The Health Literacy Component (HLC) of the 2003 NAAL

1. A webcast presentation August 3, 2004 The Health Literacy Component (HLC) of the 2003 NAAL Sheida White Project Officer National Assessment of Adult Literacy (NAAL) The Health Literacy Component (HLC) of the 2003 NAAL Sheida White Project Officer National Assessment of Adult Literacy (NAAL)

2. Topics covered by this presentation • 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

3. HLC Background, Definitions, and Limitations

4. Importance of health literacy • 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

5. 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

6. The 2003 NAAL • 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

7. Key features of NAAL • 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

8. Partnership between NCES and HHS • 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

9. HHS definition of health literacy • 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

10. 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

11. NAAL definition of health literacy—Graphic representation S. White 8-04

12. Uses for HLC data 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

13. Aspects of health literacy not covered by HLC data • 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

14. Task Types and Skill Requirements

15. Overview of the three types of health literacy tasks SOURCE: Based on information in Communicating Health: Priorities and Strategies for Progress. (2003). Washington, DC: U.S. Department of Health and Human Services

16. Clinical 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

17. Preventive 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

18. Navigation 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

19. 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

20. Breakdown of NAAL health-related tasks by type

21. 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

22. Relationship 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

23. Health-Related Items and Stimulus Materials

24. Health-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

25. Health-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

26. 166 items in the 1992 NALS 6 health-related items using HHS definition 2 reused in 2003 4 to be released Graphic summary of 1992 health-related items S. White 8-04

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

28. Test Questions Search Tool on the NCES website—Sample screen #2

29. 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. Example of a health-related item from the released 1992 NALS items S. White 8-04

30. 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

31. Health-Related Background Questions

32. 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

33. 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.

34. 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,…)?

35. Analysis of Health Literacy Data

36. Analysis 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

37. 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

38. Health 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)

39. 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

40. Measuring 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

41. 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

42. 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

43. 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)

44. Summary of Unique Features of the NAAL HLC

45. Unique 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

46. Contribution of the NAAL HLC to Written Health Communication

47. Key factors in written health communication 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

48. Significance of the NAAL HLC 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

49. NCES Contacts and Website

50. National Center for Education Statistics Sheida WhiteNAAL Project Officer(202) 502-7473Sheida.White@ed.gov Andrew KolstadSenior Technical Adviser(202) 502-7374Andrew.Kolstad@ed.gov Web Sitehttp://nces.ed.gov/naal