Transcript Health Literacy and Incoming College Students: A Pilot Study

Health Literacy and
Adolescents (15min)
Jennifer A. Manganello, PhD, MPH
University at Albany School of Public Health
American Public Health Association
Annual Meeting
November 5, 2007
Introduction

Health literacy defined as “the degree to which individuals have the
capacity to obtain, process, and understand basic health information
and services needed to make appropriate health decisions” (Selden et al.,
2000)

Health literacy has been receiving more attention in recent years
(funding through NIH, conferences like one sponsored by the
American College of Physicians Foundation)

IOM Report in 2004 (“A Prescription to End Confusion”)

A lot of work at Emory (Mark Williams and Ruth Parker), LSU (Terry
Davis), and Northwestern (David Baker and Michael Wolf)

Seen as a way to improve health outcomes and reduce health
disparities
Health Literacy and Adults
Low levels of health literacy may limit:

the ability to provide medical histories and accurate
responses to questionnaires, understand instructions for
prescription medications, and comprehend provider
instructions (Ad Hoc Committee on Health Literacy for the Council of
Academic Affairs, 1999; Baker et al., 1996; Lee, 1999; Weiss & Palmer, 2004)

participation in or benefit from health education programs,
including media interventions (Lindau et al., 2002; Rudd et al.,
2003; Williams et al., 1998)

communication between patients and providers (Schillinger,et
al., 2004; Williams et al., 2002)
Why Study Adolescents?

Research has focused on groups with low literacy, especially
the elderly (same for intervention development)
BUT

Adolescents are increasingly more involved with their health
care (Gray et al., 2005)

Growing prevalence of chronic illnesses such as asthma and
diabetes among youth ages 0-17, increases interaction with
the health care system (Boice, 1998; Millstein & Litt,1990; Millstein,
1993)
Why Study Adolescents?

Adolescents access health information which informs their actions and
behaviors

The internet is widely used by adolescents and has an unlimited
amount of health information

However, it is unclear how well adolescents are able to understand,
process, and evaluate health information

Adolescents involved in settings, such as schools, that can facilitate
interventions

Improving health literacy at an early age will enhance adult health
Davis et al. (2006)

Recently, Terry Davis and colleagues revised a
testing instrument (REALM) to use with teens.

N=1,533 teens from schools, a clinic, summer
programs

46% of adolescent participants were reading
below grade level according to the SORT-R
A Framework for Adolescent
Health Literacy

Includes three main concepts
Individual, interpersonal, and systemic
contributors to health literacy (based on the
Ecological Model)
 Multiple types of literacy deserve attention
when assessing health literacy for adolescents
 Health literacy potentially affects health
outcomes (behavior, service use, costs)

Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Individual Influences

Race, age, gender, cultural background, cognitive and
physical abilities, and social skills can predict one’s health
literacy (Nielsen-Bohlman et al., 2004)

Media use:
 youth ages 8-18 spend almost 6 and ½ hours per day
with media (KFF, 2005)
 adolescents report using the media, especially the
internet, as a source of health information (Borzekowski &
Rickert, 2001)

Given that media use has been linked to development,
health behavior, and literacy, there may be an association
with health literacy (Brown & Witherspoon, 2002; Jordan, 2004;
Zarcadoolas et al., 2006)
Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Peer and Parent Influences

Peers have a growing role in the lives of youth as they transition into
adolescence, and families continue to be important (illustrated in
research on sexual behavior, for instance)

Information-sharing

Relationship exists between family interaction and school achievement
 For example, reading aloud at home can enhance vocabulary skills
(Blachowicz & Fisher, 2007)

Parent health literacy can directly impact health outcomes for
adolescents
 A study of Latino parents found that people with higher literacy
levels were more likely to use medications for their children
correctly (Leyva et al., 2004)
Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Systems

Schools play a central role in the development of literacy skills
 Reading comprehension
 Numeracy
 How to access information

The health system influences accessibility of health care and how well
information is communicated to patients (Nielsen-Bohlman et al., 2004)
 Readability of materials, clarity of provider communication

Media influences societal norms and what information is available

Systems can be used for interventions to improve health literacy
Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Health Literacy

Types of health literacy (Nutbeam, 2000)




Functional literacy- ability to read and write
Interactive literacy- one’s ability to coordinate
functional literacy and social skills to fully participate
in daily activities
Critical literacy- a person’s potential to evaluate
information
Media literacy- the ability to critically evaluate media
messages (ie, credibility, accuracy, etc.)
Health Literacy

Measurement

Test of Functional Health Literacy in Adults
(TOFHLA), the Rapid Estimate of Adult Literacy in
Medicine (REALM), and REALM- Teen (Parker et. al.,
1995; Davis et al., 1993; Davis et al., 2006)

These instruments mainly assess literacy as it relates to
written comprehension and do not test other aspects of
health literacy (Nielsen-Bohlman et al., 2004)

There is currently no adequate tool to assess health
literacy (Nielsen-Bohlman et. al., 2004)
Framework
Individual Traits
Age, race, culture,
gender, language
education
Health Outcomes
Family and peer
influences
Health Behavior
Social skills
Health Literacy
•Functional
Cognitive skills
Health Costs
•Interactive
Physical abilities
•Critical
•Media literacy
Media use
Mass Media
Education System
Health Service
Use
Health System
Health Outcomes

Little research to date on health outcomes as a function of
health literacy for adolescents-likely impacted by
parent/guardians and their health literacy

One study that included adolescents found that higher
literacy was correlated with likelihood of being tested for
gonorrhea, even though low literacy participants believed
they were at higher risk for the disease (Fortenberry et al., 2001)

Literacy closely related to academic achievement which
has been linked to health behaviors
 One study found an association with reading below
grade level and violent behavior (Davis et al., 1999)
Future Research

Develop and validate tools to measure
health literacy in adolescent populations

Specifically measure health literacy in
adolescents

Scales and questions should allow for selfadministration when possible for inclusion in
large scale surveys

Include measures for different types of literacy
Future Research

Study predictors of health literacy levels
among adolescents

Understand the association of individual traits
with health literacy skills

Examine the influence of peers, families, and
systems on health literacy
Future Research

Study the relationship between adolescent
health literacy and health outcomes


Once measures are created to assess health
literacy, resulting scores can be used as
predictor variables for behaviors or other health
outcomes of interest
Consider different cultural groups and
conduct studies in other countries
Future Research

Develop and evaluate interventions that can
promote a greater understanding of health
information for adolescents

Interventions may include programs in school or health
care settings

Interventions can use mass media to teach health
literacy skills to adolescents
Potential Interventions

Develop or enhance instruction offered at high
schools (via health education courses, English
classes)

Find ways to use mass media to teach health
literacy skills (for example, a web-based
instructional program tailored for adolescents)

Training for pediatricians around health literacy
issues for adolescents
College Student Study 1 (2007-08)

Goal: to collect information about health literacy from 18
and 19 year olds (close in age to high school students)

Convenience sample of 40 English-speaking students
attending the University at Albany

In-depth interviews

Questions to obtain information about:
 health care use
 ability to understand health information
 attitudes and experiences with health literacy

REALM-Teen will be administered
College Student Study 2 (2008)

Effort to develop the HAS-A (Health Literacy Assessment
Scale for Adolescents)

Use findings from Study 1 to begin to develop a list of
questions that could eventually be used in a scale to measure
health literacy

Refine list of questions with pilot testing/input from experts

Administer questions to 225 18 and 19 year old
undergraduate students along with the REALM-Teen (to
look for correlation)

Reliability will be assessed using Cronbach’s Alpha/Factor
analysis to identify any scales
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