Health Literacy and Relevant Cancer Screening: The story of middle class African Americans

BROWN BAG PRESENTATIONAUGUST 20, 2015CALANDRA WHITTED

Objectives• What is Health Literacy

•Examine the relationship between Health Literacy and Cancer Prevention

•Relevance to Health Disparities

•Associations with Cancer Screening

•Study 1: Preliminary findings

•Discussion and Future Directions

What is 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.” (IOM, 2004)

•Cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. (Nutbeam, 2008)

•The degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community.(Freedman, 2009)

Who has low Health Literacy?• Racial/ethnic minorities• Low SES populations (less than high school diploma/income

below poverty level)• Non-native speakers of English• Recent refugees and immigrants• Adults over 65 years of age

(USDHHS, 2010)

Is Health Literacy really just Education?EDUCATION

•Acquire knowledge to gain understanding on a topic

•Informal or formal process

•Literacy is required to actively participate

HEALTH LITERACY

•Acquire and use health information

•Assist in making health related decisions

•Needed to actively participate in the health care process

Those with high education can still have low/limited health literacy. (Kutner, 2006; Chadhury, 2011; Smith 2012)

Health Literacy Categories

The U.S. Department reports assessment of health literacy with four levels:

•Proficient• Skills necessary to perform more complex and challenging literacy activities• 12% of adults

• Intermediate• Skills necessary to perform moderately challenging literacy activities.• 53% of adults

•Basic• Skills necessary to perform simple and everyday literacy activities.• 22% of adults

•Below Basic• No more than the most simple and concrete literacy skills• 14% of adults

(Hauser, 2005)

Measuring Health Literacy

•Over 43 assessment tools that vary by disease type, method/length of administration, assessment type • Test of Functional Health Literacy in Adults (TOFHLA)-An indicator of a

patients’ reading ability that measures comprehension, including the ability to read and understand both prose passages and numerical information.

• REALM-Rapid Estimate of Adult Literacy in Medicine-used to test reading ability and correctly pronounce a list of words.

• Newest Vital Sign (NVS)- uses an ice cream nutrition label to test individuals ability to identify information and measure comprehension. Literacy and numeracy skills are tested.

• Single item literacy screener (SILS)-A single item screening item that identifies patients that need help with printed or written material.

Health Literacy Measures

TOFHLA (reading comprehension and numeracy)

Let’s say that after deductions, your monthly income and other resources are $1,129. And, let’s say you have 3 children. Would you have to pay for your care at that clinic?

REALM (Word recognition) Fat, Flu, Pill, Jaundice Newest Vital Sign (Literacy , comprehension, and Numeracy)

A nutrition label is provided

“If you eat the entire container, how many calories will you eat?

Single item literacy screener “How confident are you filling out medical forms by yourself”

Health Literacy Measures

•TOFHLA• Pros-tests reading ability and comprehension of health related passages and numeracy.• Cons-Screens for reading ability, long administration.

•REALM• Pros-Useful for predicting general reading ability in English and used in health literacy

research settings.• Cons-Does not measure comprehension or numeracy.

•Newest Vital Sign• Pros-Tests numeracy, reading ability and comprehension skills, correlates with TOFHLA,

able to detect patients with marginal health literacy than other functional HL assessments.• Cons-May overestimate the number of patients with low literacy.

•Single item screener• Pros-Brief and practical for clinical setting, a direct assessment of need than skill.• Cons-False negatives are possible because of participants not recognizing that they need

help with reading, feeling ashamed, or not understanding the question.

Health Literacy and Health

•Low health literacy is associated with:• Increased hospitalizations • Greater use of emergency care• Less likely to take medications properly• Poor ability to interpret health messages (ex. medication labels)• Poorer overall health status and higher mortality in elderly populations

(Berkman, 2011)

Health Literacy and Cancer Prevention

•Health Literacy is associated with screening, diet, physical activity.

•Cancer Screening• Oldbach( 2013)-Association of inadequate health literacy and lower cancer

screening rates within recommended guidelines.• Garbers (2004)-Lower receipt of cervical cancer screening in Hispanic

women.

•Smoking and Diet• Rothman (2006)-poor label comprehension was highly correlated with low

health literacy levels and numeracy skills.• Stewart (2013)-Lower health literacy was associated with higher nicotine

dependence and lower risk perception and knowledge of smoking risks.

Is Health Literacy important for Cancer Screening

•Affects ability to read brochures/labels (Davis, 2006)

•Preparation for screening (Smith, 2012)

•Decision making/ Evaluation of risk vs. benefits (Amalraj, 2009)

•Communication and counseling with providers (Williams, 2002)

Health Literacy InterventionsRAISE HEALTH LITERACY

•Brochures/leaflets

•Photographs

•Education sessions

•Audio/Video

REDUCE IMPACT OF HEALTH LITERACY

•Patient Navigation

•Clear communication from providers

•Lay health workers

Research Question and Aim

Question:

Aim :To determine whether health literacy (assessed using an established single-item screening question “How confident are you filling out medical forms by yourself” (Chew, 2004)) is associated with colorectal, prostate, and cervical and breast screenings in African American men and women.  

The purpose of the proposed study is to explore the relationship between health literacy and cancer screening (breast, cervical, colorectal, and prostate).

Study Design•Project CHURCH is a longitudinal cohort study to investigate behavioral, social, and environmental cancer risk factors among a church-based sample of African-American adults.

•Established by the University of Texas MD Anderson Cancer Center in partnership with a large African-American mega-church in Houston.

•Sub-study:• Cross sectional study• N=1476• AA recruited from churches• Baseline Data

Ethical ConsiderationsStudy was approved by the MD Anderson Institutional Review Board

Participants provided written informed consent prior to participation in the study

Participant data was de-identified and stored on secure MD Anderson server

Measures•Health Literacy

• “How confident are you filling out medical forms by yourself” (Chew, 2004)

• Range (not at all-extremely)• Scored on a 5 point Likert scale • Cut-off score for high health literacy >2 and <2 for low health literacy

•Cancer Screening• Prostate-PSA • Cervical-Pap test (every 3 years)• Colorectal-colonoscopy, sigmoidoscopy (every 5 or 10 years)• Breast-mammography (annually)

Analysis/Results•Chi-square and Logistic Regression were used to determine associations between health literacy and relevant cancer screenings (breast, cervical, colorectal, prostate.

•Age, gender, education, income, martial and employment status were examined as covariates.

•P value 0.05

Table 1: Participant Characteristics    Variables Sample size Mean(SD)/n(%)Age 1467 45.2 (12.9)Gender 1467 Male 372 (25.4) Female 1,095 (74.6)Education 1466 <BS 756 (51.6) BS 432 (29.5) >=MS 278 (19.0)Income 1418 <40K 359 (25.3) 40-799K 559 (39.4) >=80K 500 (35.3)Marital status 1465 No 827 (56.5) Yes 638 (43.5)Employment status 1465 No 382 (26.1) Yes 1,083 (73.9)Health Literacy 1467 Low 275 (18.7) High 1,192 (81.3)Current prostate cancer screening 239 Not current/Never had 9 (3.8) Current 230 (96.2)Current colorectal cancer screening 582 Not current/Never had 184 (31.6) Current 398 (68.4)Current breast cancer screening 759 Not current/Never had 280 (36.9) Current 479 (63.1)Current cervical cancer screening 758 Not current/Never had 290 (38.3) Current   468 (61.7)

Breast

• Health literacy level was not significantly associated with breast cancer screening

Odds Ratio CI

Health Literacy 1.135 0.730-1.765

Age 1.034 1.012-1.057

Colorectal

• Health literacy level was not significantly associated with colorectal cancer screening

Odds Ratio CI

Health Literacy 0.776 0.459-1.311

Age 1.110 1.065-1.157

Income 40-79.9K 1.748 1.030-2.966

Income >80k 2.887 1.541-5.410

ProstateOdds Ratio CI

Health Literacy 0.979 0.183-5.241

• Health literacy level was not significantly associated with prostate cancer screening

Cervical

• Health literacy level was not significantly associated with cervical screening;.

Odds Ratio CI

Health Literacy 0.914 0.587-1.423

Age 0.977 0.956-0.997

Education (BS) 1.545 1.074-2.223

Income >80k 1.643 1.016-2.657

Discussion•In general, health literacy is not associated with cancer screening in this sample

• Unclear why we did not find significant associations• Was a trend toward lower literacy being associated with more literacy. It is

possible that low literacy groups may be more likely to engage with a provider and receive and act on screening recommendations compared to higher health literacy groups.

• Higher SES population which might explain findings• Need to better understand factors that predict low health literacy; in this

study we were trying to understand how literacy impacts screening

Study Limitations•Cross sectional study

•Use of the 1-time health literacy measure. Perhaps need a more comprehensive measure.

•Self-report of cancer screening; unable to verify

•Low generalizability due to:• African American sample• Middle class sample

Limitations of Health Literacy

•The many definitions of Health Literacy

•Measurement disagreements

•Lack of knowledge about intervention dosage to determine effectiveness for health literacy

•Multiple cut off points for high, low, or limited health literacy can vary; unclear on the exact amount of the population that are low health literate.

My Interests in Health Literacy

•Understand health literacy in the context of community health settings

•Understand how consistently measure health literacy in interventions with low literate populations

•How can improving health literacy increase uptake of cancer screening, specifically colorectal cancer.

Why Improving Health Literacy is Important

“Low health literacy is a threat to the health and wellbeing of Americans. And low health literacy crosses all sectors of our society. All ages, races, incomes, and education levels are challenged by low health literacy."

Rear Admiral Kenneth P. Moritsugu, MD, MPHActing United States Surgeon GeneralDecember 2006

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Acknowledgement Mentors: Dr. Lorna McNeill, Dr. Wendell Taylor, Dr. Melissa Valerio, Dr. Lara Savas.

Dr. Shine Chang and Dr. Carrie Cameron

Research staff of the McNeill team in Health Disparities Research

The research described was supported by a cancer prevention fellowship for Calandra Whitted supported by the National Cancer Institute grant R25T CA057730, Shine Chang, Ph.D., Principal Investigator.

This research is supported in part by the National Institutes of Health for Calandra Whitted through MD Anderson's Cancer Center Support Grant CA016672.

Questions