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?
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 [email protected]