Health Literacy and Aging Presentation by Irving Rootman to SFU Class on Principles and Practices of Health Promotion October 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) Health Literacy Framework Health Health Literacy Contexts Health Outcomes Literac y & Costs Individuals (I.O.M., 2004) Actions Literacy Effects of Literacy Communication Indirect General Literacy Capacity Reading ability Lifestyles Development Numeracy Community Listening and Speaking ability Development Comprehension ability Use of services Income Negotiation skills Organizational Critical thinking& judgement Development Direct Health Quality Policy (Medication use, Of Compliance, Status safety practices.) Life Health Literacy Determinants Ability to find, understand Work Education and communicate health environment information Early Child Development Ability to assess health information Aging Stress level Personal Capacity Living/Working Indirect Conditions Other Literacy Gender Scientific, Computer, 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 Enhancing Interventions Literacy Outcomes Outcomes Communication Basic/Functional Health Decisions Health Status Literacy Capacity Development Communicative/ Health Actions Health Care Costs Interactive Literacy Community Development Health Advocacy Critical Literacy Organizational v Personal Development Empowerment Policy 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 Lfp Gender Occ Litw Pared Lang Aded Health lit ED Infl1 Aborig Infl2 Immig Lith French Comm1 Rural Comm2 Source: Desjardins, unpublished paper in review Andersen-Newman Behavioural Model (1960’s) (Andersen, 1995, p.2) PREDISPOSING ENABLING NEED USE OF HEALTH CHARACTERISTICS 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 95% Confidence interval 16-25 26-35 Estimated average 36-45 score 46-55 56-65 66+ 190 200 210 220 230 240 250 260 270 280 290 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 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 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) Literacy practices at home Educational attainment Parents' education Gender Informal learning by self study Adult education and training Community size English speaking Age Informal learning by exposure to varied contexts Foreign-born 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): 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?