Literacy Assessment In Health Care Is the Cheese Moving? Terry - PowerPoint PPT Presentation

Literacy Assessment In Health Care “Is the Cheese Moving?” Terry Davis, PhD Professor of Medicine and Pediatrics LSUHSC Russ Rothman, MD, MPP Associate Professor of Medicine and Pediatrics Vanderbilt Elizabeth Hahn, MA Associate Professor of Medical Social Sciences Northwestern Lauren McCormack, PhD, MSPH Director, Health Communication RTI 1

Measurement •Where we have come from •Where we are now • Numeracy, pediatrics, language •Where we are going •What we are measuring and why •Do we lack conceptual agreement on health literacy? •New modes of data collection •Challenges and opportunities 2

Standard of Literacy Changes with Demand of Society • Signing name (civil war) • 3 rd , 4 th grade education (CCC, WWII) • 8 th grade education (war on poverty) • HS diploma/GED (today’s GI) • College or more (emerging global economy) 3

Toward a Literate Society* Any national program to improve literacy skills needs to be based on the best possible information on the deficits and their severity. 1988 – Congress asked DOE to define literacy and address need for information on the nature and extent of adult literacy. 4 *1975 Carroll, Chall

Literacy A National Problem Limiting U.S. Competitiveness 1990 – Governor’s conference set goal By year 2000 every adult American will be literate and possess knowledge and skills to compete in global economy. 1991 – National Literacy Act 5

National Literacy Act Literacy Compute Speak in Solve Read Write (Math English Problems Skills) “…at a level needed to function on the job and in society to achieve ones goals and develop ones knowledge and potential.” 6 1991; 1992 National Adult Literacy Survey; Kirsch, 2001

National Literacy Assessments Prevalence of low literacy 13-59% (pre-NALS) • Profiles of America’s Young Adults (21-25) 1971-1992 (literacy lower in 92) • English Language Proficiency Study (1980 census) • Literacy proficiency in job seekers 1990 (DOL) NAEP. Nation’s report card 1984-2004 (4 th , 8 th and 12 th graders) • • NALS 1993 • Adult Literacy in US (4 military, 6 civilian assessments 1917- 1986) (Sticht and Armstrong) 1994 • NAAL 2003 (H.L. component) • HALS 2004 (linked to NALS database) • NAAL 2016 (internet component) 7

Literacy Rates By State (National Adult Literacy Survey) % Adults with Level 1 Literacy Skills > 30 % 20 % to 30 % 15% to 20 % < 15% 21% U.S. Adults are Level 1 8 National Institute for Literacy 1998

Literacy Assessment In Healthcare Where I’ve Come From 1987-2009 I was once “homeless” 9

Academic Achievement •PIAT-R •WRAT-R Word Recognition •SORT-R •REALM Raw scores translate to grade level estimates. 10 Davis Fam Practice 1990, Davis Fam Med , 1991, 1993, Davis Pediatrics 1994

Test of Functional Health Literacy in Adults (TOFHLA) • 3 reading comprehension sections (close technique) and a numeracy section • English and Spanish • Long and short versions. • Translates into three categories 0-16 Inadequate functional literacy 17-22 Marginal functional literacy 23-36 Adequate functional literacy Parker J Intern Med 1995, Williams JAMA 1995, Baker Patient Educ Counseling 1999

Health Literacy is Branded AMA 1999, NLM 2000 IOM 2004, Healthy People 2010 – “the degree to which individuals have the capacity to obtain, process, & understand basic health information & services needed to make appropriate health decisions.” HHS, National Institutes of Health, National Library of Medicine (NLM). Health Literacy, 12 January 1990 Through 1999 . NLM Pub. 2000, vi.

Dual Nature of Health Literacy Literacy and Health in America • Conceptualize H.L. framework • Looks at populations (vulnerable) and complexity of material and demand on the individual • Linked literacy to disparities in healthcare Meaning and Measure of HL Healthy People 2010 Objective 11: Improve health communication and literacy • Improve health literacy (both individual skills and materials) • Increase research and evaluation in health communication 13 Rudd, 2004, Baker, 2006

Health Literacy is More Than 14 Individual Ability But what are we assessing? Ruth Parker

Literacy Tests Cited In Literature Test Year Type # Cites WRAT-R3 65, 95 Word recognition >2000 REALM* 91,93 Health word recognition 472 TOFHLA* 95 Comprehension of health 393 materials S-TOFHLA* 99 Comprehension of 2 health 249 forms HALS 04 Use print materials to 45 accomplish health tasks N.V.S. 05 Comprehension, numeracy 95 interpretation food label 15 * Highly predictive of health outcomes.

Literacy Tests Cited In Literature Literacy Tests Cited In Literature Test Year Type # Cites MART 97 Medical word recognition 23 LAD 01 Diabetes word recognition 16 REALM-R 03 Health word recognition (11) 42 REALM-SF 06 Health word recognition (7) 1 REALM-Teen 06 Adolescent health word 18 recognition SAHLSA 07 Spanish word recognition and 21 comprehension 16

Literacy Tests Cited In Literature “CAGE” questions 3 Screening questions Year Type # Cites Williams 95 Self-report Bennett (parents) 03 Self-report 27 Chew 04 Self-report 70 1 question Wallace 06 Self-report 31 Chew 08 Self-report 70 Demographics: age, ethnicity, education? 17 Can be given over the phone

Assessing HL of Population 2003 NAAL: 1 st large scale national literacy assessment to contain a component designed specifically to measure health literacy in US adults • 19,000 adults in U.S. households and prisons • 152 tasks (28 health related), 40 (8 health) given to each adult • Oral reading fluency added to better understand reading difficulty 2 passages (3-5 th grade and 7 th to 8 th grade) – – Fluency = words read correctly/minute • Supplement assessment for adults very low literacy (navigating/understanding) Vicks 44 + 8 other “stimulus” items – 10 questions asked for each stimulus 18 Sheida White

Key conceptual features continued Several factors affect an individual’s performance on any given task . 19 Sheida White

NAAL Health Literacy Data* NAAL Health Literacy Data* *Correlation HL & NAAL prose .87 12% Proficient 14% Below Intermediate Basic 53% Basic Hispanic 22% Average Medicare National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. 20 Department of Education, 2003.

Current Population Testing Issues • FDA requires industry to test consumer understanding of OTC & Rx information – what % sample low literacy? • “Mall intercept” is standard. Is it representative? • Testing patient literacy level alone will not confirm ability to navigate, understand and act on health information and manage care. • Need studies assessing navigation, comprehension, self-care and actual use of medication. • These can then be correlated with literacy level to give an estimate of an individual’s OTC (or other domain specific) health literacy. 21

Considerations in Testing in Health Care Research • Reports in literature • Validity/ Reliability • Cost • Training required • Ease and method of administration (in person, phone, computer) • Time required • Age, language, cognitive ability of patients • Confidentiality 22

Cautions • All existing tools measure literacy in health context (i.e. not health literacy). • Current tests do not include children or languages other than English, Spanish Developers of commonly used tests:* • Do not recommend testing patients clinically UNLESS providers are willing to alter communication. 23 *Davis, Parker, Weiss

The Conundrum of Measuring Health Literacy • Lack of conceptual agreement on WHAT IS HEALTH meaning of health literacy LITERACY? • Are we only measuring individual skills? • Can health literacy (as we are measuring it) be improved? • What interventions improve scores on health literacy tests? • Will higher scores translate to improved health outcomes? 24

Challenges and Opportunities • What literacy or HL skills are needed today? – What skills/demands do we anticipate for tomorrow? • Can health literacy of U.S. population be tracked? – Difficulty in tracking L or HL is that the “cheese moves” and demands become more complex • Do literacy or HL include navigating the internet? • Can NAAL questions and database be released? 25

Is This the Dawning of the Age of Aquarius? Russell Rothman • Numeracy’s emergence • Assessing parents/children Beth Hahn and Lauren McCormack • NIH funded development of HL assessments • Novel computer based methods of data collection • New psychometric methods 26