# Presentation: 103841

## Why is Health Literacy Important for Seniors?Overview & Quick Guide 

**Older Adult Subcommittee**
**January 10, 2007**

**Notes:**
Thanks for inviting me to talk to you today.
I understand some of you know a lot about health literacy, while others are new to the issue.
To the experts – as I go thru my presentation, I invite you to think about how you might be able to use this presentation to advocate for including health literacy in your organization’s work.
To those who are new to the issue, I hope you come away  with a better understanding of the problems and can share some new ideas with us as we look for solutions – especially as it pertains to seniors. 

##       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**.

**Notes:**
As Kay mentioned, I’m from the Office of Disease Prevention and Health Promotion – the home of Healthy People 2010, so I’m going to start by sharing with you the definition of health literacy that we use in HP2010.  This is the same definition used in the 2004 IOM Report Health Literacy: A Prescription to End Confusion 

## What is literacy?

- A person’s ability to read, write, speak, and compute and solve problems at levels necessary to:
-    Function on the job and in society
-    Achieve one’s goals
-    Develop one’s knowledge and potential
*   **Illiteracy means being unable to read or write.*

**Notes:**
Kay also suggested it might be useful to look at the difference between “health literacy” and “literacy”...as well as “illiteracy”.  
And to point out that people who have limited or low health literacy are NOT illiterate.  In fact , we know that virtually everyone has limited health literacy at some point, regardless of ones education or reading level.  Especially when confronted with a serious illness (your own or a loved ones), it’s hard to comprehend and retain what you are begin told.

Let’s take a look at some real people in real health situations.  

## Why is health literacy important?

- Low literacy is linked to poor health outcomes such as:
-   Higher hospitalization rates
-   Less frequent use of preventive services
-   More likely to have chronic conditions (e.g.    	diabetes, high blood pressure) and less 	able to manage them effectively

**Notes:**
Why is HL important:  Studies have show that...

## Who is at risk?

- The problem of limited heath literacy is greater among:
-   Older Adults
-   Those who are poor
-   People with limited education
-   Minority populations
-   People with limited English proficiency

**Notes:**
Think about these categories when you begin to develop communication plans for your audience and develop materials

## Linking health literacy to poor health outcomes

*Surgeon General’s Workshop on Improving Health Literacy*
*September 7, 2006*
- 	Panel 1 – Health Literacy, Literacy and Health Outcomes
- David Baker, MD, NWU, Feinberg School of Medicine
- Dean Schillinger, MD, UC San Francisco
- 	Panel 2: Meeting the Health Literacy Needs of Special Populations
- Denise C. Park, Ph.D., U. of Illinois

**Notes:**
Last September, ODPHP co-sponsored with the OSG a Workshop on Improving HL.  We invited 13 researchers to present to the Surgeon General the latest in communication science/research related to HL.  Since most of you were not able to attend, I thought you might want to hear a snapshot of the research findings that address low health literacy, seniors and poor health outcomes.

## Low health literacy leads to worse health outcomes

- Higher emergency department use
- More hospitalizations
- Worse self-reported physical health and limitations in activities of daily living
- Higher mortality, especially cardiovascular disease
- 						David Baker, 9/7/06

**Notes:**
Dr. Baker’s research showed that ...

## Literacy and health

- In elderly population, limited literacy associated with
- worse self-rated access to care,
- lower self-rated health
- higher rates of some chronic diseases,
- higher adjusted mortality
- In public hospital patients with diabetes, limited literacy associated with higher rates of complications
- Sudore et al. 2006 JGIM
- Schillinger et al. 2002 JAMA

**Notes:**
In a similar vein, Dr. Schillinger, along with his colleague Dr. Rebecca Sudore, found that:  In the elderly population...

## What do we know about health literacy and older adults?

- Healthy older adults experience cognitive decline which affects their ability to comprehend medical information and follow treatment regimens.
- Even in a well-educated, affluent population:
- 30% of residents had poor comprehension of written health care information (Baker et al., 2000)
- Only 50% could accurately answer questions from a Medicaid application.
- 										Denise Park, 9/7/06

**Notes:**
And finally, Dr. Park focused her entire talk on seniors, so I thought you might be interested in a few of her findings.

## Very old show particular vulnerability

- Very old age (over 80) is a particular risk factor for poor health literacy.
- Poor literacy enhances health risk in an already fragile population.
- 					Denise Park, 9/7/06

## Processing complex medical information

- Older adults, when presented with a medical decision, seek out less information than young adults and make quicker decisions. Zwahr, Shifren & Park (1999)
- Reasons given for decision are less complex but decisions made are same as young.
- 					 Denise Park, 9/7/06

**Notes:**
While we know that aging can lead to cognitive decline, there are also some positive things that can happen as we age.  Dr Park reported there are data which suggest that old adults may be less effective at processing and reasoning about medical information than younger people.  At the same time, they are more likely to rely on their experience (e.g., experience has shown them that seeking out a large amount of information about a condition is not always useful) in making a decision and may also rely more on the advice of their physician than younger adults.  Thus older adults, to some extent, compensate for decreased cognitive abilities in medical decision-making by relying on different strategies than young for making medical decisions—strategies that rely more on knowledge, experience, and others judgments rather than their own information processing abilities. 

## Effects of familiarity on memory for health information

- The Illusion of Truth:
- Familiar information feels true, particularly to older adults who forget where they learned or heard something.
- 						 Denise Park, 9/7/06

**Notes:**
One unusual finding gives us useful information about how NOT to present information to seniors.  It’s called the Illusion of Truth

## Can information presented as false seem true?

- Older adults studied medical phrases and some of it was designated to be false at the time of study
-  “Antihistamines will cause your pupils to dilate”.  FALSE
- Memory was tested for the statements three days later.
- Older adults were more likely to judge a statement to be TRUE if they heard it was FALSE 3 times compared to
- 	1 time. (Skurnik, Yoon, Park, & Schwarz, 2005).
- 					Denise Park, 9/7/06

**Notes:**
(after I review the slide)
...so don’t present info to seniors as a True or False test or say “It’s a myth that...”.

## How do we measure Health Literacy?

**The National Assessment of **
**Adult Literacy (NAAL)   2003**
**	****	****Health Literacy Component**

**Notes:**
Now that we know why Health Literacy is important, how do we know who has low or limited health literacy skills?

## What is the NAAL?

- Assessment of the English literacy of U.S. adults
- Conducted in 1992 and 2003
- Nationally representative sample of over 19,000 adults ages 16 and older
- Administered one-on-one in households and prisons

**Notes:**
Before I read the slide say: The NAAL was done by the National Center for Education Statistics, part of the Institute of Education Sciences, in the U.S. Dept. of Education.
After I read the slide say:  The HLC of the NAAL consisted of 28 questions.  The materials were selected to be representative of real-world health–related information, including insurance info, medicine directions and  preventive care info.  ODPHP/DHHS suggested materials and questions based on input from other HHS agencies and stakeholders and experts, and on info from federal health materials.

## Three types of literacy

- Prose

- Document

- Quantitative

**Notes:**
They included in NAAL HLC -- 12 prose; 12 document; & 4 quantitative items

## Description of literacy levels

**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
**	**
**Nonliterate in English** – unable to complete a minimum number of screening tasks or could not be tested because did not speak English or Spanish

**Notes:**
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 Component

##        Measuring health literacy

- Tasks used to measure health literacy were organized around three domains:
**Clinical:** filling out a patient form
**Prevention**: following guidelines for age-appropriate preventive health services
**Navigation of the health care system**: understanding what a health insurance plan will pay for

**Notes:**
To be sure there was a variety of health-related questions, they covered 3 areas.  
Here’s the dental benefit we just mentioned – under navigation

## Measuring health literacy

**Number & Percentage of Adults in Each Health Literacy Level: 2003**

- Source: National Center for Education Statistics, Institute for Education Sciences

**Notes:**
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?

## Percentage of adults in each literacy level: 2003

- Source: National Center for Education Statistics, Institute for Education Sciences

**36%**
**77M adults**

**Notes:**
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.

## Percentage of adults in the Below Basic NAAL health literacy population

- 1The “Did not obtain health information over the Internet” category does not include prison inmates because they do not have access to the Internet.
- 2Disabilities include vision, hearing, learning disability, and other health problems.
- SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy (NAAL).

**Notes:**
Look at the age 65+ line in the middle

## Average health literacy scores of adults, by age: 2003/strong>

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                                  |
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**Average health literacy scores of adults, by age: 2003/strong>**

**Notes:**
Adults in the oldest age group—age 65 and older—had lower average health literacy scores than adults in the younger age groups.
(The average score is 245.)

## Percentage of adults in each health literacy level, by age: 2003

**Notes:**
Note that nearly 60% of adults 65 and over score Basic or Below Basic

## Sources of health information

- Percentage of adults with *Below Basic* or *Basic* health literacy who get **little** **or no health information** from the following sources:
_**Source**__**	**__**	**__**Below Basic**__**	**__**Basic**_
**Internet****	****	****      ****85%****	****	****70%**
- Magazines		      64%		47%
- Books or Brochures	      62%		45%
- Newspapers		      59%		51%
- Family or Friends	      47%		40%
- Health Care Providers	      35%		30%
- Radio or TV		      33%		29%

**Notes:**
Look at how people get (or rather do not get) health info.  The vast majority of those scoring in the Basic & Below Basic categories do not use the Internet.
More than half rely on family/friends, healthcare providers, and radio/TV.  Compare that info with how you disseminate information to seniors. 

## Health Literacy at HHS

**Notes:**
Now that we know more about how many adults have low literacy skills and about the problems that result from low health literacy---what can we do? What is HHS doing?

## Healthy People 2010 Health Literacy Objectives

- 11-2. Improve the health literacy of the population
- 	a. Decrease percentage of adults in the *Below Basic* category
- 	b. Increase the percentage of adults in the *Proficient *category
- 11-6. Increase the proportion of persons who report that their healthcare providers have satisfactory communication skills.

**Notes:**
Healthy People 2010 - -- a set of national disease prevention and health promotion objectives led by HHS.

This is the 3rditeration of the Healthy People initiative (with target dates of 1990, 2000, 2010), but the first one to include Health Communication as a Focus Area.  Two of the six objectives in Focus Area 11 (Health Communication) are health literacy objectives.
Original 11-2 developmental objective: “Improve the HL of persons with inadequate or marginal literacy skills.”

11-6a Patients reporting that doctors or other health providers always listen carefully to them
11-6b Patients reporting that doctors or other health providers always explain things so they can understand 
11-6c Patients reporting that doctors or other health providers always show respect for what they have to say 
11-6d Patients reporting that doctors or other health providers always spends enough time with them 

## What factors affect health literacy?

- Communication skills of the public and health professionals
- Knowledge of health-related topics
- Culture
- Demands of the healthcare and public health systems
- Demands of the situation/context

## Who is responsible for improving health literacy?

**WE ARE!**
-   Public health professionals
-   Healthcare system
-   Public health systems
- We must work together to ensure health information and services can be understood and used by all Americans.

## Quick Guide to Health Literacy

- Basic overview of key health literacy concepts
- Techniques for improving health literacy
- Examples of health literacy best practices
- Strategies for addressing health literacy in your organization
**www.health.gov/communication/literacy**

**Notes:**
To spread the word about HL, ODPHP – working with members of the HHS HL Workgroup – developed the “Quick Guide to HL”
Audience: HHS staff, HHS contractors and grantees and our partners.

I strongly encourage to take 20-30 minutes and read the entire guide.  Do it today. You’ll find it’s VERY well written.

## Strategies for Improving Health Literacy

## 1. Improve the Usability of Health     Information  

**1. Improve the Usability of Health ****    Information  **

- Is the information appropriate for the users? (*Have you tested it?)*
- Is it easy to understand? 			*(Have you tested it?)*
- Are you speaking clearly and listening carefully?  *(Did you use the teach-back method?)*

**Notes:**
Is it written in Plain Language?
If you tested it, did you test it on the intended audience – on REAL users?

## 2. Improve the Usability of     Health Services

**2. Improve the Usability of ****    Health Services**

- Improve the usability of health forms and instructions.
- Improve accessibility of the physical environment.
- Establish a patient navigator program.

**Notes:**
Again, did you test forms with real users?
Physical environment – hospital signs understandable, easy flow thru healthcare facilities, train staff to maintain shame-free environment.

Patient Navigator – are any of you familiar with a patient navigator program?  (see Harold Freeman ‘s 9-7-06 talk

## 3. Build Knowledge To Improve     Decisionmaking

**3. Build Knowledge To Improve ****    Decisionmaking**

- Improve access to accurate and appropriate health information.
- Facilitate healthy decision-making.
- Partner with adult educators.

## 4. Advocate for Health Literacy     Improvement in Your Organization

**4. Advocate for Health Literacy ****    Improvement in Your Organization**

- Change professional practice.
- Make the case for improving health literacy to management and colleagues.
- Establish accountability in your organization.

**Notes:**
Discuss Action Plan (bring copy)

## www.health.gov/communication/literacy

## Contact Information:Joanne Lockejoanne.locke@hhs.gov(240) 453-6113