1. Welcome to Tanoa Williams’ Dissertation Presentation Important Note: Please turn off your microphone while the presentation is taking place. Microphones should be turned on only when you wish to speak. Health literacy: A Descriptive Analysis

2. Overview Introduction Background Problem Statement Sub-Problems Literature Review Methodology Results Implication of Findings Limitations Recommendations for Future Research

3. Introduction 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 decisions” (NNLM, 2014, p. 1). Low health literacy is a priority issue in the United States affecting people of all ages, races, genders, education levels, and socioeconomic status (Carmona, 2006). Several organizations have developed research programs dedicated to improving health literacy in the United States and military, including the Department of Defense.

4. Introduction The health literacy level of the U. S. population is inadequate, causing a financial strain on the economy. The Department of Health and Human Services defined health literacy as an objective in Healthy People 2010 and 2020 reports. Only one descriptive health literacy study involving active duty military members has been conducted.

5. Background Health literacy research began in the United States in the mid-1970s. Health literacy requires a person to read, write, use numerical skills, understand and follow directions on prescriptions, appointment slips, and health documents (Ad Hoc Committee, 1999). Two major health literacy studies became a focus: the National Adult Literacy Survey (NALS)(1993) and the National Adult Literacy Survey (NAALS) (2003).

6. Background The NALS was the first exclusive and most detailed report of adult literacy conducted in the United States (Kirsch et al., 1993). – Between 40 and 44 million adults in the US had the lowest performance of literacy proficiency. – Around 54 million adults demonstrated skills in the second level of literacy proficiency.

7. Background The 2003 NALS was the second major literacy study in the United States and had a health literacy component (Kutner et al., 2006). – About 35% of the U. S. population have basic or below basic health literacy skills. – Results indicated that the majority of the U.S. population (53%) have intermediate health literacy skills.

8. Background People with low health literacy are more likely to be hospitalized for longer periods and do not have skills to navigate the health care system (NNLM, 2012; PCHC, 2013). Economic repercussions of poor health literacy: – At least $73 billion in 1998 (NAAS) – Between $106 and $238 billion in a 2007 report (Vernon et al.) – Between $32 and $58 billion in a 2013 report (CHCS)

9. Background Based on the 2003 National Health Literacy Survey, the Institute of Medicine (IOM) noted military personnel who receive universal access to health care, specifically new recruits, are at risk of limited or low health literacy.

10. Problem Statement The health literacy skills among military personnel who are active duty military personnel who work in non-medical areas at a major military installation has not been adequately evaluated.

11. Sub-Problems Sub problem 1: How does ethnicity/race influence health literacy skills? Sub problem 2: How does education level influence health literacy skills?

12. Literature Review Several strategies and interventions were created to address the problem of health literacy in adults and children. In a 2012 Department of Defense Internet blog, the Deputy Director of TRICARE (military healthcare system) Management Activity, Brigadier General Bryan Gamble, encouraged all military members to take control of their health by being health literate.

13. Literature Review Weld, Padden, Ricciardi, and Bibb (2009) conducted a study to “identify and describe the literacy skills among a sample of active duty military personnel using the [Short form Test of Functional Health Literacy in Adults (S- TOFHLA)] S-TOFHLA and [Rapid Estimate of Adult Literacy in Medicine (REALM)] REALM” (p.1138).

14. Literature Review 155 active duty military personnel participated in the Weld et al. (2009) health literacy research 89 participants had professional health training 66 participants did not have professional health training

15. Literature Review Comparisons across sociodemographic subgroups indicated military personnel have overall higher levels of literacy and health literacy than participants in the 2003 NAAL Survey. Results demonstrated African American participants had lower health literacy levels than other race/ethnicities, which is consistent with the 2003 NAAL Survey results.

16. Instrumentation Demographic Survey – Consisted of 10 questions compiled from the NAAL (2003) health literacy survey and the Weld et al. (2009) study.

17. Instrumentation Rapid Estimate of Adult Literacy in Medicine Short Form (REALM-SF) – A medical-word recognition and pronunciation test that “measures the functional literacy level of patients, using real-to-life health care materials” (Columbia University School of Nursing, 2013, para. 5). – Contains seven medical terms used to provide rapid assessment of patient literacy skill level that takes about 30 seconds to complete. – Scored using a point system (each word being one point), 7 being the highest score.

18. Instrumentation Short Test of Functional Health Literacy in Adults (S-TOFHLA) – Contains four numeracy items and 17 reading comprehension items. – The reading passages are written at a 4 th grade reading level and 10 th grade reading levels respectively. – Takes an average of 7 minutes to administer and is a good indicator of a person’s ability to read and comprehend health related reading passages – Scored using three levels: inadequate health literacy (0-16), marginal health literacy (17-22), and adequate health literacy (23-36).

19. Methodology Descriptive survey research methods were used for this study. Convenience sampling was used to gather research participants. Participants completed an informed consent form, the demographic survey, the REALM- SF, and the S-TOFHLA.

20. Methodology This study interpreted data and compared results with previous health literacy research conducted using active duty military members. The results provided a better understanding of the health literacy skill level of active duty military personnel who had no professional medical training.

21. Demographics GenderN% ________________________________________________ Male6868% Female3232% ________________________________________________ Age 18-256776% 26-331717% 34-411414% 42-492 2% ________________________________________________

22. Demographics Race/EthnicityN% ________________________________________________ White (non-Hispanic)5656% African American/Black (non-Hispanic)2626% Native American/Alaskan Native0 0% Asian/Pacific Islander4 4% Hispanic4 4% Multicultural/Other10 10% ________________________________________________

23. Demographics Highest Level of EducationN% __________________________________________ High School Diploma4646% GED certificate 0 0% Technical Degree 0 0% Associates Degree (CCAF or other)1010% Some College but not 4-year degree2323% Bachelor’s Degree1616% Master’s Degree 5 5% Doctorate/Terminal Degree 00%_

24. Results: Overall population One hundred twelve active duty military members completed the necessary surveys to participate in this research study. This research included 100 (N= 100) eligible participants. Of the 100 participants the majority in this study were White (56%; n = 56); male (68%; n =68); and ranged in age from 18-25 years old (67%; n = 67).

25. Results: Overall Population Twenty-six participants (26%) self-identified as Black/African American, 4% (n = 4) were Hispanic, 4% (n = 4) were Asian/Pacific Islander, and 9% (n = 9) self-identified as Multicultural/Other. With regard to REALM-SF scores, the majority of participants (73%; n = 73) scored at the highest level, verbalizing each word correctly with no hesitation.

26. Results: Overall Population Pearson’s product moment results showed there was a significant correlation between the results of the S- TOFHLA and REALM-SF, r (98) =.26, p =.009. Results of S-TOFHLA scores show the majority of participants (99%; n = 99) had adequate functional health literacy. Seventy-four of participants (74%) were enlisted between the ranks of E1-E4, 23 participants (23%) were enlisted between the ranks of E5-E9, and three participants (3%) were of the officer ranks of O1-O6.

27. Results: Sub Problem 1 REALM-SF ScoreS-TOFHLA Score __________________________________________________________________ _7 4-6 1-3 0 0-16 17-22 23-36 White (non- Hispanic) 45 11 56 African American/Black (non-Hispanic) 12 14 26 Native American/ Alaskan Native Asian/Pacific Islander 4 4 Hispanic 4 1 4 Multicultural/ Other 9 1 1 8 __________________________________________________________________ Total 73 27 1 99

28. Results: Sub problem 1 Military personnel have overall higher levels of literacy and health literacy than participants in the 2003 NAAL survey. Black/African American participants had lower literacy and health literacy levels than other race/ethnicities, which is consistent with the 2003 NAAL survey and Weld et al. (2009).

29. Results: Sub problem 1 99% (n =99) of participants had adequate functional health literacy and 1% (n = 1) had marginal functional health literacy. Fifty-six White participants (56%), 26 Black/African American participants (26%), four Hispanic participants (4%), four Asian/Pacific Islander (4%), and 9 Multicultural/Other (90%) scored at the highest Level of the S-TOFHLA. One (10%) Multicultural/Other participant scored 22 on the S-TOFHLA representing marginal functional health literacy.

30. Results: Sub Problem 2 Education LevelREALM-SF score categories ____________________________________________________________ 74-61-30 ____________________________________________________________ High School2917 Associates/military equivalent91 Some college not 4 year degree176 Bachelor degree142 Master degree41 ____________________________________________________________

31. Results: Sub Problem 2 There was a statistically significant correlation between level of education, REALM-SF, and S-TOFHLA scores in this research. Pearson’s r showed a very strong relationship between education level, the REALM-SF, and S-TOFHLA scores (r =.141 on the REALM- SF, r =.056 on the S-TOFHLA, N= 100, p <.05).

32. Results: Sub Problem 2 Independent t-tests were conducted to compare S- TOFHLA scores and education level and REALM-SF scores and education levels. Results showed that there were no significant differences between education level and REALM- SF scores and education level (t = 12.460, sig. =.136) and S-TOFHLA scores (t = 7.171, sig. =.583). Participant’s education level did not significantly affect the outcome of the literacy or health literacy surveys.

33. Implication of Findings Majority of active duty members had adequate functional health literacy and high literacy skills. There is a barrier between a member’s health literacy and willingness to make responsible health choices due to the continuously high rate of military members with preventable health disparities and diseases.

34. Limitations The number of participants was not a true representation of the population of the military base. All military members are required to have at least a high school education to enter active duty and are required to maintain educational standards while on active duty.

35. Limitations Military members are required to maintain minimum physical and health standards, have individual assistance maintaining health and wellness, and have access to universal healthcare Participation was limited because the literacy and health literacy surveys were not electronic documents.

36. Recommendations for Future Research Add a qualitative element to future research to gain personal thoughts of medical personnel on how military personnel communicate and understand medical procedures and instructions. Evaluate the effectiveness of health literacy initiatives created by the DoD in response to the NAAL and NALS surveys.

37. QUESTIONS? Qu