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     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.
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
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   Welcome!
Improving the Health
   of Adults with
  Limited Literacy:
What’s the evidence?
The Health Evidence Team


                               Kara DeCorby        Heather Husson       Jennifer Yost
                               Managing Director   Project Manager      Guest Presenter




Maureen Dobbins
Scientific Director
Tel: 905 525-9140 ext 22481
E-mail: dobbinsm@mcmaster.ca




                               Lori Greco          Robyn Traynor        Lyndsey McRae
                               Knowledge Broker    Research Coordinator Research Assistant
What is www.health-evidence.ca?


                     Evidence
                          inform



              Decision Making
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
Knowledge Translation
 Supplement Project
    CIHR-funded KTB-112487
National Collaborating Centre for
Determinants of Health




   Connie Clement        Karen Fish
   Scientific Director   Knowledge Translation
                         Specialist
About the National Collaborating
Centre for Determinants of Health

Our work
  Translate and share evidence to influence interrelated
  social determinants of health and advance health equity
  through public health practice
Our 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
Visit us at www.nccdh.ca


•   Resource Library
•   Health Equity Clicks: Community
•   Health Equity Clicks: Organizations
•   Networking events & workshops
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.
Questions?
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/skills


Quality Rating: 10 (strong)
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
Definition of Health Literacy
Canadian 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.”
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.
General Implications
Public 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.
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.
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
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).
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.
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.
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.
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.
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).
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.
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.
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)
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.
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).
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)
General Implications
Public health should include and/or support complex,
multi-faceted interventions, for adults with limited
literacy, 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.
General Implications
For 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.
Questions?
Posting Board
For 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.
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.
Canadian Institutes of Health Research
Institute 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
Population Health Intervention Research
                   Example
Evaluation of traffic safety interventions in B.C.
Jeffrey Brubacher, et. al (UBC)
Looking at whether number of vehicle crashes changed after
changes to the province’s Motor Vehicle Act.
Findings will influence B.C.’s road safety strategy and will be of
interest to traffic safety lawmakers from other Canadian
provinces and territories.




                                  40
• Visit ResearchNet for current CIHR
  funding opportunities:
  http://www.researchnet-
  recherchenet.ca/

• For further information please contact us
  ipph-ispp@uottawa.ca




                    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

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

  • 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 Panel Housekeeping 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 Presenter Maureen Dobbins Scientific Director Tel: 905 525-9140 ext 22481 E-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.
  • 10. National Collaborating Centre for Determinants of Health Connie Clement Karen Fish Scientific Director Knowledge Translation Specialist
  • 11. About the National Collaborating Centre for Determinants of Health Our work Translate and share evidence to influence interrelated social determinants of health and advance health equity through public health practice Our 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
  • 12. Visit us at www.nccdh.ca • Resource Library • Health Equity Clicks: Community • Health Equity Clicks: Organizations • Networking events & workshops
  • 13. 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.
  • 15. 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/skills Quality Rating: 10 (strong)
  • 16. 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
  • 17. Definition of Health Literacy Canadian 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.”
  • 18. 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.
  • 19. General Implications Public 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.
  • 20. 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.
  • 21. 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
  • 22. 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).
  • 23. 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.
  • 24. 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.
  • 25. 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.
  • 26. 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.
  • 27. 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).
  • 28. 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.
  • 29. 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.
  • 30. 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)
  • 31. 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.
  • 32. 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).
  • 33. 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)
  • 34. General Implications Public health should include and/or support complex, multi-faceted interventions, for adults with limited literacy, 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.
  • 35. General Implications For 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.
  • 37. Posting Board For 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.
  • 38. 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.
  • 39. Canadian Institutes of Health Research Institute 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
  • 40. Population Health Intervention Research Example Evaluation of traffic safety interventions in B.C. Jeffrey Brubacher, et. al (UBC) Looking at whether number of vehicle crashes changed after changes to the province’s Motor Vehicle Act. Findings will influence B.C.’s road safety strategy and will be of interest to traffic safety lawmakers from other Canadian provinces and territories. 40
  • 41. • Visit ResearchNet for current CIHR funding opportunities: http://www.researchnet- recherchenet.ca/ • For further information please contact us ipph-ispp@uottawa.ca 41
  • 42. 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