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?