1

Distribution of Health Literacy in CanadaIrving Rootman, Ph.D.

Executive Director, HLKCCPHA Conference Workshop

June 2, 2008Halifax, Nova Scotia

22

Outline

• Why health literacy matters in Canada

• Distribution of health literacy skills

• Vulnerable groups

• National progress

33

Health Literacy is…

• the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course (Rootman and Gordon-El-Bihbety, CPHA, 2008).

44

Why Health Literacy matters in Canada

1. Large numbers of people appear to have low levels of health literacy

2. Lower levels of health literacy appear to be related to poorer health outcomes

3. Increasing rates of chronic disease will increase the need for health literacy skills

4. Lower health literacy appears to be related to higher health care costs

5. Increasing complexity of the healthcare system and the deluge of health information now available put high demands on people for health literacy skills

6. Low health literacy may reflect inequities in health

55

Many people in Canada have low levels of HL

• Based on the 2003 IALSS, 11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs (CCL, 2007a).

• When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale in the 2003 IALSS survey (CCL, 2007a).

Level 3 is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information

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Health Literacy Scores by Self-perceived General Health Status, Canada, 2003

Poor

Fair

Excellent and Very good

190 200 210 220 230 240 250 260 270 280 290

interval95% Confidence

Interval

Estimated average score

Good

scoresSource: CCL, 2007b, CCL, based on IALSS 2003

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Incidence of diabetes by health literacy mean scores of each health disctrict in Canada

0

2

4

6

8

10

220 230 240 250 260 270 280 290

health literacy mean score

Incid

en

ce (

in %

) o

f d

iab

ete

s i

n t

he p

op

ula

tio

n (

12

an

d o

ver)

Source: IALLS 2003 and

Source: CCL, 2008, based on IALSS 2003

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Increasing chronic disease and health literacy

• The number of people with diabetes in Canada is projected to increase from approximately 1.4 million patients in 2000 2.4 million in 2016 (Ohinmaa, et al., 2004)

• One of the ways to address chronic disease which is being increasingly used is patient self-management (McGowan, 2005)

• Low health literacy is a barrier to effective self-management. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management (Johnston et al., 2006)

• Improving literacy and health literacy should lead to improved

self-management of chronic diseases

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Health Literacy (Reading Proficiency) and Cost:

• An analysis of expenditure data from a study of public hospital patients found that predicted in-patient spending for a patient with inadequate HL (Reading Proficiency) was $993 higher than a patient with adequate reading skills. A difference of $450 remained after controlling for health status (IOM, 2004).

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Estimated Economic Drain of Low Health Literacy on U.S. Economy:

• “initial approximation places an order of magnitude of the cost of low health literacy to the U.S. Economy in the range of $106 billion to $238 billion annually” (Vernon et al., 2007)

• “When one accounts for the future costs of low health literacy that result from current actions (or lack of action), the real present day cost of low health literacy is closer in range to $1.6 trillion to $3.6 trillion” (Vernon et al., 2007)

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The relationship between GDP and average health literacy scores by province

240.0

245.0

250.0

255.0

260.0

265.0

270.0

18000 20000 22000 24000 26000 28000 30000 32000

GDP per capita

Hea

lth

Lit

erac

y A

vera

ge

Sco

re

Source: CCL, 2008, based on IALSS 2003

1212

Demands of health information materials:

• Over 800 studies have found that health- related material for patient education far exceeds the reading levels of the average adult (Rudd, 2007). A Canadian study found that the mean reading level of patient education materials in a primary care clinic in Montreal was grade 11.5 (Smith and Haggerty, 2003)

• A study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11 (Petch, 2004)

1313Source: CCL, 2007b, based on IALSS 2003

200 210 220 230 240 250 260 270 280 290

Nunavut

New foundland and Labrador

Prince Edw ard Island

Ontario

Manitoba

New Brunsw ick

Quebec

Canada

Nova Scotia

Northw est Territories

British Columbia

Alberta

Saskatchew an

Yukon Territiory

Health literacy score

95% Confidence interval

Estimated average score

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Distribution of Health Literacy Scores, adult population (16 and over), 2003

0 100 200 300 400 500

Quebec

Yukon Territory

New Brunswick

Saskatchewan

Alberta

Canada

Manitoba

Nova Scotia

British Columbia

Prince Edward Island

Ontario

Newfoundland and Labrador

Northwest Territories

Nunavut

Health Literacy Scale

Mean± s.e.25%

Perc.75%Perc.

5%Perc.

95%Perc.

Source: CCL, 2008, based on IALSS 2003

1515

1616The analysis and mapping of the health-literacy results were conducted by J. Douglas Willms, Canada Research Chair in Human Development at the University of New Brunswick (UNB), with the assistance of Teresa Tang, GIS Programmer at the Canadian Research Institute for Social Policy at UNB

1717

Health Literacy Scores and Confidence Intervals by Age Group, Canada, 2003

66+

56-65

46-55

36-45

26-35

16-25

190 200 210 220 230 240 250 260 270 280 290

95% Confidence interval

Estimated average score

Source: CCL, 2008, based on IALSS 2003

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Health Literacy Mean Scores for key adult sub-population (16 and over) subgroups and sub-population size, 2003

26-35 Yrs

36-45 Yrs46-55 Yrs

56-65 Yrs

Over 65 Yrs

Male

ImmigrantNot Employed

Aboriginal (Off reserve)

16-25 Yrs

Female

Not Immigrant

Non Official Language

Official Language

French Minority Language

Employed

Canada Total

190

215

240

265

290

0 5,000,000 10,000,000 15,000,000 20,000,000 25,000,000

Sco

res

wit

h 9

5% C

on

fid

ence

In

terv

als

Population Size

Level 1Level 2

Level 3

Source: State of Learning in Canada 2007, Canadian Council on Learning, based on IALSS 2003

1919

-0.25 -0.15 -0.05 0.05 0.15 0.25 0.35

Engagement in community or volunteer activities

Age

Gender

English speaking

Literacy practices at w ork

Foreign-born

Community size

Mother tongue different than test language

Occupational status

Informal learning by exposure to varied contexts

Aboriginal status

Labour force participation

Household income

Adult education and training

Informal learning by self study

Parents' education

Educational attainment

Literacy practices at home

Standardized regression w eight

Factors Predicting Health Literacy for Adults aged 16-65

Source: CCL, 2008, based on IALSS 2003

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National Progress in Health Literacy in Canada in Last Decade

• 2000: Workshop at First Canadian Conference on Literacy and Health

• 2004: Workshop at Second Canadian Conference on Literacy and Health

• 2005: Establishment of CCL Health and Learning Knowledge Centre with Health Literacy as cross-cutting theme

• 2006: Establishment of Expert Panel on Health Literacy

• 2007: Publication of national data on Health Literacy

• 2008: Release of Expert Panel on Health Literacy Report; National Symposium on Health Literacy; Workshops at CPHA Conference

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References

• Canadian Council on Learning. (2008) A Healthy Understanding: What have we learned about health literacy in Canada? Ottawa: CCL

• Canadian Council on Learning. (2007a). State of Learning in Canada: No Time for Complacency. Ottawa, ON: Author.

• Canadian Council on Learning. (2007 b). Health Literacy in Canada: Initial Results

From the International Adult Literacy and Skills Survey. Ottawa: CCL.

• Institute of Medicine. (2004). Health Literacy: A Prescription to End Confusion. Washington, D.C.: National Academies Press.

• Johnston L, Ammary N., Epstein, L, Johnson, R, Rhee, K. (2006). A Transdisciplinary Approach to Improve Health Literacy and Reduce Disparities. Health Promotion Practice, 3.

• McGowan P. (2005). Self-Management: A Background Paper. Paper presented at New Perspectives: International Conference on Patient Self-Management.

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References (Cont.)

• Ohinmaa A, Jacobs P, Simpson S, Johnson J. (2004). The projection of prevalence and cost of diabetes in Canada: 2000 to 2016. Canadian Journal of Diabetes, 28(2).

• Petch, T. (2004). Final Report: Analysis of Health Information Web Sites, Vancouver, B.C.: ACT4Health project, Simon Fraser University.

• Rootman, I. & El-Bihbety, D., A Vision for a Health Literate Canada, Ottawa: CPHA, 2008.

• Rudd, R.E. (2007). Health Literacy Skills of U.S. Adults, American Journal of Health Behavior, 31, supp.1, S8-S18.

• Smith, J.L. and Haggerty, J. (2003). Literacy in Primary Care Populations: Is it a Problem? Canadian Journal of Public Health, 94(6), 408-412.

• Vernon, J.A., Trujillo, A., Rosenbaum, S., and DeBuono, B. (2007). Low Health Literacy: Implications for National Health Policy, New York: Pfizer. Can be accessed at www.clearcommuncation.org/

• Weiss B. & Palmer R. (2004). Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. Journal of American Board of Family Practitioners, 2004, 17:44-47.