The Evaluation and Measurement of Health Literacy

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the third blog in a three-part series the IH Blog will feature this summer, Global health literacy: Conceptual basis, measurement and implications.

Part III. The Evaluation and Measurement of Health Literacy

While the IOM’s (now National Academy of Medicine) definition of health literacy (HL) is recognized and accepted, there is a lack of standardization in its conceptualization and operationalization within and between countries. Initially HL was perceived as a derivation of literacy with it’s primary purpose serving to as important tools to maximize comprehension during clinical encounters. In recent years the meaning and purpose of HL have broadened in scope to incorporate a health promotion perspective. This expanded and dynamic definition has resulted in increased utility in both clinical medicine and public health but has left this construct susceptible to conceptual drift.  A recent systematic review of the construct of HL found 17 varying definitions and 12 conceptual models that were employed in the literature.  

According to IOM’s report Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary, countries around the world have used a wide range of designs and approaches as well as purposes for examining HL.  These approaches have involved the usage of proxies such as education, income, or literacy to approximate HL. Other countries have relied on single items, often as a part of other measures (e.g. school attendance/enrollment, reading score), to evaluate HL. Thus, currently there is lack of comparability between estimates of HL within and between countries. Furthermore, the validity of many measures in assessing IOM’s definition of HL remains unclear. It is important to note that nearly all of the studies in this review were conducted in high income countries. Very little research has constructed a measure for use in LICs and LMICs. A robust measure of HL provides the foundation for comparison of HL across countries as well as its evaluation in relation to health outcomes.

My colleagues and I (see acknowledgements below) sought to develop a robust measure of HL using data from Demographic Health Surveys (DHS) conducted between 2006-2015 in 14 developing countries: Cameroon, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Ivory Coast, Lesotho, Rwanda, Niger, Namibia, Sierra Leone, Swaziland, Toto, and Zambia. The same survey was administered in all countries, after translation into versions appropriate by language.  The DHS Program is administered by the United States Agency for International Development (USAID). Beginning in 1984, surveys have been administered in over 90 countries. The DHS survey includes items that represent domains of the IOM definition of HL. We identified eight survey questions that corresponded to elements of the four domains of health literacy as defined by the IOM: capacity to interpret, capacity to obtain, capacity to understand, and ability to make appropriate health decisions. We then applied factor analysis methods to extract a single factor – a measure of health literacy – and evaluate the results for reliability and validity.

In our work, a total of 259,684 individuals between the ages of 15 and 49 years were included.  The derived dichotomous measure of health literacy demonstrated internal consistency (Cronbach’s α = 0.72), good content validity, and importantly, was comprised of the elements described by the IOM.  The prevalence of high health literacy overall was 35.2%.  Health literacy varied by sex (females, 34.1% vs males, 39.2%) and education level (primary education or less, 8.9%, some secondary education, 69.4%, secondary education or higher, 84.4%). Health literacy varied considerably across nations, from 8.5% in Niger to 63.9% in Namibia.  

This was the first study to derive a robust indicator of health literacy following the IOM definition in a large number of national samples. In future work we plan to use this indicator with DHS datasets to measure health literacy in other countries, and ultimately test how health literacy relates to health behavior and outcomes, including for HIV/AIDS and domestic violence. An abstract of these findings was published in the Lancet Global Health, Volume 5, Special Issue, S18, April 2017.

Acknowledgements:

The following individuals contributed to the investigation of HL as discussed in this blog series:

Douglas J. Wiebe, Phd, Associate Professor, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania

Julia M. Alber, Phd, Postdoctoral Fellow, Center for Health Behavior Research, University of Pennsylvania

Sara M. Schrauben, MD, Renal Research Epidemiology Fellow, University of Pennsylvania

Carmella M. Mazzola, College of Health Sciences, Arcadia University

Ashley Andrews, MPH, Perelman School of Medicine, University of Pennsylvania

McClintock.Picture

Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.

 

 

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Health Literacy: Is Educational Attainment Enough?

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the second blog  in a three-part series the IH Blog will feature this summer, Global Health Literacy: Conceptual Basis, Measurement and Implications.

Part II: Health Literacy: Is Educational Attainment Enough?

For over a decade I worked in primary care practices providing health education to patients with a broad range of educational and professional backgrounds, from persons who had dropped out of high school to those with dual doctoral degrees. I recall that when I first started I assumed that persons with higher levels of educational attainment would more readily understand and incorporate health education into their daily lives. I soon realized that I was entirely wrong. While persons who had higher levels of education were somewhat more likely to comprehend health information, a large proportion of these persons were unable to adequately understand and act on the health information presented to them. I remember sitting with a patient who had a doctoral degree who explained to me how his depression medication worked best when taken only on Sundays. Conversely, one patient who had not completed high school explained to me the intricacies of high blood pressure management with such clarity that it would have rivaled any veteran educator’s attempts at explaining it. All of these experiences fostered my interest in this concept of health literacy. What was health literacy? How could we adequately measure and improve it? What caused poor health literacy? Was it poor communication, a lack of numeracy skills, cultural barriers or other factors? The complexity of these questions fascinated me and I have pondered them over the last several years in my research.

In recapping my exploration let’s start by discussing how health literacy was initially distinguished from educational attainment. Much evidence has demonstrated that social factors occurring outside of the clinical encounter, namely education and income, profoundly influence health outcomes. Health disparities based on population (e.g. age, race, class, disability) or geographic residence (e.g. neighborhood, urban, country) are significant and have been the subject of much investigation. While a myriad of indicators have been explored in relation to such disparities, many investigations report that educational attainment is the most influential predictor of health. This relationship has been substantiated in a wide range of settings and time periods as well as by the application of varying methodological approaches and indicators of health. Educational attainment improves health through mechanisms on the individual level (e.g., health literacy and skill development); community level (e.g., location of residence characteristics); and macro level (e.g., policies, legislation, infrastructure).

The term health literacy (HL) was introduced and differentiated from educational attainment or literacy beginning in the 1970’s. During this time it was found that while one’s HL level was related to educational attainment (years of schooling) or reading ability/literacy, there was not a perfect linear correlation between educational attainment/literacy and HL. Research showed that individuals who functioned successfully at home or work often lacked adequate literacy to function within the context of a health care system. While varying opinions on the definition of HL have existed over time and are the subject of ongoing debate, generally speaking, being health literate meant that one could read, understand, and act on health information that was provided to them. HL encompassed proficiency in more than just reading ability but also writing, speaking, and listening as well as computational abilities (numeracy). A health literate individual was able to understand health information and use that health information appropriately. For example, a health literate elderly adult who received instructions from a primary physician on how to take medication for blood pressure would both understand the instructions and then take the medication as instructed by the physician. Thus, those with low HL were unable to adequately function within the healthcare environment increasing their risk for poor outcomes.

Some recent initiatives have sought to document stories related to health literacy. To this end, the U.S. federal government hosted an initiative called ‘Stories from the field’ as a part of a program to reduce the burden of low HL. In one story a doctor in Wisconsin struggled with his patients’ lack of comprehension of his instructions during medical encounters. He pondered whether it was poor communication on his part or whether there were other causes. After research and reflection he identified low HL as a prominent underlying cause and founded a small statewide literacy organization aimed at improving low HL called Wisconsin Literacy.

In order to address what has been called a “Health Literacy Epidemic,” both governmental and non-governmental initiatives have been developed to improve HL and in turn, reduce it’s public health burden. A transdisciplinary approach has been encouraged and specific guidelines have been established to foster improved communication. The U.S. Department of Health and Human Services (HHS) developed a National Action Plan to Improve Health Literacy. Broad goals and strategies of this plan are to improve HL in every sector and organization that provides health information and services. With the aim of fostering effective communication the federal government created The Plain Language.gov which is an internet clearinghouse of information pertaining to the use of clear and understandable language. This initiative defines plain language as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others.” The Plain Language Action and Information Network (PLAIN), a group of federal employees from many different agencies and specialties who support the use of clear communication in government writing, work to manage the initiative’s website. The Partnership for Clear Communication was established to spread awareness and address the issue of low HL. It established the “Ask me 3” program which informs healthcare consumers of 3 questions that should be asked during a medical encounter: (1)“What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”  The Health Literacy Tool Shed, is a database created and administered by Boston University and the National Library of Medicine to foster collaboration and resource-sharing related to health literacy. The online search engine includes 129 tools related to the assessment of health literacy which range in terms of their purpose and design. They are either general in scope or focus on a certain domain(s) within the construct of health literacy (e.g. numeracy). Many of these tools aim to assess HL related to a specific medical condition (e.g. arthritis or cancer), categorization of health (e.g. oral health) or population (e.g. Dutch, Japanese).  Some tools were developed for rapid assessment.

For the global examination of HL the Institute of Medicine Roundtable on Health Literacy was convened to bring together leaders in the global health field to discuss activities and progress around the world related to HL. The United Nations as well as over a dozen countries were present at this meeting. The roundtable discussed different country’s unique approach to addressing low HL. For example, in Australia HL initiatives are part of the national Commission on Safety and Quality in Health Care. Canada connects HL with health promotion activities and the public health sector governs HL initiatives. A consensus from the meeting was that educational systems do not provide their students with the skills to adequately use health information and access health services. Furthermore, participants agreed that there was a lack of capacity for health care services to meet the needs of persons with low HL. This was accompanied by a lack of data on the nature and scope of the problem of low HL as well as the effectiveness of interventions targeting HL. This issue was particularly pronounced in LICs and LMICs, in which very little research had examined HL in any form.

Given the lack of evaluation of HL in LICs and LMICs there is an urgent need to develop a measure HL that can be feasibly employed. Establishing a measure that can assess the burden of low HL as well assess it’s relation to health outcomes is important so that effective interventions can be developed and deployed. Please stay tuned for Part III: The Evaluation and Measurement of Health Literacy in which I discuss my research group’s work in creating and establishing a measure of HL for use in LICs and LMICs.

McClintock.Picture

Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.

What is Health Literacy and Why Does it Matter?

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the first in a three-part series the IH Blog will feature this summer, Global health literacy: Conceptual basis, measurement and implications.

Part I. What is Health Literacy and Why Does it Matter?

Health literacy (HL) has been identified as a key indicator of population health. HL is a critical, yet frequently overlooked, competency required to adequately navigate an increasingly complex modern healthcare system.  The Institute of Medicine (IOM) defines HL as the degree to which individuals have the capacity to obtain, interpret and understand basic health information and services needed to make appropriate health decisions.  Due the recognition of the importance of understanding and addressing the issue of widespread low HL, the IOM convened a Committee on Health Literacy in 2002. This committee was charged with defining the scope of the problem of low HL, identifying obstacles to creating a health literate public, assessing approaches that attempted to improve HL, identifying goals for HL efforts and suggesting approaches for overcoming obstacles to improving HL.

The IOM’s Committee on Health Literacy published a report summarizing their findings and recommendations entitled ‘Health Literacy: A Prescription to End Confusion.’ In this report the committee summarized research findings on the burden and impact of low health literacy reporting that approximately 90 million adults in the United States (U.S.) lacked the necessary literacy skills to effectively navigate the U.S. health system. The report indicated that persons who were older, poor, from minority populations, and groups with limited English proficiency were more likely to have low HL skills. While persons with higher educational attainment were less likely to have low HL skills, higher educational attainment did not ensure adequate HL. The report summarized findings in which persons who lacked of HL skills had less knowledge of disease management/health-promoting behaviors, reported poorer health status, and were less likely to use preventive services than persons with adequate HL skills. The committee recommended that support should be provided for the development, testing, and use of culturally appropriate new operational measures of health literacy that could be assessed as a part of large ongoing population surveys.

In 2003, the U.S. Department of Education, National Center for Health Statistics conducted a National Assessment of Adult Literacy (NAAL).  Based on this assessment, approximately 12% of U.S. adults had proficient health literacy and over a third of U.S. adults (77 million people) were projected to have difficulty with common health tasks, such as following directions on a prescription drug label or adhering to a childhood immunization schedule using a standard chart.  Low HL affected persons regardless of age, race, education, income, or social class. Since this assessment, many investigators have examined prevalence and associated outcomes of low HL using statistical modeling techniques and demographic characteristics.

From a global perspective, little research has evaluated HL in low middle income or low income countries (lower income). A recent review by the Agency for Healthcare Research and Quality, Health Literacy Interventions and Outcomes: an Update of the Literacy and Health Outcomes Systematic Review of the Literature, aimed to include all studies conducted anywhere in the world that employed an objective measure of HL. This work was intended to expand the scope of a prior review by including studies that were carried out in developing countries. Despite this intention, over 90% of studies included in this recent review were conducted in high income countries and approximately 1% were conducted in low income countries. The large discrepancy in the objective assessment of HL between high income and lower income countries is indicative of many underlying factors such as a lack of available resources or technical capacity to examine HL, competing demands for limited resources, and conceptual variation in the implementation of such initiatives. Thus little information is available to evaluate the burden and scope of low HL in countries that are not high income. In high income countries the burden of low HL is substantial leading to poorer overall health status and higher mortality. Persons in lower income countries likely experience this health impact which is exacerbated by greater existing vulnerability for poor health due to both individual level (poverty, lower educational attainment) and health system factors (lack of services availability). Thus it is likely that the burden of low HL in lower income countries has a devastating impact on health and well-being. Future research is needed to construct a measure of HL that can feasibly be employed to evaluate HL in lower income countries. This will provide the foundation for interventions to reduce the burden of low HL.

Low HL is a widespread problem that exacts a tremendous toll on health and well-being globally. A common misconception is that HL is synonymous with educational attainment. HL is established as a distinct and separate construct that measures one’s ability to understand and act on health information provided in an increasingly complex modern health care system. For more information about the distinction between educational attainment and HL please stay tuned next month for Part II in this series on Global Health Literacy called Understanding Health Information: Is Educational Attainment Enough?

 

McClintock.Picture

Dr. Heather F. de Vries McClintock, is currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.

 

 

Preventing Rickets Globally

This is a guest blog post by Dr. Mark Strand, IH Section Councilor and Professor in the Pharmacy Practice and Master of Public Health Departments at North Dakota State University.

For the last fifteen years, I have collaborated with a group of scholars to research and prevent nutritional rickets in children. Recently our newest paper was published, a look at the global burden of disease due to rickets, and prospects for reducing this preventable disease of poverty. Rickets is caused by insufficient circulating 25-OH-D (vitamin D levels), as a result of insufficient sun exposure, high amounts of melanin in the skin, or both; as well as inadequate intake of dietary calcium. Therefore, the condition begins at birth in children facing these conditions, and worsens up to age 2 or 3, when self-selection of food, and outdoor play, tend to slow or stop the progression. However, during that time these children have higher rates of pneumonia and other preventable conditions, and if severe, will maintain the skeletal deformities for life.

I am deeply committed to research which provides scientific evidence to explain causes of disease and burden among underserved and vulnerable populations. This has been one of my more satisfying contributions.

My colleagues and I published this paper on nutritional rickets nearly ten years ago: https://www.researchgate.net/publication/7282059_Nutritional_rickets_around_the_world_Causes_and_future_directions

Here is a link to our newest article:
http://www.tandfonline.com/eprint/p5idF3CXdvKph3tBMHhT/full

Five important business lessons I learned from developing country public health professionals

This is a guest blog post by Dr. Sharon Rudy, IH Section member and director of the Global Health Fellows Program II. It is the first in a three-part series the IH Blog will feature this week, Global health career insights: Lessons on the job market, how to crack it, and what to do once you’re in.


You might say I stumbled into my dream job. Although I was an exchange student in college, I never meant to end up in an international career (and certainly not advising about careers!).

I spent my senior year in The Netherlands where I thought I was really roughing it – little did I know what lay ahead. In fact, I can remember praying that I NOT be called to the “Mission fields” overseas. I felt a bit guilty about it, but I just never wanted to be uncomfortable.

After a few years of working in low-level administrative jobs in hotels, law firms, retail, and a yacht brokerage, I was so ready for graduate school to open all the doors. With a new Masters and Ed.S degree in Counseling, I just needed to work and wasn’t looking for an international setting. However, I unknowingly clinched the deal when an interviewer from an international exchange program asked me what I had learned from living abroad. I said, “What it means to be an American.” That was, evidently, a brilliant answer.

I got the job and spent the first 15 years of my professional life working in international exchange with a deep focus in cross-cultural adaptation, à la the Peace Corps. My Ph.D. dissertation was on how Americans adjust to cultural change and I’ve always felt strongly that in all the jobs I’ve had, good relationships are just as critical as technical expertise. In fact, as the Director of USAID’s flagship global health fellowship program, when I’ve had to fire an underperforming fellow, it has rarely been about technical skill. More often, problems come from their inability to connect with their team, their clients, or their colleagues.
It’s strange to me that when I started working in international development almost 30 years ago, everyone just assumed you were culturally competent and were happy to throw you into an environment that requires the highest levels of cross-cultural know-how. GHFP-II’s research, conducted with almost 50 global health employers, underscores the wide gap between the in-demand skills needed to succeed in global health and those being taught in the classroom. One skill cluster is the ability to thrive in a multi-cultural environment, take in new information, and adapt to your circumstances.

Here are five key lessons I learned from the patient, long-suffering developing country public professionals, including USAID Foreign Service Nationals (FSNs), who took pity upon me and showed me the ropes:

1. When you begin work as a technical adviser, your two immediate overriding objectives should be to establish trust and to demonstrate that you can add value. Seek first to understand by practicing active listening. Their country interests override anything else so try to identify what those interests are. Don’t be afraid to show initiative in learning the full truth. Initially, they may only be telling you what they think you want to hear.

2. Practice humility. A lack of humility destroys trust. Don’t assume you know more than your host counterpart. You will never know all the answers, so it is the attitude of empathetic awareness that allows mistakes to be forgiven. It’s not about you proving yourself with a barrage of data and other-country stories. Don’t try to establish the relationship by showing off your expertise and knowledge, especially by going quickly to the solution. This will result in a quiet “sigh” from your colleagues that you might not even notice in your hurry to fix things. Trust me, you aren’t the first American who has come their way, ready to fix everything, and you probably won’t be the last. Instead, find a way to balance the power and privilege that is reflected in your being an American, with access to American institutions and American resources, with an acute awareness and a learner’s heart.

3. Be their champion. Although complete “country ownership” rarely happens, it has to be an authentic, high priority for you. This means you are coming into the relationship with a focus on a post-“you” environment. Remember, it’s their country, not yours. Decisions will stick only if they truly own them. In communication about your work, promote the real picture of your host country – it usually differs from international media stories. Be generous about helping your local counterparts make connections with the international community and make available all your “secret” resources and technical knowledge. This is a joint venture with peers, so start it with a sense of mutual respect and a culture of sharing. Value local talent and make the best use of it to make your work more meaningful and sustainable.

4. Respect the culture. Make efforts to understand local norms, culture, and traditions. Seek to understand how people approach key issues in their daily life. No culture is a monolithic construct, but rather an intricate web of narratives. For example, in most cultures, family importance can’t be overstated, so don’t blow off dinner with your new colleagues so you can send emails. Even though USAID is an American agency, and local public health professionals, including the FSNs, have adapted to that reality, the most important things are happening outside the compound. Cultural competence is never a “checklist” and, admittedly, you can never learn everything about the culture, history, and politics of the country you are involved in, but honest efforts will be noted and appreciated.

5. Solutions must be contextualized within existing systems and structures. Don’t assume you have the answer even if you easily see all the things that are wrong. Seek to cause change in slow, measured steps to avoid negative or unintended consequences. Don’t offer solutions without understanding host country systems. Remember, not everything local needs to change – there are best practices already in place in your host country. And don’t assume that modern technology will magically fix everything – context and environment matter.

So, thank you to my developing country public health professional colleagues for being too dignified to criticize, for your patience with us as we come and go in your country, and for your generosity of spirit and forgiveness of my many mistakes over the years! I have learned so much from you, and continue to, even to this day.


These are valuable insights for professionals who are currently in global health practice. However, breaking into the technical advisor role is becoming increasingly challenging for recent graduates and aspiring global health professionals. Please stay tuned for the second part of our series, “Five sobering job search lessons I learned from analyzing the global health job market.”