Erin Moaratty

In this podcast, Erin Moaratty talks with Helen Osborne about:

• Medical debt: What this term means, who it affects, why it matters so much.
• Patient Advocacy Foundation (PAF): Services, resources, and examples of how PAF helps patients with catastrophic illnesses.
• Ways you can help: Strategies for professionals, friends, family members, and organizations.

More ways to learn:

• Patient Advocate Foundation. Visit http://www.patientadvocate.org/ or call 1-800-532-5274.
• Co-Pay Relief, http://copays.org/
• insureUStoday, http://insureustoday.org/drupal/PAC/
• National Financial Resource Guidebook for Patients: A State-by-State Directory, http://www.patientadvocate.org/report.php
• National UNDERinsured Resource Directory, http://www.patientadvocate.org/help4u.php
• NeedyMeds, http://www.needymeds.org/
• Partnership for Prescription Assistance, http://www.pparx.org/

Alice Villalobos, DVM, DPNAP

In this podcast, Dr. Villalobos talks with Helen Osborne about:

• How the animal-human bond enriches people, pets, and the environment.
• Ways that animals help humans during sickness as well as health.
• Strategies practitioners can use when talking with patients who have pets.

More Ways to Learn:

• American Association of Human-Animal Bond Veterinarians, http://aahabv.org/
• Delta Society, http://www.deltasociety.org/
• Healing Heart Foundation, Inc. and Pet Hospice, http://www.hhfipethospice.org/
• PAWS (Pets Are Wonderful Support), http://www.hhfipethospice.org/ Go to the Contact page to find your city or state.
• Pawspice Library and Quality of Life Scale at www.pawspice.com
• Society for Veterinary Medical Ethics, http://www.svme.org/

Jessica Ridpath

In this podcast, Ridpath talks with Helen Osborne about:

• Informed consent forms for research. Why these forms can be difficult to read and ways to make them easier for the lay public to understand.
• Problematic words. Examples of words and terms that may cause confusion even though these words are short and familiar.
• Strategies and tools to improve understanding of health research concepts.

More Ways to Learn:

• Program for Readability In Science & Medicine (PRISM). Learn more at http://www.grouphealthresearch.org/capabilities/readability/readability_home.html
• PRISM Readability Toolkit. Available at http://www.tinyurl.com/prismtoolkit
• PRISM Online Training, at http://prism.grouphealthresearch.org

Maureen Johnson

Johnson received a Victorian Travelling Fellowship from the Victorian Quality Council. This fellowship allows emerging leaders to conduct international investigations into innovative responses to health care quality and safety. As part of this program, Johnson recently visited the USA, Canada, England, the Netherlands and Finland.

In this podcast, Maureen Johnson talks with Helen Osborne about:

• Johnson’s health literacy journey. Why she traveled, who she met, what she learned along the way.
• The value of health literacy networking. How it extends beyond hospitals and healthcare settings.
• Salutogenesis. A way of looking at individual health factors, not just causes of disease.

More Ways to Learn:

• Maureen Johnson’s blog, healthliteracyvic.blogspot.com
• Salutogenesis. Learn more at http://www.salutogenesis.fi/
• Women’s Consumer Health Information at the Royal Women’s Hospital, www.thewomens.org.au/HealthInformation
• Victorian Quality Council, http://www.health.vic.gov.au/travelfellowships/
• Hill S (ed), The Knowledgeable Patient: Communication and Participation in Health, Wiley-Blackwell. Released October 2011. Maureen Johnson co-authored one chapter.
• Osborne H (podcast). November 23, 2009. Health Literacy Out Loud #28: Applying Adult Education Principles to Medicine & Public Health. Available at http://healthliteracy.com/hlol-adult-education
• Osborne H (podcast). August 26, 2009. Health Literacy Out Loud #20: Selina Maphorogo Talks About Community Health Education in South Africa. Available at http://healthliteracy.com/hlol-health-education-south-africa

Susan Pisano

In this podcast, Susan Pisano talks with Helen Osborne about:

• Organizing a health literacy task force. How, who, what, why, and when of leading a large and diverse committee.
• Making a strategic plan and being clear about goals.
• Creating tools, tookits, and policies to help task force members.
• Measuring success as a way move projects and ideas forward.

More Ways to Learn:

• America’s Health Insurance Plans (AHIP), http://www.ahip.org/
• AHIP’s health literacy resources. Includes “Health Plan Organizational Assessment of Health Literacy Activities.” Learn more and access health literacy tools at http://www.ahip.org/content/default.aspx?bc=39|341|22050
• Peterson PN, Shetterly SM, Clarke CL et al. “Health Literacy and Outcomes Among Patients with Heart Failure, JAMA 2011:305(16):1695-1701.
• Osborne H (podcast), April 26, 2011. Health Literacy Out Loud #57: Texting Important Health Messages. An audio interview with Julie Gazmararian. Available at http://healthliteracy.com/hlol-texting

In this podcast, Helen talks with Adam Weiss about the second edition of her book, “Health Literacy from A to Z: Practical Ways to Communicate Your Health Message.”

Together, Helen and Adam discuss:

• Who this book is for. What is new and different in the second edition.
• Why health literacy matters to everyone communicating health information.
• How health literacy is about mutual understanding between providers (anyone on the giving end of health communication) and patients (everyone on the receiving end of such communication).

More Ways to Learn:

• Jones & Bartlett Learning. To learn more and order copies of “Health Literacy from A to Z,” go to http://go.jblearning.com/healthliteracy
• Health Literacy Consulting, www.healthliteracy.com
• Health Literacy Out Loud, at www.healthliteracyoutloud.com
• Health Literacy Month, at www.healthliteracymonth.org
• Osborne H, May/June 2006. “In Other Words…Communicating When Naked: My Perspective as a Patient,” On Call. Available at http://www.healthliteracy.com/communicating-when-naked
• Adam Weiss, at www.adamweiss.net and www.podcastconsultant.net

Rebecca Burkholder JD is a healthcare attorney and Vice President of Health Policy at the National Consumers League–a national, nonprofit membership organization that has been representing consumers and workers since1899. Burkholder coordinates the League’s work on various health care issues including safe use of medication, patient safety, doctor-patient communication, and direct-to-consumer advertising. She also coordinates the League’s new national medication adherence campaign, “Script Your Future.”

In this Health Literacy Out Loud podcast, Burkholder talks with Helen Osborne about:

• Medication adherence. What it is and why it is so important today.
• Research about why patients do not take medication as directed.
• Script Your Future, a broad-based educational campaign with tools, resources, and links to help improve medication adherence.

More Ways to Learn:

• Script Your Future, at http://scriptyourfuture.org/
• National Council for Patient Information and Education (NCPIE) Medication Adherence National Action Plan, http://www.scriptyourfuture.org/hcp/download/fact_sheet/Medication%20Adherence%20National%20Action%20Plan.pdf
• World Health Organization (WHO) Report on Adherence http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf
• Questions are the Answer, from AHRQ. Available at http://www.ahrq.gov/questionsaretheanswer/
• Osborne H, June 25, 2008. “In Other Words…’Questions Are the Answer’ to Helping Patients Understand Their Health,” On Call. Available at http://healthliteracy.com/question-asking

Jan Berger, MD, MJ

In this podcast, Dr. Berger talks with Helen Osborne about:

• “Chronic engagement,” a positive term referring to lifelong habits that support good health.
• Using technology to communicate health information in scalable, personalized, cost-effective ways.
• Measuring the effectiveness of health communication and chronic engagement.

More Ways to Learn:

• Silverlink Communcations, at http://www.silverlink.com
• Gerencher K, “Your Health is Calling: Get That Screening Test,” MarketWatch June 27, 2011. Available at http://www.marketwatch.com/story/your-health-is-calling-get-that-screening-test-2011-06-27
• Russo F, “Wellness: Does Your Doc Know What to Look For?” Time Magazine, January 29, 2011. Available at http://www.time.com/time/magazine/article/0,9171,2040210,00.html

Diana Zuckerman, Ph.D.

Dr. Zuckerman is a nationally respected expert on health and health policy, including the safety and effectiveness of medical treatments and the impact of violence on women and families. She has testified dozens of times before U.S. Congressional hearings and other federal and state agencies. Dr. Zuckerman is often interviewed or quoted on television, radio, and the national press.

In this podcast, Dr. Zuckerman talks with Helen Osborne about:

• Why and how national guidelines, policies, and recommendations change.
• How to clearly communicate ever-changing, nuanced health messages.
• Communication challenges ahead as science continues to evolve.

More Ways to Learn:

• National Research Center for Women & Families, http://www.center4research.org/
• Cancer Prevention and Treatment Fund, a new program of the National Research Center for Women & Families. Available at http://www.stopcancerfund.org
• Osborne H (host). 2011, April 5. Health Literacy Out Loud #56: Helping Others Understand Health Messages. Available at http://healthliteracy.com/hlol-helping-others-understand
• Schousboe JT, Kerlikowske K, Loh A, Cummings SR, “Personalizing Mammography by Breast Density and Other Risk Factors for Breast Cancer: Analysis of Health Benefits and Cost-Effectiveness,” Annals of Internal Medicine. July 5, 2011, 155:10-20.
• Welch HG, Schwartz LM, Woloshin, Overdiagnosed. Beacon Press, 2011.
• Woloshin S, Schwartz LM, Welch HG, Know Your Chances: Understanding Health Statistics. University of California Press, 2008. (The book can be downloaded for free from http://www.jameslindlibrary.org/testing-treatments.html

Lee Rainie

In this podcast, Rainie talks with Helen Osborne about:

• The rise of “e-patients.” Who they are. How they use the Internet for health.
• The Internet as a way to increase patient engagement. How Internet usage may differ for those with chronic conditions versus new diagnoses.
• Ways that health professionals can be active members of online conversations, too.
• Rainie’s vision of what health communication might be like in years ahead.

More Ways to Learn:

• Pew Internet & American Life Project. You can access all its reports and datasets for free at http://www.pewinternet.org.
• Health Literacy Out Loud Podcast #54: Dr. David Blumenthal Talks About Health Information Technology. At http://healthliteracy.com/hlol-healthIT
• Health Literacy Out Loud Podcast #53: Blogging to Communicate the Experience of Illness. At http://healthliteracy.com/hlol-blogging

Leslie Bank

Bank has worked as a healthcare “change agent” for over three decades, always striving to assure that the patient’s voice is heard in all aspects of care. This includes her ongoing work in billing reform. In fact, many refer to Leslie Bank as “The Mother of Patient Friendly Billing.”

In this podcast, she talks with Helen Osborne about:

• What empathy is and how it helps build trusting healthcare relationships.
• Strategies and suggestions for using empathy in day-to-day practice.
• Stories and examples of empathy in action.

More Ways to Learn:

• To speak with Leslie Bank, call 718-920-4060.
• “I’m Sorry to Hear That…Real Life Responses to Patients’ 101 Most Common Complaints About Health Care.” Available at http://tinyurl.com/3e4v2g4
• Susan Keane Baker (Bank’s co-author) provides many articles, tips sheets, and other resources about exceptional patient care. Available athttp://www.susanbaker.com/
• The Language of Caring Video-Based Skill-Building Program, by Wendy Leebov. Available at http://www.quality-patient-experience.com/language-of-caring.html

Geri Lynn Baumblatt

In this podcast Baumblatt talks with Helen Osborne about:

• How her health literacy journey began with an interest in science, graduate study in literature, and frustration with being a patient.
• Why clarity and simplicity are needed for multimedia patient education projects.
• Tips, strategies, lessons learned for people seeking health literacy careers.

More Ways to Learn:

• Emmi Solutions: http://www.emmisolutions.com/
• Engaging the Patient blog: http://engagingthepatient.com

Dr. Richard Carmona

In this podcast, Dr. Carmona talks with Helen Osborne about:

• Why he is such a champion of health literacy,
• How health literacy factors in all we do, including emergency and crisis situations as well as public health, and
• What others can do to help. As Dr. Carmona says, “Every citizen needs to become a health literacy public health practitioner.”

More Ways to Learn:

• Canyon Ranch Institute: The Power & Possibility of a Healthy World. At http://www.canyonranchinstitute.org.
• Canyon Ranch Institute’s Perspectives about Health Literacy, at http://www.canyonranchinstitute.org/perspectives/healthlit/

Click here to read a transcript of this interview

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on some amazing conversations with truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today, I have the privilege of talking with Dr. Richard Carmona. He is the 17th Surgeon General of the United States, distinguished professor at the University of Arizona, and vice chairman of Canyon Ranch.

Dr. Carmona understands the importance of health literacy from a lifetime of personal and professional experiences.

Welcome, Dr. Carmona.

Dr. Carmona: Thank you. I’m happy to be with you.

Helen Osborne: I’m delighted. You’re our country’s foremost health literacy champion. How did all this get started?

Dr. Carmona: I don’t know that I want to accept that title. I think I’m one of many that we see here today with Wisconsin Literacy and others around the country who are very passionate about this. I’m happy to be part of the team.

This started years ago as a child with the barriers of growing up with an immigrant family and fast-forwarding into a lot of different jobs I’ve had. I learned I had to become a good communicator, especially as Surgeon General of the United States.

Helen Osborne: I think you’re modest, being the Surgeon General of the United States and touting health literacy. When I heard you speak about it, it was almost an out-of-body experience for me.

I remember way back when we didn’t have the words “health literacy.” I’d ask people, “What are we going to do about health literacy?” They would say, “Health what? Isn’t that teaching people to read?”

Somehow you’ve gotten on board with this and are championing the cause loud and clear. Why does health literacy matter so much to you?

Dr. Carmona: In my lifetime, over about 40 years and lots of different jobs around healthcare and public service, I recognize that part of our responsibility is to be able to communicate with those we serve. If we don’t effectively communicate, then sometimes we’re wasting our time.

Health literacy is simply taking what we know and translating it in such a way that the average person who has a different life, language or culture can use that information to affect behavioral change to improve their health. It’s a really simple equation, but it eludes us because we spend a lot of time on high-tech things.

This is about communication. I’m so happy to see that this health literacy advocacy has grown and swelled in the United States. There are so many organizations, like here in Wisconsin, that are positive advocates because we cannot undergo healthcare transformation effectively without being good health communicators. That’s what health literacy is all about.

Helen Osborne: I know your background is in emergency medicine and crisis communication. It’s also taken a path down public health communication. Do you see health literacy as a factor in both of these spheres? They’re at very different ends of the continuum.

Dr. Carmona: Health literacy is a factor in everything I’ve done in my whole life. Even as a police officer, paramedic, registered nurse, physician assistant or physician, you have to be an effective communicator.

When a police officer shows up in an emergency and there’s somebody unconscious or down, they become the doctor of the moment. They become the savior. Communicating with the people around and giving instructions in an emergency is very important.

With every job I’ve had I see more and more, especially retrospectively, how important communication has been and continues to be for our nation.

Helen Osborne: I think that nobody else listening to this podcast will ever be Surgeon General of the United States. Maybe we will, but probably we won’t. There are people who are advocating within their organizations and communities. They are championing their cause for whatever their realm is. What would you like those people to know and do about health literacy?

Dr. Carmona: As citizens of the United States, every one of us should listen, learn and have a greater understanding of how we interact with our environment, and most importantly, what we can do to stay healthy and prevent disease. That’s health literacy.

As we look at our United States, it is so diverse. Paradoxically, the strength in this nation is its diversity, yet it’s sometimes what creates barriers for us in culture and language.

Every citizen has to understand what we know so that they can incorporate it into their life and make appropriate changes to reduce morbidity and mortality, improve the quality of life and decrease the cost of care. There are a whole lot of endpoints that are desirable.

As we go through this debate about healthcare in our nation, we’re never going to be successful unless every citizen is touched by these messages and then is able to contribute and be part of their pursuit of optimal health. That’s the bottom line.

We who have the privilege to understand health literacy have the obligation to educate our fellow citizens so they get the best benefit of all this great science that’s out there.

Helen Osborne: When you talk about education, what would that look like? In a real way, how can we help educate people to take better care of their own health?

Dr. Carmona: I look at this in a hierarchy. First of all, there are professionals who know the science, but do they really understand how to teach that science and transfer that information? Then there’s the citizen who may be health illiterate. It may be someone with a college degree, but they don’t understand how their daily behaviors ultimately contribute to their health status.

There are all types of gradations. When we move into a community and have people who are trained in health literacy, they understand the culture and environment they’re in and how to deliver resident messages that will hopefully change behavior. One size doesn’t fit all.

What needs to happen is that the concept of health literacy is embedded in everything we do in grammar school, high school and college old-fashioned home economics courses, which we don’t see too much, and all of our professional education. Health literacy needs to be part of that.

Helen Osborne: That’s inspirational hearing that there’s really room for all of us. I’ve often thought, being a health professional myself, that I’m part of the problem. For years, I communicated in ways that I think a lot of the people I worked with couldn’t understand.

I feel that in many ways we are part of the problem, but I also feel that we are part of the solution. You’re helping find ways that we can be putting that into our day-to-day work. That’s just commendable.

What do you see in about five years? What would a health literate United States or world look like?

Dr. Carmona: If I just look at the last decade from when I became Surgeon General, throughout my time as Surgeon General, and then my time working in the last few years with the Canyon Ranch Institute, which is about health literacy as well, that gives us a nice timeline.

When I first started as Surgeon General, as you alluded to earlier, when we’d say “health literacy,” people would say, “What’s that?” Even our professionals would say, “What do you mean?” People would think, “You mean we need an interpreter.” It’s not about an interpreter. This is really about truly translating not only language but culture and understanding.

What I’d like to see in the future is that this concept is embedded in everything we do. Whether you’re talking to the paramedic on the street, a nurse in a public health clinic or a teacher in a school, they all understand the concept that they have to carefully figure out how they’re going to translate what they know to an end user who needs that information so they can pursue optimal health and wellness.

That’s what I’d like to see in the future.

Helen Osborne: That’s a wonderful vision. What do you see as some of the stumbling blocks to get there?

Dr. Carmona: One stumbling block is our own culture. The fact is that those of us who have been educated in the Western world see allopathic medicine in a certain way and don’t take into account the many people who really look at what we call complementary and alternative medicine. There are people who don’t have understanding and people who are displaced because of disparities of health, wealth and so on.

We have to figure out a way to breach those barriers that we call “social determinants of health” today. It’s the message we deliver in an inner-city, underserved population in the South Bronx, like we’re working with in Canyon Ranch Institute, versus where we would deliver a message in Beverly Hills, California.

It’s the same science, but you’re delivering a different message to the population because different populations will resonate based on how you deliver that message. It’s being sensitive to their culture.

Sometimes it works best if you work in an underserved community through the opinion leaders in that community. It might be a priest, rabbi or mullah.

Helen Osborne: It could be a hairdresser.

Dr. Carmona: Barbershops and hairdressers are great for information. It’s a great public health model. In a Hispanic community, they use promotoras, young men and women who are not health professionals but are trained in a particular area. It might be for asthma prevention or mitigation. It may be for maternal/child health.

All of those are extraordinarily important, but we have to use every aspect of society, get them involved, and be better public health practitioners. Every citizen needs to become a health literate public health practitioner.

Helen Osborne: Thank you. That’s wonderful to be able to hear. I also know from your work that is very much based in evidence-based medicine. This is not just the person at the drugstore or barbershop deciding on a health message. We’re giving science-based, accurate health information. Is that correct?

Dr. Carmona: Absolutely. As you see in our meeting with Wisconsin Literacy and others, some of the thought leaders in our world are right here who have studied this for years.  My colleague, Dr. Andrew Pleasant at the Canyon Ranch Institute, is a prolific researcher and writer of textbooks.

So there is a very strong science behind health literacy but incorporating that and being able to translate it is what’s important.

Anybody can do this. It’s not that difficult. It’s not rocket science, as they say. It’s paying attention, being culturally sensitive and learning how to deliver these resonate messages to communities that need this information.

Helen Osborne: Thank you. You’re a wonderful advocate. What would surprise most of us about the work you’ve discovered in health literacy? What about your work would really make someone think, “I didn’t think of that”?

Dr. Carmona: I’ll give you a perfect example that may be concrete. At our Canyon Ranch Institute, we’ve embedded ourselves in the South Bronx in a federally qualified health center where there are 40,000 of the poorest Hispanic immigrants in the country. There are many barriers, like language and culture. We have the highest rates of obesity, type 2 diabetes, hyperlipidemia and depression.

We have measureable indices that we look at. In the two years we’ve been there, we’ve gradually been able to change all of those indices in a health literate model. It’s figuring out how to communicate with this population in a resonant fashion where they see us now as friends, not foreigners. We’ve become part of their family. They trust us.

The proof is in the pudding. All of those metrics I measured are changing. Diabetes is going away. Weight loss is happening. People are becoming more socially and physically active. They’re developing new social networks. The interesting thing is that it’s very simple principles of health literacy that have done it.

Health Osborne: Thank you for that. That’s at the local, individual level. It’s really making a difference to people, communities and health literacy advocates everywhere. I thank you so much for sharing that with listeners of Health Literacy Out Loud.

Dr. Carmona: It’s my privilege. Thank you for the opportunity to be with you today.

Health Osborne: I learned so much from talking to Dr. Carmona, and I hope that you did too.

Health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes as well as the Health Literacy Out Loud website,www.HealthLiteracyOutLoud.com.

Did you like this podcast?

Dr. Carmona: I loved it. It was fun.

Helen Osborne: Did you learn something new?

Dr. Carmona: I did.

Helen Osborne: Tell your colleagues. Tell your friends. Together, let’s tell the whole world why health literacy matters. Until next time, I’m Helen Osborne.

Jeanette Courtad DDS

Dr. Courtad is also an artist with a lifetime of experience painting, dancing, and sculpting. She combines her artistic talents with a passion for educating children about the need for better oral hygiene in her new book, Toothful Tales: How We Survived the Sweet Attack.

In this podcast, she talks with Helen Osborne about:

• Why preventive health messages are often difficult to communicate.
• Ways to draw attention to your message with empathy, wit, and whimsy.
• Strategies that work with children, young adults, and even parents.

More Ways to Learn:

• Toothful Tales, at http://www.toothfultales.com/
• American Dental Association, at http://www.ada.org
• Power of Sour on Your Teeth, Minnesota Dental Association. Available at http://www.mndental.org/public_home/educational_activities/the_power_of_sour_on_your_teeth

Julie Gazmararian PhD

Dr. Gazmararian has published many articles on health literacy topics including medication refill adherence and use of preventive services. Now she is evaluating an innovative project called “Text4Baby” that brings together text messaging with prenatal/newborn care.

In this podcast, she talks with Helen Osborne about:

• How “Text4Baby” is being used to teach about prenatal and newborn care.
• Why text messaging is a communication tool to consider now.
• What researchers are learning early in the evaluation process.
• Recommendations for using text messaging in your practice.

More Ways to Learn:

• Text4Baby. Available for free at http://text4baby.org
• Osborne H. “In Other Words…Using text messages to improve medication adherence,” On Call magazine. September 18, 2008. Available athttp://www.healthliteracy.com/article.asp?PageID=7987
• Archer N, Cocosila M, Haynes RB, Yuan Y. “Can wireless text messaging improve adherence to preventive activities? Results of a randomised controlled trial.” International Journal of Medical Informatics. (2009). PubMed. Web. 28 Dec. 2009.
• Balas EA, Boren SA, Krishna S. “Healthcare via cell phones: a systematic review.” Journal of the American Telemedicine Association. (2009). PubMed. Web. 28 Dec. 2009.
• Chen WS, Leong KC, bLeong KW, Mastura I, Mimi O, Ng CJ, Phua KL, Sheikh MA, Teng CL, Zailinawati AH. “The use of text messaging to improve attendance in primary care: a randomized controlled trial.” Family Practice. (2006). PubMed. Web. 30 Dec. 2009.
• Fry JP, Neff RA. “Periodic prompts and reminders in health promotion and health behavior interventions: systematic review.” Journal of Medical Internet Research. (2009). PubMed. Web. 28 Dec. 2009.
• Haller DM, Patton GC, Sanci LA, Sawyer SM. “Text message communication in primary care research: a randomized controlled trial.” Family Practice. (2009). PubMed. Web. 30 Dec. 2009.

Lisa M. Schwartz, MD, M.S., and Steven Woloshin, MD, MS,

Together, they are working to address two important barriers to health communication: 1) many patients and providers are limited in their ability to interpret medical data, and 2) health messages are often exaggerated or incomplete. Dr. Schwartz and Dr. Woloshin have written extensively on this topic and are co-authors of several books including Know Your Chances: Understanding Health Statistics and Overdiagnosed.

In this podcast, they talk with Helen Osborne about:

• Health statistics, health messages, and health claims. Helping people make sense of what they hear on the news, see on TV, and read in the ads.
• Three questions to help others better understand health messages.
• Ways to communicate complicated health messages more simply and clearly.

More Ways to Learn:

• Woloshin S, Schwartz LM, Welch HG, Know Your Chances: Understanding Health Statistics. University of California Press, 2008. (The book can be downloaded for free from http://www.jameslindlibrary.org/testing-treatments.html
• Welch HG, Schwartz LM, Woloshin, Overdiagnosed. Beacon Press, 2011.
• S Woloshin, LM Schwartz, BS Kramer. “Promoting health skepticism in the news: Helping journalists get it right,” J Natl Cancer Institute 101(23): 1596–1599.
• “Healthy Skepticism,” White River Junction Outcomes Group. Available at http://www.vaoutcomes.org/washpost.php
• Osborne H, “In Other Words…Working With Numbers,” On Call magazine, June/July 2004. Available at http://healthliteracy.com/article.asp?PageID=3745

Dr. Ruth Parker

Dr. Parker’s accomplishments are many, including helping to develop the TOFHLA (Test of Functional Health Literacy in Adults) and co-writing the health literacy definition included in many publications and initiatives including the U.S. Patient Protection and Affordable Care Act (otherwise known as “Health Care Reform”).

In this podcast, Dr. Parker talks with Helen Osborne about:

• Why health literacy matters so much to her, and everyone else.
• Health literacy milestones, especially in the past ten years.
• Health literacy opportunities ahead in this era of health care reform.

More Ways to Learn:

• HealthCare.gov, “Understanding the Affordable Care Act.” Available at http://www.healthcare.gov/law/introduction/index.html
• HealthyPeople 2020, http://www.healthypeople.gov/2020/default.aspx
• Institute of Medicine: Roundtable on Health Literacy. Learn more at http://www.iom.edu/Activities/PublicHealth/HealthLiteracy.aspx
• Nielsen-Bohlman L, Panzer AM, Kindig DA (ed) 2004. Health Literacy: A Prescription to End Confusion. The National Academies Press: Washington, DC.
• Osborne H (host), Baur C (guest). Health Literacy Out Loud Podcast #39: National Action Plan to Improve Health Literacy. June 8, 2010. Available athttp://www.healthliteracyoutloud.com/2010/06/08/hlol-39-national-action-plan-to-improve-health-literacy/
• Osborne H (host), Clancy C (guest) Health Literacy Out Loud Podcast #27: CAHPS Health Literacy Item Set: An Interview with Dr. Carolyn Clancy.November 9, 2009. Available at http://www.healthliteracyoutloud.com/2009/11/09/hlol-27-cahps-health-literacy-item-set-an-interview-with-dr-carolyn-clancy/
• Parker R, Ratzan SC, “Health Literacy: A Second Decade of Distinction for Americans.” Journal of Health Communication, 2010;15 Suppl 2:20-33.
• Somers SA, Mahadevan R, “Health Literacy Implications of the Affordable Care Act,” Center for Health Care Strategies, November 2010. Available at http://www.chcs.org/publications3960/publications_show.htm?doc_id=1261193

Click here for a transcript of the episode.

Transcript:

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen on my conversations with some pretty amazing people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Dr. Ruth Parker who is professor of medicine in the department of medicine at Emory University School of Medicine. Dr. Parker is nationally recognized for her health literacy research, teaching and advocacy.

Dr. Parker’s accomplishments are many, including helping to develop the TOFHLA, or Test of the Functional Health Literacy in Adults, and co-writing the widely used health literacy definition that is in many prominent publications and nationwide initiatives, including the US Patient Protection and Affordable Care Act, otherwise known as Healthcare Reform.

Dr. Parker servers on numerous health literacy panels and advisory boards and has won many awards for her health literacy work. If all of this doesn’t keep her busy enough, Dr. Parker is a marathon runner and an advocate for women athletes of all ages.

Welcome, Dr.Parker.

Dr. Ruth Parker: It’s nice to speak with you Helen.

Helen Osborne: You’re speaking with me, and we have listeners from everywhere listening in on our conversation. I’m so glad to have this opportunity to talk with you. You do so much work in health literacy and have for so long. Why is it so important to you?

Dr. Ruth Parker: It started as kind of a little, lonely endeavor. There were a few folks out there that you know well. Terry Davis and Barry Weiss were certainly out there thinking about how many things are written so much above the level of the patients that we’re trying to help their ability to understand and act on them.

I came into this probably 20 years ago when I was actually involved in working on something totally unrelated with a colleague of mine. He was looking at waiting times in the emergency rooms and how long it took to get cared for in a big, urban public health hospital setting.

What we noticed in a little survey we were giving folks was how quickly they would come back to us and how there just wasn’t time for patients to be able to read them and understand them.

I turned to a hospital administrator, and I remember saying, “Gosh, can our patients read?” He turned back to me and said, “Yes, most of them can.” I said, “What is most?” He said, “I don’t know, two-thirds or so.”

It really just struck me that I had gone all the way through medical school and residency and was practicing and teaching internal medicine as a faculty member, and I had never stopped to think about whether or not people can understand all of the information and all it takes to be a patient.

Helen Osborne: That was your aha moment.

Dr. Ruth Parker: It was an aha moment. I turned to some people who knew a whole lot about it. There certainly are a lot of people that this is no secret to. They’ve been thinking about it and working in it.

The people I turned to were actually from Georgia State University down the street. I learned from those who live in the world of literacy and all that is known about how many people really do not understand what they need to be able to understand to act and that literacy is functional. It is context and setting specific.

Over the next several years we worked on developing a tool for measuring it and then measuring it. Then we worked with others to look at associations. Over the last five, seven to 10 years, we’ve been trying to figure out what in the heck we are going to do about it.

It’s been a long haul with a lot of great accomplishments, but there’s still a lot more to do.

Helen Osborne: There is. I appreciate hearing your story from the beginning. I can resonate with that as well. About 15 years ago, I was in practice myself, and I got bitten by that health literacy bug. It was maybe building on work that you had already started.

This was after reading an article that I found in JAMA, Journal of the American Medical Association, by Williams et al, saying that about half the adults in this country struggle to understand printed information. I looked at the patient population I was treating at a community hospital in Boston and said, “What can I do about it?”

Dr. Ruth Parker: Many of us in the early phases were really trying to figure out how we could quantitate the problem and put reliable numbers as to just how big a problem it was, defining it, putting some words around it, and identifying the prevalence and how common it was.

There were people out there who knew it was real, but we needed the data to back that up. Then we needed to put some studies beside it to say, “What does this mean? How is this related to what we’re seeing about peoples’ understanding of chronic diseases, self-management and outcomes of various sorts?”

I think there was a good decade of work to really amass that information, but it was pretty exciting with the IOM report that came out.

Helen Osborne: The Institute of Medicine report.

Dr. Ruth Parker: Right, and also a lot of other people were coming to the table with various backgrounds saying, “This looks real, but what are we going to do about it?”

It’s pretty exciting to take it from something that’s now recognized as real to saying, “What do we do with that and how do we begin to go after something that is this big of an issue for so many people?”

Putting the mirror on ourselves, those of us who are involved in providing health information, health services, medical care and public healthcare, what can we do to make ourselves more health literate and more understandable?

Helen Osborne: That’s something I think about a lot, the fact that it takes all of us together. Some people bring the research, some people bring the policy, and some people bring the programmatic parts of it.

There is an article of yours that you co-wrote with Scott Ratzan that came out recently. It’s called “Health Literacy: A Second Decade of Distinction for Americans.” It was published in the Journal of Health Communication in 2010. I just think that this is a brilliant overview of what’s been happening in health literacy in the last 10 years.

There’s a sentence in there that particularly resonates with me, and that is, “Health literacy has grown from an under-recognized silent epidemic to an issue of health policy and reform.” I wonder if you could help walk us through exactly how that has happened.

When I look at this wonderful chart you have in there of all that’s happened in the last decade of health literacy, what are some of our milestones?

Dr. Ruth Parker: Helen, you’ve certainly been there at the table and heard a lot of this as it unrolled, but it was probably back in the year 2000 that Scott and I put out the definition for the National Library of Medicine. It went in their current bibliography.

Helen Osborne: You put out the definition of health literacy?

Dr. Ruth Parker: Correct. It was important to have a definition even though there is always going to be discussion and room for improvement, but we needed to put something together that people could come around.

That definition went forward in Healthy People 2010 and was picked up and used by the NIH and the Institute of Medicine for the report that our committee was working on. We had this definition and we started moving forward around that.

Very central to this was the inclusion in Healthy People 2010 early on of a couple of objectives that specifically were around health literacy.

Helen Osborne: Can you give an example?

Dr. Ruth Parker: The main one probably had to do with improving the health literacy of persons with inadequate or marginal literacy skills. That was a specifically mentioned objective. That, of course, helped set some of the policy agenda for federal agencies that are working under the guidance of Healthy People 2010 and what it does for setting a public health agenda for our country.

There were some other very important initiatives that started happening as well. Health and Human Services created and began to have a work group across agencies.

The IOM came out with a report in 2003 that was also really important. It linked health literacy with self-management as a crosscutting priority for the country for transforming healthcare quality to the 21^st century.

This was really important because it meant not only is taking care of and self-managing your health a priority but you have to understand what it is you need to do.

These were crosscutting across all the priorities for transforming the quality of healthcare, with quality obviously being one of the main policy goals for health in our country.

That came out in 2003 before we had the health literacy Institute of Medicine report which was published in 2004, “A Prescription to End Confusion.” Like I mentioned, that did use the definition that Scott and I had put out back in 2000 for the National Library of Medicine.

That report went a long way to lay out specific recommendations and was just a sentinel event in helping to frame health literacy for the country as well as lay out some concrete recommendations.

Helen Osborne: As I look back on my journey with health literacy, I see that Institute of Medicine report as a real turning point. It’s a time when it went from, “What is health literacy?” which is the response I got from others, to “Health literacy: What are we going to do about it?” It’s interesting to see how all of this has been leading up to that. What happened after 2004 to take us to now?

Dr. Ruth Parker: The IOM report in 2004 requested more research. We were fortunate to have the National Institute of Health and the Agency for Healthcare Research and Quality issue a program announcement with review. This stimulated the beginning of some federal funding specific to it.

That was so important to stimulate the work of many to try to advance what it is we can do about the problem. That was first issued in 2004 and was reissued in 2007 and again in 2010. With that, we saw more and more people coming to the table and being involved.

The Institute of Medicine continued their good work of pulling together stakeholders by creating a roundtable. Since 2006 they have met at least twice a year, bringing together people around all kinds of issues related to what we know, what we need to learn more about, who the stakeholders are and what we can do.

They’ve also published a series of workshop summaries that have helped to raise awareness and educate. They have looked at specific issues like quality of care and prescription medication labels.

Helen Osborne: I have been to some of those, and they are really impressive. They are very fast-paced. Every 15 minutes somebody different is presenting. I just go to listen in and sit on the sidelines. It’s very impressive.

Dr. Ruth Parker: It has drawn a lot of people from different constituencies. One of the last ones we had had to do with a state-based approach. It was held out in California. It’s a wonderful venue. We’ve got another one that has become very active on health reform, looking at what the opportunities are and what we could do with that.

It’s a wonderful opportunity to bring together stakeholders from multiple constituencies who are vested in doing something to address the issue and to continue to make this a part of the public health agenda for the country. I’m always incredibly grateful to the IOM for their convening and continuing to support the efforts of all types of people who see this as a real issue for us to be engaged in.

Helen Osborne: I’m looking at your article now. There are so many more landmarks and milestones along the way. I also want to get to what the opportunities are ahead. You talked about the Affordable Care Act, otherwise called Healthcare Reform in the US. Where does health literacy fit in in that?

Dr. Ruth Parker: It was certainly wonderful to see the definition of health literacy actually written into the Affordable Care Act, the ACA as many call it, and to have that definition included. It’s very extensive legislation and there is a whole lot in it. I think most people are still trying to digest what all is in it and what does it mean for me?

We did have a recent Institute of Medicine roundtable workshop where we focused very specifically on health literacy implications of the Affordable Care Act.

In addition to noting that the definition was in there, we were able to identify through a white paper that was presented at that workshop where there is direct mention of health literacy relating to research and the dissemination of research in order to get information out to the people that it can help and who might benefit from it.

It went into shared decision making and what it means to share information between providers and patients as consumers of health and healthcare. It also covered medication labels, which patients need to be able to pick up and understand on an everyday basis as they self-manage all types of conditions.

In workforce development, for those of us who are involved in providing health and healthcare, what is it that we need in order to be confident as health literacy providers? There again, the emphasis has more recently been on those of us who are involved in the delivery of health and health information. How health literate are we?

We spent a lot of time early on defining the public and saying, “What do we know about the skills and the abilities of the public?” I think it’s very exciting that in the last five to seven years we’ve really been willing to turn it the other way.

We can say as we move toward interventions, “What is it that we can do to make ourselves health literate and understandable and to make sure that what we tell people is actionable and meets them with their abilities and skills to use the information?”

Helen Osborne: That’s how I am seeing the health literacy definition evolving. It’s as looking at the alignment between the needs of the system and the needs of the individuals.

Many people email me and ask, “How do I measure health literacy of my colleagues? I want to do some training. How do I figure that out before and after?” Under this workforce development part, do you have any ideas or recommendations for us?

Dr. Ruth Parker: I think that is still very much an evolving area. It’s on the horizon and we’re seeing it mentioned. We’re seeing people talk about it. Certainly awareness and understanding of the issue is a first phase.

Then you get into the nitty-gritty. What exactly does it mean? Helen, I think you would be a good one to say. You know it when you see it, but how do you measure it?

We also know that what gets measured gets done. That’s really true from an organization or a system level. If we want to see impact on something that’s as big a problem as health literacy in our country, we need to have ways to measure it and to gauge it.

Helen Osborne: I actually comment that the opposite way. I’m more on the practice side of what I do. Some things right now are hard to measure, and I see these standards where things need to be written at whatever low grade level they can come up with and it frustrates me time after time.

Just because you reduce the number of syllables doesn’t make something easy to understand, but it’s easy to measure. How would you go about balancing between the need to measure something, and I appreciate that, but finding the right things to measure?

Dr. Ruth Parker: I think you’re right, and I think ultimately the goal is to measure the alignment. How well does what you need to be able to do align with the skills and abilities of the people who need that information?

What we really need to know is how well aligned are we? How good a job are those of us who are putting out all this content doing at aligning that with what people need?

A very simple example I think, is to take a look at a pill bottle. You pick up a pill bottle, and very commonly you will see an instruction that would say, “Take one pill twice a day.”

What’s the reading grade level requirement of that? It’s very low, but then you and I could immediately say, “What is twice? Is twice in the morning? When is the morning? Is it morning and midday? When is midday? Is it 8:00 a.m. and 8:00 p.m.? Does it matter in terms of how the medication works and its safety or efficacy?”

If it matters, why doesn’t it specify that on a bottle that is given out so commonly, every day in our country and varies across state lines?

The question is how well are we as providers doing at offering to the people who need it something that is understandable, actionable and actually useful? We’re flunking.

How do you measure and capture that? You capture it when you don’t have a problem with the misalignment any more. How do we go about coming up with useful gauges and measures?

We’re struggling with that. I think this is doable, but I think it is all still part of being nescient and also being new to realizing what our ultimate goal is.

Helen Osborne: That’s what I was wondering about. What is this goal? You’re a marathon runner. You know that 26.2 miles, or whatever it is down the road, there’s a finish line. What is that finish line we’re all running toward?

Dr. Ruth Parker: The finish line is the alignment. When what you need to know to understand, know and do for your health meets you with your own skills and abilities across various skills and abilities, everybody gets it because it’s presented in multiple ways with reinforcing messages that mean the same thing. That’s the art and science of communication.

You would probably agree with me that we’re masters at putting out volumes of content. We do it more and more, but more is not always better. More is just more. What we really need to do is understand what the essential need to know to do is.

For example, with the pill bottle it’s the real meaning. It’s take one at 8:00 a.m. and at 4:00 p.m. If we know that, we can find a way to say it. “Take one twice a day” is not clear by its inherent nature, yet that’s what’s on the bottle. That’s a very simple example, but it’s so common.

Helen Osborne: It is so common. It’s everywhere. I see another problem ahead is that it seems to be a moving object, what it is that we as patients and family members need to understand, such as nutrition information. Some days it’s good to eat this kind of food. The other day don’t eat that kind of food. It’s constantly changing. Maybe that’s why we have so much information out there. It’s confusing.

Dr. Ruth Parker: It’s confusing, and what we do is put out lots of information. Just because it’s content doesn’t mean that it’s good. I think that many people just begin to ignore it because they don’t know what to believe, why to believe it, what is really valuable and what is really necessary

I think in general, people care about their health and are vested in it. They want to be healthy. We’ve said over and over that it really is hard to be a patient. It really is hard to know what to do.

It’s so incredibly easy to make a mistake, mess up and lose trust in knowing what to believe and why, especially when information that you may need is not even accessible in terms of its navigability or understandability. The clearer those of us who care about this are about what the essential need to know to do is, the better.

It’s not only taking an entity like your diet, care for your diabetes, care to get to the optimum weight or the optimum approach to your own fitness. Once you know what you need to know, it’s understanding with clarity what that is, what that means and then finding a way to communicate that so its meaning is accessible to people of various literacy levels.

Helen Osborne: I wonder if you could help. For all of us who are advocates of health literacy, for our listeners who really are passionate about the topic and want to make a difference, how can we challenge people? What can we give them to do that maybe could make a difference tomorrow, not just way down the road?

Dr. Ruth Parker: I think for all of us who care, it comes down to figuring out who it is we’re trying to reach with whatever it is we’re doing. Are we looking to address individuals or an entire system that provides health information or health services?

We can take wherever we are and say, “What is it I’m trying to communicate? What is the evidence for it? Do I understand what the message is? Do I understand the real nitty-gritty of this?”

Take that and make sure that people across levels of understanding can understand it, and then find multiple channels that reinforce that. Use print, but beyond that, how do we reinforce evidence-based content and make it accessible across levels?

We have to do this up front. So much of what we do is try to retrofit and take content that’s out there and say “People didn’t understand this. How do we make it fit now?”

We’ve already lost a lot of our audience in that approach. If, on the front end, we work to make things understandable, actionable and accessible rather than trying to take volumes of content and retrofit it, we’re going to find it easier.

We’re still trying to figure out what that process really looks like. There are some people doing it and doing it effectively, but the real challenge is to make this seamless. This needs to become a part of what we do all the time.

Helen Osborne: Do you see us getting there?

Dr. Ruth Parker: I absolutely do. Look at the opportunity for enrollment of all the people who currently don’t have health services. Under the opportunities to reform, we could take the process of enrollment and make it on the front end a process that people understand, navigate and recognize.

We can make it process that’s not something that tries to do the same thing hundreds of different ways and becomes just inaccessible by its own design.

Helen Osborne: I thank you for all of that. You really are bringing that whole big picture and big vision. You’re working on policy and research at the highest level, but you’re also giving us that how-to information so we can make a difference wherever we enter this conversation. You’re making it very accessible for us to understand, follow and do.

Thank you so much for being a part of this podcast but also for helping champion the cause and lead the way for health literacy.

Dr. Ruth Parker: It is a pleasure, Helen. Thank you for getting the word out. There are wonderful people working on this, and it’s a lot of fun. We welcome others to the table. It’s a delight to chat with you about it.

Helen Osborne: We will be having some of the references that you mentioned on the Health Literacy Out Loud website. Thank you very much.

I learned a lot from Dr. Parker and hope that you did too. Health literacy isn’t always easy. For help in clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free e-newsletter, “What’s New in Health Literacy Consulting.”

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes as well as the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? More importantly, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.

Dr. Blumenthal’s credentials are extensive. He not only was a practicing primary care physician but also is a renowned researcher and national authority on health IT. Dr. Blumenthal serves on numerous national boards and has authored over 200 scholarly publications, including “Heart of Power: Health and Politics in the Oval Office,” which tells the history of U.S. Presidents’ involvement in health reform, from FDR through George W. Bush.

In this podcast, Dr. Blumenthal talks with Helen Osborne about:

• What Health IT is and why it’s needed in healthcare today.
• How Health IT benefits providers, researchers, and patients.
• Concerns about Health IT and work being done to address them.
• What an ideal Health IT world would look like 20 years from now.

More ways to learn:

U.S. Department of Health & Human Services: The Office of the National Coordinator for Health Information Technology. Available at http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204

Pamela Katz Ressler, RN, BSN, HN-BC

In this podcast, she talks with Helen Osborne about:

• What blogging is and why it matters to both patients and providers.
• Ways that blogging reflects the experience of illness and fosters resilience.
• Practical strategies and resources for those new to blogging.

More Ways to Learn:

There are many ways to contact Pam and learn about her work:

• Website: http://www.StressResources.com
• Blog: http://pamressler.blogspot.com
• FB: http://facebook.com/StressResources
• Twitter: @stressresources @pamressler
• LinkedIn: http://www.linkedin.com/in/pamelakatzressler

Blogging references and examples include:

• http://www.stressresources.com/patientblogging.html
• http://learn.wordpress.com/get-started/
• http://www.youtube.com/watch?v=BnploFsS_tY

Beyond her work with Reach Out and Read, Dr. Klass is a professor of journalism and pediatrics at New York University and also works at Bellevue Hospital Clinic. She served on the Health Literacy Project Advisory Committee of the American Academy of Pediatrics. In addition, Dr. Klass is a widely published author of both fiction and nonfiction, who writes frequently about topics concerning children and health. She also writes about her ongoing interest in knitting.

In this podcast, she talks with Helen Osborne about:

• Reach Out and Read, a program to encourage early literacy and promote reading aloud.
• Why it is important to address literacy in well-child pediatric visits.
• The intersection of literacy, learning, and health from childhood on.

More Ways to Learn:

• Reach Out and Read, http://www.reachoutandread.org
• Osborne H, “In Other Words…Make a Difference…Be a Literacy Volunteer,” On Call magazine, April 2001. Available at www.healthliteracy.com/literacy-volunteer

Barbra Rabson

In this podcast, Barbra Rabson talks with Helen Osborne about:

• How comparative performance data helps providers and consumers alike.
• “Expect the Best,” a consumer campaign focused on healthcare quality.
• Strategies and tips for climbing the “mountain of mutual understanding.”

More Ways to Learn:

• Massachusetts Health Quality Partners (MHQP) Quality Reports, at www.mhqp.org
• National Guideline Clearinghouse, at http://www.guideline.gov
• Partnership for Healthcare Excellence, at http://www.partnershipforhealthcare.org/
• U.S. Preventive Services Task Force, at http://www.ahrq.gov/clinic/uspstfix.htm

Carolyn Ijams Speros DNSc, FNP-BC

In this podcast, she talks with Helen Osborne about communicating with older adults. Topics include:

• Special learning needs of older adults due to cognitive, psychological, and physical changes associated with aging.
• Strategies to communicate effectively, even when there is limited time.
• Respectful ways to assess and confirm that information is understood.

More Ways to Learn:

• Dr. Carolyn Speros is Associate Professor at the University of Memphis Loewenberg School of Nursing. You can email her directly at csperos@memphis.edu
• Speros CI, “More than Words: Promoting Health Literacy in Older Adults,” The Online Journal of Issues in Nursing. 2009; 14(3). Available at http://www.medscape.com/viewarticle/717469
• Speros CI, “Health Literacy: Concept Analysis,” Journal of Advanced Nursing. 2005; 50(6), 633-640.
• Centers for Medicare & Medicaid Services, Toolkit for Making Written Material Clear and Effective. Part 9: Material for older adults. Available at http://www.cms.gov/WrittenMaterialsToolkit/11_ToolkitPart09.asp#TopOfPage
• Knowles M, 1990. The Adult Learner: A Neglected Species, 4th ed. Houston, TX: Gulf Publishing Company.
• Knowles M, 1980. The Modern Practice of Adult Education: From Pedagogy to Andragogy. Englewood Cliffs, NJ: Cambridge Adult Education.
• Osborne H (host), Stuen C (guest), September 8, 2009. Health Literacy Out Loud Podcast #21: Age-Related Vision Loss. Available at http://www.healthliteracyoutloud.com/2009/09/08/hlol-21-age-related-vision-loss/
• Osborne H, 2005. Health Literacy from A to Z: Practical ways to Communicate Your Health Message, Jones & Bartlett: Sudbury, MA.

Transcript:

Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month, and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some pretty amazing people. You will hear what health literacy is, why it matters, and ways we all can help improve health understanding.

Today, I’m talking with Dr. Carolyn Speros, who is a nationally recognized expert in patient and public health education. As a nurse, she has worked in nursing education, administration and advanced practice, all focusing on systems and strategies to promote health literacy.

Dr. Speros is associate professor of nursing at the University of Memphis and also maintains a practice as a nurse practitioner.

Welcome, Carolyn.

Carolyn: It’s good to be here and talk with you, Helen.

Helen: I first met you, so to speak, when I was reading the article that you wrote in The Online Journal of Issues in Nursing. The name of the article is “More Than Words: Promoting Health Literacy in Older Adults.”

I was so wowed by reading this article. Not only are you addressing a topic that is near and dear to my heart and that I’ve been focusing on for a while, but you included so many how-to strategies. Thank you for being willing to share these with the listeners of Health Literacy Out Loud.

Carolyn: It’s my pleasure. It’s a topic that I’m very passionate about.

Helen: Let’s put this into context. What’s so special about the learning needs of older adults?

Carolyn: There are several things. First of all, older adults are subject to changes associated with aging. So many times, those of us who communicate with our older adult patients fail to accommodate those changes. We often teach just like we teach patients in other age groups.

Helen: What are some of those changes? Can you give us some examples?

Carolyn: Sure. There are certainly cognitive changes that are associated with aging, along with psychological and physical changes.

Some of the cognitive changes are the inability to do what I call “mental multitasking” and putting a lot of pieces of information together. Another kind of change we often see is a decline in what we call “fluid intelligence” or the process of reasoning. That’s why you see a lot of elderly people get so frustrated if you rush them.

Helen: Is it multitasking or that you’re asking people to think about something and do it physically? What is included in that multitasking or fluid intelligence?

Carolyn: It’s managing a variety of different bits of information and recalling them from their short-term memory. Here I am, aging myself at 61. I find myself a lot of times not being able to recall certain things that I need to use just to function or make a certain decision.

As we age, the ability to recall those multiple bits of information declines. That’s why we recommend, when teaching and communicating with elderly patients, that you keep it down to three to four different concepts. That’s the max. People just can’t process more than that.

Helen: Is there a factor with time? I know it’s always an issue that our appointments aren’t long enough. We’re always having to get hither and yon and do something else. Is that more acutely a problem with the older population?

Carolyn: It is a huge problem. I know in my family practice, we are seeing patients at a very quick pace. We have to see a lot of patients.

It is something that has to be accommodated for because in the end, you’re going to find that if the patients don’t understand what you’re talking about or guiding them through, then they’re going to be coming back and having more questions. In the end, they’re not going to be compliant or able to manage like you hope that they will.

Helen: What can we do with the very real constraints we have of limited time?

Carolyn: What I try to do myself is be as efficient in teaching as possible. I’ve tried to master these principles so that when I have an older adult that comes in, I know my communication is as effective and efficient as it can be.

I try to pace my speaking throughout the examination and teach from the very minute that I see the individual so that I maximize the limited time that I have with my patient in the practice.

We also do try to work with our scheduling staff so that the older patients are scheduled in the mid morning, if possible. They’re rested and more receptive to the teaching and communication that we have with them at that time, as opposed to being rushed or tired in the afternoon. They’re kind of collapsing mentally at the end of the day.

There are certain kinds of controls that we try to build into the systems in which we work.

Helen: That makes sense. I would think that maybe you have a little bit more time in mid morning, too, when you’re not as rushed.

Carolyn: Exactly.

Helen: You talked about all the changes. Thank you for addressing the cognitive ones. What about the others?

Carolyn: The psychological ones are very real to the elderly people. They have to deal with loneliness and the depression associated with that. There’s a loss of independence and almost a grief response that they go through with that. Certainly, it’s hard to generalize across the board, but many elderly people suffer with that.

Often we don’t address that as we work with our patients. As we talk with them, we tend to just tell them what we think they need to know without taking these emotional and psychological concerns into consideration.

Helen: Can you give an example of how you would do that in practice?

Carolyn: I’m fortunate that in a family practice, I can see people over time. I can get to know them better. I just try to work with that individual as much as I can. I may know that they’ve recently lost their spouse, or they may share that. I’ll ask about their family. It’s all part of the assessment.

Try to ask them specifically and get to know them as a person in terms of what makes them happy. What kind of social support system do they have? Do they get out and do the kinds of things that energize them or help them deal with some of the issues that they’re going through?

Helen: Thank you. I really appreciate hearing that. My background is that I worked as an occupational therapist in psychiatry for many years, so it really resonates when we see people as people, with all their issues that are going on, including emotional ones.

You talked about one that really resonated with me about grieving the loss of independence. Sometimes we think about grief just from losing a spouse, loved one or maybe a function, but really, grieving that independence is vital in somebody’s life.

Carolyn: It is, and so much of our teaching should be directed toward helping someone sustain that independence as much as possible. If you can reach that as a common goal, the elderly person may be more receptive to what you’re trying to share with them.

It may be a different type of independence than you and I may imagine, but given the physical and functional limitations that elders are experiencing, teaching something that’s realistic within those constraints can give that individual a lot of hope.

Helen: I know from my mother’s last days about the importance of hope in her life. What she hoped for and what was realistic and achievable may have changed from when she was younger, but there was always some measure of hope.

Carolyn: That’s right. That is the common goal, that you have a sensitivity to that and appreciate it.

Helen: Thank you. The third part you talked about was the physical changes. Tell us more about that.

Carolyn: As people age, we all go through a great deal of physical change. Particularly, the vision and hearing change and dramatically impact receptivity to teaching.

There are very specific visual changes that we can address. Of course, the presbyopia or decreased visual acuity is something to work with, along with the changes in the structure of the eye. The yellowing of the lens affects an individual’s perception, for instance, of colors on the blue end of the spectrum.

I always try to encourage others to do this and do it in my own practice. I avoid highlighting or using any colors that are blue or green, like violet, for instance. Stay away from those and go for the brighter colors of the spectrum.

Helen: Thank you for that. I wanted the listeners to know that I’ve actually done a podcast about visual changes as people age. We’ll put a link on the Health Literacy Out Loud website.

Carolyn: Please do because there is a lot involved in doing that.

Certainly, hearing changes. That’s associated with the presbycusis that occurs. You may have a podcast on that as well.

Helen: Not yet.

Carolyn: It’s avoiding those high-pitched sounds. The elderly tend to have problems processing them.

Helen: What is a high-pitched sound?

Carolyn: It’s a female voice, for one thing.

Helen: Oh dear!

Carolyn: Yes, there are a lot of female voices that are very high-pitched. We just need to be conscious of that and lower the pitch of our voice. We don’t need to lower the loudness of it, but the pitch.

Helen: When you talked about the loudness, there’s no benefit in shouting, is there?

Carolyn: There is no benefit in shouting. If you get an appropriate distance and face your patient, many patients as they age are so dependent on looking at your facial expressions, reading your lips and watching what you say. It’s just something that we need to be cognizant of as we talk with people who are older.

Helen: Thank you for putting all of that into context along with your many strategies of what to do. I know you do a lot of work and teaching about health literacy. How do you frame this within the greater principles of health literacy?

Carolyn: In terms of working with the elderly, these are probably our most vulnerable patients as I’ve worked with nursing people and people in medical fields. These are our biggest users of our healthcare services and the ones who are affected most by chronic illness.

There is so much education and communication that goes along with managing those chronic illnesses. Our impact is greatest if we just adapt how we work with this particular group of patients. Our work is extended beyond just how we work with other age groups.

Helen: I really like the way that you expand the definition of health literacy to include all of us and those of us who are most vulnerable, for whatever reason. That certainly is the way that I frame health literacy too.

Talking about framing, I know that you and I go with the same theory behind what we do. That’s called the “theory of geragogy.” It’s a way of teaching. I wonder if you could explain that for some of our listeners.

Carolyn: I was first introduced to the term “geragogy” in the ’90s. Originally, it came out of Germany from the educational group who built and expanded on Malcolm Knowles’ theory of adult learning, which is andragogy.

Geragogy is really teaching in a way that compensates and adapts to the cognitive, physical and emotional changes that go along with aging, just like we’ve been talking about. It is a process of teaching that is very specific to this older age group.

Helen: Thank you. I like the way that you framed it in terms of compensating and adapting to what the other person brings us.

Let’s say we put into place a lot of these strategies and are doing our best to be very respectful and clear in how we’re communicating. How in the world will we ever know if we’ve done our job well?

Carolyn: Of course, I’m a huge believer in the teach-back technique of evaluating. It’s just giving our patients the respect of saying, “Tell me how you’re going to use this in your everyday life,” “Tell me what you’re going to be doing now that we’ve talked about this,” or “Is there anything different in terms of what you’re going to be doing that will help you along the way?”

Helen: Carolyn, I’ve run across this question lately. I know I have my own set of answers, but I’d be interested in yours. Some people are afraid that that question alone seems disrespectful. How can we frame it in ways that are respectful? I’m sure that you do that. I feel it’s respectful, but people sometimes feel like they’re putting the other person on the spot or testing them.

Carolyn: What’s interesting is that I don’t encounter that in my practice. A lot of it is just the compassion or caring that is transferred through every bit of your nonverbal and verbal behavior.

The element of respect is hard to articulate, but as I’m working with my elderly patients, from the very beginning, I try really hard to establish a relationship where there’s honest two-way communication. When I say, “Tell me how you’re going to be doing this,” that’s conveying genuine concern that they’re processing what it is that I’ve been sharing with them.

Helen: I hear that in your voice, for sure. I was just trying to address what I hear from other people. Maybe those are the folks who are writing the protocols or something. How can you say in any protocol, “Respect the other person”? You can say it, but how can you act on it? It certainly comes through strongly and clearly in how you are communicating with us.

Carolyn: It’s just very difficult to say what the steps are in caring and respect and articulate that.

Helen: Maybe that’s your next paper.

Carolyn: There is some work out there on caring that is excellent.

Helen: Talking about your next or past papers and all your work, how can listeners learn more about the concepts of health literacy and education with older adults?

Carolyn: We’re very fortunate that, as an area of interest, health literacy is being written about and studied more than I’ve ever seen before. You and I have been doing this for a long time. I go back to the early ’80s, when I became involved in patient education. We didn’t use the term “health literacy” at the time, but I’ve seen this whole area of interest and work expand.

I would encourage the listeners to read and search the literature. There’s such good work out there. People are doing amazing research and thinking in this area.

Helen: You’re one of our big thinkers in that area. I thank you. We will have a link to your article, the one that I referenced, on our website, as well as other resources.

Carolyn: That’s great.

Helen: Putting this together, Carolyn, you and I aren’t getting any younger here.

Carolyn: No, and that’s why I’m hoping that all of the people listening who are younger than us and will be future caregivers of us will put these kinds of steps in place as they touch, care for and communicate with us.

Helen: That’s what I was going to ask you. It’s exactly what I was thinking as you were talking about this. What would be number one on your wish list as we’re the ones being talked to and with?

Carolyn: That’s it. Number one is that I would hope my care provider would talk with me. They would come to know me as a person as best as they can, show that respect, and understand what kinds of limitations I have and what makes me unique as an older person. I’d like an appreciation of that and how to communicate with me directly. That’s my number-one wish.

Helen: I’m right with you. I hope that whoever will be my caregivers in the years ahead will listen to this podcast, read your article, and know how to communicate with us as individuals in a respectful way and ways we can understand.

Carolyn, thank you so much for sharing your wisdom, sensitivity and lessons learned with the listeners of Health Literacy Out Loud.

Carolyn: Helen, I appreciate the opportunity to do this. Thank you so much.

Helen: I learned a lot from Carolyn Speros and hope you did, too.

Health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website atwww.HealthLiteracy.com. While you are there, feel free to sign up for the free e-newsletter, “What’s New in Health Literacy Consulting?”

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, as well as the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? I sure did, and I hope you did, too. Please tell your colleagues and friends about Health Literacy Out Loud so together, we can let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.

Jeff Belkora PhD is a faculty member at the University of California, San Francisco (UCSF). There he runs the Medical Center’s Decision Services program, helping patients weigh the risks and benefits of their treatment options. Belkora also consults with outside organizations about decision support for patients making life-changing choices. In all this work, Belkora’s focus is on leadership, teamwork, and decision-making.

In this podcast, he talks with Helen Osborne about:

• How decision support helps patients reflect critically on life-changing choices.
• Strategies and systems to help patients understand decisions and communicate effectively.
• Lessons learned that listeners can use in day-to-day practice.

More Ways to Learn:

• UCSF Medical Center: Breast Cancer Decision Services, at http://decisionservices.ucsf.edu
• Jeff Belkora’s Guidesmith site, www.jeffbelkora.com
• Foundation for Informed Medical Decision Making, http://www.informedmedicaldecisions.org/
• American Cancer Society, http://www.cancer.org/
• National Cancer Institute Help Options, http://www.cancer.gov/help
• Osborne H, “In Other Words…Helping Patients Make Difficult Decisions,” On Call magazine, April 2004. Available at http://www.healthliteracy.com/article.asp?PageID=3808
  

Michael Mackert PhD

• Advertising and public health campaigns. How these strategies are alike and how they differ.
• Ways to use social media and traditional press to promote your public health message.
• Stories, examples, and practical suggestions you can use right away.

More Ways to Learn:

• Michael Mackert PhD is an Assistant Professor in the Department of Advertising at The University of Texas at Austin. You can reach him by email at mackert@mail.utexas.edu.
• To learn more about Mackert’s research, go to his blog at http://www.healthcommunicationresearch.com.
• AHRQ’s campaign, “Real Men Wear Gowns” is available at http://www.adcouncil.org/default.aspx?id=501

Deborah Wachenheim

HCFA’s Consumer Health Quality Council drafted legislation that was recently enacted to establish Patient and Family Advisory Councils at all hospitals in Massachusetts. In this podcast, Wachenheim talks about the process of making this happen.

Topics include:

• Patient and family advisory councils. What they are, how they help, and who they include.
• Process of drafting and enacting a new statewide law.
• Lessons learned about patient councils and the legislative process.

More ways to learn:

• Deborah Wachenheim is the Health Quality Manager at Health Care for All. You can contact her by email at dwachenheim@hcfama.org.
• Health Care for All, http://www.hcfama.org/. Click this link to find more information about Patient and Family Advisory Councils.
• Institute for Patient and Family-Centered Care, http://www.ipfcc.org/