Health Literacy Overview Rima E Rudd, MSPH, ScD Health Literacy Studies Harvard University School of Public Health National Center for the Study of Adult Learning and Literacy

2 Functional Literacy NALS NAALS IALS

3 Functional Literacy Ability to read, write and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential. The National Literacy Act of 1991

4 NALS: National Adult Literacy Survey Prose Literacy: 1. Prose Literacy: process information presented in full sentences/ paragraphs. 2. Document Literacy: 2. Document Literacy: process information presented in forms, tables, maps, schedules, charts… 3. Quantitative Literacy: 3. Quantitative Literacy: apply numerical operations.

5 2002: National Assessment of Adult Literacy Survey National Assessment of Adult Literacy Survey, 2002: Assessment items will include materials used for health related tasks.

6 Functional Literacy Assessments Findings grouped by 5 skill levels for each literacy area. Level 1 is the lowest skills level. People at Level 1 have reading skills of grade 1-3 level.

7 Progression: Learning to Read Reading to Learn Readers at Grade 1-3 level are learning to: decode letter groups recognize and sound out words derive meaning from words link words in sentences derive meaning from sentences.

8 Prose Literacy 49% of Adults May Have Some Difficulty: Finding one piece of information in a sports article; Finding 2 pieces of information in a news article. They Generally Cannot: Interpret instructions Infer theme from a poem Describe contrasting views in an editorial.

9 Document Literacy 51% of Adults May Have Some Difficulty: Completing a job application; Interpreting a payroll forms. They Generally Cannot: Read tables and graphs Locate intersection on street map Use a bus or train schedule.

10 Quantitative Literacy 47% of Adults May Have Some Difficulty: Balancing a checkbook; Figuring a tip. They Generally Cannot: Complete an order form Determine the amount of interest from a loan advertisement.

11 Literacy as a Tool Reading to Do: Health Context

12 Basic Health Literacy Read and comprehend health information and directions. Complete medical history, informed consent, and insurance forms. Apply literacy skills to: prescriptions appointment cards medicine labels directions for care.

13 Interactive Health Literacy Engage in decision making. Take independent action to promote health and prevent disease. Engage in partnerships with professionals.

14 Critical Health Literacy Be aware of and advocate for rights. Consider health implications of community, workplace, and social policy. Take part in policy analysis and decision making. Take action for personal, community, and societal health.

15 When Words Get in the Way Get lost Make errors Run out of words Retreat into silence Cover up or Lie Limit participation Assume a passive role Be assigned a passive role Lose entitlements Lose rights

16 Research to Date Trends Scope Findings

17 Review of the Literature: Trends Number of Citations 1970s - ~ s - ~ s - ~ 240 Each Year within Current Decade: ~ ~ 16 [through Sept]

18 Review of the Literature: Scope Materials Assessment Comprehension of written materials Match between patients’ abilities and reading materials Use of services Knowledge level Outcomes

19 Research Findings: Materials and Comprehension Materials written at inappropriate reading grade levels. Mismatch between reading levels of materials & reading ability of intended audience.

20 Research Findings: Health Impact Poorer overall health Less likely to make use of screening Present in later stages of disease More likely to be hospitalized Poorer understanding of treatment Lower adherence to medical regimens

21 Research Finding: Shame Almost 40% of patients with low functional literacy admitted feelings of shame: –67% had never told their spouses –53% had never told their children

22 Review: Materials on the Internet Digital Divide: Of the 1,000 sites reviewed, only 10 were appropriate for limited-literacy adults. Generalized information on topics of interest is available but not at literacy levels that underserved Americans need. Lazarus and Mora, The Children’s Partnership, 2000

23 Review: Materials on the Internet Review of 89 pediatric patient information web sites: information is not written at appropriate reading levels for the average adult (8 th grade or lower) D'Alessandro et al, The Readability of Pediatric Patient Education Materials on the World Wide Web 2001.

24 Agenda Research & Practice

25 Unexplored Areas How well are people with limited literacy skills managing: Health Promotion and Protection Early Detection and Screening Broader health services such as Mental Health, Oral Health Interactions with social services and entitlement programs Community, work and social action for policy change

26 Unexplored Areas How well are people with limited literacy skills managing health related decisions: At Home, Work, Schools, Community In medical, dental, and other health service settings In the Policy Arena

27 New Territories for Research Links between literacy and verbal skills Links between literacy and oral comprehension Links between literacy and background knowledge

28 New Territories for Research  Causal pathways of how poor health literacy influences health  Outcomes & costs associated with poor health literacy  Effective health education techniques  Evaluation of plain language directives and use of non-print media