HealthHealth Literacy: Literacy: Potential Pathway toPotential Pathway toOral Health for the Elderly?Oral Health for the Elderly?

Alice M. Horowitz, PhDAlice M. Horowitz, PhD

School of Public HealthSchool of Public Health

June 28, 2007June 28, 2007

Santa Fe, New MexicoSanta Fe, New Mexico

OverviewOverview

What is health literacy and why is it What is health literacy and why is it important?important?

Historical perspectiveHistorical perspective Recent activitiesRecent activities Strategies for improving health literacyStrategies for improving health literacy

Health literacy is a relatively Health literacy is a relatively new concept especially as it new concept especially as it

relates to oral healthrelates to oral health

Health Literacy is an Emerging Health Literacy is an Emerging Issue that is Ripe for Leadership:Issue that is Ripe for Leadership:

Pre-doctoral educationPre-doctoral education Resident and post-doctoral-trainingResident and post-doctoral-training ResearchResearch Policy Policy

Literacy - DefinedLiteracy - Defined

The ability to read, write, speak and The ability to read, write, speak and compute and solve problems at levels of compute and solve problems at levels of proficiency necessary to function on the job proficiency necessary to function on the job and in society, to achieve one’s goals and and in society, to achieve one’s goals and develop one’s knowledge and potential.develop one’s knowledge and potential.

National Literacy Act 1991National Literacy Act 1991

Health Literacy -DefinedHealth Literacy -Defined

Health literacy represents the cognitive and social Health literacy represents the cognitive and social skills which determine the motivation and ability of skills which determine the motivation and ability of individuals to gain access to, understand, and use individuals to gain access to, understand, and use the information in ways which promote and the information in ways which promote and maintain good health. Health literacy means more maintain good health. Health literacy means more than being able to read pamphlets and than being able to read pamphlets and successfully make appointments. By improving successfully make appointments. By improving people’s access to health information and their people’s access to health information and their capacity to use it effectively, health literacy is capacity to use it effectively, health literacy is critical to empowerment (WHO, 1998)critical to empowerment (WHO, 1998)

Health Literacy-Defined Health Literacy-Defined

““The degree to which individuals have the The degree to which individuals have the capacity to obtain, process and understand capacity to obtain, process and understand

basic health information and services basic health information and services needed to make appropriate health needed to make appropriate health

decisions”decisions” Ratzan and Parker, 2000Ratzan and Parker, 2000

HP2010 2000HP2010 2000

IOM Report 2004IOM Report 2004

Oral Health Literacy-DefinedOral Health Literacy-Defined

““The degree to which individuals have the The degree to which individuals have the capacity to obtain, process and understand capacity to obtain, process and understand basic health information and services basic health information and services needed to make appropriate needed to make appropriate oraloral health health decisions”decisions”

HP2010, 2000HP2010, 2000

Health Literacy is Dependent Upon Health Literacy is Dependent Upon Individual and Systemic Factors:Individual and Systemic Factors:

Communication skills of consumers Communication skills of consumers andand providersproviders

Knowledge of consumers Knowledge of consumers andand providers of providers of health topicshealth topics

Culture and societal impact Culture and societal impact Demands of the healthcare systemDemands of the healthcare system Demands of the situation/contextDemands of the situation/context

Communication SkillsCommunication Skills

Health literacy is dependent on the Health literacy is dependent on the communication skills of consumers communication skills of consumers andand providersproviders– Communication skills include literacy skills—Communication skills include literacy skills—

reading, writing, numeracy, speaking, listening reading, writing, numeracy, speaking, listening and comprehensionand comprehension

– Communication skills are context specific for Communication skills are context specific for both patients and providersboth patients and providers

Knowledge of Health TopicsKnowledge of Health Topics

Health literacy is dependent on knowledge of consumers Health literacy is dependent on knowledge of consumers andand providers of health topicsproviders of health topics

– Patients with limited or inaccurate knowledge about the body and causes of Patients with limited or inaccurate knowledge about the body and causes of disease may not:disease may not:

– Understand the relationship between lifestyle factors (e.g. diet and Understand the relationship between lifestyle factors (e.g. diet and exercise; oral hygiene practices and gingivitis) and health outcomesexercise; oral hygiene practices and gingivitis) and health outcomes

– Recognize when they need to seek careRecognize when they need to seek care– Have current prevention informationHave current prevention information

– Health information can overwhelm anyone--even people with advanced literacy Health information can overwhelm anyone--even people with advanced literacy skills.skills.

– Providers who do not keep current with the state of the science cannot provide Providers who do not keep current with the state of the science cannot provide accurate knowledge and information and evidence-based services for their accurate knowledge and information and evidence-based services for their patients.patients.

Cultural and SocietyCultural and Society

Culture and societal impacts on Individuals:Culture and societal impacts on Individuals:– How people communicate and understand How people communicate and understand

health informationhealth information– How people think and feel about their healthHow people think and feel about their health– If and how people value oral healthIf and how people value oral health– When and from whom people seek careWhen and from whom people seek care– How people respond to recommendations for How people respond to recommendations for

lifestyle changes and treatmentlifestyle changes and treatment

Cultural and SocietyCultural and Society

Culture affects Providers:Culture affects Providers:– How providers communicate and understand health How providers communicate and understand health

informationinformation– How providers think and feel about How providers think and feel about

racial/ethnic/economic groups other than their ownracial/ethnic/economic groups other than their own– How providers value preventive measuresHow providers value preventive measures– Where they obtain new informationWhere they obtain new information– If and how providers respond to recommendations and If and how providers respond to recommendations and

guidelinesguidelines

Demands of the Healthcare Demands of the Healthcare SystemSystem

Health literacy is dependent on the demands of Health literacy is dependent on the demands of the healthcare and public health systems. the healthcare and public health systems. Individuals need to:Individuals need to:– know how to locate and navigate a health facilityknow how to locate and navigate a health facility– read, understand, and complete many kinds of forms to read, understand, and complete many kinds of forms to

receive treatment, provide consent for treatment and receive treatment, provide consent for treatment and payment reimbursementpayment reimbursement

– articulate their signs and symptomsarticulate their signs and symptoms– know about various types of health professionals and know about various types of health professionals and

what services they provide and how to access those what services they provide and how to access those servicesservices

– Know how to ask questionsKnow how to ask questions

Demands of the Situation or Demands of the Situation or ContextContext

Health literacy is dependent on the demands of Health literacy is dependent on the demands of the situation/contextthe situation/context– Health contexts are unusual compared with other Health contexts are unusual compared with other

contexts because of an underlying stress or fear factorcontexts because of an underlying stress or fear factor– Health contexts may involve unique conditions such as Health contexts may involve unique conditions such as

physical or mental impairment due to illnessphysical or mental impairment due to illness– Health situations are often new, unfamiliar, intimidating Health situations are often new, unfamiliar, intimidating

and often exhausting and often exhausting – Some health facilities have staff that are not particularly Some health facilities have staff that are not particularly

empathetic---not user friendly empathetic---not user friendly

Scope of Health LiteracyScope of Health Literacy

Functional skills include reading, writing, Functional skills include reading, writing, speaking, listening, basic arithmetic skillsspeaking, listening, basic arithmetic skills

Knowledge of health topics --information & Knowledge of health topics --information & servicesservices

Knowledge must be related to decision Knowledge must be related to decision makingmaking

CORE ISSUE: UNDERSTANDINGCORE ISSUE: UNDERSTANDING

Health Literacy is Important Because it Health Literacy is Important Because it Affects One’s Ability to: Affects One’s Ability to:

Understand dental/medical conceptsUnderstand dental/medical concepts Share personal and health information with Share personal and health information with

providersproviders Participate in their health care & that of Participate in their health care & that of

their childrentheir children Navigate the healthcare system, including Navigate the healthcare system, including

locating providers and services, finding locating providers and services, finding transportation and completing formstransportation and completing forms

Health Literacy is Important …Health Literacy is Important …cont’dcont’d

Act on health-related news and Act on health-related news and announcementsannouncements

These outcomes impact: These outcomes impact: – health outcomes health outcomes – healthcare costs healthcare costs – quality of carequality of care

According to a 1998 study, the According to a 1998 study, the cost of low health literacy in cost of low health literacy in

the US could be anywhere from the US could be anywhere from $30 billion to as much as $73 $30 billion to as much as $73

billion annually.billion annually.

National Academy on an Aging SocietyNational Academy on an Aging Society

Individuals with Limited Health Individuals with Limited Health Literacy Skills Have:Literacy Skills Have:

Lower use of preventive servicesLower use of preventive services Higher use of treatment services which Higher use of treatment services which

result in higher healthcare costsresult in higher healthcare costs Often reported feeling a sense of shame Often reported feeling a sense of shame

about their skill level and/or developed about their skill level and/or developed strategies to compensatestrategies to compensate

Measuring Health LiteracyMeasuring Health Literacy

Health literacy is measured as functional literacyHealth literacy is measured as functional literacy—people’s ability to apply reading skills to —people’s ability to apply reading skills to everyday tasks involving prose, documents, and everyday tasks involving prose, documents, and numbers.numbers.

Current population data on literacy come from Current population data on literacy come from the 2003 National Assessment of Adult Literacy the 2003 National Assessment of Adult Literacy (NAAL): (NAAL): – Health literacy data from the NAAL were released in Health literacy data from the NAAL were released in

2006.2006.

2003 NAAL Findings2003 NAAL Findings

• Prose literacyProse literacy:: Skills needed to search, comprehend, and Skills needed to search, comprehend, and use continuous texts such as news stories and brochuresuse continuous texts such as news stories and brochures

• Document literacyDocument literacy:: Skills needed to search, comprehend, Skills needed to search, comprehend, and use noncontinuous texts such as job application and use noncontinuous texts such as job application forms, maps, and food labelsforms, maps, and food labels

• Quantitative literacyQuantitative literacy:: Skills needed to identify and Skills needed to identify and perform computations using numbers embedded in perform computations using numbers embedded in printed materials, such as numbers used in balancing a printed materials, such as numbers used in balancing a checkbook or completing an order formcheckbook or completing an order form

NAAL reports a separate score for each of three NAAL reports a separate score for each of three literacy areas:literacy areas:

2003 NAAL Findings2003 NAAL Findings

• Below BasicBelow Basic:: Can perform tasks involving brief and Can perform tasks involving brief and uncomplicated texts and documents. Adults can generally uncomplicated texts and documents. Adults can generally locate a piece of information in a news story.locate a piece of information in a news story.

• BasicBasic:: Able to locate information in text, make low-level Able to locate information in text, make low-level inferences, and integrate easily identifiable pieces of inferences, and integrate easily identifiable pieces of information.information.

• IntermediateIntermediate:: Able to integrate information from relatively Able to integrate information from relatively long or dense texts, determine appropriate arithmetic long or dense texts, determine appropriate arithmetic operations, and identify how to perform the operation.operations, and identify how to perform the operation.

• ProficientProficient:: Demonstrate proficiencies associated with long Demonstrate proficiencies associated with long and complex documents and text.and complex documents and text.

Findings reported participants’ ability to complete Findings reported participants’ ability to complete these tasks with 67% accuracy by levels:these tasks with 67% accuracy by levels:

Number of Adults in Each Prose Number of Adults in Each Prose Literacy Level: NAAL 2003Literacy Level: NAAL 2003

30 million

63 million95 million

28 million

0

50

100

Below Basic Basic Intermediate Proficient

Most adults scoring in Below Basic would not be able to read Most adults scoring in Below Basic would not be able to read the dosage chart on a package of over-the-counter pediatric the dosage chart on a package of over-the-counter pediatric cold medicine.cold medicine.

Adults scoring in Basic would find the dosage chart difficult.Adults scoring in Basic would find the dosage chart difficult.

Millions of adults

Measures of Health LiteracyMeasures of Health Literacy

Most measures of health literacy at the Most measures of health literacy at the individual level were developed in the individual level were developed in the 1990s:1990s:

• Rapid Estimate of Adult Literacy in Medicine (REALM)Rapid Estimate of Adult Literacy in Medicine (REALM)

• Test of Functional Health Literacy in Adults (TOFHLA Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA)and S-TOFHLA)

• Newest Vital Sign (NVS)Newest Vital Sign (NVS)• Literacy Assessment for Diabetes (LAD)Literacy Assessment for Diabetes (LAD)• REALD-30 & 99; TOFHLiD (dental)REALD-30 & 99; TOFHLiD (dental)

Measurement NeedsMeasurement Needs

Health literacy measures based on functional Health literacy measures based on functional literacy do not capture the full range of skills literacy do not capture the full range of skills needed for health literacy.needed for health literacy.

Current assessment tools (for populations and Current assessment tools (for populations and individuals) cannot differentiate among:individuals) cannot differentiate among:– Reading abilityReading ability– Lack of health-related background knowledgeLack of health-related background knowledge– Lack of familiarity with language and materialsLack of familiarity with language and materials– Cultural differences in approaches to health.Cultural differences in approaches to health.

Who Is at Risk?Who Is at Risk?

The problem of limited health literacy is The problem of limited health literacy is greater among:greater among:

– Older adultsOlder adults– Those who are poorThose who are poor– People with limited educationPeople with limited education– Minority populationsMinority populations– Persons with limited English proficiency (LEP)Persons with limited English proficiency (LEP)

Who is at Risk?Who is at Risk?

Many of the same populations at risk for Many of the same populations at risk for limited health literacy also suffer from limited health literacy also suffer from disparities in health status, illness (including disparities in health status, illness (including heart disease, diabetes, obesity, HIV/AIDS, heart disease, diabetes, obesity, HIV/AIDS, dental caries, periodontal disease, cancer, dental caries, periodontal disease, cancer, lead poisoning and low birth weight), and lead poisoning and low birth weight), and death.death.

Health Literacy: Use of Health Literacy: Use of Preventive ServicesPreventive Services

• Mammograms Mammograms • Pap smearsPap smears• Flu shotsFlu shots• Use of fluoride toothpasteUse of fluoride toothpaste• Preventive dental appointmentsPreventive dental appointments• Lead screening for childrenLead screening for children

Persons with limited health literacy skills are less Persons with limited health literacy skills are less likely to use preventive measures such as:likely to use preventive measures such as:

Health Literacy: Knowledge About Health Literacy: Knowledge About Medical Conditions, Prevention and Medical Conditions, Prevention and

TreatmentTreatment

Are more likely to have chronic health conditions Are more likely to have chronic health conditions and less likely to manage them effectively.and less likely to manage them effectively.

Have less knowledge of their disease (e.g., Have less knowledge of their disease (e.g., diabetes, asthma, HIV/AIDS, high blood diabetes, asthma, HIV/AIDS, high blood pressure) periodontal diseases, dental caries pressure) periodontal diseases, dental caries and its management.and its management.

Persons with limited health literacy skills:

Health Health SystemSystem

CultureCultureAndAnd

SocietySociety

Oral Health Oral Health Outcomes Outcomes and Costsand Costs

Education Education SystemSystem

OralOralHealthHealth

LiteracyLiteracy

11

22

33

Oral Health Literacy FrameworkOral Health Literacy Framework

Source: Adapted from Institute of Medicine, Health literacy: A prescription to end confusion.

Health Literacy: A prescription to end Health Literacy: A prescription to end confusion, IOM’s report has and is having a confusion, IOM’s report has and is having a

significant impact.significant impact.

NIH issued two PA’s on understanding and NIH issued two PA’s on understanding and promoting health literacypromoting health literacy

18 projects were awarded on the first round 18 projects were awarded on the first round of applicationsof applications

A PI meeting was held September 2006A PI meeting was held September 2006 The PAR was reissued for 3 more yearsThe PAR was reissued for 3 more years

For example in the research arena:For example in the research arena:

Understanding and PromotingUnderstanding and PromotingHealth Literacy Health Literacy

(PAR-04-116; PAR-06-132)(PAR-04-116; PAR-06-132)

Healthy behaviorsHealthy behaviors Illness prevention and treatmentIllness prevention and treatment Chronic disease managementChronic disease management Health disparitiesHealth disparities Risk assessmentRisk assessment Health outcomesHealth outcomes

GOAL: Increase scientific understanding of the nature of health literacy and its relation to:

Understanding and PromotingUnderstanding and PromotingHealth LiteracyHealth Literacy

PAR-04-116PAR-04-116

Understanding and Promoting Health Understanding and Promoting Health Literacy (R01)Literacy (R01)

PAR-06-132PAR-06-132

Understanding and Promoting Health Understanding and Promoting Health Literacy (R03)Literacy (R03)

In AdditionIn Addition

HRSA has stepped up their work in health HRSA has stepped up their work in health literacyliteracy

CMS has increased their efforts in this areaCMS has increased their efforts in this area AHRQ supported an evidence-based AHRQ supported an evidence-based

review, and co-funds some of the NIH review, and co-funds some of the NIH projectsprojects

ADA has recently organized a National Oral ADA has recently organized a National Oral Health Literacy Advisory CommitteeHealth Literacy Advisory Committee

Oral Health LiteracyOral Health Literacy

The results of a 2004 NIDCR workgroup on oral health literacy, recently published,* includes recommendations for dental and craniofacial research and background on health literacy and its impact on health outcomes.

*Report of Workgroup: The Invisible Barrier: Literacy *Report of Workgroup: The Invisible Barrier: Literacy and its Relationship with Oral Health. J Public Health and its Relationship with Oral Health. J Public Health Dent. 2005;65:174-183 Dent. 2005;65:174-183

Research NeedsResearch Needs

Instrument (s) to evaluate oral health literacyInstrument (s) to evaluate oral health literacy Compare oral health literacy instruments with health Compare oral health literacy instruments with health

literacy instrumentsliteracy instruments Determine impact of health literacy on oral health Determine impact of health literacy on oral health

outcomesoutcomes Determine roles of dental care providers in increasing Determine roles of dental care providers in increasing

health literacyhealth literacy Determine what dental & dental hygiene schools teach Determine what dental & dental hygiene schools teach

regarding communication skillsregarding communication skills Assess best methods for teaching communication skills Assess best methods for teaching communication skills

in dental provider schoolsin dental provider schools Determine communication skills of Determine communication skills of practicingpracticing dental care dental care

providers providers

Healthy People 2010 Health Healthy People 2010 Health Communication Objectives Communication Objectives

11-1 Internet access in the home11-1 Internet access in the home 11-2 Health literacy11-2 Health literacy 11-3 Research & evaluation of health 11-3 Research & evaluation of health

communication programscommunication programs 11-4 Quality of internet health Web sites11-4 Quality of internet health Web sites 11-5 Centers of excellence in health 11-5 Centers of excellence in health

communicationcommunication 11-6 Increase the proportion of persons who 11-6 Increase the proportion of persons who

report that their health care providers have report that their health care providers have satisfactory communication skills satisfactory communication skills

Two Healthy People 2010 Objectives Two Healthy People 2010 Objectives Specifically Address the Need for Specifically Address the Need for

Health Literacy Improvement: Health Literacy Improvement:

11-2. Improve the health literacy of persons 11-2. Improve the health literacy of persons with inadequate or marginal literacy skillswith inadequate or marginal literacy skills

11-6 Increase the proportion of persons 11-6 Increase the proportion of persons who report that their health care providers who report that their health care providers have satisfactory communication skills have satisfactory communication skills

Key Point:Key Point:

Communication between patient and Communication between patient and provider is pivotal to positive health provider is pivotal to positive health outcomesoutcomes

Medical Expenditure Panel Medical Expenditure Panel Survey: Evaluating ProvidersSurvey: Evaluating Providers

How often did doctors or other health providers How often did doctors or other health providers listen carefully to you? [56% 2000 MEPS]listen carefully to you? [56% 2000 MEPS]

How often did doctors or other health providers How often did doctors or other health providers explain things in a way you could understand? explain things in a way you could understand? [58%][58%]

How often did doctors or other health providers How often did doctors or other health providers show respect for what you had to say? [58%]show respect for what you had to say? [58%]

How often did doctors or other health providers How often did doctors or other health providers spend enough time with you? [45%]spend enough time with you? [45%]

Clear & Effective Communication Clear & Effective Communication Includes:Includes:

Plain languagePlain language Culturally and linguistically appropriate Culturally and linguistically appropriate

languagelanguage Appropriate reinforcementAppropriate reinforcement Teach back to ensure patient understandsTeach back to ensure patient understands Patient centeredPatient centered

Educate policy makers at all Educate policy makers at all levels about the importance levels about the importance

of health literacy and its of health literacy and its impact on health impact on health

outcomesoutcomes

Questions Policy-makers Should Questions Policy-makers Should ask:ask:

What are the literacy rates among those eligible to participate in public programs What are the literacy rates among those eligible to participate in public programs in my state?in my state?

At what reading level is current health information provided?At what reading level is current health information provided?

Have changes been made to simplify the process for enrolling in public programs Have changes been made to simplify the process for enrolling in public programs in my state?in my state?

Is it possible to create a coordinated application process to decrease the number Is it possible to create a coordinated application process to decrease the number of forms that need to be completed to receive medical assistance?of forms that need to be completed to receive medical assistance?

Is public health information suitable for those with low literacy?Is public health information suitable for those with low literacy?

What can be done to increase literacy in my state?What can be done to increase literacy in my state?

The Council of State Governments 2002The Council of State Governments 2002

Additional Questions to AskAdditional Questions to Ask

What do providers know and do about primary What do providers know and do about primary prevention? (e.g. how to prevent dental caries).prevention? (e.g. how to prevent dental caries).

What do providers teach/tell their patients?What do providers teach/tell their patients? Are informed consent forms in plain language?Are informed consent forms in plain language? Do provider schools teach communication skills?Do provider schools teach communication skills? Do providers provide communication skills to their Do providers provide communication skills to their

staff? staff? Do dental examining boards require testing on Do dental examining boards require testing on

communication skills? communication skills?

More QuestionsMore Questions

Is the hospital/clinic environment user Is the hospital/clinic environment user friendly?friendly?

Are interpreters available?Are interpreters available? Are the signs understandable to patients?Are the signs understandable to patients? Are patient navigators available?Are patient navigators available?

Who Is Responsible for Who Is Responsible for Improving Health Literacy?Improving Health Literacy?

A health literate America is a society in A health literate America is a society in which health systems and institutions take which health systems and institutions take responsibility for providing clear responsibility for providing clear communication and adequate support to communication and adequate support to facilitate health-promoting actions based facilitate health-promoting actions based on understandingon understanding..

——Institute of Medicine, 2004Institute of Medicine, 2004

Health Literacy is an Emerging Health Literacy is an Emerging Issue that is Ripe for LeadershipIssue that is Ripe for Leadership

Pre-doctoral educationPre-doctoral education Resident and post-doctoral trainingResident and post-doctoral training ResearchResearch Policy Policy

What will the Santa Fe Group What will the Santa Fe Group do to Increase Oral Health do to Increase Oral Health

Literacy Among the Elderly?Literacy Among the Elderly?

Thank you!Thank you!