.) • Text Construction • The cover or title should clarify the point of the document • Write at the 6th-grade level or lower • Use one- or two-syllable words • Use short sentences and paragraphs • Use active voice • Avoid tables & graphs unless really simple; include legends

50. Ensuring Suitability (cont.) • Font • Minimum 12 point font • Use serif font (has little feet) – e.g., Times New Roman • Don’t use sans serif font – Like this! (in headings is ok) • Limitfontstylesto2or 3 • ALL UPPERCASE IS HARD TO READ • Use bold text to highlight important points • Don’t use italics or underlining – these are harder to read