# Presentation: 684095

## 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?

## Determinants of Health

- Gender
- Age
- Race/ethnicity
- Co-morbidities

## Social Determinants of Health

- Employment status
- Income level
- Health insurance status
- Marital status

## Social Determinants of Health

- Education level
- High school diploma or equivalent
- Literacy level

## Question?

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

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Men **
**(367)**

**Milwaukee County (424)**

**High school or less (459)**

**Native Americans (592)**

**African Americans (624)**

**Worst state Mississippi (519)**

**Wisconsin **
**(296)**

**Best state Minnesota (257)**

**Asians **
**(170)**

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Men **
**(367)**

**Milwaukee County (424)**

**High school or less (459)**

**Worst state Mississippi (519)**

**Wisconsin **
**(296)**

**Best state Minnesota (257)**

**Asians **
**(170)**

**African Americans (624)**

**Native Americans (592)**

**(279)**

**(279)**

**(277)**

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Men **
**(367)**

**Milwaukee County (424)**

**High school or less (459)**

**Native Americans (592)**

**African Americans (624)**

**Worst state Mississippi (519)**

**Wisconsin **
**(296)**

**Best state Minnesota (257)**

**Asians **
**(170)**

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Men **
**(367)**

**Milwaukee County (424)**

**High school or less (459)**

**Native Americans (592)**

**African Americans (624)**

**Worst state Mississippi (519)**

**Wisconsin **
**(296)**

**Best state Minnesota (257)**

**Asians **
**(170)**

**(275)**

**(275)**

**(266)**

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Milwaukee County (424)**

**High school or less (459)**

**Native Americans (592)**

**African Americans (624)**

**Worst state Mississippi (519)**

**Best state Minnesota (257)**

**Asians **
**(170)**

**Men **
**(367)**

**(225)**

**Wisconsin **
**(296)**

**(225)**

## Wisconsin Working-Age Adult Mortality Rates

- (Ages 25-64, rates per 100,000 population)

**Some college (212)**

**College graduates (188)**

**Whites **
**(279)**

**Women **
**(225) **

**Suburban **
**(247)**

**Non-urban**
**(275)**

**Rural **
**(319)**

**Men **
**(367)**

**Milwaukee County (424)**

**Native Americans (592)**

**African Americans (624)**

**Worst state Mississippi (519)**

**Best state Minnesota (257)**

**Asians **
**(170)**

**High school or less (459)**

**(212)**

**Wisconsin **
**(296)**

**(206)**

## 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.

## Answer:

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

## 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.

## NAAL Health Literacy Assessment

- Background questions
- Self-rated health status
- Health insurance
- Sources of health information

## NAAL Health Literacy Assessment

- Entire population
- Below basic     	14%
- Basic           		22%
- Intermediate		53%
- Proficient    		12%

## NAAL Health Literacy Assessment

- Basic and Below Basic Health Literacy
- White                                  28%
- Native Americans               48%
- Blacks                                 58%
- Hispanics                            66%

## NAAL Health Literacy Assessment

- Basic and Below Basic Health Literacy
- Age16-64          28-34%
- Age 65+              59%

## 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%**

## NAAL Health Literacy Assessment

- Basic and Below Basic by Self-reported health status
- Excellent                  25%
- Very Good                28%
- Good                        43%
- Fair                           63%
- Poor                          69%

## Sources of Health Information

- TV and radio
- Family and Friends
- Health Care Professionals

## Sources of Health Information

- Text Media
- Newspaper
- Magazines
- Books or brochures
- Internet

## Sources of Health Information

- Percent of people that NEVER obtain health information from the internet
- Proficient                  12%
- Intermediate             14%
- Basic                         58%
- Below Basic              80%

## In Their Own Words

- Insert video clip here

## The Impact of Low Literacy on Health 

- Poorer health knowledge
- Poorer health status
- Higher mortality
- More hospitalizations
- Higher health care costs

## 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

## 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

## 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

## Poorer Health Status 

- 2923 new Medicare enrollees
- Inadequate literacy had increased frequency of:
- Diabetes
- Hypertension
- Heart failure
- Arthritis

## 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

## Poorer Health Status 

- Diabetics with retinopathy

- 36%

- 19%

## 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.

## Increased Mortality

- Risk of Death         Hazard ratio:  1.75

## More Hospitalizations 

- 2 year hospitalization rate for patients visiting ED

- 31%

- 14%

## 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

## 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**

## 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

## Focus Groups Major Themes

- Communication and understanding.
- Completing/understanding forms including consents.

## Focus Groups Major Themes

- Difficulty in accessing healthcare
- Medication errors
- Anxiety and shame

## 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.

## The “System” is Broken

- Adult education
- Lack of funding for literacy programs
- Family
- Workforce
- Corrections

## 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.

## 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

## How do we fix this problem?

- Pre-school
- _Effective_ programs
- Reach Out and Read
- Refer parents to family literacy programs

## 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

## How do we fix this problem?

- K-12
- Everyone graduates functionally literate
- Address the social and other issues that influence HS drop out rates.

## How do we fix this problem?

- Adult education
- More money for _effective_ literacy programs.
- Community-based
- Family
- Workforce
- Corrections

## How do we fix this problem?

- Health content in literacy curriculum
- Susan Levy, Ph.D.
- Breakout at 3:45

## Education Will Not Solve Everything

- Health Care
- Continuing Medical Education (CME) for clinicians
- Medical education is stuck in the 60’s

## Education Will Not Solve Everything

- Universal Design
- If it works for people with low literacy or low English skills, it will work for everyone.

## The Healthcare System Has to Change

- Communication strategies
- Improve oral communication
- Easier to read written documents
- Effective informed consent process
- Check understanding

## The Healthcare System Has to Change

- Commonwealth Fund Report
- A team effort, beginning at the front desk.
- Use of standardized communication tools
- Clinicians partner with patients to achieve goals

- Barrett S, et al. Health Literacy Practices in Primary Care Settings: Examples from the Field, January 2008
- http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=645961

## The Healthcare System Has to Change

- Use of:
- Plain language
- Face-to-face communication
- Pictorials
- Educational materials

## The Healthcare System Has to Change

- Organizational commitment to create an environment where health literacy is not assumed.

## More Research is Needed

- _Effective_ preschool and K-12 programs.
- _Effective_ adult literacy programs.
- _Effective_ health literacy interventions.

## Summary

- Low health literacy is a common problem
- Low literacy affects health

## Summary

- The System has to change

## What can YOU do?

- Learn more about health literacy
- IOM “A Prescription to End Confusion”
- Health literacy resource list
- Google “health literacy toolkit”

## What can YOU do?

- Be a catalyst for change
- Raise awareness

## Raising Awareness

- Your own local, state and national organizations.
- Health care organizations.
- State and federal legislators.
- Medical Education.

## What can YOU do?

- Add health content to curricula.

## What can YOU do?

- Collaborate with health care groups
- Hospitals
- Large medical groups
- Health care insurers

## “Action expresses priorities.” 

“Be the change that you want to see in the world.”

                              ---Mohandas Gandhi   

- “Be the change that you want to see in the world.”
-                               ---Mohandas Gandhi

## Paul D. Smith M.D.
paul.smith@fammed.wisc.edu
608-265-4477

- _[paul.smith@fammed.wisc.edu](mailto:paul.smith@fammed.wisc.edu)_
- 608-265-4477

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