Literacy_ Health Literacy and Aging

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					Health Literacy and Aging

 Presentation by Irving Rootman to SFU
   Class on Principles and Practices of
            Health Promotion
            October 4, 2010
   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)
           Health Literacy Framework

                       Health              Health
Literacy              Contexts
                      Health              Outcomes
                         y                 & Costs

                                    (I.O.M., 2004)
     Actions                    Literacy                              Effects of Literacy
                              General Literacy
     Capacity                    Reading ability                                Lifestyles

     Community            Listening and Speaking ability
    Development              Comprehension ability            Use of services                  Income
                                Negotiation skills
   Organizational          Critical thinking& judgement

                                                             Direct              Health           Quality
                                                           (Medication use,                         Of
                                                           safety practices.)                      Life

                              Health Literacy
                          Ability to find, understand                                         Work
     Education             and communicate health                                          environment
Early Child Development     Ability to assess health
        Aging                                                                                Stress
 Personal Capacity

  Living/Working                                                                Indirect
     Conditions               Other Literacy
      Gender                      Scientific,
                                Cultural, Media
      Culture                         Etc.                              Source: Rootman and Ronson, 2005
Health Literacy Framework (Kwan, Frankish
and Rootman, 2006)
Source: Wharf Higgins et al., 2009
 Health Literacy Framework (Gillis, 2009)

                                         Health                                  Health
Health Promoting                                                                                       Health
  Interventions                         Literacy                                                      Outcomes

   Communication                        Basic/Functional                      Health Decisions        Health Status
      Development                       Communicative/                          Health Actions       Health Care Costs
                                       Interactive Literacy
     Development                                                               Health Advocacy
                                        Critical Literacy
    Development                                                                 Empowerment


Provider Practice:                           Social Determinants of Health:
e.g. nature of client/provider rel.,         e.g. level of literacy, education, income, ethnicity,
communication skills, resources              employment, age, social support, culture, gender…

                                                   Situations & Contexts
                                                                                                            DEG 13/06/06
Structural model of health literacy determinants from lifelong-lifewide learning perspective

          Age                          Income

                                        Occ          Litw

         Lang                                       Aded
                                                                             Health lit
                         ED                          Infl1

         Aborig                                      Infl2

         Immig                                       Lith

        French                                               Comm1


   Source: Desjardins, unpublished
   paper in review
Andersen-Newman Behavioural
Model (1960’s) (Andersen, 1995, p.2)

PREDISPOSING        ENABLING              NEED      USE OF
        |                 |                    |
   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
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

                   95% Confidence
                       interval                                                  16-25


                   Estimated average                                   36-45




             190       200       210     220     230       240   250       260       270   280   290

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

Age               % Below Level 3
16-25                  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

   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.,

   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,
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

              (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
   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)
                        Literacy practices at home

                             Educational attainment

                                 Parents' education


                     Informal learning by self study

                       Adult education and training

                                    Community size

                                  English speaking


   Informal learning by exposure to varied contexts


   Engagement in community or volunteer activities

                                 Household income

        Mother tongue different than test language

                                                   -0.20   -0.10   0.00   0.10     0.20     0.30      0.40   0.50
                                                                    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):
   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
   Abstracted data from articles and assessed
Pignone Review: Findings
   Effectiveness mixed

   Variation in research quality and outcome

   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

   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):
   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
   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

    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

   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:
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;

For more information go to: www.
A forth Example of Strategy
   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
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:
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:
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.

   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?