Measuring Health Literacy

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					Health Literacy of Adults
   in North America
  Measuring Health Literacy
     IUHPE June 2007
    Rima E. Rudd, MSPH, ScD
     Harvard School of Public Health
  National Center for the Study of Adult
          Learning and Literacy
What is Health Literacy?
Health literacy incorporates a range of abilities: to
  read, comprehend, and analyze information;
  decode instructions, symbols, charts, and
  diagrams; weigh risks and benefits; and,
  ultimately, make decisions and take action.
However, the concept of health literacy extends to
  the materials, environments, and challenges
  specifically associated with disease prevention
  and health promotion.

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Health Literacy
The wide range of skills, and competencies
  that people develop over their lifetimes to
  seek out, comprehend, evaluate, and use
  health information and concepts to make
  informed choices, reduce health risks, and
  increase quality of life
                Zarcadoolas, Pleasant, & Greer, 2006

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Literacy within
Health Contexts
Health Literacy:
An interaction between
skills of individuals and
social demands

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Measuring Health Literacy
 Why measure?
 Under what circumstances?
 To what end?

 What do current measures capture?

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Commonly Used Measures in
  REALM: Rapid Estimate of Adult Literacy in
  TOFHLA: Test of Functional Health Literacy in
  Newest Vital Sign

Value +/-

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Missing Elements
 Applied literacy skills
 Multiple contexts
 Variety of tasks

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Logic Model: Face Validity
 Literacy influences one’s ability to access
 information and to navigate the highly
 literate environments of modern society
 Those with more general literacy skills will
 also be more likely to have stronger
 health literacy skills
 Provide analysis for policy making

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Functional Literacy
Using printed and written information to
 function in society, to achieve one’s goals,
 and to develop one’s knowledge and


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Focus on use of health materials to accomplish
  a range of health related tasks
Examination of national level assessments of
  adult literacy skills to measure health literacy
    Code all materials & tasks
    Focus on health related items

  Calibrated measures
  Potential for change
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Examination of All Materials &
 Home & family
 Health & safety
 Community & citizenship
 Consumer economics
 Leisure & recreation

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Coding Schema:
Typology of Health Activities
Health Promotion
Health Protection
Disease Prevention
Health Care & Maintenance
Systems Navigation

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 Health       Focus                  Materials                    Tasks

Health       Enhance           Articles in                     Maintain
Promotion    &                 newspapers and                  weight
             maintain          magazines,                      Eat fruits and
             health            booklets,                       vegetables
                               brochures,                      Plan daily
                               charts, graphs,                 exercise
                               lists, food and                 regimen
                               product labels

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 Health      Focus                Materials                  Tasks

Health     Safeguard         Articles in                  Decide among
Protection health of         newspapers and               product
           individuals       magazines,                   options
           &                 postings for                 Follow safety
           community         health and                   precautions
                             safety warnings              Vote on
                             at work or in the            community
                             community, air               referendums
                             and water
                             quality reports

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 Health      Focus              Materials                    Tasks

Disease    Take            News alerts [TV,               Determine risk
Prevention preventive      radio, papers],                Engage in
           measures        postings for                   screening or
           & engage        inoculations &                 diagnostic
           in early        screening,                     tests
           detection       letters with test              Purchase food
                           results, graphs,               with low salt
                           charts                         Make a follow-

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  Health        Focus                Materials                Tasks

Health Care & Seek care             Health                 Describe &
Maintenance & form a                history                measure
              partnership           forms,                 symptoms
              with health           medicine               Follow
              providers             labels,                directions on
                                    discharge              medicine
                                    instructions,          labels
                                    education              Calculate
                                    booklets &             timing for
                                    brochures              medicine.

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 Health      Focus              Materials                     Tasks

Systems    Access          Maps,                          Locate
Navigation needed          Application                    facilities,
           services        forms,                         Apply for
           Understand      statements of                  benefits
           rights          rights and                     Offer
                           responsibilities,              informed
                           informed                       consent
                           consent, benefit

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Health Activity Items
     Health Activities                         Number of Items
                                                  (n= 238)
Health Promotion                                            78
Health Protection                                           86
Disease Prevention                                          18
Health care and disease                                     24
Navigation                                                  32

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ALLS: Adult Literacy and LifeSkills
Survey 2003
 Prose and Document Literacy
 Numeracy: the ability to interpret, apply, and
 communicate mathematical information in
 commonly encountered situations.
 Problem solving skills: the ability to apply
 cognitive processes toward determining a solution
 when that solution is not immediately apparent or
 obvious to the problem solver.

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Use of new technologies: the ability to
integrate and apply the cognitive and
technical skills that are associated with
performing tasks using information and
communication technologies.
Commonly used measures of health status:
self rating of health, SF-12® Health

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Overall Findings
A significant number of                   A significant number of
  adults have low-level                     adults do not have the
  literacy skills that                      literacy skills needed to
  constrain their                           use health related print
  participation in the                      materials and tools with
  economy and in society.                   accuracy and consistency
    Skills have increased in              Health sector expectations
    Canada between 1994 & 2003
    Skills have decreased in US
                                            and demands exceed
    between 1992 & 2003                     adults’ literacy skills

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Analytic Constraints
 Measures have changed over time
 Background health information is missing for
 NALS/IALS but available in ALLS
 ALLS changed from Quantitative measures to
 Numeracy and added problem solving
 Immigration patterns have changed over time
 Immigration patterns differ between US and
 Health disparities/minority population groups are
 discussed differently

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HALS Mean Scores and by
 Composite Scores                     Canada             United
Health Literacy          English French                    All

Overall                  268                  261         254
For Men                  267                  261         253
For Women                269                  262         255

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Mean Scores by Educational
  Educational   <High                       High         >High
  Achievement    School                   School/GED      School

  English        254                            272       287
  French         248                            273       279

United States    244                            250       282

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Mean Scores by Health Rating
Rating of
  One’s Own Excellent Very Good Fair                           Poor
 English    274       272 258 250                              225
 French     268       266 256 235                              220
 States     264                  263              250    234   211

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Social Determinants
& Disparities
Differences in health literacy proficiencies
  based on educational attainment, poverty
  and access to resources, and on majority
  versus minority status indicate powerful
  effects of social factors.

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Findings: Limited Health Literacy
Very Low: Inability to use health materials with
  accuracy and consistency [scores below 226 on
  scale of 0-500]
   16% of Canadian English speaking adults
   18% of Canadian French speaking adults
   24% of U.S. adults
Average overall scores in the range of 254-268
  represents problematic use of health materials

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More Lessons from Alice
“Would you tell me please, which way I
  ought to go from here? ”
  “That depends a good deal on where you
  want to get to,” said the Cat.
  “I don’t much care where,” said Alice.
  “Then it doesn’t matter which way you go,
  said the Cat. ”
          Alice’s Adventures in Wonderland

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