Health Literacy

Health Literacy
By: Farhad Zargari, MD, PhD

Introduction
 Farhad Zargari, MD, PhD
 Education:
 Mashhad University of Medical Sciences
 Southern Illinois University
 University of Phoenix

Contents
 1-Literacy and Health
 2-What is Health Literacy
 3-Improving Health Literacy
 3.1-Plain Language and Health
 3.2-Cultural and Linguistic Competency
 4-Why Do we Care About Health Literacy?
 5-Health Literacy Promotion
 6-Digital Health Literacy

Literacy
and
Health:
WhatWeNeed
toKnow?
 It can not be said more
eloquently…
 “….as we know, there are
known knowns; there are
things we know we know.
 We also know there are known
unknowns; that is to say we
know there are some things
we do not know.
 But there are also unknown
unknowns - the ones we don’t
know we don’t know”.

Literacy
and Health
 “ I can’t pronounce the names of my pills. I ask
for them by their shape, size, and color”.

Literacy
and Health
 Relationship between low literacy and a range of
health related outcomes are well established.
Dewalt DA et al Literacy and health outcomes: a systematic
review of the literature. Journal of General Internal Medicine,
19. 128-39 2004

Literacy
and
Health:
LiteracyNeedsin
Context
 Historic Perspectives
 Multiple meanings
 Changing measures
 20th Century Changes
 1900 – 1950’s . . . . . . . . Industrialization
 1960’s . . . . . . . . . . . . . . Space race
 1970’s . . . . . . . . . . . . . . International development
 1980’s . . . . . . . . . . . . . . Technological advancement
 1990’s . . . . . . . . . . . . . . Globalization

Literacy
and
Health:
Traditionalvs
Modernhealth
Model
 Traditional Healthcare, Historic Health
Information Model: Asymmetry of Information
 Physician or health care providers have all the
answers
 Patients follow the directions
 Participatory Healthcare:
 Consumers are more responsible for their own health
 Physician – patient partnership
 Data & Info accessibility has become extremely
easier
 Patient right to know clearly and thoroughly about
his/her health status is part of the basic human rights

Literacy
and Health
 Failure to address the impact of literacy on
health may inadvertently exacerbate existing
inequalities.
 “Removing the numerous barriers to
achievement of primary education will be a
crucial part of action on the social determinants
of health”.
http://www.who.int/social_determinants/resources/interim_
statement/ en/index.html

Literacy
and Health
 Literacy has “central role in health equity” in
countries rich and poor.
 Promoting literacy is a public health goal.

Literacy
and Health
 “People who read at lower
levels are generally 1.5 to 3
times more likely to have an
adverse (health) outcome as
people who read at higher
levels”
 “Removing the numerous
barriers to achievement of
primary education will be a
crucial part of action on the
social determinants of health”
 Literacy has “central role in
health equity” in countries rich
and poor Dewalt DA et al Literacy and health outcomes: a systematic
19. 128-39 2004

Literacy
and Health
 Some direct effects:
 1-Engaging in preventive health practices
 2-Early detection of disease
 3-Access to and use of health care services
 4-Medication adherence and chronic disease
management
Dewalt DA et al Literacy and health outcomes: a systematic
19. 128-39 2004

Definition
of Health
Literacy
Health Literacy!

Definition
of Health
Literacy
 Health literacy is the ability to obtain, read,
understand and use healthcare information to
make appropriate health decisions and follow
instructions for treatment.
Board on Population Health and Public Health Practice;
Institute of Medicine

Definition
of Health
Literacy
 “…people’s knowledge, motivation and
competences to access, understand, appraise
and apply health information in order to make
judgements and take decisions in everyday
 life concerning health care, disease prevention
and health promotion to maintain or improve
quality of life during the life course.”
HLS-EU. 2012

Definition
of Health
Literacy
 Literacy is context and content specific
 More accurate to talk about literacies for
example:
 Financial literacy
 Media literacy
 IT literacy (new literacy)
 And
 Health literacy

Definition
of Health
Literacy
 Content specific literacy in a health context
Short version:
 “the ability to access, understand, and use
information for health”
 Even where a person has advanced literacy skills
their ability to obtain, understand and apply
health information in a specific health context
may be poor.
Nutbeam D. Health Promotion Glossary (1999) Health
Promotion International, 13(4): 349-364. 1999 (also -
WHO/HPR/HEP/98.1)

Definition
of Health
Literacy
 Health literacy is also context and content
specific related to age and stage of life:
a young person
receiving health
education on
illicit drugs at
school
a person with
diabetes who
is receiving
patient
education
a pregnant
woman
attending
ante-natal
classes

Definition
of Health
Literacy
 Health literacy is the degree to which an
individual has the capacity to obtain,
communicate, process, and understand basic
health information and services to make
appropriate health decisions.
The Patient Protection andAffordable Care Act of 2010

Definition
of Health
Literacy
 Health Literacy has been defined as the
cognitive and social skills which determine the
motivation and ability of individuals to gain
access to, understand and use information in
ways which promote and maintain good health.
 Health Literacy means more than being able to
read pamphlets and successfully make
appointments. By improving people's access to
health information and their capacity to use it
effectively, health literacy is critical to
empowerment.
World Health Organization

Definition
of Health
Literacy
 The ability of individuals to access and use
health information to make appropriate health
decisions and maintain basic health.
Murray et al.,2007

Definition
of Health
Literacy
 The ability to access, understand, evaluate, and
communicate information as a way to promote,
maintain and improve health in a variety of
settings across the life course.
Rotman & Gordon- El- Bihbety, 2008

Definition
of Health
Literacy
 The degree to which individuals have the
capacity to obtain, process, and understand
basic health information and services needed to
make appropriate health decisions.
Ratzan and Parker, 2000

Definition
of Health
Literacy
 The ability to use printed, written, and digital
information associated with a broad range of
health-related tasks to accomplish one’s goals at
home, in the workplace, and in the community
(including health care settings).
National Assessment of Adult Literacy (2003)

Definition
of Health
Literacy
Health
Literacy
Demographic
SES,
Occupation,
Income
Psychosocial
Social support
Cultural
Language,
Religious beliefs
General
Literacy
Reading,
Numeracy,
ICT
Knowledge
Individual
Characteristics
Age, Gender

Definition
of Health
Literacy
 Health literacy allows the public and personnel
working in all health-related contexts to find,
understand, evaluate, communicate, and use
information. Health literacy is the use of a wide
range of skills that improve the ability of people
to act on information in order to live healthier
lives.
 These skills include reading, writing, listening,
speaking, numeracy, and critical analysis, as well
as communication and interaction skills.
Calgary Charter on Health Literacy, 2008

Definition
of Health
Literacy
 Health literacy includes numeracy skills. For
example, calculating cholesterol and blood
sugar levels, measuring medications, and
understanding nutrition labels all require math
skills. Choosing between health plans or
comparing prescription drug coverage requires
calculating premiums, copays, and deductibles.

Definition
of Health
Literacy
 In addition to basic literacy skills, health literacy
requires knowledge of health topics. People with
limited health literacy often lack knowledge or
have misinformation about the body as well as
the nature and causes of disease. Without this
knowledge, they may not understand the
relationship between lifestyle factors such as
diet and exercise and various health outcomes.

Definition
of Health
Literacy
 Health information can overwhelm even persons
with advanced literacy skills. Medical science
progresses rapidly. What people may have
learned about health or biology during their
school years often becomes outdated or
forgotten, or it is incomplete. Moreover, health
information provided in a stressful or unfamiliar
situation is unlikely to be retained.

Definition
of Health
Literacy
Understanding
conditions that
determine health
and how to
change them
Self-efficacy
Motivation
Applying relevant
health
information for
personal benefit
Personal skills Cognitive skills
Media literacy
skills
Critical thinking
skills
Problem-solving
Health literate
knowledgePersonal
knowledge and
capability
Capacity to
understand and
personalize
information
Health Literacy

Definition
of Health
Literacy
 Health literacy is dependent on individual and
systemic factors:
 1-Communication skills of lay persons and
professionals
 2-Lay and professional knowledge of health topics
 3-Culture
 4-Demands of the healthcare and public health
systems
 5-Demands of the situation/context
 6-Relative ICT literacy

Definition
of Health
Literacy
 1-Communication skills of lay persons and
professionals:
 Communication skills include literacy skills (e.g.,
reading, writing, numeracy), oral communication
skills, and comprehension.
 Communication skills are context specific.

Definition
of Health
Literacy
 2-Lay and professional knowledge of health
topics:
 People with limited or inaccurate knowledge about
the body and the causes of disease may not:
 Understand the relationship between lifestyle factors
(such as diet and exercise) and health outcomes
 Recognize when they need to seek care
 Health information can overwhelm people with
advanced literacy skills.

Definition
of Health
Literacy
 3-CultureAffects:
 How people communicate and understand health
information.
 How people think and feel about their health.
 When and from whom people seek care.
 How people respond to recommendations for
lifestyle change and treatment.

Definition
of Health
Literacy
 4-Demands of the healthcare and public health
systems:
 Individuals need to read, understand, and complete
many kinds of forms in order to receive treatment
and payment reimbursement.
 Individuals need to know about the various types of
health professionals and services as well as how to
access care.

Definition
of Health
Literacy
 5-Demands of the situation/context:
 Health contexts are unusual compared to other
contexts because of an underlying stress or fear
factor.
 Healthcare contexts may involve unique conditions
such as physical or mental impairment due to illness.
 Health situations are often new, unfamiliar, and
intimidating.

Definition
of Health
Literacy
 6-Relative ICT literacy:
 Digitalization of health related resources makes it
mandatory to have relative internet literacy and
access.
 Recent advances in telemedicine modalities require
the public to have necessary functional knowledge of
the technological developments.
 Mobile health and the innovative apps are in the core
of today’s health service provision inevitable.

Components
of Health
Literacy
Cultural and
Conceptual
Knowledge
Listening Speaking Writing Reading Numeracy
Health
Literacy
Literacy
Health
Information
Traditional
Resources
Digital
Resources
Technology
Computers Mobile
Apps
Medical
Devices

Definition
of Health
Literacy
lives.
Roles

Definition
of Health
Literacy
information on a well understood cultural
background. Health literacy is the use of a wide
lives.
Methods

Definition
of Health
Literacy
lives.
Outcomes

Definition
of Health
Literacy
Health
Literacy
Roles
Outcomes
Methods

Definition
of Health
Literacy
Health
Literacy
Training
Systems
Tools

Definition
of Health
Literacy
Health
Literacy
Training
Systems
Tools
-Support and Services
-Clinical Interactions
-Policies
-Processes
-Material
-Means

Definition
of Health
Literacy
Health
Literacy
Training
Systems
Tools
-Support and Services
-Clinical Interactions
-Policies
-Processes
-Plain Language
-Cultural and
Linguistic Competency

Multiple
Definitions
 There are multiple definitions of health literacy,
in part, because health literacy involves both the
context (or setting) in which health literacy
demands are made (e.g., health care, media,
internet or fitness facility) and the skills that
people bring to that situation
Rudd, Moeykens, & Colton, 1999

Multiple
Definitions
 Defined this way, Health Literacy goes beyond a
narrow concept of health education and
individual behavior-oriented communication,
and addresses the environmental, political and
social factors that determine health.
World Health Organization

Historical
Background
of Health
Literacy
 The young and multidisciplinary field of health
literacy emerged from two expert groups;
physicians, other health providers, and health
educators, and Adult Basic Education (ABE) and
English as a Second Language (ESL)
practitioners.

Historical
Background
of Health
Literacy
 Physicians are a source of groundbreaking
patient comprehension and compliance studies.
Adult Basic Education / English for Speakers of
Languages OtherThan English (ABE/ESOL)
specialists study and design interventions to
help people develop reading, writing, and
conversation skills and increasingly infuse
curricula with health information to promote
better health literacy. A range of approaches to
adult education brings health literacy skills to
people in traditional classroom settings, as well
as where they work and live.

Health
Literacy
Levels
 Proficient: Can perform complex and
challenging literacy activities.
 Intermediate: Can perform moderately
challenging literacy activities.
 Basic: Can perform simple everyday literacy
activities.
 Below Basic: Can perform no more than the
most simple and concrete literacy activities.
 Non-literate in English: Unable to complete a
minimum number of screening tasks or could
not be tested because did not speak English or
Spanish.

Health
Literacy
Levels
 Circle the date of a medical
appointment on a hospital
appointment slip.
 Give two reasons a person should be
tested for a specific disease, based
on information in a clearly written
pamphlet.
 Determine what time a person can
take a prescription medication,
based on information on the drug
label that relates the timing of
medication to eating.
 Calculate an employee’s share of
health insurance costs for a year,
using a table.
Below Basic
Basic
Intermediate
Proficient
500
0
National Center for Education Statistics, Institute for
Education Sciences

Health
Literacy
Levels
 Studies reveal that only 12 percent of the adults
in the U.S. have proficient health literacy.This
means 77 million adults have basic or below
basic health literacy.These individuals have less
active role in maintaining their wellbeing and
difficulty with common health tasks including
reading the label of a prescribed drug.
"America's Health Literacy: WhyWe Need Accessible Health
Information". health.gov. Retrieved 2015-11-20.

Health
Literacy
Levels:
HealthLiteracy
AcrosstheGlobe
 Australia:
 60% of adults were below Level 3 health literacy skills
 The percentage of individuals with low health literacy
skills increased with age.
 Canada:
 60% do not have the necessary skills to manage their
health adequately.
 United States:
 >43% of adults have literacy levels below what they
need to understand even basic written health
information
 33 % of older patients have limited health literacy
 Europe
 47% of Europeans have limited health literacy
 Limited health literacy varies from country to country
(ex: Limited HL = 29% for Netherlands and 62% for
Bulgaria)

Health
Literacy
Levels
 Low health literacy is more prevalent among:
 Older adults
 People with low income
 People with limited education
 Minority populations
 People with limited English proficiency (LEP)

Improving
Health
Literacy
 There are four major strategies for improving
health literacy:
1-Improve the
Usability of Health
Information
2-Improve the
Usability of
Health Services
3-Build Knowledge
to Improve
Decision Making
4-Advocate for
Health Literacy
Improvement

Improving
Health
Literacy
1.Improvethe
Usabilityof
Health
Information
 Improve the Usability of Health Information:
 Is the information appropriate for the users?
 Is the information easy to use?
 Are you speaking clearly and listening carefully?
 Decide which channel(s) and format are most
appropriate.
 Acknowledge Cultural Differences and Practice
Respect:
 Accepted roles of men and women
 Value of traditional vs.Western medicine
 Favorite or forbidden foods
 Manner of dress
 Body language, especially touching or proximity

Improving
Health
Literacy
1.Improvethe
Usabilityof
Health
Information
 Improve the Usability of Health Information on
the Internet:
 People cannot find the information they seek onWeb
sites 60% of the time.
 Many elements that improve written and oral
communication can be applied to information on the
Web:
 — Plain language*
 — Large font
 — White space
 — Simple graphics
*3.1

Improving
Health
Literacy
1.Improvethe
Usabilityof
Health
Information
 Health literacy has implications forWeb-based
communication beyond written text. Consider
the following strategies:
 Apply user-centered design principles and conduct
usability tests.
 Include interactive features and personalized
content.
 Organize information to minimize scrolling.
 Use uniform navigation.

Plain
Language
and Health
 What is plain language?
 Clear communication is essential to ensure
patients receive plain, unbiased and culturally
appropriate information that will equip them to
understand their condition and make educated
choices about treatment.
 Information must be in accessible format and
presented in a range of modalities.

Plain
Language
and Health
 Plain language is a strategy for making written
and oral information easier to understand. It is
one important tool for improving health literacy.
 Plain language is communication that users can
understand the first time they read or hear it.
With reasonable time and effort, a plain
language document is one in which people can
find what they need, understand what they find,
and act appropriately on that understanding.

Plain
Language
and Health
 Plain language addresses varied health contexts
in accessible ways so patients are better able to
 Locate
 Decode
 Understand
 Question
health information.

Plain
Language
and Health
 Plain Language: A SolutionThat Works
 StepsTo Success
 1.EnhanceCommunications
 2. Know your audience
 3. Organize your message
 4.Write clearly
 5. Design for your audience
 6.Test with users

Plain
Language
and Health
1.Enhance
Communications
 Attitude of helpfulness, caring and respect by all
staff
 Conduct patient-centered visits
 Explain things clearly in plain language
 Focus on key messages and repeat
 Use a “teach back” or “show me” technique to
check for understanding
 Use patient-friendly educational materials to
enhance interaction

Plain
Language
and Health
2.KnowYour
Audience
 Readers With Lower Health Literacy, Anyone
can have low health literacy:
 Take words literally
 Read slowly and miss meaning
 Skip over unknown words
 Miss context clues
 Tire quickly
 Get frustrated and give up.

Plain
Language
and Health
2.KnowYour
Audience
 Readers of Health Content May:
 Feel stressed or fearful
 Be shocked at a diagnosis
 Not feel well at this moment in care
 Worry about how they’ll pay their medical bills
 Have limited time with the doctor
 Be on medicine that impairs them.

Plain
Language
and Health
2.KnowYour
Audience
 1-KnowYourAudience… It’s Not Just About the
Words
 Race/Ethnicity
 Age
 Gender
 Socioeconomic status
 Body type
 Relationship depicted
 Provider (if shown) ethnicity and gender

Plain
Language
and Health
3.OrganizeYour
Message
 2. OrganizeWith the User in Mind, Make it easy
to follow:
 Put most important information first
 Have a purpose, and highlight it
 Chunk it! Use lists, bullets, tables, etc
 Write headings and subheadings that tell people
what is coming and that they can scan.

Plain
Language
and Health
4.WriteClearly
 3.Write Clearly (Think Living-Room Language):
 Use active voice
 Break up long sentences
 Focus on one idea
 Use pronouns
 Use familiar words
 Do not rely only on grade level to judge readability.

Plain
Language
and Health
5.DesignforYour
Audience
 4.Design to Help Users, Use visual cues:
 Use headings and subheadings
 Use white space
 Pictures and/or videos help people learn
 Color and font can help people navigate
 Lists and bullets and boxes attract attention.

Plain
Language
and Health
6.TestwithUsers
 5.Test WithTarget Audience, Make sure you
achieved the goal:
 Test early, test often
 Test with people who are like your audience
 Test content, design, functionality
 Use test results to improve product
 Any testing is better than no testing!

Plain
Language
and Health
1-Oral

Plain
Language
and Health
1-Oral:Examples
 Anti-inflammatory
 Benign
 Contraception
 Hypertension
 Oral
 Echocardiogram
Stops Swelling
Not Cancer
Birth Control
High BP
By Mouth
Picture of the heart

Plain
Language
and Health
2-Printed
 Use a size 14 font or larger
 Leave adequate white space
 Use jargon-free language
 Use a grade reading level of 5 or below
 Use concrete and familiar words
 Emphasize key points in headings
 Chunk related information
 Use bulleted lists
 Use simple tenses (present is best)
 Use short sentences with active voice
 Use relevant and simple diagrams/graphics
 Caption the graphics

Plain
Language
and Health
2-Printed
 Key elements of plain language include:
 Organizing information so that the most important
points come first
 Breaking complex information into understandable
chunks
 Using simple language and defining technical terms
 Using the active voice
 Passive Sentences to Active Sentences
 Long Paragraphs to Short Paragraphs
 Poly-syllable Words to Mono – Bi-syllable
 ClinicalTerminology to ColloquialTerminology
 Past/MixedTense to PresentTense
 3rd Person to 1st and 2nd Person

Plain
Language
and Health
3-Digital
 Digital resources fall into two main categories:
 Web
 Health Apps
 Organize content and simplify navigation
 Label links clearly
 Include printer-friendly tools and resources
 Incorporate audio and visual features
 Use bold colors with contrast; avoid dark
backgrounds
 Make sure the “back button” works
 Use linear information paths

Plain
Language
and Health
 It’s more fun to talk with
someone who doesn’t use
long, difficult words but
rather short, easy words
like “What about lunch?”
WinnieThe Pooh

Improving
Health
Literacy
2.Improvethe
Usabilityof
HealthServices
 Improve the usability of health forms and
instructions:
 Healthcare and public health settings rely heavily on
forms and printed instructions.
 Revise forms to ensure clarity and simplicity.
 Test forms with intended users and revise as needed.
 Provide forms in multiple languages.
 Offer assistance with completing forms and
scheduling follow up care.

Improving
Health
Literacy
2.Improvethe
Usabilityof
HealthServices
 Improve the accessibility of the physical
environment:
 Settings with lots of signs and postings have a high
literacy demand:
 Include universal symbols and clear signage in
multiple languages.
 Promote easy flow through healthcare facilities.
 Create a respectful and shame-free environment.

Improving
Health
Literacy
2.Improvethe
Usabilityof
HealthServices
 Establish a patient navigator program:
 Patient navigators are health professionals or
community health workers who help patients:
 Evaluate their treatment options
 Obtain referrals
 Find clinical trials
 Apply for financial assistance

3.2-Cultural and Linguistic
Competency

Cultural and
Linguistic
Competency
 What is cultural and linguistic competency?
 Cultural competency is the ability of health
organizations and practitioners to recognize the
following in diverse populations to produce a
positive health outcome:
 Cultural beliefs
 Values
 Attitudes
 Traditions
 Language preferences
 Health practices

Cultural and
Linguistic
Competency
 What is cultural and linguistic competency?
 Culture affects how people communicate,
understand, and respond to health information.
Cultural and linguistic competency of health
professionals can contribute to health literacy.

Cultural and
Linguistic
Competency
 Cultural competence is the ability of health
organizations and practitioners to recognize the
cultural beliefs, values, attitudes, traditions,
language preferences, and health practices of
diverse populations, and to apply that
knowledge to produce a positive health
outcome.Competency includes communicating
in a manner that is linguistically and culturally
appropriate.

Cultural and
Linguistic
Competency
 Healthcare professionals have their own culture
and language. Many adopt the “culture of
medicine” and the language of their specialty as
a result of their training and work environment.
This can affect how health professionals
communicate with the public.
McKinney J, Kurtz-Rossi S. 2000. Culture, Health, and Literacy: A Guide to
Health Education Materials for AdultsWith Limited English Skills. Boston, MA:
World Education.

Cultural and
Linguistic
Competency
Example
 Use Patients’ Social History:
 How far did you go in school?
 Did you ever have any difficulty in school?
 Has reading ever been a problem for you?
 Other possible ways to ask:
 Have you ever had difficulty reading materials the
doctor gave you?
 Has a doctor ever been unclear when they explained
things to you?

Cultural and
Linguistic
Competency
D.I.R.E.C.T.
 D- Do you have any Difficulty reading
 I- Are you interested in Improving
 R- We have Referrals/resources available
 E- Ask Everyone
 C- This is a Common problem
 T- Take down the barriers to obtaining the
resources and take down current barriers to
providing effective care
Balydon, Glusman, and Sharkey-Asner, 2009
For Reach Out and Read Illinois

Health
Literacy is
NOT the
SameAs:
 Plain Language. Plain language is a technique
for communicating clearly. It is one tool for
improving health literacy.
 Cultural Competency. Cultural competency is
the ability of professionals to work cross-
culturally. It can contribute to health literacy by
improving communication and building trust.

Improving
Health
Literacy
3-Build
Knowledgeto
ImproveDecision
Making
 Improve access to accurate and appropriate
health information:
 Create new mechanisms for sharing and distributing
understandable health education materials:
 Create audience or language-specific databases.
 Partner with adult educators.
 Identify new methods for information dissemination:
 Cell phones, palm pilots, personalized and interactive
content, information kiosks, talking prescription
bottles, etc.
 Form partnerships with civic and faith-based
organizations trusted in the community.
 Work with the media to increase awareness of health
literacy issues.
 Work with providers to ensure that the health
information they share is accurate, current, and
reliable.

Improving
Health
Literacy
3-Build
Knowledgeto
ImproveDecision
Making
 Facilitate healthy decision making:
 Use short documents that present “bottom-line”
information, step-by-step instructions, and visual
cues that highlight the most important information:
 People process and use a limited amount of
information when making a decision.
 Align health information and recommendations with
access to services, resources, and support!

Improving
Health
Literacy
3-Build
Knowledgeto
ImproveDecision
Making
 Partner with educators to improve health
curricula:
 Co-develop adult basic education lessons on health
topics:
 Adult learners want information that is relevant to
their lives; health content is likely to engage them.
 Construct lessons in which students use health-related
texts, forms, and content from the Internet.
 The K–12 education system is a critical point of
intervention to improve health literacy.
 Incorporate health-related tasks, materials, and
examples into lesson plans.
 Design and disseminate health information to
support existing state standards.
 Speak to students or help organize health-related
field trips for local schools.

Improving
Health
Literacy
4-Advocatefor
HealthLiteracy
Improvement
 Make the case for improving health literacy:
 Identify specific programs and projects affected by
limited health literacy.
 Target key opinion leaders with health literacy
information:
 Explain how health literacy improvement relates to
your mission, goals, and strategic plan.
 Circulate relevant research and reports on health
literacy to colleagues.
 Post and share health literacy resources.

Improving
Health
Literacy
4-Advocatefor
HealthLiteracy
Improvement
 Incorporate health literacy in mission and
planning:
 Include goals and objectives specifically related to
health literacy improvement in:
 Strategic plans
 Program plans
 Educational initiatives
 Goals can be broad (e.g.,Achieving Healthy People
2010 Objective 11-2) or specific to the mission of the
office/program.

Improving
Health
Literacy
4-Advocatefor
HealthLiteracy
Improvement
 Establish accountability for health literacy
activities:
 Include health literacy improvement criteria in
program evaluation.
 Implement health literacy metrics.

4-Why do we care about
health literacy?

Why do we
care about
health
literacy?
 Low health literacy affects:
 Health outcomes
 medication errors
 increased doctor visits and hospitalizations
 Healthcare costs
 Quality of care
 Health literacy is essential to promote healthy
individuals and communities.

Why do we
care about
health
literacy?
“Poor health literacy is a
stronger predictor of a
person’s health than age,
income, employment
status, education level, and
race.”
The American Medical Association

Why do we
care about
health
literacy?
 Impact of Low Health Literacy, patients with low
health literacy have more:
 Medical non-adherence
 Serious medication errors
 Difficulty navigating the health system
 Communicating with providers
 Chronic disease and mortality for themselves & their
families
 Problems during transitions of care
 Which results in:
 Lower patient engagement
 Costs as much as $236 billion annually

Why do we
care about
health
literacy?
 Patients with limited health literacy may have
difficulty:
 Locating providers and exploiting services
 Filling out health forms
 Sharing personal information, such as health history,
with providers and participating in the course of
decision making process
 Seeking preventive health care
 Engaging in self-care and chronic-disease
management
 Understanding directions on medication
 Understanding and acting on health-related news
and information
 Understanding mathematical concepts such as
probability and risk

Why do we
care about
health
literacy?
LowHLLeadsto
Difficultyin:
Navigating the
Healthcare
System
Chronic
Disease
Management
Adopting
Health-promoting
Behaviors
Sharing
Personal and
Health Information
Self-care
Acting on
Health Related
Information

Why do we
care about
health
literacy?
 Persons with limited health literacy skills:
 Are more likely to have chronic conditions and less
likely to manage them effectively.
 Have less knowledge of their illness (e.g., diabetes,
asthma, HIV/AIDS, high blood pressure) and its
management.
 Experience more preventable hospital visits and
admissions.
 Are significantly more likely to report their health as
“poor.”

Why do we
care about
health
literacy?
PersonsWith Limited Health Literacy Skills:
Higher utilization of
treatment services:
Hospitalization
Emergency services
Lower utilization of
preventive services
Higher utilization of
treatment services
results in higher
healthcare costs

Why do we
care about
health
literacy?
Patient Engagement
depends on Health
Literacy

Why do we
care about
health
literacy?
Health Literacy is An
Empowerment AsWell
As Cost Containment
Strategy

Why do we
care about
health
literacy?
 Health literacy is of continued and increasing
concern for health professionals, as it is a
primary factor behind health disparities.

Why do we
care about
health
literacy?
 The proportion of adults aged 18 and over in the
U.S., in the year 2010, who reported that their
health care providers always explained things so
they could understand them was about 60.6%.
 This number increased 1% from 2007 to 2010.
"Health Communication and Health Information
Technology - Healthy People 2020"

Why do we
care about
health
literacy?
 Review of effectiveness of strategies for
informing educating and involving patients
indicates mostly positive results from different
strategies.
 Improving clinical decision-making, through
shared and informed decision making using
decision-aids and other educational
interventions.
CoulterA, Ellins J. 2007. Effectiveness of strategies for
informing, educating and involving patients. BMJ 335:24-7

Why do we
care about
health
literacy?
 Health literacy eventually leads to:
 Self care and self management based on tailored
patient education.
 Improving patient safety primarily through
improvement in the use of medicines.
 Improving health literacy is described as the “key” to
improved patient engagement.

Why do we
care about
health
literacy?
 The Healthy People 2020 initiative of the United
States Department of Health and Human
Services has included it as a pressing new topic,
with objectives for addressing it in the decade to
come.
"Health Communication and Health Information
Technology - Healthy People 2020"

Why do we
care about
health
literacy?

Why do we
care about
health
literacy?
HealthLiteracy
andClinicalCare
 Research over past 15 years (mostly in the US)
has led to more sophisticated understanding of
poor literacy and its association with a range of
health practices and outcomes – established
case for action
 Demonstrated that rapid assessment of health
literacy is feasible in normal clinical practice
Pignone, M., DeWalt, D., Sheridan, S., Berkman, N. & Lohr, K.N. (2005).
Interventions to improve health outcomes for patients with low literacy. Journal
of General Internal Medicine, 20, 185-192.

Why do we
care about
health
literacy?
HealthLiteracyin
PublicHealth
 Origins in contemporary health promotion - a
set of capacities that enable individuals to exert
greater control over their health and the range
of personal, social and environmental
determinants of health.
 Health literacy is seen as an “asset” to be built,
as an outcome to health education and
communication that supports greater
empowerment in health decision- making.

Why do we
care about
health
literacy?
TrendsThat
AffectHealth
Literacy
 More focus on prevention, self-care.
 Aging population = more interventions.
 Outcomes are being measured, incented.
 Affordable Care Act (US)mandates use of plain
language.
 Insurance industry is responding.
 Patients are assuming more responsibility.
 President signed Plain Writing Act in 2010.
 Patients have access to EHRs.

Why do we
care about
health
literacy?
“Health literacy is the
currency of success for
everything I am doing
as the Surgeon
General.”
Dr. Richard Carmona in his speech to the
AMA House of Delegates, June 2003.

Why do we
care about
health
literacy?
Results in
Difficulty in
Low Health Literacy
Healthcare
Availability
Healthcare
Accessibility
Healthcare
Affordability
Reduced
Lifespan
Diminished
Quality of Life
Patient
Compliance
High
Healthcare Cost
Low General
Literacy
Inadequate Health
Information
Poor ICT
Knowledge

Health
Literacy
Promotion
 Who is responsible for improving health
literacy?
 Society as a whole is responsible for improving
health literacy, but most importantly the
healthcare, public health professionals, and the
public health systems.

Health
Literacy
Promotion
 The primary responsibility for improving health
literacy lies with public health professionals and
the healthcare and public health systems. We
must work together to ensure that health
information and services can be understood and
used by all Americans.We must engage in skill
building with healthcare consumers and health
professionals. Adult educators can be productive
partners in reaching adults with limited literacy
skills.

Health
Literacy
Promotion
 Health education, in this more comprehensive
understanding, aims to influence not only
individual lifestyle decisions, but also raises
awareness of the determinants of health, and
encourages individual and collective actions
which may lead to a modification of these
determinants.

Health
Literacy
Promotion
 Health education is achieved therefore, through
methods that go beyond information diffusion
and entail interaction, participation and critical
analysis. Such health education leads to health
literacy, leading to personal and social benefit,
such as by enabling effective community action,
and by contributing to the development of social
capital.

Health
Literacy
Promotion
 Anyone who needs healthcare services also
needs health literacy skills to
 Find information and services
 Communicate their needs and preferences and
respond to information and services
 Process the meaning and usefulness of the
information and services
 Understand the choices, consequences and context
of the information and services
 Decide which information and services match their
needs and preferences so they can act

Health
Literacy
Promotion
 Anyone who provides health information and
services to others, such as a doctor, nurse,
dentist, pharmacist, or public health worker, also
needs health literacy skills to
 Help people find information and services
 Communicate about health and healthcare
 Process what people are explicitly and implicitly
asking for
 Understand how to provide useful information and
services
 Decide which information and services work best for
different situations and people so they can act

Health
Literacy
Promotion
 Considering the essential role of health literacy
in the people’s overall well being and quality of
life, there is a significant trend to embrace
health literacy as a component of basic human
right.

Health
Literacy
Promotion
 Improving Health Literacy Is
 Affordable
 Pragmatic
 Enhances social welfare
 Has a moderate influence on health outcomes
 Contested intellectual territory

Who Is
Responsible
for
Improving
Health
Literacy?
We Are

Digital
Health
Literacy
 Digital or eHealth literacy describes the
relatively modern concept of an individual's
ability to use health related apps and search for,
successfully access, comprehend, and appraise
desired health information from electronic
sources and to then use such information to
attempt to address a particular health problem.

Digital
Health
Literacy
 Due to the increasing influence of the internet
for information-seeking and health information
distribution purposes, eHealth literacy has
become an important topic of research in recent
years. Stellefson (2011) states, "8 out of 10
Internet users report that they have at least
once looked online for health information,
making it the third most popularWeb activity
next to checking email and using search engines
in terms of activities that almost everybody has
done.
Stellefson, Michael; Hanik, Bruce; Chaney, Beth; Chaney, Don;Tennant, Bethany;
Chavarria, EnmanuelAntonio (1 January 2011). "eHealth Literacy Among College
Students:A Systematic Review With Implications for eHealth Education".

Digital
Health
Literacy
 Though in recent years, individuals may have
gained access to a multitude of health
information via the Internet, access alone does
not ensure that proper search skills and
techniques are being used to find the most
relevant online and electronic resources.As the
line between a reputable medical source and an
amateur opinion can often be blurred; the ability
to differentiate between the two is important.

Digital
Health
Literacy
 Health literacy requires a combination of several
different literacy skills in order to facilitate
eHealth promotion and care. Six core skills are
delineated by an eHealth literacy model referred
to as the Lily model.

Digital
Health
Literacy
 The Lily Model's six literacies are organized into
two central types: analytic and context-specific.
Analytic type literacies are those skills that can
be applied to a broad range of sources,
regardless of topic or content (i.e., skills that can
also be applied to shopping or researching a
term paper in addition to health) whereas
context-specific skills are those that are
contextualized within a specific problem domain
(can solely be applied to health).

Digital
Health
Literacy
 The six literacies are listed below, the first three
of the analytic type and the latter three of the
context-specific:
 Analytic:
 Traditional literacy
 Media literacy
 Information literacy
 Context-specific
 Computer literacy
 Scientific literacy
 Health literacy

Digital
Health
Literacy
 According to Norman (2006), both analytical
and context-specific literacy skills are "required
to fully engage with electronic health
resources."As the WorldWideWeb and
technological innovations are more and more
becoming a part of the health care environment,
it is important for information technology to be
properly utilized to promote health and deliver
health care effectively.
Kim, Henna; Xie, Bo (January 2017). "Health literacy in the
eHealth era: A systematic review of the literature". Patient
Education and Counseling.

Digital
Health
Literacy
 It has been suggested that the move towards
patient-centered care and the greater use of
technology for self-care and self-management
requires higher health literacy on the part of the
patient.

Digital
Health
Literacy
 Digital Health Literacy: Actionable Interventions
 Embedding information in patient portals:
 Medline Connect
 Embedding HL assessment in the electronic
health record (EHR):
 Should be standard part of EHR (Healthy People
2020)
 Self assessment of HL comparable to performance
based assessment ( Kiechle ES, JGIM 2015)
 Mobile apps:
 iPrescribe
 Text messaging at 11th Street

Digital
Health
Literacy
 Linking Information to Patient Portal
EHR/PHR MedlinePlus
Problems, Medications, Labs
Code-based Request
Consumer Health Information
Targeted Response

Digital
Health
Literacy:
Sample
Resources
 Pfizer Clear Health Communication Initiative
 http://www.pfizerhealthliteracy.com
 NYU Patient and Family Resource Center
 http://www.nyupatientlibrary.org/medcenter/build-
skills
 Center for Health Care Strategies, Health
Literacy Fact Sheets
 http://www.chcs.org/publications3960/publications_s
how.htm?doc_id=291711
 Institute for Healthcare Advancement
 www.iha4health.org
 American Medical Association, Health Literacy
Program and Kit
 www. ama-assn.org

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