Feinberg School of Medicine, Northwestern University, Chicago USA. Presentation given at "Health Literacy Network: Crossing Disciplines, Bridging Gaps", November 26, 2013. The University of Sydney.

1. M A K I N G S TO N E S O U P
T h e
M a n y F a c e s a n d E v e n t u a l S o l u t i o n s
t o L o w H e a l t h L i t e r a c y
d
Michael Wolf, MA MPH PhD
Professor, Medicine & Learning Sciences
Division of General Internal Medicine & Geriatrics
Feinberg School of Medicine
Northwestern University
Chicago, IL USA

2. Greetings from Chicago

3. Greetings from Chicago

4. A Parable…
d

6. Rapid Growth.
 > 3000 articles (1985 – present)
 ~ 2200 articles in past 5 years
 ~ 6000 related articles (1964 – present)
 Target of every professional society, WHO
 Few interventions
 Variable definitions

7. Health Literacy Skills
t h e
d
s o u p s t o n e

8. A Need for Clarity
 HL gained prominence as a skill set
~ 600 original studies comprise
HL evidence
(crude measures of reading, numeracy, health knowledge)
 But we want more from individuals…
- motivation, cultural factors (language, beliefs, experience)
 …And the health system
- accessibility, navigability, communication, follow-up
 …And community
- education, human services, policy, etc.

9. Cognitive & Social Skill Set.
Reading
Numeracy
Memory
Speed
Attention
Reasoning
Communication
HEALTH
LITERACY

10. A Need for Clarity
 HL gained prominence as a skill set
~ 600 original studies comprise
HL evidence
(crude measures of reading, numeracy, health knowledge)
 But we want more from individuals…
- motivation, cultural factors (language, beliefs, experience)
 …And the health system
- accessibility, navigability, communication, follow-up
 …And community
- education, human services, policy, etc.

11. A Need for Clarity
 HL gained prominence as a skill set
~ 600 original studies comprise
HL evidence
(crude measures of reading, numeracy, health knowledge)
 But we want more from individuals…
- motivation, cultural factors (language, beliefs, experience)
 …And the health system
- accessibility, navigability, communication, follow-up
 …And community
- education, human services, policy, etc.

12. A Need for Clarity
 HL gained prominence as a skill set
~ 600 original studies comprise
HL evidence
(crude measures of reading, numeracy, health knowledge)
 But we want more from individuals…
- motivation, cultural factors (language, beliefs, experience)
 …And the health system
- accessibility, navigability, communication, follow-up
 …And community
- education, human services, policy, etc.

13. 2 Primary Objectives
► A Risk Factor: Health & Healthcare Equity
1. Reduce literacy disparities in health
► An Outcome: Clear Health Communication
2. Promote HL for all healthcare consumers

14. 2 Primary Objectives
► A Risk Factor: Health & Healthcare Equity
1. Reduce literacy disparities in health
Available, imperfect metrics
Mostly – intervention trials
► An Outcome: Clear Health Communication
2. Promote HL for all healthcare consumers

15. What is the Root Cause?
Reading?
Knowledge?
Experience?
Self-Efficacy?
Activation?
Communication?
Beliefs?
Numeracy?
Cognitive Decline?

16. What is the Root Cause?
Reading?
Knowledge?
Numeracy?
Cognitive Decline?
Experience?
Self-Efficacy?
Activation?
Communication?
Beliefs?
D O E S
I T
M A T T E R
W H Y ?

17. Health Literacy ≠ Activation

18. 2 Primary Objectives
► A Risk Factor: Health & Healthcare Equity
1. Reduce literacy disparities in health
Available, imperfect metrics
Mostly – intervention trials
► An Outcome: Clear Health Communication
2. Promote HL for all healthcare consumers

19. 2 Primary Objectives
► A Risk Factor: Health & Healthcare Equity
1. Reduce literacy disparities in health
Available, imperfect metrics
Mostly – intervention trials
► An Outcome: Clear Health Communication
2. Promote HL for all healthcare consumers
Variable, tailored metrics
Widely dispersed studies

21. Daily Mail 25 May 2009

22. … & Simplify.
Reduce healthcare complexity and demands
to match consumer abilities
“Can we confuse patients less?”
Alastair J.J. Wood, MD

23. Deconstruct the Task
d
m e d i c a t i o n
u s e

24. Case Example: Medication Use
A dynamic behavior
(adding, changing, removing medication)
Multi-drug regimens, variable doses
Multiple devices
(pill, injection, inhaler, liquid, nasal, eye drops, lotions, etc.)
Tapered and escalating doses
Doses dependent on measurement (i.e. weight, blood sugar)
Daily vs. non-daily medicines
Limited duration vs. chronic, extended duration medicines
‘PRN’ (Pro Re Nata) or ‘As Needed’ and seasonal medicines
Multiple prescribers, multiple pharmacies, variable instructions
Brand vs. generic drugs (variable trade dress)
Unsynchronized fill dates from pharmacy

25. But What About…

26. Health Literacy
s
research agenda

27. An Abundance of Low Hanging Fruit
Start Early: Familiarize
Youth to Healthcare
System
Set Policies and Standards
Modify Delivery of
Healthcare Services
Train Healthcare
Professionals on Spoken ‘Best
Practices’
Empower Patients to Ask
Questions and Be Involved
Improve Written &
Multimedia Health

28. What We Need.
 Clarity in Definition
- ‘Health Literacy’ (Public Health Goal)
- New Term (risk factor…HSE?)
 New Standard Measures
- Construct measures
- Outcomes (patient, provider, system)
 Implementation of Known Best Practices
 Well-Informed Interventions
 A Good Sell

29. What We Need.
 Clarity in Definition
- ‘Health Literacy’ (Public Health Goal)
- New Term (risk factor…HSE?)
 New Standard Measures
- Construct measures
- Outcomes (patient, provider, system)
 Implementation of Known Best Practices
 Well-Informed Interventions
 A Good Sell

30. What We Need.
 Clarity in Definition
- ‘Health Literacy’ (Public Health Goal)
- New Term (risk factor…HSE?)
 New Standard Measures
- Construct measures
- Outcomes (patient, provider, system)
 Implementation of Known Best Practices
 Well-Informed Interventions
 A Good Sell

31. What We Need.
 Clarity in Definition
- ‘Health Literacy’ (Public Health Goal)
- New Term (risk factor…HSE?)
 New Standard Measures
- Construct measures
- Outcomes (patient, provider, system)
 Implementation of Known Best Practices
 Well-Informed Interventions
 A Good Sell

32. What We Need.
 Clarity in Definition
- ‘Health Literacy’ (Public Health Goal)
- New Term (risk factor…HSE?)
 New Standard Measures
- Construct measures
- Outcomes (patient, provider, system)
 Implementation of Known Best Practices
 Well-Informed Interventions
 A Good Sell

33. Measures

34. Existing Tools
 Individual traits
 Research vs. clinical
 Variable thresholds reported
 Limited modality
 Resilience over time
 Aging
 SES

36. Performance preserved:
- Verbal Ability
- REALM

37. Performance preserved:
- Verbal Ability
- REALM
Performance declines:
- Long-term memory
- Working memory
- Inductive Reasoning
- Processing Speed
- TOFHLA
- NVS

38. Outcomes

39. HL
Outcomesisk Factor
 Background Knowledge (retrieve, recall)
 ‘Functional Understanding’ of Behaviors (apply)
 Self-Efficacy (information-seeking)
 Activation
 Communication
 Behavior change/maintenance
 Health Services Use
 Outcomes

40. HL
Outcomesisk Factor
DIRECT
 Background Knowledge (retrieve, recall)
 ‘Functional Understanding’ of Behaviors (apply)
 Self-Efficacy (information-seeking)
 Activation
 Communication
 Behavior change/maintenance
 Health Services Use
 Outcomes

41. HL
Outcomesisk Factor
 Background Knowledge (retrieve, recall)
 ‘Functional Understanding’ of Behaviors (apply)
 Self-Efficacy (information-seeking)
 Activation
 Communication
 Behavior change/maintenance
 Health Services Use
 Outcomes
DISTAL

42. Implementation

43. Health Information
Evidence strong for best practices:
 Plain language, written materials (Doak 1993; AHRQ 2012)
High
- content, format, quantity(Seligman 2007; Wilson 2010)
- understandability vs. actionability
 Broader evidence base to guide multimedia
- use of imagery or icons w/ text (Morrow et al. 2012)
- video vs. print (Wilson et al. 2012)
- best practices for video/web design (Wilson 2010; Sweller 2005)
 Web/mobile apps require further study(Chomutare 2011)

44. Improve Drug Information.
Yin et al., JAMA Pediatrics, 2008

45. OTC Label
Rx Label

48. Case Example: Transplant

49. Provider Interactions
Limited evidence for verbal counseling
Single Event
 ‘Teach back’ technique (Schillinger 2003; Kandula 2011)
 Implementation Intention (Park 2007; Armitage 2009)
Moderate
Repeat Event
 Teach-to-goal (Baker et al. 2011)
 Brief Counseling (DeWalt 2009; Wallace 2009)
Speech Rate! (Gordon et al 2009)

50. 3 Minutes or Less
 Implementation Intention (Dress Rehearsal)
- Cognitive planning or ‘mapping’ a behavior
- 3 min. counseling
adherence
(Park 2007)
How will you take this?
When will you take this?
How many pills do you take at a time?
It has to be taken with food…when do you eat meals?
Where will you keep it so you remember?

51. Health System Engagement
Addressing practice redesign issues
 ‘Hardwiring’ patient education in practice
- the reality of limited resources (Wolf et al. 2012)
- leveraging electronic health records (EHRs)
- patient portals
Low
 Multifaceted Interventions
- necessary but difficult to implement (Kripalani 2012)
- Deconstructing what actually worked
(Rothman et al. 2004)

52. A New and Simpler
Insurance Provider
Premium
Claim
Essential health
benefits
Health
Obamacare
Enrollment
Marketplace
Pre-existing
condition
Deductible
COBRA
Network
Co-pay
Subsidy
The Exchange
Preventive care
County care
Allowed
amount
Out of pocket
Co-insurance
Preferred provider

54. January 8, 2013
Better Rx
Labeling, Better
Adherence
3 months
9 months
R01HS017687
Demonstrated
Proper Use
1.85 (1.31, 2.60)
1.07 (0.74, 1.57)
2.08 (1.10, 3.98)
1.19 (0.65, 2.18)
Rx Adherence
(pill count)

55. Reprogrammed, Default ‘Sigs’
Epic EHR view

56. Going (Gone) Mobile
Figure X. SMS text for UMS instructions.

57. Interventions

58. Our Current State.
 Few interventions properly evaluated
 Most negative results
 Those that worked, ‘kitchen sink’ approaches
 Need to attend to lessons from other fields
 Need buy-in from healthcare system, industry
 Measures, measures, measures

59. Recommendations
 Include HL measures in research
- preferences?
 Report Standard Thresholds
- gradient or threshold effect?
 Have reasonable, objective outcomes
- what to power to?
 Test for interactions (Goal 1)

60. Recommendations (cont.)
 Recognize performance is dependent on the
system, not just individual
- can you include system attributes?
 Mediating, Moderating Factors
 Consider Activation Separately among others

62. Michael Wolf, MA MPH PhD
Professor, Medicine & Learning Sciences
Associate Division Chief – Research
General Internal Medicine & Geriatrics
mswolf@northwestern.edu