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Health Literacy: A Clinician’s Point of View

Health Literacy: A Clinician’s Point of View. Paul D. Smith, MD, Associate Professor UW Department of Family Medicine Paul.Smith@fammed.wisc.edu. Topics today. Social determinants of health. Health literacy. Impact of literacy on health and health care. What can we do about this?.

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Health Literacy: A Clinician’s Point of View

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  1. Health Literacy:A Clinician’s Point of View Paul D. Smith, MD, Associate Professor UW Department of Family Medicine Paul.Smith@fammed.wisc.edu

  2. Topics today • Social determinants of health. • Health literacy. • Impact of literacy on health and health care. • What can we do about this?

  3. Determinants of Health • Gender • Age • Race/ethnicity • Co-morbidities

  4. Social Determinants of Health • Employment status • Income level • Health insurance status • Marital status

  5. Social Determinants of Health • Education level • High school diploma or equivalent • Literacy level

  6. Question? What would happen to Wisconsin’s overall health, if we were able to eliminate health disparities?

  7. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) Men (367) Suburban (247) Women (225) Milwaukee County (424) Some college (212) High school or less (459) College graduates (188) Native Americans (592) Asians (170) African Americans (624) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519)

  8. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) Men (367) Suburban (247) Women (225) Milwaukee County (424) Some college (212) High school or less (459) College graduates (188) Native Americans (592) (279) Asians (170) African Americans (624) (279) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519) (277)

  9. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) Men (367) Suburban (247) Women (225) Milwaukee County (424) Some college (212) High school or less (459) College graduates (188) Native Americans (592) Asians (170) African Americans (624) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519)

  10. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) (275) Men (367) Suburban (247) Women (225) Milwaukee County (424) (275) Some college (212) High school or less (459) College graduates (188) Native Americans (592) Asians (170) African Americans (624) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519) (266)

  11. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) Men (367) Suburban (247) (225) Women (225) Milwaukee County (424) Some college (212) High school or less (459) College graduates (188) Native Americans (592) Asians (170) African Americans (624) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519) (225)

  12. A B C D F Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) Whites (279) Rural (319) Non-urban (275) Men (367) Suburban (247) Women (225) Milwaukee County (424) Some college (212) High school or less (459) (212) College graduates (188) Native Americans (592) Asians (170) African Americans (624) Best state Minnesota (257) Wisconsin (296) Worst state Mississippi (519) (206)

  13. Effect of Eliminating Disparity by: Race 296  277 Geography 296  266 Gender 296  225* Education 296  206* *Wisconsin becomes the healthiest state in the U.S.

  14. Answer: • Eliminating health disparities in any category improves Wisconsin’s overall health. • The greatest potential gain is in the elimination of disparities by education.

  15. 2003 National Assessment of Adult Literacy • NAAL health literacy assessment • 28 questions specifically related to health • 3 clinical • 14 prevention • 11 system navigation Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S.Department of Education.Washington, DC: National Center for Education Statistics.

  16. NAAL Health Literacy Assessment • Background questions • Self-rated health status • Health insurance • Sources of health information

  17. NAAL Health Literacy Assessment • Entire population • Below basic 14% • Basic 22% • Intermediate 53% • Proficient 12%

  18. NAAL Health Literacy Assessment • Basic and Below Basic Health Literacy • White 28% • Native Americans 48% • Blacks 58% • Hispanics 66%

  19. NAAL Health Literacy Assessment • Basic and Below Basic Health Literacy • Age16-64 28-34% • Age 65+ 59%

  20. NAAL Health Literacy Assessment • Basic and Below Basic by education level • In High School, GED or HS grad 34-37% • Less than/some High School 76%

  21. NAAL Health Literacy Assessment • Basic and Below Basic by Self-reported health status • Excellent 25% • Very Good 28% • Good 43% • Fair 63% • Poor 69%

  22. Sources of Health Information • TV and radio • Family and Friends • Health Care Professionals

  23. Sources of Health Information • Text Media • Newspaper • Magazines • Books or brochures • Internet

  24. Sources of Health Information • Percent of people that NEVER obtain health information from the internet • Proficient 12% • Intermediate 14% • Basic 58% • Below Basic 80%

  25. In Their Own Words • Insert video clip here

  26. The Impact of Low Literacy on Health • Poorer health knowledge • Poorer health status • Higher mortality • More hospitalizations • Higher health care costs

  27. Poorer Health Knowledge • Understanding prescription labels • 395 patients • 19% low literacy (6th grade or less) • 29% marginal literacy (7-8th grade) • 52% adequate literacy (9th grade and over) • 5 prescription bottles Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

  28. Poorer Health Knowledge • At least one incorrect • 63% low literacy • 51% marginal literacy • 38% adequate literacy Literacy and Misunderstanding Prescription Labels. Davis et al. Ann Intern Med 2006;145:887-894

  29. Poorer Health Knowledge “Take two tablets twice daily” Stated correctly Demonstrated correctly 71% low literacy 35% 84% marginal literacy 63% 89% adequate literacy 80% “Show me how many pills you would take in one day.” Counted out 4 tablets-correct

  30. Poorer Health Status • 2923 new Medicare enrollees • Inadequate literacy had increased frequency of: • Diabetes • Hypertension • Heart failure • Arthritis

  31. Poorer Health Status • Medical Outcomes Study (SF-36) • Inadequate literacy had • Decreased: • Physical function • Mental health • Increased • Limitations in activity due to physical health • Pain that interferes with normal work activities

  32. Poorer Health Status Diabetics with retinopathy 36% 19%

  33. Increased Mortality • Age 70-79 • Reading level 8th grade or less • Five Year Prospective Study Sudore R, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.

  34. Increased Mortality Risk of Death Hazard ratio: 1.75

  35. More Hospitalizations 2 year hospitalization rate for patients visiting ED 31% 14%

  36. Increased Health Care Costs • Data • 2003 Medical Expenditure Panel Survey • 2003 National Assessment of Adult Literacy Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007

  37. Increased Health Care Costs • Annual cost today: • Future costs based on today’s actions (or lack of action): Low Health Literacy: Implications for National Health Policy. Vernon, J, Trujillo, A, Rosenbaum, S, DeBuono, B. Oct. 2007 $106-238 Billion $1.6-3.6 Trillion

  38. In Their Own Words • Focus group project • Three community-based literacy programs • Six groups • Fifty-one adults • Limited reading skills- Adult Basic Education • Limited English skills- English Language Learners

  39. Focus Groups Major Themes • Communication and understanding. • Completing/understanding forms including consents.

  40. Focus Groups Major Themes • Difficulty in accessing healthcare • Medication errors • Anxiety and shame

  41. The “System” is Broken • Pre-school • Children learn to read on the laps of their parents. • K-12 education • Third-fourth grade “watershed.” • HS graduation rates. • Almost 20% functionally illiterate HS graduates.

  42. The “System” is Broken • Adult education • Lack of funding for literacy programs • Family • Workforce • Corrections

  43. The “System” is Broken • Health Care • Highly educated clinicians and support staff. • Medical terminology. • Documents written at a high reading level. • Increasing complexity of medical care.

  44. How do we fix this problem? • Multi-faceted approach • Funding one aspect and ignoring the other issues will not address the problems today. • Education • Change the health care system

  45. How do we fix this problem? • Pre-school • Effective programs • Reach Out and Read • Refer parents to family literacy programs

  46. How do we fix this problem? • Pre-school • Similar programs in non-traditional settings • Women Infants and Children • Prenatal care • Ethnic community groups • Faith based

  47. How do we fix this problem? • K-12 • Everyone graduates functionally literate • Address the social and other issues that influence HS drop out rates.

  48. How do we fix this problem? • Adult education • More money for effective literacy programs. • Community-based • Family • Workforce • Corrections

  49. How do we fix this problem? • Health content in literacy curriculum • Susan Levy, Ph.D. • Breakout at 3:45

  50. Education Will Not Solve Everything • Health Care • Continuing Medical Education (CME) for clinicians • Medical education is stuck in the 60’s

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