Rethinking health literacy a meaning measures outcomes
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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. Disclosures. Overview. 1. Health Literacy: Meaning Measure - as covariate - as outcome

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RETHINKING HEALTH LITERACY a meaning, measures & outcomes

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RETHINKING HEALTH LITERACYameaning, measures & outcomes

Michael Wolf, MA MPH PhD

Professor, Medicine & Learning Sciences

Feinberg School of Medicine

Northwestern University

Chicago, IL USA


Disclosures


Overview

1. Health Literacy:

  • Meaning

  • Measure

    - as covariate

    - as outcome

    2. What’s Next


Overview

1. Health Literacy:

  • Meaning

  • Measure

    - as covariate

    - as outcome

    2. What’s Next


Overview

1. Health Literacy:

  • Meaning

  • Measure

    - as covariate

    - as outcome

    2. Health Literacy Research


medical cognition

health behavior

COMPLIANCE

health information

Health Education

patient engagement

knowledge

self-management

healthcare competencies

patient-centered care

healthcare access

equity

behavioral failure

Numeracy

care coordination

Health Literacy.

Cognitive Function

awareness

adherence

Language access

PERSONALITY

HEALTH PROMOTION

HEALTH LEARNING CAPACITY

Human Factors

motivation

health communication

Experience

navigation

PATIENT ACTIVATION

therapeutic misadventures

Unintentional non-adherence

shared decision making

comprehension


Health Communication

Human Factors

Health Promotion

Reading Problem


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


> Reading… > Numeracy

857 Adults from academic and community primary care practices, ages 55-74


> Reading… > Numeracy

857 Adults from academic and community primary care practices, ages 55-74

Reading, Numeracy, and their Combined Impact on Health Task Performance


Skill Set.

  • Reading, and …

  • Numeracy, and ...

  • Attention

  • Memory

  • Speed

  • Problem-solving (reasoning)

  • Communication skills

  • Many others


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: -


Health Literacy ≠ Activation


Why We Care: A $200 Billion Problem

HL

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)


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 – don’t self-identify problems


A Need for Clarity

HL

  • 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


A Need for Clarity

HL

  • 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


A Need for Clarity

HL

  • 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


A Need for Clarity

HL

  • 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


2 Primary Objectives

► An Outcome: Clear Health Communication

  • Promote for all healthcare consumers

    ► A Risk Factor: Health & Healthcare Equity

  • Reduce literacy disparities in health

HL


Measures


Existing Tools

  • Individual traits

  • Research vs. clinical

  • Variable thresholds reported

  • Limited modality

  • Resilience over time

  • Aging

  • SES


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


Performance preserved: - Verbal Ability

- REALM


Performance preserved: - Verbal Ability

- REALM

  • Performance declines:

  • Long-term memory

  • Working memory

  • Inductive Reasoning

  • Processing Speed

  • TOFHLA

  • NVS


Unpack from SES?

NAAL, 2003


Outcomes


Outcomesisk Factor

HL

  • Background Knowledge (retrieve, recall)

  • ‘Functional Understanding’ of Behaviors (apply)

  • Self-Efficacy(information-seeking)

  • Activation

  • Communication

  • Behavior change/maintenance

  • Health Services Use

  • Outcomes


Outcomesisk Factor

HL

DIRECT

  • Background Knowledge (retrieve, recall)

  • ‘Functional Understanding’ of Behaviors (apply)

  • Self-Efficacy(information-seeking)

  • Activation

  • Communication

  • Behavior change/maintenance

  • Health Services Use

  • Outcomes


Demonstration vs. Subjective Assessment


‘Take two pills by mouth twice daily’:

Seemingly Simple, Often Unclear


Outcomesisk Factor

HL

  • Background Knowledge (retrieve, recall)

  • ‘Functional Understanding’ of Behaviors (apply)

  • Self-Efficacy(information-seeking)

  • Activation

  • Communication

  • Behavior change/maintenance

  • Health Services Use

  • Outcomes

DISTAL


Health Literacy Research


Goal 1

Measure to Respond to Disparities

Anne Beal, MD - PCORI


Can we Close the Gap?


Goal 2

Can we Confuse People Less?

Alastair J.J. Wood, MD


Goal 3

Evaluate Health Systems

Ruth Parker, MD


Recommendations

HL

  • 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)


Recommendations (cont.)

  • Recognize performance is dependent on the system, not just individual

    - can you include system attributes?

  • Mediating, Moderating Factors

  • Consider Activation


Michael Wolf, MA MPH PhD

Professor, Medicine & Learning Sciences

Associate Division Chief – Research

General Internal Medicine & Geriatrics

[email protected]


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