City University of New York
POLICY MEMORANDUMTO: STACIE EVANS, NYC WKDEV LITERACY ADVISORFROM: THE HEALTH LITERACY COALITIONRE: TARGETING HEALTH LITERACY IN NYCDATE: DECEMBER 1, 2016Executive Summary: Health literacy is a prominent issue in the United States, as an estimated 77 million American adults have trouble completing common health-related tasks, such as reading a prescription bottle or adhering to a child’s immunization schedule (America’s Health Literacy, 2008). Low health literacy skill levels are also harmful for the economy, costing the United States approximately $106 to $238 on an annual basis (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007). Although previous community workshops have been successful, health literacy issues continue to persist in New York City (“Health Literacy Campaign,” 2007). Health literacy is dependent upon both patients and their healthcare providers. Therefore, solutions to address health literacy should seek to simultaneously increase accessibility of healthcare information, improve healthcare professionals’ ability to effectively communicate with patients, and improve the health literacy skills of both children and adults. The two most cost-effective strategies include: implementation of health literacy skills in K-12 curriculums and mandatory patient communication workshops for healthcare professionals. Problem: Health literacy is a Challenge for Patients and Their Healthcare ProvidersHealth literacy is the degree to which an individual has the ability to obtain, process, and understand health information and services necessary to make appropriate health decisions.Health literacy affects people’s ability to navigate the healthcare system for essential services. Important components of navigating the healthcare system include: finding providers or services, filling out medical forms, and self-advocacy (“Quick Guide to Health Literacy,” n.d.). Health literacy also impacts people’s ability to share personal information and communicate with providers. In addition, health literacy greatly influences people’s ability to understand written and oral information given by various healthcare professionals, such as doctors, nurses, and pharmacists. Lastly, health literacy impacts people’s ability to manage chronic diseases due to difficulty with following directions for taking medication, preparing for a procedure, and scheduling appointments.Some risks of low health literacy include: poor health status, late entry into treatment for disease, and higher rates of hospitalization (“Health Literacy Campaign,” 2016). Low health literacy hinders patients’ ability to act on information by initiating appropriate appointments and scheduling follow-up visits. Patients with low health literacy may not be able to make decisions about basic healthy behaviors, such as healthy eating and exercise (Mayagah & Mitic, 2009). Prevalence: The Extent of Low Health Literacy0206321Figure 1. Adult Health Literacy Levels in the United States (America’s Health Literacy, 2008)As seen in Figure 1, only 12 percent of adults in the United States have proficient health literacy, which means that only 12 percent of the adult population would be able to figure out healthcare insurance costs and contributions. Just over half of the adult population has intermediate health literacy, which is required to correctly read instructions on a prescription bottle and take medication as directed. Meanwhile, 35 percent (over a third) of the United States adult population is at the basic or below-basic health literacy level, which translates to about 77 million people (America’s Health Literacy, 2008). These individuals have trouble and struggle with common health-related tasks, such as following directions on a prescription bottle or adhering to a child’s immunization schedule. While it is likely a challenging task to improve health literacy to a proficient level, it is important to improve health literacy so that individuals are at least at the intermediate level and able to successfully complete such common health-related tasks. Figure 2. Health Literacy by Ethnicity (America’s Health Literacy, 2008)As evidenced by Figure 2, limited health literacy impacts adults in all racial and ethnic groups. The proportion of adults with basic or below basic health literacy ranges from 28 percent of white adults to 65 percent of Hispanic adults (America’s Health Literacy, 2008). Figure 3. Health Literacy by Education Level (America’s Health Literacy, 2008) According to Egbert & Nanna (2009), much of being able to process and understand information is directly related to a person’s basic level of literacy. However, Figure 3 demonstrates that even high school and college graduates could have limited health literacy (America’s Health Literacy, 2008). For instance, 25 percent of adults with some college education have basic or below-basic health literacy and 12 percent of adults with a bachelor’s degree or higher have basic or below-basic health literacy. Furthermore, the problem of health literacy is prevalent for the 18 percent of Americans whose primary language is not English. These individuals not only lack the access to health information that they need, but they also struggle to process and understand health information that they are actually able to obtain.Factors Contributing to Low Health Literacy:Mayagh & Mitic (2009) describes other factors that may influence health literacy proficiency. In addition to language barriers, cultural differences can affect an individual’s health beliefs, knowledge, and communication. An individual may also have disabilities, such as cognitive limitations, that may negatively impact their ability to fully comprehend information and instructions given by healthcare providers. Although health information is accessible through the internet, individuals who are less educated or of lower socioeconomic status may not have regular access to the internet. Therefore, these individuals have difficulty accessing audience-appropriate information that may be readily available on the internet and still rely heavily on information provided by healthcare professionals (Egbert & Nanna, 2009).In consequence, health literacy is not only dependent on the individual, but also on the features of their health care providers and the public health systems in which their providers practice (Mayagah & Mitic, 2009). Often, patients are not treated by the same provider each time they visit a clinic or hospital, making it challenging for providers and patients to develop and maintain strong relationships. Additionally, hospital demands may be too high for healthcare professionals to spend an adequate amount of time to discuss treatment protocols with patients. As a result, patients may not feel comfortable asking follow-up questions and healthcare providers may have difficulties determining if the patient understands the information or instructions. In an effort to bridge the gap of understanding, many healthcare providers will offer patients printed health information in the form of brochures, articles, or books. However, healthcare professionals are not always careful to make sure that the content of these materials are understandable for the patient (Egbert & Nanna, 2009).When the provider differs from the patient in age, ethnic background, education level, and socioeconomic status, the patient may feel uncomfortable asking questions or sharing personal health information (Egbert & Nanna, 2009). More often than not, patients mask their inability to understand information or directions due to embarrassment. Demands of the context or situation, such as a complex diagnosis, may be also challenging, for the patient to understand.Low Health Literacy Levels are Costly for the Economy:Low health literacy is not only extremely harmful for patients, but harmful for our economy as well. As estimated by Vernon et al. (2007), the cost of low health literacy to the economy of the United States ranges from $106 billion to $238 billion annually. Whereas, improving health literacy could possibly save enough money to insure millions of people in the country who lack coverage.National Efforts to Target Health Literacy:Evidently, low health literacy is a national issue. The U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion (2010), lists nationwide goals to target health literacy including: developing and disseminating accurate and accessible health information, promoting changes in the healthcare system to improve communication and informed-decision making, supporting and expanding local efforts to provide adult education and English language instruction, building partnerships and changing policies, increasing basic research for the implementation and evaluation of practices to improve health literacy, and increasing use of evidence-based health literacy practices and interventions.Potential Local Solutions to Improve Health literacy:Overall, low health literacy is an obstacle to quality, access, and cost-effective healthcare across America. While the U.S. Department of Health and Human Services is addressing the issue on the national level, the New York City Government can also take action steps to address low health literacy on a local level. Due to the importance and the urgency of this issue, we are presenting the following policy options to help resolve the issue of low health literacy in NYC.1. Patient Health Literacy WorkshopsWorkshops in Hospitals:Hospitals may provide opportunities for patient education. For instance, a hospital may host classes or workshops to help improve patients’ health literacy, such as learning how to read prescription labels. These workshops could also be diagnosis specific, such as learning how to self-manage diabetes. Workshops could also target mothers of young children for education on various topics, such as immunization schedules and nutrition. Furthermore, the workshops should be available for and directed at caregivers as well. Caregivers are unpaid individuals such as neighbors, family members, or friends who provide care to older patients or patients who are unable to care for themselves due to a disability. These caregivers can influence the health decisions made by older adults, including how they manage their diagnosis.Workshops in the Community:Healthcare professionals can host health literacy workshops in local centers, places of worship or libraries in efforts to reach individuals in the community. For example, in 2007, the former Mayor’s Office of Adult Education implemented a health literacy campaign. The campaign involved nutrition classes, which included field trips to neighborhood bodegas and groceries (“Health Literacy Campaign,” 2007). Data from Ashraf (2008), indicated that the program was successful. Following completion of the nutrition classes, most adult learners would be able to read the Nutrition Facts Label on drink bottles and more adult learners were able to correctly identify the healthier drink options when given two choices. The NYC government can hold classes at local libraries or collaborate with non-profit organizations, such as the Literacy Assistance Center (“Literacy Assistance Center,” n.d.).Benefits: Patient workshops could be effective because they provide education directly to the individuals who need to improve their health literacy levels, as well as that of their caregivers. Offering these programs in the community would make it more accessible to the public. By improving health literacy, patients would be better able to understand and comply with health providers’ instructions. Consequently, patients will also make better health choices and improve their lifestyle. Drawbacks: Although patient health literacy workshops have optimal effectiveness at increasing patients’ health literacy, it could be costly. Uncompensated volunteers can reduce the high costs of patient workshops, but recruiting and retaining these types of volunteers may be difficult. In addition, workshop attendance may be low due to lack of knowledge about the workshops or lack of advertising.2. Implementing Health Literacy in K-12 Educational CurriculumsThe NYC government can develop and implement policies to make health literacy courses paramount in the elementary, high school, and college education curriculums through mandatory classes. By doing so, health literacy education would be made available to all students who acquire a basic education. Students would gain the skills needed to improve their health literacy levels. For instance, students can learn how to read a prescription bottle, how to read a nutrition label, and learn more about maintaining a healthy lifestyle. According to Kickbush, Pelikan, Apfel, & Tsouros (2013), health literacy empowers people as citizens, members of the workforce, consumers and patients. Improving health literacy levels will inspire people to make better decisions about their health and improve their ability to manage their health. Benefits: Health literacy promotes individuals’ adoption of appropriate lifestyles and sustainable health practices. Students would have easy access to health literacy education through required courses in school. By targeting health literacy issues at the elementary school level, this solution aims to teach basic health management and literacy skills to all individuals, even those who may not complete a high school education. Through this program, healthcare costs in NYC could decrease. The society as a whole would benefit from such educational policies.Drawbacks: While implementing health literacy classes throughout the education system in NYC would be a very effective method of improving health literacy, this solution may be costly and may be unfeasible. For instance, schools may have to hire health teachers or professors if they do not have any readily available on staff. Of course, instructors would have to be compensated for their time spent teaching this class. 3. Inclusion of Patient Communication in Healthcare Professional Education ProgramsThe NYC government can work with professional programs to revamp their curriculums. For instance, healthcare professional education programs can include development and proficiency in plain-language communication as an accreditation requirement. Programs can include health literacy in their curriculums and provide certificates for future healthcare workers so that they can become proficient in the use of plain-language (Kickbush et al., 2013). This would help healthcare professionals in training to learn the importance of using lay terms so that patients can better understand any given information and instructions.In addition, healthcare professional education programs can include cultural sensitivity in their curriculums. As previously stated, patients’ cultural beliefs and practices may impact their desire or ability to follow through with instructions from healthcare providers. It is important for healthcare providers to recognize, understand, and respect their patients’ cultural beliefs, even if these beliefs are much different from their own.Benefits: Plain-language communication and cultural sensitivity are two important components of patient communication. Future healthcare practitioners should learn about these topics and how to address them, so that they are adequately prepared for practice. By including these topics in healthcare professional education programs, these healthcare practitioners will gain useful knowledge and tools to implement in their practice for effective communication with patients.Drawbacks: It may be challenging for NYC to convince healthcare programs to change their curriculums, especially if these curriculums have been in use for several years. In addition, colleges and graduate school programs may have to hire new staff members who are qualified to teach these topics. While this solution would be an effective way to teach aspiring healthcare professionals how to work with individuals with low health literacy, this solution does not reach healthcare professionals already practicing in the field. The students in these programs may forget concepts learned during their studies. Lastly, this solution does not address improving health literacy directly.4. In-house Mandatory Trainings for Healthcare ProfessionalsWorkshops can be held for healthcare practitioners to help them improve their patient-friendly language and to give them advice on making patient-friendly handouts. In addition, it is important that healthcare practitioners are informed about signals that may indicate low health literacy. Some signals include: incorrectly or incompletely filled out forms, patients who do not read any printed material during an interaction, and patients who are unable to self-manage (Egbert & Nanna, 2009). Lastly, workshops can include information on cultural sensitivity. These trainings should be mandatory for healthcare professionals so that they can communicate more effectively with their patients.Benefits: In-house mandatory trainings would ensure that attendance for these workshops is high. It is important to target healthcare professionals, as they are the ones who need to make sure that patients understand instructions and procedures on a day-to-day basis. Patients would be able to better understand information to make well-informed medical decisions, as well as directions to better self-manage their health needs. Healthcare professionals would also learn to be more respectful of their patients’ cultural beliefs and practices. This solution is the most cost-effective and would likely improve patient interactions and communication overall.Drawbacks: This solution does not target improving health literacy directly, as it solely relies on the healthcare provider to improve his or her practice. Workshops for healthcare professionals may disrupt their daily routine and busy schedules. Recommendations:We believe that in order to effectively address health literacy and improve health literacy to the intermediate level, options that address both the problem and its symptoms should be pursued and implemented simultaneously. The most comprehensive and cost-effective combination is implementing both health literacy within educational curriculums for grades K through 12 and mandating workshops for healthcare professionals to improve communication with patients. Addressing the Problem:Implementing health literacy within educational curriculums for grades K through 12 is the most cost-effective solution for improving health literacy skills in New York City. If health literacy skills are addressed at a young age, students can learn to make healthier lifestyle choices through education on various topics, such as exercise and nutrition. At the high school level, health teachers can help students understand doctor instructions or medical information pamphlets through the provision of samples. Health teachers may also give students a list of useful websites for medical information and possibly demonstrate how to navigate such websites. Health teachers can also teach their students how to read prescription labels and nutrition labels, thus empowering them with intermediate levels health literacy skills. We feel that this option is the most cost-effective in comparison to workshops held in the community for adults. Community workshops may be costly for the government and the hospitals that provide them. Furthermore, community workshops may yield low attendance rates and consequently be ineffective at improving health literacy skills. By implementing health literacy skills within pre-existing health classes, students will gain the basic and intermediate levels skills needed to successfully complete common-health related tasks and instructions as adults. This is a strong preventive tool, which will enable students to gain these crucial skills early on in life and at no cost to the students, as they already receive free K-12 education. Addressing the Symptoms:Mandatory workshops to improve healthcare professionals’ patient communication skills are the most cost-effective solution for targeting the symptoms of low health literacy levels. Healthcare practitioners will be encouraged to use simple, patient-friendly language when speaking to patients and their families. Healthcare practitioners will also learn how to make written materials, such as handouts and brochures, that their patients can easily understand. This is more effective and efficient than revamping curriculums for aspiring healthcare professional programs because it targets those who are already working in the medical field. By making these workshops mandatory on an annual basis, healthcare professionals’ communication skills would be reviewed and maintained annually. In addition, it is crucial to address the symptoms of low health literacy levels because there are people who struggle to understand medical information and instructions on a daily basis. Even with the implementation of health literacy skills in the K-12 curriculum, the issue of low health literacy levels will continue to persist for adults. Furthermore, healthcare professionals should be speaking in lay terms, regardless of their patients’ literacy or education levels, to ensure that patients understand all information and instructions provided to them. As previously stated, health literacy can be costly to the economy, so it is important to further prevents unnecessary healthcare expenditures that could arise through complication of diseases caused by low health literacy. The combination of these two options allows health literacy to be targeted at both the problem and symptom levels. Implementing health literacy skills in the K-12 curriculum, while simultaneously treating the health literacy symptoms for adults, could yield optimal outcomes for improving health literacy in New York City. Consequently, implementing these options would address and improve health literacy skills for both children and adults. In conclusion, we would like to thank you for your attention and urge you to address the pressing issue of health literacy for the benefit of the people in our city and our economy. Our hope is that you consider the options that we have outlined for you: patient health literacy workshops, implementing health literacy in educational curriculums, including topics of plain-language and cultural sensitivity in health professional training programs, and mandatory in-house trainings for healthcare professionals. However, we firmly believe that the most cost-effective solutions are implementing health literacy tasks into education curriculums and mandatory workshops for healthcare professionals. These two solutions combined are comprehensive, as they would treat both the problem and its symptoms, and ultimately improve health literacy skills for both children and adults. We are ready and willing to assist further in implementing solutions to address this problem. Please do not hesitate to contact us with any questions or concerns. Sincerely,Francielle SantiagoJoanna HerbaczewskaJoy IgbinedionJuliet KumahHao Lam Appendix: Tables and Other Supplemental Information Table 1. Descriptions of Health Literacy (America’s Health Literacy, 2008)Health Literacy LevelTask ExamplesPercentageProficientUsing a table, calculate an employee's share of health insurance costs for a year.12%IntermediateRead instructions on a prescription label, and determine what time a person can take the medication.53%BasicRead a pamphlet, and give two reasons a person with no symptoms should be tested for a disease.21%Below BasicRead a set of short instructions, and identify what is permissible to drink before a medical test.14% Based on the findings of the nationwide survey conducted in America’s Health Literacy (2008), the National Assessment of Adult Literacy (NAAL) concluded that the following most promising options should be pursued and implemented simultaneously in order to effectively address health literacy:Improve accessibility, usability, and availability of health information.Educate health professionals so that they can become more effective communicators.Improve the health literacy skills of both children and adults. References America's health literacy: Why we need accessible health information. (2008). RetrievedSeptember 5, 2016, from Ashraf, F. (2008). The new york city health literacy campaign: From knowledge to action.Retrieved from Egbert, N, & Nanna, K. (2009). Health literacy: Challenges and strategies. OJIN: The Online Journal of Issues in Nursing, 14(3). doi: 10.3912/OJIN.Vol14No03Man01 Health literacy campaign. (2016). Retrieved September 5, 2016, from Kickbush, L. Pelikan, J., Apfel, F., & Tsouros, A. (2013). Health literacy: The solid facts.Retrieved from Literacy Assistance Center. (n.d.) Retrieved September 5, 2016, from Mayagah, K. & Mitic, W. (2009). Health Literacy. Retrieved September 5, 2016, from Quick guide to health literacy. (n.d.). Retrieved September 5, 2016, from U.S. Department of Health and Human Services: Office of Disease Prevention and HealthPromotion. (2010). National action plan to improve health literacy. Washington, DC: Author. Vernon, J.A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy:Implications for national health policy. Retrieved September 5, 2016 from ................
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