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RETHINKING HEALTH LITERACY RETHINKING HEALTH LITERACY a meaning, measures & outcomes Michael Wolf, MA MPH PhD Professor, Medicine & Learning Sciences Feinberg School of Medicine Northwestern University Chicago, IL USA

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Disclosures FederalFoundationIndustry NIH - NHLBI - NIA - NICHD - NINR - OBSSR AHRQ American Cancer Society California Endowment California Healthcare Foundation Missouri Foundation for Health Atlantic Health Abbvie/Abbott Eli Lilly Emmi Solutions Land of Lincoln Health Luto Merck OptumHealth UnitedHealthcare

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Overview 1. Health Literacy: Meaning Measure - as covariate - as outcome 2. Whats Next

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Overview 1. Health Literacy: Meaning Measure - as covariate - as outcome 2. Whats Next

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Overview 1. Health Literacy: Meaning Measure - as covariate - as outcome 2. Health Literacy Research

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Health Literacy. patient engagement shared decision making PATIENT ACTIVATION medical cognition patient-centered care health communication health behavior Human Factors care coordination Health Education self-management H EALTH P ROMOTION adherence COMPLIANCE therapeutic misadventures knowledge Experience navigation healthcare access awareness healthcare competencies Numeracy HEALTH LEARNING CAPACITY equity Cognitive Function motivation PERSONALITY Language access Unintentional non-adherence comprehension health information behavioral failure

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Human Factors Health Promotion Health Communication Reading Problem

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Health Literacy is The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. - Institute of Medicine, USA The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. - World Health Organization

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> Reading > Numeracy 857 Adults from academic and community primary care practices, ages 55-74 REALMAM-NARTTOFHLA-RREADINGLipkusNVSTOFHLA-NNUMERACY REALMN/A AM-NART0.73*N/A TOFHLA-R0.75*0.72*N/A READING0.93*0.89*0.90*N/A Lipkus0.49*0.63*0.51*0.58*N/A NVS0.48*0.69*0.59*0.64*0.61*N/A TOFHLA-N0.39*0.48*0.46* 0.53*0.49*N/A NUMERACY0.54*0.73*0.62*0.68*0.90*0.84*0.73*N/A

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857 Adults from academic and community primary care practices, ages 55-74 Model I Reading Model II Numeracy Model III Reading + Numeracy Reading Factor Score10.4 (9.0,11.8)***--7.1 (5.7,8.6)*** Numeracy Factor Score--11.3 (9.7,12.8)***7.3 (5.7,8.9)*** R 2 =0.64 R 2 = 0.72 Reading, Numeracy, and their Combined Impact on Health Task Performance > Reading > Numeracy

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Skill Set. Reading, and Numeracy, and... Attention Memory Speed Problem-solving (reasoning) Communication skills Many others Reading, and Numeracy, and... Attention Memory Speed Problem-solving (reasoning) Communication skills Many others

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Age, HL, and Cognition HL to HL : 0.46 to 0.75 FA to HL : 0.37 to 0.71 CA to HL : 0.71 to 0.74 Age to FA: + Age to CA: - Age to TOFHLA: + Age to REALM: -

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Health Literacy Activation

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Why We Care: A $200 Billion Problem The business case for health literacy Inadequate/inaccurate knowledge of disease, treatment Poorer self-care skills (medication use, monitoring, device use) Inappropriate health services use Translates to: Non-adherence Costly urgent services (Unscheduled visits, ED, Hospitalizations) Medication Errors & Adverse Events Poorer outcomes (HTN, Diabetes, CHF, Asthma/COPD) HL

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Why We Care: Pertinent Epidemiology 1 in 5 adults severely lack cognitive and psychosocial skills to manage personal health Greatest risk among those that are: > 60 years old, < high school educated, racial/ethnic minorities, multi-morbidity Prior studies suggest MDs, RNs, and PharmDs cannot easily identify at-risk patients Kripalani et al low HL patients ask fewer questions; Weiss et al dont self-identify problems

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A Need for Clarity includes a skill set ~ 600 original studies comprise evidence (crude measures of reading, numeracy, health knowledge) But we want more from individuals - motivation, cultural factors (language, beliefs, experience) And the health system - accessibility, navigability, communication, follow-up And community - education, human services, policy, etc. HL

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A Need for Clarity includes a skill set ~ 600 original studies comprise evidence (crude measures of reading, numeracy, health knowledge) But we want more from individuals - motivation, cultural factors (language, beliefs, experience) And the health system - accessibility, navigability, communication, follow-up And community - education, human services, policy, etc. HL

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A Need for Clarity includes a skill set ~ 600 original studies comprise evidence (crude measures of reading, numeracy, health knowledge) But we want more from individuals - motivation, cultural factors (language, beliefs, experience) And the health system - accessibility, navigability, communication, follow-up And community - education, human services, policy, etc. HL

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A Need for Clarity includes a skill set ~ 600 original studies comprise evidence (crude measures of reading, numeracy, health knowledge) But we want more from individuals - motivation, cultural factors (language, beliefs, experience) And the health system - accessibility, navigability, communication, follow-up And community - education, human services, policy, etc. HL

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2 Primary Objectives An Outcome: Clear Health Communication 1.Promote for all healthcare consumers A Risk Factor: Health & Healthcare Equity 2.Reduce literacy disparities in health HL

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Measures

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Existing Tools Individual traits Research vs. clinical Variable thresholds reported Limited modality Resilience over time Aging SES

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How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

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Performance preserved: - Verbal Ability - REALM

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Performance declines: - Long-term memory - Working memory - Inductive Reasoning - Processing Speed - TOFHLA - NVS Performance preserved: - Verbal Ability - REALM

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Unpack from SES? NAAL, 2003

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Outcomes

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Outcomesisk Factor Background Knowledge (retrieve, recall) Functional Understanding of Behaviors (apply) Self-Efficacy (information-seeking) Activation Communication Behavior change/maintenance Health Services Use Outcomes HL

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Outcomesisk Factor Background Knowledge (retrieve, recall) Functional Understanding of Behaviors (apply) Self-Efficacy (information-seeking) Activation Communication Behavior change/maintenance Health Services Use Outcomes HL DIRECT

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Demonstration vs. Subjective Assessment

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Take two pills by mouth twice daily: Seemingly Simple, Often Unclear

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Outcomesisk Factor Background Knowledge (retrieve, recall) Functional Understanding of Behaviors (apply) Self-Efficacy (information-seeking) Activation Communication Behavior change/maintenance Health Services Use Outcomes HL DISTAL

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Health Literacy Research

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Measure to Respond to Disparities Anne Beal, MD - PCORI Goal 1

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Can we Close the Gap?

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Can we Confuse People Less? Alastair J.J. Wood, MD Goal 2

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Evaluate Health Systems Ruth Parker, MD Goal 3

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Recommendations Include measures in research - preferences? Report Standard Thresholds - gradient or threshold effect? Have reasonable, objective outcomes - what to power to? Test for interactions (Goal 1) HL

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Recognize performance is dependent on the system, not just individual - can you include system attributes? Mediating, Moderating Factors Consider Activation Recommendations (cont.)

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Michael Wolf, MA MPH PhD Professor, Medicine & Learning Sciences Associate Division Chief Research General Internal Medicine & Geriatrics mswolf@northwestern.edu