Health Literacy and Aging

Presentation by Irving Rootman to SFU Class on Principles and

Practices of Health PromotionOctober 4, 2010

Outline

What is health literacy?

How is it measured?

How does it relate to aging?

What impact does it have on older adults?

What are the determinants of health literacy in older adults?

How can be done to address health literacy in older adults?

What is health literacy? the ability to access, understand,

evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course (CPHA Expert Panel on Health Literacy).

(Rootman and Gordon-El-Bihbety, 2008)

Literacy is…

the ability to understand and use reading, writing, speaking and other forms of communication as ways to participate in society and achieve one’s goals and potential” (CPHA Expert Panel on Health Literacy)

(Rootman and Gordon-El-Bihbety, 2008)

Literacy HealthOutcomes& Costs

HealthOutcomes& Costs

Health Contexts

Individuals

Health Contexts

Individuals

Health Literac

y

Health Literacy FrameworkHealth Literacy Framework

(I.O.M., 2004)(I.O.M., 2004)

General LiteracyReading ability

Numeracy

Listening and Speaking ability

Comprehension ability

Negotiation skills

Critical thinking& judgement

Literacy

Work environment

Stress level

Income

Health

Status

Quality

Of

Life

Lifestyles

Effects of Literacy

OrganizationalDevelopment

Communication

Capacity Development

Community Development

Actions

Determinants

Use of services

Direct(Medication use,

Compliance, safety practices.)

Indirect

Indirect

Health Literacy

Ability to find, understand and communicate health

informationAbility to assess health

information

Other LiteracyScientific, Computer,

Cultural, MediaEtc.

Policy

Education

Early Child Development

Aging

Personal Capacity

Living/Working Conditions

Gender

Culture Source: Rootman and Ronson, 2005

Health Literacy Framework (Kwan, Frankish and Rootman, 2006)

Access orexposureto health

information

Understandhealth

information

Appraisehealth

informationCommunicate

healthinformation

Health knowledge

GeneralReadingWritingListeningSpeakingNumeracy

OtherScientificComputerCulturalMedia

Literacy

H e a l t h I n f o r m a t i o n C o n t e x t

Healthdecisions

Healthactions

Outcomes

PersonalValues, attitudes, beliefs,

knowledge, motivation, skills,behaviour, personal capacity,

biology, previous life experiences,current physical and psychological state

ExternalIncome, social status,social support, education system,health system, social environment,employment and working conditions,physical environment, culture,communication systems, research,economic environment

Other Factors

(Factors with respect to the individual seeking information, the sources of information, and the information itself)

Version date: May 23, 2006

Source: Wharf Higgins et al., 2009

Health Enhancing Outcomes

Health Promoting Interventions

Health Literacy

Capacity Development

Basic/Functional Literacy

Communicative/Interactive Literacy

Critical Literacy

Health Literacy Framework (Gillis, 2009)

v

Community Development

Organizational Development

Personal Empowerment

Communication

Policy

DEG 13/06/06

Provider Practice:e.g. nature of client/provider rel., communication skills, resources

Health Decisions

Health Actions

Health Advocacy

Health Outcomes

Health Status

Health Care Costs

Social Determinants of Health: e.g. level of literacy, education, income, ethnicity, employment, age, social support, culture, gender…

Situations & Contexts

Health lit

Age

Rural

Pared

Lang

Litw

Lith

ED

Gender

Immig

French

Aborig Infl2

Infl1

Occ

Income

Lfp

Aded

Comm1

Comm2

Structural model of health literacy determinants from lifelong-lifewide learning perspective

Source: Desjardins, unpublished paper in review

Andersen-Newman Behavioural Model (1960’s) (Andersen, 1995, p.2)

PREDISPOSING ENABLING NEED USE OF

HEALTHCHARACTERISTICS RESOURCES

SERVICES | | |

Demographic Personal/Family Perceived | | | Social Structure Community (Evaluated)

| Health Beliefs

Commonly Used Tools to Measure Health Literacy REALM: Rapid Estimate of Adult Literacy in

Medicine ( Davis et al., 1993)

TOFHLA: Test of Functional Health Literacy in Adults (Parker et al., 1995)

NVS: Newest Vital Sign (Weiss, 2007)

HALS: Health Activity Literacy Scale (CCL, 2007 a)

Health Activity Literacy Scale (CCL, 2007a)Using 350 unique items in

International Literacy Surveys

191 items judged to measure health-related activities

Health-related items assigned to five health literacy sub-domains

Health Literacy Scores and Confidence Intervals by Age Group, Canada, 2003

66+

56-65

46-55

36-45

26-35

16-25

190 200 210 220 230 240 250 260 270 280 290

95% Confidence interval

Estimated average score

Source: Health Literacy in Canada: A Healthy Understanding, CCL, 2008, based on IALSS 2003

Low Health Literacy by Age Group in Canada, 2003

Age % Below Level 316-25 50%26-35 49%36-45 53%46-55 59%56-65 68%66+ 88%Source: State of Learning in Canada 2007, Canadian Council on Learning,

based on IALSS 2003

Source: State of Learning in Canada 2007, Canadian Council on Learning, based on IALSS 2003

Health Literacy (Reading Proficiency) and Health-Related Outcomes (I.O.M., 2004)

More likely hospitalization and negative disease outcomes

Higher rates of diabetes

Poorer Diabetes Control

Inappropriate medication use and compliance with physician orders

Less use of preventive services and less care seeking

Difficulties using health care system

Less expression of health concerns

Higher mortality

Low health literacy and premature mortality among older adults

A recent U.S. study found that older adults with inadequate and marginal health literacy levels had a 50 per cent higher mortality rate over a five-year period than those with adequate skills. (Barker et al., 2007)

Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education.

Another study found that limited literacy was independently associated with a nearly two-fold increase in mortality in the elderly. (Sudore, et al, 2006)

Other literacy-related health outcomes for older adults

Older adults with low literacy are more likely to report difficulties with activities of daily living, few accomplishments because of their physical health, greater pain interfering with work, and have less knowledge about diseases

(Rootman and Ronson, 2005; Friedman, 2006)

Challenges faced by Older Adults with Low Literacy (IOM, 2007)

Stigma Increasing literacy demands Isolation Poverty Perceptual or cognitive difficulties Difficulty maintaining their health, safety, independence

and self-esteem Programs exclude older adults or don’t meet their needs Perceived relevance of adult education Health education materials tend to require strong

literacy skills Health workers are not trained to recognize literacy

deficits

Factors Predicting Health Literacy for Adults aged 66 and over (CCL, 2008)

-0.20 -0.10 0.00 0.10 0.20 0.30 0.40 0.50

Mother tongue different than test language

Household income

Engagement in community or volunteer activities

Foreign-born

Informal learning by exposure to varied contexts

Age

English speaking

Community size

Adult education and training

Informal learning by self study

Gender

Parents' education

Educational attainment

Literacy practices at home

Standardized regression w eight

Predictors of Health Literacy in Older Adults Sub-sample of older adults (n=2,979) from 2003

IALSS (Canadian survey)

Formal education, life-long and life-wide learning enabling factors exhibited the most robust associations with health literacy among older adults

Concluded that Programs and policies that encourage life-long and life-wide educational resources and practices are needed

(Malloy-Weir et al., 2010)

What can be done?

Very few rigorous evaluations (IOM, 2004; CPHA 2008)

Pignone Review (2005): Methods Systematic review of interventions Included controlled and uncontrolled

studies Searched variety of data sources Covered 1980-2003 Found 20 articles with interventions to

improve health among people with low literacy

Abstracted data from articles and assessed quality

Pignone Review: Findings Effectiveness mixed

Variation in research quality and outcome measures

Only 5 studies examined interaction between literacy level and effect of intervention; also found mixed results

Pignone Review: Conclusions Several interventions have been

developed to improve health for people with low literacy

Limitations of studies make drawing conclusions difficult

Further research needed to understand types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health

King Review (2007): Methods focused search and review of the

academic literature related to health literacy interventions

focused search and review of the grey literature related to health literacy interventions in Canada and around the world

Key informant interviews

King: Findings Majority of health literacy interventions involved

accessing and understanding, with very few focused on appraising or communicating health information

Very limited information was found about the effectiveness of health literacy interventions

Some evidence to support the finding and general understanding that a participatory educational and empowerment approach is effective

King: Conclusions Barriers to evaluation of programs were

time, money and lack of provider expertise

a number of areas of further investigation are suggested including: health literacy interventions focused on

appraising health information cultural issues health care professional training sources of health information learner and patient perspectives

Clement Review (2009): Methods Systematic review of randomized and quasi-

randomized controlled trials focused on complex interventions for people with limited literacy or numeracy

Searched eight databases from start to 2007

Checked references and contacted key informants

Two reviewers assessed eligibility, extracted data and evaluated study quality

Clement: Findings 2734 non-duplicate items, reduced to 15

trials Two interventions for health professionals,

one literacy education and 12 health education and management; most in North America

Most (13/15) reported at least one significant difference in primary outcome favoring intervention group

Knowledge and self-efficacy most likely outcome improvement

Clement: Conclusions A wide variety of complex interventions

for adults with limited literacy are able to improve some health-related outcomes

Review supports wider introduction of interventions for people with limited literacy, particularly within an evaluation context

Strategies for Addressing Health Literacy

1. Improve skills required to be health literate

2. Provide services appropriate for people with all skill levels

An Example of Strategy #1

Mental Fitness for Life is an 8-week series of intensive workshops based on grounded research that includes the following topics: Goal Setting; Critical Thinking; Creativity; Positive Mental Attitude; Learning; Memory; and Speaking your Mind.

Evaluations suggest that the program has a positive

impact on health, and that there is a need to promote mental fitness, like physical fitness, as a health promoting behavior that supports the progressive development of the individual across the lifespan.

For more information see: Cusack et al., 2003 and Cusack and Thompson, 2005)

A Second Example of Strategy #1

The Computer for Elder Learning project used free computer training as outreach tool to recruit older adults for literacy skills upgrading

Although it failed to recruit people with low literacy skills, participants reported that they were reading and writing more due to the computer and more confident about their reading and writing skills.

For more information, go to: http://www.nald.ca/fulltext/elder/Elder.pdf

A Third Example of Strategy #1

The Second Chance for Seniors Program addresses learning needs of older adults. It has three components: Peer tutoring; group literacy activities; education.

For more information go to: www. catalist.ca

A forth Example of Strategy #1 The COSCO health literacy

program for seniors uses a training-of-trainers approach to provide knowledge and training for seniors across BC regarding a number of health and other issues

No rigorous evaluation to date For more information go to:

http://www.coscobc.ca/

An Example of Strategy # 2

The National Literacy Program developed Guidelines for medication packaging and labeling for older adults

Process: Reviewed literature, consulted with

stakeholders; collected samples of packaging and labeling materials; developed guidelines; held national symposium

Outputs: Guidelines, resources

Available at: http://www.nlhp.cpha.ca/Labels/seniors/english/GoodMed-E.pdf

A Second Example of Strategy #2

The Older Adult Literacy Resource Manual is two-part workshop resource manual intended to help trainers of literacy tutors, and others , to raise awareness of the particular needs of older adult literacy learners.

Available from: http://library.nald.ca

Network: National The Canadian Network for Third Age

Learning fosters later life learning through shared knowledge, expertise, research, and resources is located at the University of Regina, Seniors' Education Centre.

The Network links approximately 50 organizations involved in providing learning opportunities for older adults across Canada.

Go to http://www. catalist.ca

Conclusions

Health Literacy among older adults is an issue that needs to be addressed in Canada

It can be done either by improving health literacy skills or by providing services appropriate for people with all skill levels

The provision of opportunities for lifelong learning may be particularly important

There are some innovative efforts in Canada to address the health literacy needs of older adults

Most of the efforts are short-term and not well supported

Few of them have been evaluated rigorously

Questions? Comments?