Health Literacy:Two Reports,

Time for Action

April 23, 2008Presentation to School Health 2008

Debra Lynkowski, Canadian Public Health AssociationNadine Valk, Canadian Council on Learning

Health literacy is…

…the ability to access, understand and act on information for health

CPHA is…

• a national, not-for-profit, voluntary association

• committed to universal and equitable access to the basic conditions necessary for the health of all Canadians

Health is…

• "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.“--World Health Organization

• determined by complex interactions between individual characteristics, social and economic factors and physical environments.

Public health focuses on…

• the health of the community

• social contexts

• health promotion and prevention

Health promotion…

• strengthens people’s skills and capabilities

• enables individuals to control the determinants of health

Determinants of health..

• income• social status• social supports• working conditions• social environments• education• physical environment• personal health practices• genetics• gender• culture• literacy

Health and literacy

• National Literacy and Health Program (1994)• Plain Language Service (1997)• First Canadian Conference on Literacy and

Health (2001)• Second Canadian Conference on Literacy and

Health (2004)• Chronic Disease Prevention and Management

(2007)• Expert Panel on Health Literacy (2008)

Health Literacy in Canada: A Healthy Understanding

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January 2007

CCL released, for the first time in public domain, health literacy scores and levels by age, education level and health status.

September 2007

CCL released a special feature report providing background information on the evolution of health literacy research, measurements, Canada-US comparisons, some preliminary findings. Introduction of community health literacy maps.

February 20, 2008

CCL releases a new report providing further analysis of the impact of health literacy in Canada.

Sponsored by Health and Learning Knowledge Centre and based on evidence supported by CCL reports, the panel developed a vision for a Health Literate Canada and a set of recommendations on strategies to improve health literacy in Canada. To be released by CPHA on March 3, 2008

CPHA Expert Panel

on Health Literacy

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Measuring Literacy

• 1980s and 1990s: new way to measure adult skills and across different population

• 1994: International Adult Literacy survey (IALS): prose, document, numeracy

• 2003: Adult Literacy and Life Skills Surveys (ALLS): addition of problem solving, refinements to health-related items and self-reported health status

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Measuring Literacy

The International Adult Literacy Survey (IALS) The U.S. National Adult Literacy Survey (NALS) The Adult Literacy and Life Skills Survey (ALLS)

• Large-scale direct assessments of adult skills administered to representative samples of adults

• Internationally comparable data available for 25 countries, 1990-1998, and in 6 countries in 2003

• Survey based on theoretical understanding of the determinants of the relative difficulty of adult literacy and numeracy tasks

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Skills-age profiles

Source: Adult Literacy and Life Skills Survey, 2003.

Relationship between age and prose literacy scores by health status (self-reported)

175

200

225

250

275

300

325

10 20 30 40 50 60 70

Age

Scale scores

Excellent and Good Health Fair Health Poor Health

1

3

2

Level

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Measuring Health Literacy

• Using 350 unique items in NALS/IALS/ALLS

• 191 items judged to measure health-related activities

• Health-related items assigned to health literacy sub-domains

Health Activities Number of Items (n=191)

Health Promotion 60Health Protection 65Disease Prevention 18

Health Care and Disease Management 16

Navigation 32

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Measuring Health Literacy

• 66 tasks represent activities directly related to health care settings.

• 125 tasks represent activities likely to occur outside formal health care settings

• new 500-point health activities literacy scale (HALS)

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Health Activities FocusExamples of Materials Examples of Tasks

Articles in newspapers and magazines, booklets, brochures

Purchase food

Charts, graphs, lists

Plan exercise regimen

Food and product labels

Articles in newspapers and magazines

Decide among product options

Postings for health and safety warnings

Use products

Air and water quality reports

Vote

Referendums

News alerts [TV, radio, papers]

Determine risk

Postings for inoculations & screening

Engage in screening or diagnostic tests

Letters re: test results

Follow up

Graphs, charts

Disease Prevention Take preventive measures & engage in early detection

Health Promotion Enhance & maintain health

Health Protection Safeguard health of individuals & communities

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Health history forms Describe & measure symptoms

Medicine labels Follow directions on medicine labels

Discharge instructions

Calculate timing for medicine

Education booklets & brochures, health information on the Internet

Collect information on merits of various treatment regimes for discussion with health professionals

Access needed services

Maps Locate facilities

Application forms Apply for benefits

Understand rights Statements of rights and responsibilities, Informed consent

Offer informed consent

Health benefit packages

Health Care & Maintenance

Seek care & form a partnership with health providers

Systems Navigation

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(adopted for the NALS, IALS and ALLS analysis)

The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions

The measurement definition of health literacy

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Limitations of the Health Literacy Scale

• The ALLS-based health literacy scale excludes several dimensions of health literacy that theory suggests are important, such as: – measures of oral fluency, – reading component skills, – problem solving, and – scientific literacy.

While not perfect, HL measures can provide new insights that carry implications for both policy and further research. We now have a measurement tool that can further identify the link between health literacy and social and economic determinants and outcomes.

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Proportion of population with low literacy levels,

by literacy type, ages 16 and older

There are more adults with low levels of health literacy (60%) than with low levels of prose literacy (48%), suggesting that health literacy and prose literacy are different.

To master health-literacy tasks, adults are required to use prose literacy, document literacy and numeracy skills simultaneously.

A weakness in any of the three skills will limit an individual’s ability to master the full range of health-literacy tasks.

Health literacy…a composite of all basic literacies

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Comparison of social and health outcomes,

by health-literacy level

Health literacy …. matters

After controlling for the effect of age, gender, education, mother tongue, immigrant and Aboriginal status, individuals with low levels of literacy are still more likely to have fair or poor health, rely on income support or not engage in the community.

.

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Prevalence of diabetes,

average health-literacy scores by health regions The analysis of the relationshipbetween health literacy and health risks such as arthritis, diabetes, heavy drinking, high blood pressure, injuries, stress and asthma for each of Canada’s health regions is worth noting.

Of the factors analyzed, diabetes was the most significant.

Health literacy…impacts population health

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Distribution of health-literacy scores

Health Literacy…varies significantly

Percentage at Level 2 and below

25The analysis and mapping of the health-literacy results were conducted by J. Douglas Williams, 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

Local HL maps can identify communities where programs or policies could be

targeted

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Health Literacy Mean Scores for key groups

Over 65 Yrs

56-65 Yrs

26-35 Yrs

36-45 Yrs46-55 Yrs

16-25 Yrs

Male Female

Immigrant

Not Immigrant

Non Official Language

Official Language

Not Employed

Employed

Aboriginal (Off reserve)

French Minority LanguageCanada 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

Inte

rval

s

Population Size

Level 1Level 2

Level 3

Health literacy…affects some groups more than others

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Comparative distributions for key groups

While the mean health-literacy score for

certain groups, such as seniors, is well below

Level 3, there are significant percentages

of the population in these groups who are

above Level 3.

Health literacy…varies within key groups

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Factors predicting health literacyages 16 to 65 ages 66 and

over

Health Literacy….influenced greatly by literacy practices at home

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How can we improve Canada’s health literacy situation?

Individuals Read every day to help keep your brain

healthy and active, and to maintain your literacy skills.

Ask questions about your health and health care: clarify information and instructions.

Seek out reputable sources of health information—use the library and verify information with a health-care professional.

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What will CCL do next?

CCL plans to undertake further work in the field of health literacy:

• Enhance Canada’s understanding of health literacy by commissioning research, disseminating new reports, and making information available on the CCL website.

• Work with stakeholders to develop better indicators and establish clear benchmarks and objectives for health literacy in Canada.

• Partner with other groups and stakeholders to develop tools and resources that will address Canadians’ health-literacy needs.

Expert Panel on Health Literacy

Barriers to school health literacy include • Different philosophies about health and education• Limited budgets • No structured health and physical education curriculum• Few professional development opportunities for teachers• Lack of health and physical education specialists• Lack of support for public health engagement with

schools (Source: Canadian Association for Health, Physical

Education, Recreation and Dance)

Expert Panel on Health Literacy

Comprehensive school health, including a range of activities and services in schools and communities

Introduce health information in ESL/FSL programs

Expert Panel on Health literacy

Suggested that health literacy be integrated into primary and secondary school and adult education curricula

Expert Panel on Health Literacy

• A comprehensive, coordinated, cooperative and integrated pan-Canadian strategy on health literacy to improve levels and provide support for people trying to cope with demands

National Symposium on Health Literacy • January 2008

• Canadian Public Health Association

• National Collaborating Centre on Determinants of Health

Principles for a national health literacy strategy • literacy begins early in childhood and is

strengthened over time• health literacy is an issue of social equality• solutions are embedded in existing

structures• diverse needs and cultures are recognized

and respected• adult literacy learners are engaged in the

development of solutions

Priorities for action

• make health and education sensitive and responsive to language, culture and literacy

• establish literacy as a national priority• better use of health services• support practitioners and professionals as

agents of change• integrated, comprehensive Aboriginal strategy • determine research and evaluation priorities

CPHA’s next steps

• raising awareness of Expert Panel report

• mobilizing policy-makers, practitioners, and researchers

• developing tools to facilitate health sector communication

• social determinants of health focus at CPHA national conference, June 1 – 4 in Halifax

Time for Action

• Senate Sub-Committee on Population Health (February 2007)– To examine and report on the impact of

determinants of health in Canada– To identify federal strategies to reduce health

inequities– Public consultations underway– Final report, Dec. 2008

Time for Action

• WHO Commission on Social Determinants of Health – to address social factors leading to ill health– nine Knowledge Networks have completed interim reports on

• early child development• globalization • health systems • measurement and evidence• urban settings • employment conditions• social exclusion • priority public health conditions • women and gender equity

• final report, fall 2008

Time for Action

• Building on momentum– Health literacy research and initiatives– Promising family literacy programs

• e.g, Parenting and Family Literacy Centres (Ontario)

– Senate and WHO recommendations– Role of literacy in health equity

Report of the Expert Panel on Health Literacy

available at:

www.cpha.ca

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Report & Interactive Maps Available at:www.ccl-cca.ca