1. Health Literacy and Aging
Presentation by Irving Rootman to SFU Class on Principles and Practices of Health Promotion
October 4, 2010

2. Outline What is health literacy? How is it measured?
How does it relate to aging?
What impact does it have on older adults?
What are the determinants of health literacy in older adults?
How can be done to address health literacy in older adults?
This is what I would like to cover

3. What is health literacy?
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 (CPHA Expert Panel on Health Literacy).
(Rootman and Gordon-El-Bihbety, 2008)
So, what is health literacy? This is a slight modification of the definition which was developed by our BC Health Literacy Research Team. It was modified a bit by the Expert Panel on Health Literacy which I co-chaired which was established in 2006 with funding from the HLKC, and reported two years ago It draws from a number of other definitions including the definition adopted by the IOM.
Among other things, it recognizes that health literacy consists of a complex set of skills required to cope with the information-processing demands of a variety of health contexts or settings. In contrast to most other definitions, it also adds that idea that these skills and demands will likely vary over the course of an individual’s life. Although no definition is perfect, this one was helpful in guiding the work of the Expert Panel.
I would like to stress that HL depends on literacy, which our Panel defined as…

4. Literacy is…
the ability to understand and use reading, writing, speaking and other forms of communication as ways to participate in society and achieve one’s goals and potential” (CPHA Expert Panel on Health Literacy)
(Rootman and Gordon-El-Bihbety, 2008)

5. Health Literacy Framework
Outcomes
& Costs
Health Contexts
Individuals
Literacy
Health Literacy
This chart from the IOM reprot makes is clear that HL is dependent on Literacy and that Health Literacy results from the interaction of individuals with the social and informational demands of health contexts which could include health care contexts, public health contexts health promotion contexts or chronic disease management contexts.
It also makes it clear that health literacy and general literacy could lead to health outcomes as well as costs to individuals and society.
(I.O.M., 2004)

6. Literacy Effects of Literacy Direct
Actions
Literacy
Effects of Literacy
Communication
Indirect
General Literacy
Reading ability
Numeracy
Listening and Speaking ability
Comprehension ability
Negotiation skills
Critical thinking& judgement
Capacity Development
Lifestyles
Community Development
Use of services
Income
Organizational
Development
Health
Status
Quality Of
Life
Direct
(Medication use, Compliance, safety practices.)
Policy
Health Literacy
Ability to find, understand and communicate health information
Ability to assess health information
Determinants
Work environment
Education
Early Child Development
-I developed a first draft in the late 90’s based on a review of the literature at the time by Bert Perron but added materials from other sources such as the Ottawa Charter for Health Promotion
- It was modified to its present form based on a national consultation in 2003 and published in a 2005 Supplement to CJPH as well as in a paper in the Canadian Journal of Nursing Research in 2004.
It was intended to be a visual way of communicating the relationships between various categories of literacy and between literacy effects, determinants and actions in order to guide research and practice in this field.
I used it a lot in presentation that I did about up to about 2005, but and not sure how widely it was adopted for use in research and practice.
However, as you will see, some elements were adopted by Doris in the Framework that she will present.
This model was developed by Joan Wharf Higgins and colleagues to situate health literacy in the school context for a study to measure HL among high school students in BC. As well as a study of the impact of curricula. Proved to be fairly useful in this context. It is based on these ecological principles:
Health is influenced by multiple facets of the physical and social environment
Environments are multi-dimensional
Human-environment interactions can be described at varying levels of aggregation
There is feedback across different levels of environments and aggregates of persons
As you can see, health literacy which is at the Centre of is diagram is subject to influences at three levels—Micro, Meso and Macro.
At the Micro level, it is influenced by internal factors, other types of literacy skills as well as aspects of the information that people are exposed to
At the Meso level, it is hypothesized that it is influenced by school and peer factors as well as curricula and at the Macro level by various external factors such as technology
It captures some of the elements of the model that Jim has just presented but is much more detailed in terms of the environment influences as well as impacts.
Although focused on the school context, this type of model could be adapted to other contexts, inlucuding the population as a whole.
This is a less precise model than the one that I have just shown you but does provide some guidance in situating health literacy within a larger context and was used in this way by our BC HL research team.
Aging
Stress level
Personal Capacity
Living/Working Conditions
Indirect
Other Literacy
Scientific, Computer,
Cultural, Media
Etc.
Gender
Culture
Source: Rootman and Ronson, 2005

7. Health Literacy Framework (Kwan, Frankish and Rootman, 2006)

8. Source: Wharf Higgins et al., 2009

9. Health Enhancing Outcomes Health Promoting Interventions
Health Literacy Framework (Gillis, 2009)
Health Enhancing Outcomes
Health
Literacy
Health Outcomes
Health Promoting Interventions
Communication
Basic/Functional
Literacy
Health Decisions
Health Status
Capacity Development
Health Care Costs
Communicative/
Interactive Literacy
Health Actions
Community Development
Health Advocacy
Critical Literacy v
Personal Empowerment
Organizational Development
Policy
Social Determinants of Health:
e.g. level of literacy, education, income, ethnicity, employment, age, social support, culture, gender…
Provider Practice:
e.g. nature of client/provider rel., communication skills, resources
Situations & Contexts
DEG 13/06/06

10. Source: Desjardins, unpublished paper in review
Structural model of health literacy determinants from lifelong-lifewide learning perspective
And this is the model that he came up with and tested using data from the 2003 IALSS.
Some of these are obvious particularly the ones on the left and right.
Ones that are not so obvious are:
x1, Parents’ education (PARED),
x2, Age (AGE),
x3, Gender (GENDER),
x4, Mother tongue not same as test language (LANG),
x5, Community size (URBAN),
x6, Aboriginal (ABORIG),
x7, French (FRENCH),
x8, Born in country (IMMIG),
h1, Formal education (ED),
h2, Labour force participation (LFP),
h3, Occupation (OCC),
h4, Household income (INCOME),
h5, Literacy practices at work (LITW),
h6, Participation in adult education (ADED),
h7, Learning by exposure to educative contexts (INFL1),
h8, Self learning (INFL2),
h9, Literacy practices at home (LITH),
h10, Health literacy (HEALTHLIT)
Comm 1 and 2 were two community participation variables which subsequently were dropped because neither were statistically significant.
Applying these variables using sophisticated statistical tests he found that the best predictors of HL were:
Literacy practices at home, educational attainment, parents education, and being foreign born, each one of which reflect people’s peoples’ access to opportunities for learning at various stages of their lives.
Source: Desjardins, unpublished paper in review

11. Andersen-Newman Behavioural Model (1960’s) (Andersen, 1995, p.2)
PREDISPOSING  ENABLING  NEED  USE OF HEALTH
CHARACTERISTICS RESOURCES SERVICES
| | |
Demographic Personal/Family Perceived
| | |
Social Structure Community (Evaluated) |
Health Beliefs

12. Commonly Used Tools to Measure Health Literacy
REALM: Rapid Estimate of Adult Literacy in Medicine ( Davis et al., 1993)
TOFHLA: Test of Functional Health Literacy in Adults (Parker et al., 1995)
NVS: Newest Vital Sign (Weiss, 2007)
HALS: Health Activity Literacy Scale (CCL, 2007 a)
The REALM and TOFHLA are the most frequently used tools to measure health literacy and the Newest Vital Sign has recently been introduced. Unfortunately, none of them capture HL as reflected in any of the definitions that we have considered. They are mainly measures of reading proficiency. So for example, the REALM asks people to read a list of medical terms with varying degrees of difficulty and scores them on their ability to do so. And the TOHFLA asks them to fill in blanks in sentences or paragraphs with the appropriate words. THE NVS gives people a ice cream label to read and then asks them six questions about the information in the label. It may be a useful way for medical people to get a sense of whether or not their clients may have a problem with literacy or health literacy, but its is not robust enough to use as a research tool.
To summarize the shortcomings of these measures, none of them tests applied literacy skills or measures literacy in different contexts to any degree. Nor do they present the respondents with a variety of tasks, or test oral communication. Fortunately, recently some progress has been made recently in developing a more robust measure of HL which address the first three limitations.
This measure called the HALS was developed using data collected for the International literacy surveys as well as some national surveys of literacy in the US.

13. Health Activity Literacy Scale (CCL, 2007a)
Using 350 unique items in International Literacy Surveys
191 items judged to measure health-related activities
Health-related items assigned to five health literacy sub-domains
Some of the designers of these general literacy surveys decided a couple of years ago to develop a measure of HL, items from several of the surveys which were related to types of health-related activities shown here. Of the 350 unique assessment items, some 191 (55%) literacy tasks were judged to measure health-related activities. The items used to create the health literacy scale are of varying levels of difficulty and represent a broad range of contexts. The health-related literacy tasks are summarized along a single health activity literacy scale (HALS) that ranges from 0 to 500.
Each literacy level represents a progression of knowledge and skills; individuals within a particular level not only demonstrate the knowledge and skills associated with that level but the proficiencies associated with the lower levels as well.
They all provide measures of three types of literacy—prose, document, and quantitative or numeracy.
They also assign levels to people’s skills as measured by the surveys from 1-5, base on maximum scores of 500.
All this results in a new 500 point health activities literacy scale (HALS) derived from health items reflecting prose, document and quantitative (numeracy) skills
As is the case of the other measures that I mentioned, this measure does have some limitations:
Excludes oral skills
No measures of component skills that underlie fluent and automatic reading
No measure of the specialized vocabulary used in health settings
No measure of scientific literacy
No measure of problem solving skill
Limited measures of attitudes, values and beliefs
Less than optimal representation of HL sub-domains in pool of test items
May underestimate ability of individual to deal with a specific HL demand with which they are familiar
However, it is the best existing measure of HL and was used by our Expert Panel.

14. As you can see in this chart, age groups differ from each other in terms of rates of health literacy, with a peak in health literacy skills in the age group and declines thereafter, with a very substantial decline after the age of 65. In depth analysis has revealed that this decline is mainly due to deteriorating skills rather than being a cohort effect.
Source: Health Literacy in Canada: A Healthy Understanding, CCL, 2008, based on IALSS 2003

15. Low Health Literacy by Age Group in Canada, 2003
Age % Below Level 3 % % % % % %
Source: State of Learning in Canada 2007, Canadian Council on Learning, based on IALSS 2003
Looking at it another way, here are some data on the extent of HL on the 2300 IALSS. It indicates the percentages of the population below level 3 which is considered to be the minimum level required to function in a modern complex society such as ours. As you can see, the %’s below that level increase by age category until we get to almost 90% in the 65+ group.
In comparison to other provinces, we are almost at the top of the pack. However, we should not rush to congratulate ourselves as being the most literate jurisdiction in Canada, because at least one other jurisdiction appears to be more literate and about 40% of BC residents fall in the lowest two categories suggesting that they have some difficulty in reading materials needed in everyday life. Moreover, for older adults the figures are even higher, with 37% in the lowest category and 32.7% in the second with a combined total of almost 70% which suggests that we have a problem that we need to address.

16. The most recent evidence from the IALLS where as this chart shows, people who rate their health good or excellent are more likely to have higher levels of literacy, particularly among those who are 40 or older. In contrast, those in poor health a least likely to also experience lower levels of literacy. Unfortunatetly, this doesn’t ell is whether low literacy causes or leads to poorer health or poorer health leads to lower levels of literacy. If I was to guess, I would say that it probably works both ways.
Source: State of Learning in Canada 2007, Canadian Council on Learning, based on IALSS 2003

17. Health Literacy (Reading Proficiency) and. Health-Related Outcomes (I
Health Literacy (Reading Proficiency) and Health-Related Outcomes (I.O.M., 2004)
More likely hospitalization and negative disease outcomes
Higher rates of diabetes
Poorer Diabetes Control
Inappropriate medication use and compliance with physician orders
Less use of preventive services and less care seeking
Difficulties using health care system
Less expression of health concerns
Higher mortality
In addition, the literature there is considerable evidence of relationships between health literacy as measured by the REALM (Rapid Estimate of Adult Literacy in Medicine) and the TOFHLA (Test of Functional Health Literacy in Adults) suggesting a relationship between health literacy and a number of health outcomes including the ones noted here. I might add that in an analysis of data using the HALS Scale in Canada, a relatively strong relationship has been found between HL rates at the regional level and rates of diabetes.
Health literacy have been found to be associated with various intermediate outcomes including: Inappropriate medication use and compliance with physician orders; Less use of preventive services and less care seeking; Difficulties using the health care system; and Less expression of health concerns. These studies included people with a variety of chronic diseases including diabetes, all of which appear to be increasing.
All of these behaviours are clearly related to people’s ability to manage chronic diseases including diabetes

18. Low health literacy and premature mortality among older adults
A recent U.S. study found that older adults with inadequate and marginal health literacy levels had a 50 per cent higher mortality rate over a five-year period than those with adequate skills. (Barker et al., 2007)
Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education.
Another study found that limited literacy was independently associated with a nearly two-fold increase in mortality in the elderly. (Sudore, et al, 2006)
Specifically, two prospective studies have found strong relationships between HL and premature mortality among older adults. I don’t think we would want to conclude that they are causal relationships, as there could be a common variable such as cognitive deterioration which accounts for it. However, it does suggest some kind of a link between reading proficiency and premature death.
So to sum up, based on his informration ,older adults appear to be more likely to have lower HL than younger adults and this seems to be associated with poorer health outcomes
What is your reaction to this? Do you think it is real and that we need to be concerned about it? And if yes, what should we do about it?

19. Other literacy-related health outcomes for older adults
Older adults with low literacy are more likely to report difficulties with activities of daily living, few accomplishments because of their physical health, greater pain interfering with work, and have less knowledge about diseases
(Rootman and Ronson, 2005; Friedman, 2006)
However, we also know from research that has been done that there do appear to be some other health-related and other outcomes associated with lower levels of literacy. These have been reviewed in a paper which I published last year and are also cited in a Ph.D. thesis that is under preparation. In this regard, several studies have found that Older adults with lower literary or health literacy are less likely to report using preventive services
They are also more likely to report difficulties with activities of daily living, few accomplishments because of their physical health, greater pain interfering with work, and have less knowledge about diseases

20. Challenges faced by Older Adults with Low Literacy (IOM, 2007)
Stigma
Increasing literacy demands
Isolation
Poverty
Perceptual or cognitive difficulties
Difficulty maintaining their health, safety, independence and self-esteem
Programs exclude older adults or don’t meet their needs
Perceived relevance of adult education
Health education materials tend to require strong literacy skills
Health workers are not trained to recognize literacy deficits
According to Allan Quigley, low-literate older adults we are talking about saw less and less relevance to “going back to school.”  The issue we face with this growing sub-group is not so much stigma as relevance, I think.  The idea they are too old, too set in their ways,  is endemic in the group itself but they are perpetually at the mercy of the medical system. And many know it……..  We found this in our study here in NS. So, the unique nuance in this age group is convincing them that literacy education (“i.e., health literacy”) makes a lot of sense .
So what can be done to address these an other challenges faced by older adults with low literacy. With the help of my colleagues, I have identified eight promising initiatives from across the country. This doesn’t mean that these are the only ones are who considering, but they do give some sense as to what might be possible.
I should note however, that most have not been evaluated rigorously.

21. Factors Predicting Health Literacy for Adults aged 66 and over (CCL, 2008)
This analysis indicates that daily reading habits had the single strongest effect on health-literacy proficiency. It is particularly notable that educational attainment is the second-strongest factor explaining health-literacy proficiency, especially since a similar analysis of prose and document literacy found education to be the single-most important determinant. [1]
This suggests that there is something unique about daily reading that provides a health-literacy boost.
“Practice engagement theory” suggests that individuals acquire literacy through participation in different literacy practices.[2] According to this theory, those who engage more in literacy practice both at work and at home will enhance or at least maintain their literacy skills. This implies that reading in daily life (outside of work life) may be just as important. A number of studies suggest that literacy practice is associated with higher literacy skills. [3],[4],[5],[6]
[1] Desjardins, Richard. “Determinants of literacy proficiency: a lifelong-lifewide learning perspective.” International Journal of Educational research. Volume 39, Issue 3, 2003, Pages
[2] Reder, S. “Practice-engagement theory: A sociocultural approach to literacy across language and cultures.” In B.M. Ferdman, R-M. Weber, & A. G. Ramirez (Eds.), Literacy across languages and cultures (pp ). Albany, NY: State University of New York. (1994).
[3] Organisation for Economic Co-Operation and Development (OECD) and Human Resources Development Canada (HRDC). “Literacy Skills for the Knowledge Society: Further Results from the International Adult Literacy Survey, Paris and Hull. (1997).
[4] Organisation for Economic Development and Co-Operation (OECD) and Statistics Canada. “Literacy in the Information Age: Final Report on the International Adult Literacy Survey, Paris and Ottawa. (2000).
[5] Rubenson, K. “Participation in recurrent education: A research review.” In H.G. Schuetze & D. Istance (Eds.), Recurrent Education Revisited: Mode of Participation and Financing (pp ). Stockholm: Almqvist & Wiksell International. (1987)
[6] Meissner, M. “The long arm of the job: A study of work and leisure.” Industrial Relations: Journal of Economy & Society, 10, (1971)

22. Predictors of Health Literacy in Older Adults
Sub-sample of older adults (n=2,979) from 2003 IALSS (Canadian survey)
Formal education, life-long and life-wide learning enabling factors exhibited the most robust associations with health literacy among older adults
Concluded that Programs and policies that encourage life-long and life-wide educational resources and practices are needed
With regard to predictors, a study conducted by a graduate student at SFU using the IALSS data base, but focused on sub sample of older adults, found that formal education, life-long and life-wide learning enabling factors exhibited the most robust associations with health literacy and concluded that Programs and policies that encourage life-long learning and life-wide educational resources and practices are needed. This study will be published later this year in the Journal of Aging and Health one of the highest impact journals in the field of aging.
(Malloy-Weir et al., 2010)

23. What can be done?
Very few rigorous evaluations (IOM, 2004; CPHA 2008)

24. Pignone Review (2005): Methods
Systematic review of interventions
Included controlled and uncontrolled studies
Searched variety of data sources
Covered
Found 20 articles with interventions to improve health among people with low literacy
Abstracted data from articles and assessed quality

25. Pignone Review: Findings
Effectiveness mixed
Variation in research quality and outcome measures
Only 5 studies examined interaction between literacy level and effect of intervention; also found mixed results

26. Pignone Review: Conclusions
Several interventions have been developed to improve health for people with low literacy
Limitations of studies make drawing conclusions difficult
Further research needed to understand types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health

27. King Review (2007): Methods
focused search and review of the academic literature related to health literacy interventions
focused search and review of the grey literature related to health literacy interventions in Canada and around the world
Key informant interviews
Also done for Expert Panel sponsored by NCDOH

28. King: Findings
Majority of health literacy interventions involved accessing and understanding, with very few focused on appraising or communicating health information
Very limited information was found about the effectiveness of health literacy interventions
Some evidence to support the finding and general understanding that a participatory educational and empowerment approach is effective
The UVic paper that I assigned is one example, but there are others cited by King including one by Maria Hahn

29. King: Conclusions
Barriers to evaluation of programs were time, money and lack of provider expertise
a number of areas of further investigation are suggested including:
health literacy interventions focused on appraising health information
cultural issues
health care professional training
sources of health information
learner and patient perspectives

30. Clement Review (2009): Methods
Systematic review of randomized and quasi-randomized controlled trials focused on complex interventions for people with limited literacy or numeracy
Searched eight databases from start to 2007
Checked references and contacted key informants
Two reviewers assessed eligibility, extracted data and evaluated study quality
Finally, these is the most recent systematic review which I sent to you in Advance

31. Clement: Findings 2734 non-duplicate items, reduced to 15 trials
Two interventions for health professionals, one literacy education and 12 health education and management; most in North America
Most (13/15) reported at least one significant difference in primary outcome favoring intervention group
Knowledge and self-efficacy most likely outcome improvement

32. Clement: Conclusions
A wide variety of complex interventions for adults with limited literacy are able to improve some health-related outcomes
Review supports wider introduction of interventions for people with limited literacy, particularly within an evaluation context
There is considerable evidence that certain population groups and geographic areas are more likely to experience low health literacy
There is some evidence that certain interventions can be helpful, particularly complex interventions and participatory approaches

33. Strategies for Addressing Health Literacy
Improve skills required to be health literate
Provide services appropriate for people with all skill levels
Two key strategies for addressing low Hl are:
I would like to present a couple of examples of each.

34. An Example of Strategy #1
Mental Fitness for Life is an 8-week series of intensive workshops based on grounded research that includes the following topics: Goal Setting; Critical Thinking; Creativity; Positive Mental Attitude; Learning; Memory; and Speaking your Mind.
Evaluations suggest that the program has a positive impact on health, and that there is a need to promote mental fitness, like physical fitness, as a health promoting behavior that supports the progressive development of the individual across the lifespan.
For more information see: Cusack et al., 2003 and Cusack and Thompson, 2005)
The Mental Fitness for Life program was developed by Sandra Cusack and her colleagues at SFU Centre for Gerontology over several years. The program is an 8-week series of intensive workshops based on grounded research that includes the following topics: Goal Setting; Critical Thinking; Creativity; Positive Mental Attitude; Learning; Memory; and Speaking your Mind.
Results suggest the impact of the program on health, and the need to promote mental fitness, like physical fitness, as a health promoting behavior that supports the progressive development of the individual across the lifespan.

35. A Second Example of Strategy #1
The Computer for Elder Learning project used free computer training as outreach tool to recruit older adults for literacy skills upgrading
Although it failed to recruit people with low literacy skills, participants reported that they were reading and writing more due to the computer and more confident about their reading and writing skills.
For more information, go to:
Done in Chilliwack. Called Computers for elder learning, used free computer training as a motivators to bring older adults for skills training as well as avoid stigma

36. A Third Example of Strategy #1
The Second Chance for Seniors Program addresses learning needs of older adults. It has three components: Peer tutoring; group literacy activities; education.
For more information go to: www. catalist.ca
Through the Second Chance for Seniors program SEC works to address the literacy learning needs of older adults. The Second Chance for Seniors program has three main components:
peer tutoring with older literacy learners and tutor training
community based group literacy activities
public education about older adult literacy issues
Since 1997 the program has assisted many older adults to improve their reading and writing skills.
The Second Chance for Seniors program was started with a bequest from Eva Bassett which was matched by the National Literacy Secretariat. Current literacy activities are also being carried out with assistance from PSEST. A number of literacy resources and general reading materials are housed in the Learning Centre in Room CNB 028 of the Seniors’ Education Centre. SEC members are welcome to browse and borrow from the collection.
Seniors Serving Seniors Program - Evaluation Report. Cathy Ellis, Price:$5.00.
Seniors Serving Seniors - Peer Counseling and Health Education Modules. Complete lesson plans to teach courses for older adults in peer counseling and health education. Twenty(20) modules $35.00.
Seniors Serving Seniors: Volunteers Promoting Healthy Aging Project Feasibility Study Report. A health promotion project proposing to involve older adults as volunteer health promoters and peer counselors. Cathy Ellis, Price: $5.00
Seniors Serving Seniors - VIDEO. This six and a half minute video explains the Seniors Serving Seniors program for older adults. Through this program, they learn to be peer counselors and health promoters so that they can work as trained volunteers with health-related organizations and agencies. Cathy Ellis and Susan Risk, Price: $20.00
A process evaluation was carried out which resulted in numerous recommendation on how to improve the program and an over all recommendation to continue it and to use it as an opportunity to experiment with seniors' literacy opportunities and to document activities and results to assist the Seniors' Education Centre and other centres in developing and strengthening literacy outreach.

37. A forth Example of Strategy #1
The COSCO health literacy program for seniors uses a training-of-trainers approach to provide knowledge and training for seniors across BC regarding a number of health and other issues
No rigorous evaluation to date
For more information go to:

38. An Example of Strategy # 2
The National Literacy Program developed Guidelines for medication packaging and labeling for older adults
Process: Reviewed literature, consulted with stakeholders; collected samples of packaging and labeling materials; developed guidelines; held national symposium
Outputs: Guidelines, resources
Available at:
In term of the second strategy, The first is a national project to develop guidelines for medication packaging by the National which focused particularly on the requirements of older adults. Thus, the guidelines had recommendations regarding the size of the printing and the need for them to be in clear language they have been used widely by pharmaceutical manufacturers and professionals who work with older adults.

39. A Second Example of Strategy #2
The Older Adult Literacy Resource Manual is two-part workshop resource manual intended to help trainers of literacy tutors, and others , to raise awareness of the particular needs of older adult literacy learners.
Available from:
Part one of the manual contains the background reading to explore the topic. Part two is the workshop guide for those who are interested in holding a workshop for their group or organization.
The video Diane was involved in producing has been shared widely. I know that Nova Scotia has developed program based on having seen the video according to NS Seniors Secretariat newsletter I picked up while at the Canadian Association of Gerontology Conference held in Halifax last fall.
We have not done a formal impact assessment on the program, but impact will be a focus of the review we are doing over the next few months.

40. Network: National
The Canadian Network for Third Age Learning fosters later life learning through shared knowledge, expertise, research, and resources is located at the University of Regina, Seniors' Education Centre.
The Network links approximately 50 organizations involved in providing learning opportunities for older adults across Canada.
Go to catalist.ca
By serving as a point of contact for information sharing and collaboration about third age learning, the Network serves to encourage and enhance learning opportunities for all Canadian older adults. The CATALIST web site is located at The web site contains research and funding information, quarterly newsletters and links to Internet resources.
CATALIST is supported by the Office of Learning Technologies, Human Resources Development Canada and The Lorne and Evelyn Johnson Foundation, and its members.
Anyone interested in learning more about CATALIST is encouraged to contact Moira Bloom, CATALIST Coordinator, at (306) or

41. Conclusions
Health Literacy among older adults is an issue that needs to be addressed in Canada
It can be done either by improving health literacy skills or by providing services appropriate for people with all skill levels
The provision of opportunities for lifelong learning may be particularly important
There are some innovative efforts in Canada to address the health literacy needs of older adults
Most of the efforts are short-term and not well supported
Few of them have been evaluated rigorously

42. Questions? Comments?