The Health Literacy Component (HLC) of the 2003 NAAL

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The Health Literacy

Component (HLC)

of the 2003 NAAL

The Health Literacy

Component (HLC)

of the 2003 NAAL

Sheida White

Project Officer

National Assessment of Adult Literacy

(NAAL)

Sheida White

Project Officer


(NAAL)

The Health Literacy

Component (HLC)

of the 2003 NAAL

The Health Literacy

Component (HLC)

of the 2003 NAAL

Sheida White

Project Officer


(NAAL)

Sheida White

Project Officer


(NAAL)

A webcast presentationAugust 3, 2004

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HLC background, definitions, and limitations

Task types and skill requirements

Health-related items and stimulus materials

Health-related background questions

Analysis of health literacy data

Summary of unique features of the NAAL HLC

Contribution of the NAAL HLC to written health communication

NCES contacts and website

References

Topics covered by this presentationTopics covered by this presentation

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HLC Background, Definitions, and Limitations

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Research indicates that adults with limited health literacy “. . . report poorer health status, and are less likely to use preventive services” (Nielson-Bohlman, Panzer, and Kindig 2004)

Several studies suggest that inadequate health literacy is related to higher health care costs—for example, Howard (2004) estimates $993 more per year in inpatient spending for a patient with inadequate health literacy, although he also cautions that more research is needed

Importance of health literacyImportance of health literacy

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Importance of health literacy (continued) Importance of health literacy (continued)

The Health Literacy Component (HLC) of the 2003 National Assessment of Adult Literacy (NAAL) is the first-ever national assessment designed specifically to measure health literacy

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Sponsored by the National Center for Education Statistics (NCES), NAAL is a nationally representative assessment of the English language literacy skills of American adults

The 2003 NAAL is the first assessment of the nation’s progress in adult literacy since NCES’s 1992 National Adult Literacy Survey (NALS)

NAAL’s prose literacy, document literacy, and quantitative literacy scores are comparable to those of the 1992 NALS

A separate health literacy score, based solely on health-related items, is a new feature of NAAL

The 2003 NAALThe 2003 NAAL

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Household survey of approximately 18,000 Americans age 16 and older

Data for the United States as a whole, individual states choosing to participate in a state-level assessment, and the nation’s prison population

Emphasis on the use of printed everyday materials (such as bills, prescriptions, newspapers) needed to function adequately in one’s environment

Data on background characteristics, performance of everyday literacy tasks, and skills underlying task performance

Key features of NAALKey features of NAAL

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NAAL’s HLC was developed in response to a request by the U.S. Department of Health and Human Services (HHS)

The HHS Office of Disease Prevention and Health Promotion (ODPHP), in consultation with health literacy experts, helped identify stimulus materials and develop tasks for HLC

Partnership between NCES and HHSPartnership between NCES and HHS

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Healthy People 2010 (HHS 2000) uses the following definition of health literacy:

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)

HHS recognizes the importance of improving both (1) the health literacy skills of target audiences, and (2) efforts made to communicate health-related information to these audiences

HHS definition of health literacyHHS definition of health literacy

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NAAL definition of health literacy NAAL definition of health literacy

NAAL’s health literacy definition focuses on one key aspect of health literacy:

The ability to use printed and written information associated with a broad range of health-related tasks to accomplish one’s goals at home, in the workplace, and in the community (including health care settings)

HLC will provide objective data on health literacy as defined above

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NAAL definition of health literacy—Graphic representation

NAAL definition of health literacy—Graphic representation

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HLC data can assist in

Identifying the health literacy skills of target audiences

Guiding the development of health information tailored to the literacy strengths and weaknesses of target audiences so that the written material is less likely to exceed the literacy skills of target audiences

Providing input for development of programs to improve health literacy skills

Uses for HLC dataUses for HLC data

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Ability to orally consult about a condition or treatment or provide medical history and descriptions of symptoms

Knowledge of health issues, such as how to prevent hypertension, how to identify signs of Alzheimer’s disease, and how to change eating and exercise habits

Ability to understand health materials containing medical jargon and scientific terms

Aspects of health literacy not covered by HLC data

Aspects of health literacy not covered by HLC data

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Task Types and Skill Requirements

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Overview of the three types of health literacy tasks

Overview of the three types of health literacy tasks

Tasks of this type Are associated with For example

Clinical Interactions between the health care provider and the patient, diagnosis and treatment of illness, and medication

Taking medication as prescribed

Preventive

Preventing disease, intervening early in emerging health prob-lems, and engaging in self-care and healthy behaviors

Understanding health risks associated with obesity

Navigation (of the health care system)

Understanding how the health care system works and individual rights and responsibilities

Understanding eligibility for and benefits of health insurance plans

SOURCE: Based on information in Communicating Health: Priorities and Strategies for Progress. (2003). Washington, DC: U.S. Department of Health and Human Services

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Clinical tasksClinical tasks

Clinical tasks require the ability to use printed and written information associated with interactions between the health care provider and the patient, clinical encounters, diagnosis and treatment of illness, and medication

Examples include filling out a patient information form for an office visit, understanding dosing instructions for medication, understanding steps for the self-manage-ment of acute and chronic illness, and following a health care provider’s written recommendation for a diagnostic test

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Preventive tasksPreventive tasks

Preventive tasks require the ability to use printed and written information associated with maintaining and improving health, preventing disease, intervening early in emerging health problems, and engaging in self-care and healthy behaviors

Examples include following guidelines for age-appro-priate preventive health measures, understanding health risks associated environmental hazards, and understanding directions for screening to rule out a serious illness

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Navigation tasksNavigation tasks

Navigation tasks require the ability to use printed and written information associated with the way the health care system works and individual rights and responsi-bilities

Examples include understanding covered and non-covered benefits for health insurance plans, determin-ing eligibility for public assistance programs, and being able to give informed consent for a health care service

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Key features and specific examples of clinical, preventive, and navigation tasks

Key features and specific examples of clinical, preventive, and navigation tasks

Clinical tasks have to do with the health care itself—for example, following the directions to prepare for a mammogram

Preventive tasks have to do with healthy habits and prevention of illness—for example, understanding what a mammogram is and why it is important

Navigation tasks have to do with bureaucratic demands to get to the health care—for example, finding the radiology department and, later, interpreting the bill

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Breakdown of NAAL health-related tasks by typeBreakdown of NAAL health-related tasks by type

Type of health-related task Number of tasks (N=28)

Clinical 4

Preventive 14

Navigation 10

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Reasons for the preponderance of preventive and navigation tasks

Reasons for the preponderance of preventive and navigation tasks

Most clinical materials and tasks are targeted toward a specific disease or condition; therefore, they tend to include specialized vocabulary that is not consistent with the NAAL framework

A wide range of preventive and navigation tasks and their associated stimulus materials apply to all or most of the adult population; we want to capture the diversity of these tasks

There are no subscales for clinical, preventive, and navigation tasks; instead, there is a single health literacy scale

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Relationship between tasks and skillsRelationship between tasks and skills

In order to perform the clinical, preventive, and navi-gation types of tasks described in the earlier slides, respondents need to apply general literacy skills

NCES will soon release a framework for the 2003 NAAL that discusses these general literacy skills

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Health-Related Items and Stimulus Materials

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Health-related items in the 2003 NAALHealth-related items in the 2003 NAAL

NAAL includes 28 health-related assessment items (out of a total of 149 items)

Two of the health-related items are repeated from the 1992 NALS, while 26 are newly created for NAAL

The 26 new health-related items were specifically designed to measure health literacy

All respondents receive some health-related items

The material for a single health-related stimulus may have more than one item associated with it, and each item may represent a different level of difficulty

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Health-related items in the 1992 NALSHealth-related items in the 1992 NALS

The 1992 NALS included 6 health-related assessment items (out of a total of 166 items)

The number of health-related items was not sufficient to provide a separate health literacy score

Of the 6 health-related items from 1992, NCES

Reused 2 items in 2003

Will soon release the other 4 items—along with the 88 non-health-related items that were not reused in 2003—on the NAAL website (http://nces.ed.gov/naal)

Two common items is not enough to establish health literacy trends between 1992 and 2003

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Graphic summary of 1992 health-related itemsGraphic summary of 1992 health-related items

166 items in the 1992 NALS

6 health-related items using HHS definition

2 reused in 20034 to be released

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Test Questions Search Tool on the NCES website—Sample screen #1


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Example of a health-related item from the released 1992 NALS items

Example of a health-related item from the released 1992 NALS items

Vitamin E (tocopherol)—helps protect red blood cells.May aid the circulatory system and counteract the agingprocess. Best sources: wheat germ, whole grains, eggs, pea-nuts, organ meats, margarine, vegetable oils, green leafy veg-etables.

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Health-related stimulus materials in the 2003 NAAL

Health-related stimulus materials in the 2003 NAAL

NAAL uses 12 health-related stimulus materials (out of a total of 60 stimulus materials)

The health-related materials include

Medication information

Medical instructions

Health insurance and other forms

Prevention and wellness information

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Health-Related Background Questions

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Health-related background variables Health-related background variables

NAAL includes 10 health-related background questions (out of a total of 118)

The health-related background questions cover

Self-reported health status

Sources of health information (e.g., Internet)

Preventive health practices (e.g., mammogram)

Health insurance status

A background variable may consist of subvariables

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Sample health-related background questions (abbreviated)

Sample health-related background questions (abbreviated)

In general, how would you rate your overall health?

Do you have any difficulty seeing the words and letters in ordinary newspaper print even when wearing glasses or contact lenses, if you usually wear them?

Do you have any difficulty hearing what is said in a normal conversation with another person even when using a hearing aid, if you usually wear one?

Have you ever been diagnosed or identified as having a learning disability?

Do you have any other health problem, impairment, or disability now that keeps you from participating fully in work, school, housework, or other activities?

NOTE: Arrows indicate questions that are new in 2003.

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Sample health-related background questions (continued) Sample health-related background questions (continued)

Do you have any kind of medical insurance or are you enrolled in any kind of program that helps to pay for your health care?

Is your medical insurance through your work, another family member’s policy, the military, or Medicare/ Medicaid?

Do the children living in this household have any type of medical insurance or health care coverage?

How much information about health issues do you get from…(newspapers, the Internet, television, other sources)?

In the past year, have you…(gotten a flu shot, colon cancer exam,…)?

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Analysis of Health Literacy Data

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Analysis of data from health-related itemsAnalysis of data from health-related items

Data from health-related items are analyzed

As part of NAAL prose, document, and quantitative scores

As a separate health literacy score

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Health literacy as part of NAAL Health literacy as part of NAAL

Task-based measures

Each health-related task is also classified as a prose, document, or quantitative task. Therefore, it is included with other tasks when calculating the prose, document, and quantitative scale scores

Skill-based measures

Each health-related task requires multiple literacy skills

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Health literacy as a separate scoreHealth literacy as a separate score

A single health literacy score

Measures performance on health literacy tasks for the U.S. adult population

Establishes a baseline for future assessments

Is analyzed in relation to other types of NAAL data (listed on the next slide)

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Analysis of the health literacy score in relation to other NAAL data

Analysis of the health literacy score in relation to other NAAL data

The health literacy score is analyzed in relation to

Various levels of prose, document, and quantitative literacy

The types of skills that adults must use to successfully perform health-related tasks

Subgroups of interest

Appropriate health-related background variables

Low performance on measures of basic reading skills

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Measuring performance on the health literacy scaleMeasuring performance on the health literacy scale

NCES will

Report health literacy results based on a new health literacy scale

Describe the types of health literacy tasks that adults scoring at different percentiles and scale scores can and cannot perform

Provide (in an appendix) the percentage of the popu-lation giving a correct answer to each of the 28 health literacy tasks

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Measuring skills required perform health-related tasks Measuring skills required perform health-related tasks

In addition to reporting on task performance, NCES will provide information about

The general literacy skills (e.g., Text Search) required to successfully complete health literacy tasks

The deficits in general literacy skills that prevent people from successfully completing health literacy tasks

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Analysis of health literacy scores in relation to NAAL scores

Analysis of health literacy scores in relation to NAAL scores

There is a relationship between NAAL scores and health literacy scores

The link is the set of general literacy skills required by all tasks

Regardless of the topic of the stimulus material or type of literacy task, adults must be able, for example, to recognize the words, search the text, or perform calculations

Therefore, the distribution of health-related literacy scores cannot be independent of the distribution of general literacy skills

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Difference between NAAL general literacy scores and the health literacy score

Difference between NAAL general literacy scores and the health literacy score

The two types of scores differ in that health-related tasks are associated with health-related materials requiring knowledge of health-related vocabulary, abbreviations, and forms

Although health-related tasks are free of medical jargon and do not require specialized knowledge, they do assume some familiarity with everyday health-related vocabulary (e.g., blood cholesterol) and how the health care system works (e.g., that a health insurance card shows an ID number)

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Summary of Unique Features of the NAAL HLC

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Unique features of the NAAL HLCUnique features of the NAAL HLC

The NAAL HLC is based on

Current (2003) NAAL data A nationally representative sample of about 18,000 adults

Tasks are designed specifically to measure health literacy

Scale is based on 28 health-related tasks

Background questionnaire includes new health-related questions (in addition to questions from 1992)

HLC score is correlated with a new assessment instrument (FAN) designed to measure basic skills

New performance levels are developed by the National Academy of Sciences

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Contribution of the NAAL HLC to Written Health Communication

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Three key factors affecting all written health communication are

The literacy skills of the audience

The appropriateness of written materials to the audience’s literacy level

The task to be performed using the materials

Key factors in written health communicationKey factors in written health communication

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HLC data can have a positive impact on written health communication by

Helping adult literacy practitioners address deficiencies in health literacy

Providing input to help health communicators create more effective materials

Significance of the NAAL HLCSignificance of the NAAL HLC

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NCES Contacts and Website

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Sheida WhiteNAAL Project Officer

(202) [email protected]

Andrew KolstadSenior Technical Adviser


Web Sitehttp://nces.ed.gov/naal

Sheida WhiteNAAL Project Officer


Andrew KolstadSenior Technical Adviser


Web Sitehttp://nces.ed.gov/naal

National Center for Education StatisticsNational Center for Education Statistics

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References

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ReferencesReferences

HHS (U.S. Department of Health and Human Services). (2000). Healthy People 2010: Understanding and Improving Health. Washington DC: U.S Department of Health and Human Services.

Howard, D.H. (2004). The Relationship Between Health Literacy and Medical Costs. In L. Nielsen-Bohlman, A.M. Panzer, and D.A. Kindig (Eds.), Health Literacy: A Prescription to End Confusion (pp. 256-266). Washington DC: The National Academies Press.

Nielsen-Bohlman, L., Panzer, A.M., and Kindig, D.A. (Eds.). (2004). Executive Summary from Health Literacy: A Prescription to End Confusion. Washington DC: The National Academies Press.

Selden, C.R., Zorn, M., Ratzan, S.C., and Parker, R.M. (2000). Current Bibliographies in Medicine: Health Literacy (NLM Pub. No. 2000-1). Bethesda, MD: National Library of Medicine, National Institutes of Health, U.S. Department of Health and Human Services.

Documents

The Health Literacy Component (HLC) of the 2003 NAAL