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Improving the Health of Adults with Limited Literacy: What's the Evidence?

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Health Evidence, in partnership with the National Collaborating Centre for Determinants of Health (NCCDH), hosted a 60 minute webinar, funded by the Canadian Institutes of Health Research …

Health Evidence, in partnership with the National Collaborating Centre for Determinants of Health (NCCDH), hosted a 60 minute webinar, funded by the Canadian Institutes of Health Research (KTB-112487), on interventions to improve the health of adults with limited literacy, presenting key messages, and implications for practice on Wednesday October 31, 2012 at 1:00 pm EST. Maureen Dobbins, Scientific Director of Health Evidence, lead the webinar, which included interactive discussion with Karen Fish, Knowledge Translation Specialist, and Connie Clement, Scientific Director, both from the NCCDH.

This webinar focused on interpreting the evidence in the following review:

Clement, S., Ibrahim, S., Crichton, N., Wolf, M., Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.

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  • 1. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome!Improving the Health of Adults with Limited Literacy:What’s the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  • 2. What’s the evidence? Clement, S., Ibrahim, S., Crichton, N., Wolf, M., Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351. http://health-evidence.ca/articles/show/19393
  • 3. Participant Side PanelHousekeeping in WebEx Use Q&A to post comments/questions during the webinar  ‘Send’ questions to All (not privately to ‘Host’) Connection issues  Recommend using a wired Internet connection (vs. wireless), to help Q&A prevent connection challenges WebEx 24/7 help line: 1-866-229-3239
  • 4. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome!Improving the Health of Adults with Limited Literacy:What’s the evidence?
  • 5. The Health Evidence Team Kara DeCorby Heather Husson Jennifer Yost Managing Director Project Manager Guest PresenterMaureen DobbinsScientific DirectorTel: 905 525-9140 ext 22481E-mail: dobbinsm@mcmaster.ca Lori Greco Robyn Traynor Lyndsey McRae Knowledge Broker Research Coordinator Research Assistant
  • 6. What is www.health-evidence.ca? Evidence inform Decision Making
  • 7. Why use www.health-evidence.ca? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  • 8. Knowledge Translation Supplement Project CIHR-funded KTB-112487
  • 9. National Collaborating Centre forDeterminants of Health Connie Clement Karen Fish Scientific Director Knowledge Translation Specialist
  • 10. About the National CollaboratingCentre for Determinants of HealthOur work Translate and share evidence to influence interrelated social determinants of health and advance health equity through public health practiceOur audience • Organizations that make up the public health sector in Canada • The practitioners, decision makers and researchers who work within public health Visit us at www.nccdh.ca
  • 11. Visit us at www.nccdh.ca• Resource Library• Health Equity Clicks: Community• Health Equity Clicks: Organizations• Networking events & workshops
  • 12. Review Clement, S., Ibrahim, S., Crichton, N., Wolf, M., Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.
  • 13. Questions?
  • 14. Summary Statement:Clement(2009) P Adults with limited literacy or numeracy I Complex, multi-faceted interventions C Any active or inactive control O Health-related outcomes: clinical outcomes; health knowledge; health behaviours; self-reported health status/quality of life; health-related self-efficacy/confidence; utilization of health care; health professional behaviour/skillsQuality Rating: 10 (strong)
  • 15. Complex Interventions Multi-faceted intervention (more than one element) & intended to improve outcomes for people with limited literacy. Main categories:  Health professional-directed  Literacy education  Health education/management Most common elements included:  Care management  Videos  Verbal presentation  Audiotapes  Material in simplified language  Checking for understanding  Pictorial information  Spacing information
  • 16. Definition of Health LiteracyCanadian Expert Panel on Health Literacy, 2008 “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.”
  • 17. Overall Considerations Complex interventions are effective in improving some health-related outcomes – health-related self efficacy/confidence; utilization of health care; and health provider behaviour/skills – for people with limited literacy The evidence is mixed on clinical outcomes, health knowledge and health behaviours. There is no impact on self-reported health status/quality of life.
  • 18. General ImplicationsPublic health should promote/support/implement: Complex, multi-faceted interventions to address patients with limited literacy in the areas of health- related self efficacy, utilization of health care, and communication with health providers.
  • 19. Public health should consider that… High quality review, based on low-moderate quality RCTs Many outcomes are based on the results of 1 study; majority of included studies may not have had an adequate sample size to observe statistical significance Interventions studied varied widely – health issue addressed; duration, intensity, and delivery; extent to which literacy factored into the intervention – as did the types of measures and control groups used. Due to this variation, it is not possible to identify if specific intervention components were more effective than others.
  • 20. What’s the evidence?Outcomes reported in the review* *Only the primary outcomes from each study are Clinical Outcomes addressed in this evidence table. Review authors reported on primary and secondary outcomes but only included Health Knowledge data for primary outcomes. Health Behaviours Self-Reported Health Status / Quality of Life Health-Related Self-Efficacy / Confidence Utilization of Health Care Health Provider Behaviour / Skills Satisfaction Levels
  • 21. What’s the evidence?Clinical Outcomes Literacy education:  Reduced median depression scores in adults with depressive symptoms (6) vs. usual care (10) in a community setting (p=0.04).
  • 22. What’s the evidence?Clinical Outcomes (continued) Health education:  Educational session with clinical pharmacist reduced death/hospital admission for adults with heart failure (IRR 0.53, 95% CI 0.32-0.89).  Educational session with pharmacist reduced systolic (mm Hg, -7 vs. 2, 95% CI -16 to -3, p=0.008) and diastolic blood pressure (mm Hg, -4 vs. 1, 95% CI -9 to -1, p=0.002) in adults with poorly controlled type II diabetes. No impact on total blood cholesterol or haemoglobin levels.  No impact on blood pressure and cholesterol for African- American adults with high blood pressure or cholesterol.
  • 23. What’s the evidence?Health Knowledge Health education:  Verbal counseling, provided with dispensed medication, increased understanding of dosage regimen (% correctly reporting, 88%) vs. usual care (70%) in a hospital pharmacy (p=0.03).  Group education improved understanding of HIV-related terms (mean score (SD), 6.16 (7.97)) vs. usual care (1.91 (3.60)), (t=-3.16, p<0.0001) but had no impact on overall HIV knowledge in Latino Spanish-speaking adults with HIV.
  • 24. What’s the evidence?Health Knowledge (continued) Health education (continued):  No impact on mothers’ knowledge of newborn hearing screening in a maternity unit setting but, in a subgroup analysis, there was a significant increase for mothers with lower levels of education (5.00 vs. 3.38, p<0.05)  No impact on: veterans’ hypertension knowledge; medication knowledge in adults aged 65+ with a chronic illness.
  • 25. What’s the evidence?Health Behaviours Health education:  Personalized dietary feedback, booklets and structured telephone calls reduced self-reported fat intake (mean score (SD), 1.87 (0.35)) vs. usual care (1.95 (0.34)) (p=0.0027) but had no impact on self-reported fiber intake for adults in a rural area.  A nutrition-focused heart disease prevention program reduced sodium intake (mean mg (SD), 2545.97 (1164.12)) vs. attention control (3118.13 (2386.19)), (p<0.05) in Hispanic adults, but had no impact on total fat, saturated fat, or cholesterol intake.
  • 26. What’s the evidence?Health Behaviours (continued) Health education (continued):  Low-fat nutrition group education improved self-reported healthy low fat eating in low-income families (mean difference, -0.03, 95% CI -0.01 to -0.005).  Low-fat nutrition group education reduced caloric intake (change in % calories from total fat, -2.8 (2.4)) vs. an alternative program (-0.5 (2.0)), (p=0.01).
  • 27. What’s the evidence?Health Behaviours (continued) Health education (continued):  Intensive diabetes management program improved self-report of Aspirin use by adults with poorly controlled type II diabetes (% correctly reporting, 91%) vs. usual care + 1 hr educational session (58%), (p<0.0001).  No impact on medication adherence for veterans with hypertension or Latino Spanish-speaking adults with HIV.
  • 28. What’s the evidence?Self-Reported Health Status Health education:  Education session with a clinical pharmacist had no impact on heart failure-related quality of life reporting in adults with heart failure.
  • 29. What’s the evidence?Health-Related Self-Efficacy Health education:  Tailored health education telephone intervention (with verbal medication explanation) increased self confidence in hypertension management for veterans (mean score change, 0.33) vs. usual care (-0.10), (p=0.007)
  • 30. What’s the evidence?Utilization of Health Care Health professional-directed:  Health professional-directed intervention, in which professionals receive training on screen and patient communication, increased percentage of patients screened for colorectal cancer (42.3%) vs. usual care (32.4%) (p=0.003).  There was no impact in a subgroup analysis of higher literacy groups in the same study.
  • 31. What’s the evidence?Health Provider Behaviour Health professional-directed:  Health professional-directed intervention, in which physicians were notified of patients’ literacy status, increased use of literacy-relevant management strategies when treating adults with type II diabetes (% reporting use of >3 strategies, 20%) vs. usual care (7%) (OR 4.7, 95% CI 1.4-16.0, p=0.01). Health education:  Group health education improved Latino Spanish-speaking adults with HIV’s perceived quality of communication with health providers (mean score change (SD), 5.28 (5.37)) vs. usual care (1.11 (5.97)) (p<0.001).
  • 32. What’s the evidence?Satisfaction Levels Patients: Intervention group (adults with poorly controlled type II diabetes in an intensive educational session) were more satisfied than those receiving usual care (Diabetes Treatment Satisfaction Questionnaire, difference in mean change, 3, 95% CI 1-6). Providers: Intervention group (physicians notified of diabetes patients’ literacy status) were less satisfied (82%) than those receiving usual care (96%) (adjusted OR 0.2, 95% CI 0.1-0.5)
  • 33. General ImplicationsPublic health should include and/or support complex,multi-faceted interventions, for adults with limitedliteracy, to improve: Health-related self efficacy Utilization of health care Communication with health providers**Public health decision makers should be aware that limited evidence (i.e. 1 study) is available for most of the outcomes described in this review.
  • 34. General ImplicationsFor adults with limited literacy: The evidence does not recommend complex interventions for improving self-reported health status or quality of life. The evidence cannot definitively recommend/reject complex interventions to address dietary outcomes, overall health knowledge and behaviours. However, the interventions appear to be effective in improving specific knowledge and behaviours, such as understanding key terms, medication dosage regimes and correct medication self-reporting.
  • 35. Questions?
  • 36. Posting BoardFor a copy of the presentation please visit our posting board: http://forum.health-evidence.ca/Login with your health-evidence username and password or register if you aren’t a member yet.
  • 37. Evaluation Survey Please check your email for a link to an evaluation survey. It take 5 minutes to complete!If you did not personally register for the webinar, please e-mail Jennifer McGugan at mcgugj@mcmaster.ca to be sent the survey.
  • 38. Canadian Institutes of Health ResearchInstitute of Population and Public Health Funding Opportunities• Population Health Intervention Research to Promote Health and Health Equity• Knowledge Translation Awards• Institute Community Support Grants and Awards• CIHR’s Open Operating Grants Program 39
  • 39. Population Health Intervention Research ExampleEvaluation of traffic safety interventions in B.C.Jeffrey Brubacher, et. al (UBC)Looking at whether number of vehicle crashes changed afterchanges to the province’s Motor Vehicle Act.Findings will influence B.C.’s road safety strategy and will be ofinterest to traffic safety lawmakers from other Canadianprovinces and territories. 40
  • 40. • Visit ResearchNet for current CIHR funding opportunities: http://www.researchnet- recherchenet.ca/• For further information please contact us ipph-ispp@uottawa.ca 41
  • 41. References Rootman, I. & Gordon-El-Bihbety, D. (2008) A vision for a health literate Canada: Report of the Canadian Expert Panel on Health Literacy. Ottawa, ON: Canadian Public Health Association. Retrieved from http://www.cpha.ca/uploads/portals/h-l/report_e.pdf Begoray, D., Gillis, D., Rowlands, G. (Eds.) (2012) Health Literacy in Context: International Perspectives. Nova Science Publishers, Inc., New York Public Health Association of British Columbia. (2012). An inter-sectoral approach for improving health literacy for Canadians: A discussion paper. Victoria, BC: Author. Retrieved from http://www.phabc.org/userfiles/file/IntersectoralApproachforHealthLiteracy- FINAL.pdf National Collaborating Centre for Determinants of Health. (2007). Scan of family literacy and health: Final report. Antigonish: NS: Author. Retrieved from http://nccdh.ca/resources/entry/scan-of-family-literacy-and-health