Health Literacy: Institutional Responsibility for Increasing Access to Information & Care Dr. Rima E. Rudd Sr. Lecturer on Health Literacy, Education, & Policy Department of Social & Behavioral Sciences Harvard School of Public Health
Disclosure I declare no conflict of interest for me [or for any planners, or content reviewers] for this presentation at Legacy 2 Rudd - March 2014
Focus Dr. Rima Rudd will discuss the Health Literacy Environment of healthcare. This talk will highlight literacy related barriers to health information, services, and care. Dr. Rudd will describe mechanisms for identifying existing barriers and for correcting the current mismatch between the well documented skills of adults and the demands / assumptions of our health and healthcare systems. 3 Rudd - March 2014
Origins of Health Literacy Inquiry National assessments of adults literacy skills 1992 NALS 2003 ALLS 2003 NAAL 2012 PIAAC Research question: Given documented skills, are there health implications? 4 Rudd - March 2014
Research Findings Health Information Mismatch [Peer reviewed studies] Well over 1,000 articles in medical and public health journals indicate that most health materials are written at a level that exceeds the reading skills of the average high school graduate Readability Suitability Usability/Match Health Outcomes/Literacy Link [AHRQ Review] Credible evidence of a relationship between low health literacy & important health outcomes Knowledge Behavior Health promotion Disease prevention CD Management Chronic disease Morbidity Mortality 5 Rudd - March 2014
Recent Work Beyond Reading: Oral exchange [speaking & listening] Beyond Words: Numeracy [math calculations & math concepts] Beyond the Brochure: Forms, Questionnaires, Surveys, Applications Beyond Printed Page: Web, Medical records, ehealth, mhealth 6 Rudd - March 2014
Research Gaps Health Literacy Measures Current measures are only approximations of reading skills [health content] Demand side / Accessible Information & Services Variety of texts in print, on-line, via new technologies Talk Communication Skills of Professionals & Health Outcomes Outcomes related to Match/Mismatch between Skills and Demands Contextual Factors and Health Outcomes Facilitators & Restraints Norms & Policies 7 Rudd - March 2014
Action Conundrum How to improve health literacy skills and thereby improve health? 8 Rudd - March 2014
Lessons from Education Understanding literacy: You cannot measure reading skills of any individual without calibrating the difficulty/complexity of the text You cannot judge listening skills or any individual without measuring the clarity of the speaker Literacy is context specific Thinking outside the box 9 Rudd - March 2014
Shift the Focus From a focus on the ability of patients to access information to a focus on accessible information From a focus on the literacy skills of patients to a focus on the communication skills of health professionals From a focus on links between a patients literacy skills and health outcomes to a focus on the match or mismatch between skills and demands and subsequent outcomes From a focus on doctor/patient communication to an examination of system level issues of norms and policies 10 Rudd - March 2014
Conceptual Developments Question: How to improve health literacy? Refocus on improving communication skills of health professionals and addressing systemic barriers Consider Broader Concept: Health literacy as the policy and communication skills which determine the capability of health systems and the ability of health professionals to support and actively encourage effective social, political, and individual action for health Rudd. 2010 Rudd, McCray, Nutbeam. 2012 11 Rudd - March 2014
Theoretical Foundation Explanatory Model Epidemiology: reciprocal relationship between persons & environment Lewin Force Field Analysis Lesson: Identify & Remove Barriers Action Model Kurt Lewin s Field Theory & Force Field Analysis 12 Rudd - March 2014
Emerging Focus: Institutional Factors Health Literacy Environments Health Literate Organizations Examinations of Health Care Institutions Attention to Norms & Policies 13 Rudd - March 2014
Health Systems & Institutions World wide, we see an increased demand from complex health care systems and increased responsibility for individuals interacting with health care systems. Adult Literacy and Lifeskills Surveys, 2003 Failure to provide patients with information about their care in ways that they can understand, will continue to undermine other efforts to improve patient safety. Joint Commission Public Policy White Paper, 2007 14 Rudd - March 2014
Health Literate Organizations 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes populations served in the design, implementation, and evaluation of health information and services. 5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. 15 7. Provides easy access to health information and services and navigation assistance. 8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. 9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines. 10. Communicates clearly what health plans cover and what individuals will have to pay for services. Attributes IOM Roundtable on Health Literacy Rudd - March 2014
Consider the Literacy Environment How literacy friendly are healthcare settings? What are the facilitating factors? Where do we find barriers? Which barriers can be removed? Rudd & Anderson Harvard School of Public Health www.hsph.harvard.edu/healthliteracy Rudd - March 2014 16
Measuring the HL Environment First Impressions: web, phone, entry Navigation signs & aides Print: posting, forms, handouts On line Critical texts: e.g. Intake / Discharge Forms Norms & practices for the oral exchange Staff communication Professional communication Technology OLD [Phone & letters] NEW [on-line, ehealth, mhealth] Protocols & Policies Training Orientation Rules & regulations Processes: What we do, why we do it, how we do it, Contracts [forms, materials] drawn from on line tool: HL Environment of Hospitals and Health Centers 17 Rudd - March 2014
Journey 18 Rudd - March 2014
Entrance 19 Rudd - March 2014
Maps 20 Rudd - March 2014
Information 21 Rudd - March 2014
Hallway 22 Rudd - March 2014
Conduct an Environmental Assessment First impressions Physical attributes & design elements Social attributes Expectations Behavioral norms Interactive protocols Talk Materials & Tools Policies & regulations Rudd - March 2014 23
Examples of Findings from the U.S. & Spain [Groene & Rudd, 2012] Entrances are hard to locate Lobbies can be intimidating The environment is set up for healthcare workers rather than for visitors / patients Signs serve multiple purposes Design is often a priority Maps are not usable Postings are difficult to read Key staff are not oriented to the setting 24 Rudd - March 2014
Findings, continued Materials are not appropriate for intended audience Professionals use a foreign language Environment is busy & intimidating Unusual processes are followed Gatekeepers Measures Secretive documentation Unexplained protocols Rudd - March 2014 25
Change The definition of insanity is continuing to do the same thing over and over again and expecting a different result Albert Einstein Rudd - March 2014 26
Examples Health information language, content, organization, structure, format In print On-line Interpersonal exchanges Media use Professional education & training Institutional norms & demands Processes & Procedures Assumptions Materials Tools Labels Data gathering instruments Media messaging 27 Rudd - March 2014
Action: Raise Awareness Research findings: Literacy skills of US adults Research findings: Mismatch between literacy skills of the public and health system demands Research findings: Links between literacy and health outcomes Ameliorative action: Remove literacy related barriers, establish shame free environments, institute tested processes Rudd - March 2014 28
Action: Orientation, Training, Education for all Staff Literacy in the US Literacy and health outcomes Institutional responsibility: Norms: All staff members as ambassadors Protocols: Wayfinding assistance Training opportunities: Improved Communication Rudd - March 2014 29
Action: Normative Change Focus on accessible information Finding: Patients ability to understand health and medical issues and directions is related to the clarity of the communication. Communicating Health: Priorities and Strategies for Progress, Health and Human Services 2003 Conclusion: Health professionals must take responsibility for clarity 30 Rudd - March 2014
Action: Advocate Communication skill development in professional training schools and programs Communication skill testing on licensing examinations Opportunities for continuing education programs to enhance communication skills Rudd - March 2014 31
Action: Apply Tested Approaches Mandate use of available tools for development & assessment of information in print and on-line Formative research & piloting Guidelines for Language, Organization, Structure Change norms related to interpersonal exchanges Establish environmental norms re: Question Asking Offer training in and expectations for use of Teach-back Use Decision aids Value increased participation and engagement for decision making and action 32 Rudd - March 2014
Example: Teach-Back I want to be sure I went over everything. Tell me how you will take this medicine. Just to check if I ve covered everything: Tell me what you will say to your wife when you return home. Just to be sure I was clear: Show me how you will use this peak flow meter. Avoid: Testing Avoid: Do you Understand? Rudd - March 2014 33
Action: Institute HL Policies & Regulations Standards for critical texts Contractual obligations for rigorous material development [with all vendors] Review boards [articulated processes and assessments] for all in-house materials Environmental standards for navigation ease Accreditation requirements Professional training & licensing requirements Staff orientation & training Rudd - March 2014 34
Transforming Care Settings: Some Initial Suggestions Raise awareness Provide orientation & training for all staff [ambassadors] Develop scripts with plain/everyday words Modify time requirements Develop protocols & contractual requirements for development, piloting, and review of all critical texts Change design priorities for all new construction Provide staff and professional development opportunities E.g. How to Do the math Change practice norms: Encourage dialogue & question asking Use plain language Use teach-back Explain processes, procedures, findings Rudd - March 2014 35
Time for Action Documented: Literacy skills of adults in industrialized nations Documented: Links between literacy and health outcomes Documented: Mismatch between demands and skills Business as usual is unethical 36 Rudd - March 2014
Tools Assessing the Health Literacy Environment: www.hsph.harvard.edu/healthliteracy Health Literacy Toolkit for Medical Practice www.ahrq.gov/healthliteracy Health Literate Organizations www.nas.org/iomhealthliteracyroundtable Coming soon: white paper from Vanderbilt re suggested measures for health literate organizations 37 Rudd - March 2014