Health Literacy and Aging

1. Health Literacy and Aging Presentation by Irving Rootman to SFU Class on Principles and Practices of Health Promotion October 4, 2010

2. 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?

3. 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)

4. 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)

5. Health Literacy Health Literacy Framework Health Outcomes & Costs Health Contexts Individuals Literacy (I.O.M., 2004)

6. Use of services Direct (Medication use, Compliance, safety practices.) Quality Of Life Other Literacy Scientific, Computer, Cultural, Media Etc. General Literacy Reading ability Numeracy Listening and Speaking ability Comprehension ability Negotiation skills Critical thinking& judgement Health Literacy Ability to find, understand and communicate health information Ability to assess health information Community Development Capacity Development Communication Policy Organizational Development Work environment Lifestyles Income Education Early Child Development Aging Gender Living/Working Conditions Culture Personal Capacity Stress level Health Status Actions Literacy Effects of Literacy Indirect Determinants Indirect Source: Rootman and Ronson, 2005

7. Health Literacy Framework (Kwan, Frankish and Rootman, 2006)

8. Source: Wharf Higgins et al., 2009

9. Health Literacy Framework (Gillis, 2009) Health Enhancing Outcomes Health Literacy Health Outcomes Health Promoting Interventions Communication Basic/Functional Literacy Health Decisions Health Status Capacity Development Health Care Costs Communicative/ Interactive Literacy Health Actions Community Development Health Advocacy Critical Literacy v Personal Empowerment Organizational Development Policy Social Determinants of Health: e.g. level of literacy, education, income, ethnicity, employment, age, social support, culture, gender… Provider Practice: e.g. nature of client/provider rel., communication skills, resources Situations & Contexts DEG 13/06/06

10. Structural model of health literacy determinants from lifelong-lifewide learning perspective Source: Desjardins, unpublished paper in review

11. 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

12. 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)

13. 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

14. Source: Health Literacy in Canada: A Healthy Understanding, CCL, 2008, based on IALSS 2003

15. 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

16. Source: State of Learning in Canada 2007, Canadian Council on Learning, based on IALSS 2003

17. 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

18. 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)

19. 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)

20. 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

21. Factors Predicting Health Literacy for Adults aged 66 and over (CCL, 2008)

22. 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)

23. What can be done? • Very few rigorous evaluations (IOM, 2004; CPHA 2008)

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Strategies for Addressing Health Literacy • Improve skills required to be health literate • Provide services appropriate for people with all skill levels

34. 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)

35. 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

36. 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

37. 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/

38. 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

39. 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

40. 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

41. 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

42. Questions? Comments?