Transcript Slide 1

Health Literacy:
Potential Pathway to
Oral Health for the Elderly?
Alice M. Horowitz, PhD
School of Public Health
June 28, 2007
Santa Fe, New Mexico
Overview
 What is health literacy and why is it
important?
 Historical perspective
 Recent activities
 Strategies for improving health literacy
Health literacy is a relatively
new concept especially as it
relates to oral health
Health Literacy is an Emerging
Issue that is Ripe for Leadership:
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Pre-doctoral education
Resident and post-doctoral-training
Research
Policy
Literacy - Defined
 The ability to read, write, speak and
compute and solve problems at levels of
proficiency necessary to function on the job
and in society, to achieve one’s goals and
develop one’s knowledge and potential.
National Literacy Act 1991
Health Literacy -Defined
 Health literacy represents the cognitive and social
skills which determine the motivation and ability of
individuals to gain access to, understand, and use
the information in ways which promote and
maintain good health. Health literacy means more
than being able to read pamphlets and
successfully make appointments. By improving
people’s access to health information and their
capacity to use it effectively, health literacy is
critical to empowerment (WHO, 1998)
Health Literacy-Defined
“The degree to which individuals have the
capacity to obtain, process and understand
basic health information and services
needed to make appropriate health
decisions”
Ratzan and Parker, 2000
HP2010 2000
IOM Report 2004
Oral Health Literacy-Defined
 “The degree to which individuals have the
capacity to obtain, process and understand
basic health information and services
needed to make appropriate oral health
decisions”
HP2010, 2000
Health Literacy is Dependent Upon
Individual and Systemic Factors:
 Communication skills of consumers and
providers
 Knowledge of consumers and providers of
health topics
 Culture and societal impact
 Demands of the healthcare system
 Demands of the situation/context
Communication Skills
 Health literacy is dependent on the
communication skills of consumers and
providers
– Communication skills include literacy skills—
reading, writing, numeracy, speaking, listening
and comprehension
– Communication skills are context specific for
both patients and providers
Knowledge of Health Topics
 Health literacy is dependent on knowledge of consumers and
providers of health topics
– Patients with limited or inaccurate knowledge about the body and causes of
disease may not:
– Understand the relationship between lifestyle factors (e.g. diet and
exercise; oral hygiene practices and gingivitis) and health outcomes
– Recognize when they need to seek care
– Have current prevention information
– Health information can overwhelm anyone--even people with advanced
literacy skills.
– Providers who do not keep current with the state of the science cannot
provide accurate knowledge and information and evidence-based services for
their patients.
Cultural and Society
 Culture and societal impacts on Individuals:
– How people communicate and understand
health information
– How people think and feel about their health
– If and how people value oral health
– When and from whom people seek care
– How people respond to recommendations for
lifestyle changes and treatment
Cultural and Society
 Culture affects Providers:
– How providers communicate and understand health
information
– How providers think and feel about
racial/ethnic/economic groups other than their own
– How providers value preventive measures
– Where they obtain new information
– If and how providers respond to recommendations and
guidelines
Demands of the Healthcare
System
 Health literacy is dependent on the demands of
the healthcare and public health systems.
Individuals need to:
– know how to locate and navigate a health facility
– read, understand, and complete many kinds of forms to
receive treatment, provide consent for treatment and
payment reimbursement
– articulate their signs and symptoms
– know about various types of health professionals and
what services they provide and how to access those
services
– Know how to ask questions
Demands of the Situation or
Context
 Health literacy is dependent on the demands of
the situation/context
– Health contexts are unusual compared with other
contexts because of an underlying stress or fear factor
– Health contexts may involve unique conditions such as
physical or mental impairment due to illness
– Health situations are often new, unfamiliar, intimidating
and often exhausting
– Some health facilities have staff that are not particularly
empathetic---not user friendly
Scope of Health Literacy
 Functional skills include reading, writing,
speaking, listening, basic arithmetic skills
 Knowledge of health topics --information &
services
 Knowledge must be related to decision
making
 CORE ISSUE: UNDERSTANDING
Health Literacy is Important Because it
Affects One’s Ability to:
 Understand dental/medical concepts
 Share personal and health information with
providers
 Participate in their health care & that of
their children
 Navigate the healthcare system, including
locating providers and services, finding
transportation and completing forms
Health Literacy is Important
…cont’d
 Act on health-related news and
announcements
 These outcomes impact:
– health outcomes
– healthcare costs
– quality of care
According to a 1998 study, the
cost of low health literacy in
the US could be anywhere
from $30 billion to as much as
$73 billion annually.
National Academy on an Aging Society
Individuals with Limited Health
Literacy Skills Have:
 Lower use of preventive services
 Higher use of treatment services which
result in higher healthcare costs
 Often reported feeling a sense of shame
about their skill level and/or developed
strategies to compensate
Measuring Health Literacy
 Health literacy is measured as functional
literacy—people’s ability to apply reading
skills to everyday tasks involving prose,
documents, and numbers.
 Current population data on literacy come
from the 2003 National Assessment of Adult
Literacy (NAAL):
– Health literacy data from the NAAL were
released in 2006.
2003 NAAL Findings
NAAL reports a separate score for each of three
literacy areas:
• Prose literacy: Skills needed to search, comprehend, and
use continuous texts such as news stories and brochures
• Document literacy: Skills needed to search, comprehend,
and use noncontinuous texts such as job application
forms, maps, and food labels
• Quantitative literacy: Skills needed to identify and
perform computations using numbers embedded in
printed materials, such as numbers used in balancing a
checkbook or completing an order form
2003 NAAL Findings
Findings reported participants’ ability to complete
these tasks with 67% accuracy by levels:
• Below Basic: Can perform tasks involving brief and
uncomplicated texts and documents. Adults can generally
locate a piece of information in a news story.
• Basic: Able to locate information in text, make low-level
inferences, and integrate easily identifiable pieces of
information.
• Intermediate: Able to integrate information from relatively
long or dense texts, determine appropriate arithmetic
operations, and identify how to perform the operation.
• Proficient: Demonstrate proficiencies associated with long
and complex documents and text.
Number of Adults in Each Prose
Literacy Level: NAAL 2003
95 million
63 million
100
30 million
Millions
of adults
28 million
50
0
Below Basic
Basic
Intermediate
Proficient
 Most adults scoring in Below Basic would not be able to
read the dosage chart on a package of over-the-counter
pediatric cold medicine.
 Adults scoring in Basic would find the dosage chart difficult.
Measures of Health Literacy
Most measures of health literacy at the
individual level were developed in the
1990s:
• Rapid Estimate of Adult Literacy in Medicine (REALM)
• Test of Functional Health Literacy in Adults (TOFHLA
and S-TOFHLA)
• Newest Vital Sign (NVS)
• Literacy Assessment for Diabetes (LAD)
• REALD-30 & 99; TOFHLiD (dental)
Measurement Needs
 Health literacy measures based on functional
literacy do not capture the full range of skills
needed for health literacy.
 Current assessment tools (for populations and
individuals) cannot differentiate among:
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Reading ability
Lack of health-related background knowledge
Lack of familiarity with language and materials
Cultural differences in approaches to health.
Who Is at Risk?
 The problem of limited health literacy is
greater among:
– Older adults
– Those who are poor
– People with limited education
– Minority populations
– Persons with limited English proficiency (LEP)
Who is at Risk?
 Many of the same populations at risk for
limited health literacy also suffer from
disparities in health status, illness (including
heart disease, diabetes, obesity, HIV/AIDS,
dental caries, periodontal disease, cancer,
lead poisoning and low birth weight), and
death.
Health Literacy: Use of
Preventive Services
Persons with limited health literacy skills are less
likely to use preventive measures such as:
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Mammograms
Pap smears
Flu shots
Use of fluoride toothpaste
Preventive dental appointments
Lead screening for children
Health Literacy: Knowledge About
Medical Conditions, Prevention and
Treatment
Persons with limited health literacy skills:
 Are more likely to have chronic health conditions
and less likely to manage them effectively.
 Have less knowledge of their disease (e.g.,
diabetes, asthma, HIV/AIDS, high blood
pressure) periodontal diseases, dental caries
and its management.
Oral Health Literacy Framework
2
Health
System
1
Culture
And
Society
Oral Health
Outcomes
and Costs
Oral
Health
Literacy
3
Education
System
Source: Adapted from Institute of Medicine, Health literacy: A prescription to end confusion.
Health Literacy: A prescription to end
confusion, IOM’s report has and is having a
significant impact.
For example in the research arena:
 NIH issued two PA’s on understanding and
promoting health literacy
 18 projects were awarded on the first round
of applications
 A PI meeting was held September 2006
 The PAR was reissued for 3 more years
Understanding and Promoting
Health Literacy
(PAR-04-116; PAR-06-132)
GOAL: Increase scientific understanding of
the nature of health literacy and its relation
to:
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Healthy behaviors
Illness prevention and treatment
Chronic disease management
Health disparities
Risk assessment
Health outcomes
Understanding and Promoting
Health Literacy
PAR-04-116
Understanding and Promoting Health
Literacy (R01)
PAR-06-132
Understanding and Promoting Health
Literacy (R03)
In Addition
 HRSA has stepped up their work in health
literacy
 CMS has increased their efforts in this area
 AHRQ supported an evidence-based review,
and co-funds some of the NIH projects
 ADA has recently organized a National Oral
Health Literacy Advisory Committee
Oral Health Literacy
The results of a 2004 NIDCR workgroup on oral
health literacy, recently published,* includes
recommendations for dental and craniofacial
research and background on health literacy and its
impact on health outcomes.
*Report of Workgroup: The Invisible Barrier: Literacy
and its Relationship with Oral Health. J Public Health
Dent. 2005;65:174-183
Research Needs
 Instrument (s) to evaluate oral health literacy
 Compare oral health literacy instruments with health
literacy instruments
 Determine impact of health literacy on oral health
outcomes
 Determine roles of dental care providers in increasing
health literacy
 Determine what dental & dental hygiene schools teach
regarding communication skills
 Assess best methods for teaching communication skills
in dental provider schools
 Determine communication skills of practicing dental care
providers
Healthy People 2010 Health
Communication Objectives
 11-1 Internet access in the home
 11-2 Health literacy
 11-3 Research & evaluation of health
communication programs
 11-4 Quality of internet health Web sites
 11-5 Centers of excellence in health
communication
 11-6 Increase the proportion of persons who
report that their health care providers have
satisfactory communication skills
Two Healthy People 2010 Objectives
Specifically Address the Need for Health
Literacy Improvement:
 11-2. Improve the health literacy of persons
with inadequate or marginal literacy skills
 11-6 Increase the proportion of persons
who report that their health care providers
have satisfactory communication skills
Key Point:
Communication between patient and
provider is pivotal to positive health
outcomes
Medical Expenditure Panel
Survey: Evaluating Providers
 How often did doctors or other health providers
listen carefully to you? [56% 2000 MEPS]
 How often did doctors or other health providers
explain things in a way you could understand?
[58%]
 How often did doctors or other health providers
show respect for what you had to say? [58%]
 How often did doctors or other health providers
spend enough time with you? [45%]
Clear & Effective Communication
Includes:
 Plain language
 Culturally and linguistically appropriate
language
 Appropriate reinforcement
 Teach back to ensure patient understands
 Patient centered
Educate policy makers at all
levels about the importance
of health literacy and its
impact on health
outcomes
Questions Policy-makers Should
ask:
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What are the literacy rates among those eligible to participate in public programs
in my state?
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At what reading level is current health information provided?
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Have changes been made to simplify the process for enrolling in public programs
in my state?
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Is it possible to create a coordinated application process to decrease the number
of forms that need to be completed to receive medical assistance?
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Is public health information suitable for those with low literacy?
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What can be done to increase literacy in my state?
The Council of State Governments 2002
Additional Questions to Ask
 What do providers know and do about primary
prevention? (e.g. how to prevent dental caries).
 What do providers teach/tell their patients?
 Are informed consent forms in plain language?
 Do provider schools teach communication skills?
 Do providers provide communication skills to their
staff?
 Do dental examining boards require testing on
communication skills?
More Questions
 Is the hospital/clinic environment user
friendly?
 Are interpreters available?
 Are the signs understandable to patients?
 Are patient navigators available?
Who Is Responsible for
Improving Health Literacy?
A health literate America is a society in
which health systems and institutions take
responsibility for providing clear
communication and adequate support to
facilitate health-promoting actions based
on understanding.
—Institute of Medicine, 2004
Health Literacy is an Emerging
Issue that is Ripe for Leadership
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Pre-doctoral education
Resident and post-doctoral training
Research
Policy
What will the Santa Fe Group
do to Increase Oral Health
Literacy Among the Elderly?
Thank you!