1. HEALTH INFORMATION SEEKING BEHAVIORS OF ADULTS WITH LOW LITERACY, NUMERACY, AND PROBLEM SOLVING SKILLS Exploring Results from the 2012 U.S. PIAAC Study and Implications for Research, Policy and Practice Jackie Taylor Commission on Adult Basic Education

2.  Indicate your role in health literacy:  patient engagement specialist  health care provider  health educator  adult educator  communications specialist  health care researcher  Adult education researcher  case manager  student YOUR ROLE IN HEALTH LITERACY

3. WHAT DO WE MEAN BY HEALTH LITERACY? Health Literacy: “The degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Institute of Medicine

4.  1. What percentage of U.S. adults has proficient health literacy?  50  65  12  87 PROFICIENCY IN HEALTH LITERACY

5. What is PIAAC?

6. About PIAAC PIAAC is an international large-scale assessment administered in 2011-12 in 23 countries It assessed 16 - to 65-year-olds, non-institutionalized, residing in each country, irrespective of nationality, citizenship, or language status Laptop computer or paper-and- pencil: In the U.S., 80% took the computer tests and 15% took the paper-and-pencil tests. Assessment subjects: Literacy Numeracy Problem Solving in Technology-Rich Environments (digital problem solving) Assessment was conducted only in English in the U.S.: The background survey was conducted in English or Spanish. About 4% could not complete the BQ because of language difficulties or learning or mental disabilities, and 1% could not complete it for other reasons. 6 PPT slide provided courtesy of AIR

7. 7 Literacy is understanding, evaluating, using and engaging with written texts to participate in society, to achieve one’s goals, and to develop one’s knowledge and potential. Numeracy is the ability to access, use, interpret, and communicate mathematical information and ideas, in order to engage in and manage the mathematical demands of a range of situations in adult life. Problem solving in technology-rich environments involves using digital technology, communication tools and networks to acquire and evaluate information, communicate with others and perform practical tasks. DEFINITIONS OF PIAAC DIRECT ASSESSMENT SUBJECTS PPT slide provided courtesy of AIR

8. 20122015 Australia Austria Belgium Canada Cyprus Czech Republic Denmark Estonia Finland France Germany Ireland Italy Japan Korea, Rep of Netherlands Norway Poland Slovak Republic Spain Sweden United Kingdom United States Chile Greece Indonesia Israel Lithuania New Zealand Singapore Slovenia Turkey 8 PARTICIPATING COUNTRIES PPT slide provided courtesy of AIR

9. 9 Direct assessment of key information- processing skills Module on skill use Background questionnaire HOW PIAAC COLLECTS DATA PPT slide provided courtesy of AIR

10. 10 Cognitive skills reading, writing, mathematics, and use of information and communication technologies Learning skills coaching, formal/informal learning and updating professional skills Interaction and social skills collaboration and co-operation, work and time planning, communication and negotiation, and customer contact Physical skills use of gross and fine motor skills THE MODULE ON SKILL USE COLLECTS DATA ON USE OF THE FOLLOWING SKILLS: PPT slide provided courtesy of AIR

11.  Average Scores: reported on a scale of 0-500 for all domains.  Proficiency Levels: reported as the percentages of adults scoring at six performance levels ( from below level 1 to level 5) in literacy and numeracy and at four performance levels in problem solving in technology-rich environments (from below level 1 to level 3). 11 PIAAC RESULTS ARE REPORTED IN TWO WAYS: PPT slide provided courtesy of AIR

12. WHAT DOES PIAAC SAY ABOUT HEALTH LITERACY?

13. HEALTH MEASURES IN THE U.S. QUESTIONNAIRE Questions included:  Health status  Health insurance coverage  Sources of information about health issues  Preventive health practices

14. LITERACY AND HEALTH STATUS  Adults with lower levels of skills in literacy are more likely to report having a fair to poor health than those with higher proficiency, even when account is taken of education attainment and other background characteristics.  On average across countries, adults who score at or below Level 1 on the literacy scale have over two times the odds of reporting fair to poor health than those who score at Level 4 or 5.  Adults scoring at Level 2 are also markedly more likely, on average, to report fair to poor health even when other factors are taken into account.  Across countries, the chances of adults who score at Level 3 reporting poor health are not significantly different from those of their peers at Level 4 or 5.

15. HEALTH STATUS More people reported having “excellent” or “very good” health and fewer people reported having “good” or “fair” health when compared to the international average.

16. In literacy, U.S. adults with fair or poor health were below the international average for those with similar health statuses. HEALTH AND LITERACY

17. In numeracy, adults with fair or poor health scored below the international average for those with similar health statuses. HEALTH AND NUMERACY

18.  U.S. gaps in literacy scores similar to international average by gender, smaller by age, and larger by health. GAPS IN LITERACY

19.  U.S. gap similar to international average by gender, smaller by age, and larger by health status. GAPS IN NUMERACY

20. Adults with Higher Education Reported Better Health Adults with Higher Income Reported Better Health HEALTH STATUS BY INCOME AND EDUCATION

21. Literacy 21 Japan Finland Netherlands Australia Sweden Norway Estonia Flanders-Belgium Slovak Rep. Germany France Czech Rep. Canada Italy Spain U.K. Denmark United States Ireland Poland Cyprus Austria Japan Finland Flanders-Belgium Netherlands Sweden Norway Denmark Slovak Rep. Czech Rep. Austria Estonia Germany Australia Canada Cyprus Korea, Rep. of U.K. Poland Ireland France United States Italy Spain Japan Finland Australia Sweden Norway Netherlands Austria Denmark Czech Rep. Korea, Rep. of Germany Canada Slovak Rep. Flanders-Belgium U.K. Estonia United States Ireland Poland Italy Spain Cyprus France Numeracy PS-TRE The U.S. ranked lower than most other countries in all three domains. The US ranked better in Literacy than in Numeracy or Problem Solving in technology-rich environments. HOW DO WE COMPARE TO OTHER COUNTRIES? PPT slide provided courtesy of AIR

22.  Lower overall scores than international average in all three subjects  Ranked better in literacy than in numeracy or problem solving in technology-rich environments  Higher percentages of low performers than internationally  Health status of U.S. adults better than international average  Larger gap in U.S. than international average in literacy achievement by health status  Higher income and higher educated U.S. adults report better health SUMMARY

23. WHAT ARE HEALTH—SEEKING BEHAVIORS OF ADULTS WITH LOW LITERACY, NUMERACY, AND PROBLEM SOLVING SKILLS?

24. HEALTH LITERACY IS ESSENTIAL  Four greatest ineffeciencies in the health care system:  Compliance  Hospital readmissions  Over-testing  Unnecessary emergency room visits Effective Communication is Absolutely Critical

25.  Of the following domains, which is the stronger predictor of heath?  Literacy  Numeracy  Problem-solving in technology rich environments

26. UNDERSTANDING HEALTH INFORMATION SEEKING BEHAVIORS OF ADULTS WITH LNPS Research questions:  What sources do people with below-average LNPS utilize when seeking health information?  Which of the following factors predict different health information sources for people with below average LNPS?  Gender  Age  Race  Educational Attainment  Health Status  Use of Preventive Measures  Facility in English From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.

27. USE OF HEALTH INFORMATION BY COGNITIVE DOMAIN From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.

28. PREDICTING USE OF HEALTH INFORMATION Print MediaInternetRadio / TVSocialHealth Professional GenderFemale AgeOlderYoungerMiddleOlder RaceBAHHABHB EducationHS Health Status Good Preventive++++ ReadingHigh WritingHigh Speaking Adapted from Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.

29. KEY FINDINGS  One size doesn’t fit all. People with low level literacy, numeracy, and problem solving skills who seek health information report having better health status than those who do not seek health information.  People with low level LNPS report that oral sources of communication are used more than written sources.  Low literacy and numeracy seek information from radio/TV whereas those with low problem solving skills use the internet and health professionals.  Having high facility in writing English is a significant predictor of using the Internet and Health professionals as a source of health information for those with low LNPS.  Having a HS diploma is significant only when seeking health information through the Internet or print media. Fom Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.

30. IMPLICATIONS  Different stakeholders have unique roles to play in increasing health information seeking behaviors.  Develop more focus and skills in oral participatory care with patients and care givers  The health care industry could simplify / standardize forms and written materials  Policy makers could include health literacy at appropriate funding levels for K-12 and Adult Basic Education curricula  Health educators and researchers must develop interventions to address health information seeking behaviors through differing skill levels in multiple modalities. From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.

31. POLICY IMPLICATIONS  “Making Skills Everyone’s Business”  Create joint ownership of solutions  Expand opportunities for adults to improve foundation skills  Make career pathways available and accessible in every community  Ensure students have access to highly effective, teachers, programs, leaders  Align federal policies to integrate services for adults  Increase the ROI in skills training for business, industry, and labor  Commit to closing the equity gap for vulnerable sub- populations

32. STRATEGIES FOR PRACTICE  Find commonality in what we say. For example:  Sugars  Blood sugar  A1c  Blood too sweet  Diabetes  Diabetic counts  Sugar counts  Or:  High blood pressure  Hypertension  Pressures  Blood pressure  Systolic and dialostic

33. NARRATIVE ANIMATION In this example from Dartmouth-Hitchcock, patients not only increased their knowledge of colonoscopy procedures, they also had:  Experienced decreased anxiety  Lower doses of sedation medication  Shorter procedure times

34. OR A FAVORITE “TEACH BACK” MOMENT? From House MD, on YouTube: https://www.youtube.com/watch?v=nvwR74XpKUM https://www.youtube.com/watch?v=nvwR74XpKUM

35. YOUR TURN  What kind of educational resources or strategies do you use with your clients/patients who have low LNPS?  Have you noticed a difference in whether it helps them? If so, how do you know? (anecdotal or otherwise).  Describe it to the person next to you.  Write your idea on the 4x6 notecard. Include:  Name  Email / phone  Pass the cards to the right, then pass them forward.  Strategies shared will be posted to: http://bit.ly/HealthLiteracySummit http://bit.ly/HealthLiteracySummit

36. RESOURCES  PIAAC Gateway: http://piaacgateway.com/http://piaacgateway.com/  Making Skills Everyone’s Business: A Call to Transform Adult Learning in the United States: http://www2.ed.gov/about/offices/list/ovae/pi/AdultEd/making- skills.pdf http://www2.ed.gov/about/offices/list/ovae/pi/AdultEd/making- skills.pdf  NCES: http://nces.ed.gov/surveys/piaachttp://nces.ed.gov/surveys/piaac  https://animoto.com/play/vkcbVNuie4iIEblsjwBXKw https://animoto.com/play/vkcbVNuie4iIEblsjwBXKw  Webinar: Health Literacy Through the PIAAC Lens, May 4 at 3:00 pm ET www.national-coalition-literacy.orgwww.national-coalition-literacy.org  LINCS Health Literacy Collections and Online Community of Practice: https://community.lincs.ed.gov/ https://community.lincs.ed.gov/  World Education’s Health Literacy Special Collection: http://www.healthliteracy.worlded.org/ http://www.healthliteracy.worlded.org/  Health Literacy Discussion List: http://listserv.ihahealthliteracy.org/scripts/wa.exe?INDEX http://listserv.ihahealthliteracy.org/scripts/wa.exe?INDEX

37. THANK YOU!  National Center for Education Statistics  Organisation for Economic Co-operation and Development  American Institutes for Research  World Education  Georgia State University  Portland State University Questions? Jackie Taylor, Jackie@jataylor.netJackie@jataylor.net

40.  What skills adults actually have and can use rather than just the number of years of education they have completed or the degrees they have.  How adults acquire those skills, and what factors are related to skill acquisition and decline.  What the level and distribution of skills is within and across various subgroups within the population.  As a result. PIAAC data enables us to target our efforts to focus on raising the skills of adults with the greatest needs. 40

41.  Answer: 12% Adults Self-Rated Health Status and 2012 PIAAC Average Literacy Scores Note: Total possible score is 500. *p<.05. Average score is significantly different from “Excellent” average. Source: U.S. Department of Education, National Center for Education Statistics. 2013. Literacy, Numeracy, and Problem Solving in Technology-Rich Environments Among U.S. Adults. Washington, DC. HEALTH LITERACY IN THE UNITED STATES

42.  In the U.S. the household sample was selected through a 4-stage stratified area sample:  Counties (PSUs)  Blocks  Housing units with households  Eligible persons within households  Resulted in 5,010 respondents  A U.S. supplement will add 3,600 more adults (report due late 2015) that represent key populations (young adults 16-34 yrs, older adults 66-74 yrs, unemployed adults,16-65 yrs)  A representative prison sample will include 1,200 inmates, 16-74 yrs, in state, federal and private prisons (report due 2016). 42 A NATIONALLY REPRESENTATIVE SAMPLE OF HOUSEHOLDS IN EVERY COUNTRY

43. Focused on identifying:  Skills that are critical to functioning successfully in today’s society,  How participants acquire those skills, and  How those skills are distributed. Areas of BQ include:  Education and training, present and past,  Work experience,  Literacy, numeracy and ICT skill use at work and at home,  Other 21 st century skills used at work,  Personal traits, and background information. 43 PIAAC BACKGROUND QUESTIONNAIRE PPT slide provided courtesy of AIR

44. 5 min Background questionnaire Additions Basic skills training Political Efficacy - Information Health Race/Ethnicity Language Adaptations: Formal Education, Informal Training Occupation, Economic Sector, Earnings U.S. CHANGES INCLUDE: PPT slide provided courtesy of AIR

45. 45 Locate single piece of information in familiar texts. Read relatively short digital, print or mixed texts to locate single text. Make matches between text and information that may require low level para- phrasing and drawing low- level inferences. Identify, interpret, or evaluate one or more pieces of information and often require varying levels of inference. Perform multiple-step operations to integrate, interpret, or synthesize information from complex texts, and may require complex inferences. Integrate information across multiple, dense texts; construct syntheses, ideas or points of view; or evaluate evidence based arguments. Below Level 1 (0-175) Level 1 (176-225) Level 2 (226-275) Level 3 (276-325) Level 4 (326-375) Level 5 (376-500) PPT slide provided courtesy of AIR THESE DESCRIPTIONS OF THE PIAAC PROFICIENCY LEVELS FOR LITERACY DEFINE WHAT ADULTS CAN DO AT EACH LEVEL.

46. 46 Perform basic tasks: counting, arithmetic operations with whole numbers. Perform one- step tasks: count; sort; arithmetic operations; understanding simple percent (ex. 50%). Perform 2 or more calculations, simple measurement; spatial representation; estimation; and interpret simple tables, graphs. Understand & work with mathematical patterns, proportions, basic statistics expressed in verbal or numerical form. Perform analysis, complex reasoning, statistics and chance; spatial relationships; and communica- ting well- reasoned explanations for answers. Understand complex abstract mathema- tical and statistical ideas, embedded in complex texts, draw inferences; arguments or models; justify, reflect on solutions or choices. Below Level 1 (0- 175) Level 1 (176-225) Level 2 (226-275) Level 3 (276-325) Level 4 (326-375) Level 5 (376-500) PPT slide provided courtesy of AIR THESE DESCRIPTIONS OF THE PIAAC PROFICIENCY LEVELS FOR NUMERACY DEFINE WHAT ADULTS CAN DO AT EACH LEVEL.

47. 47 Tasks are well- defined involving use of only one function within a generic interface. Tasks require little or no navigation, and only a few steps to access information for solving the problem. There are few monitoring demands. Tasks require some navigation across pages and applications for solving the problem. Evaluating the relevance, some integration and inferential reasoning may be needed. Task may involve multiple steps and operators, navigation across pages and applications. There are typically high monitoring demands, and evaluation of relevance and reliability of information. Below Level 1 (0-240) Level 1 (241-290) Level 2 (291-340) Level 3 (341-500) These descriptions of the PIAAC proficiency levels for digital problem solving define what adults can do at each level. PPT slide provided courtesy of AIR

48. 48 Scores on literacy ranged from 296 (Japan) to 250 (Italy) U.S. scores were: Lower than in 12 countries Not significantly different than in 5 countries Higher than in 5 countries Literacy Japan Finland Netherlands Australia Sweden Norway Estonia Flanders-Belgium Slovak Rep. Germany France Czech Rep. Canada Italy Spain U.K. Denmark United States Ireland Poland Cyprus Austria Korea, Rep. of PPT slide provided courtesy of AIR THE U.S. AVERAGE LITERACY SCORE (270) WAS LOWER THAN THE INTERNATIONAL AVERAGE (273).

49. 49 Numeracy scores ranged from 288 (Japan) to 246 (Spain) U.S. scores were: Lower than in 18 countries Not significantly different than in 2 countries Higher than in 2 countries Japan Finland Flanders-Belgium Netherlands Sweden Norway Denmark Slovak Rep. Czech Rep. Austria Estonia Germany Australia Canada Cyprus Korea, Rep. of U.K. Poland Ireland France United States Italy Spain Numeracy PPT slide provided courtesy of AIR THE U.S. AVERAGE NUMERACY SCORE (253) WAS ALSO LOWER THAN THE INTERNATIONAL AVERAGE (269).

50. THE U.S. AVERAGE SCORE IN DIGITAL PROBLEM SOLVING* (277) WAS ALSO LOWER THAN THE INTERNATIONAL AVERAGE (283). 50 Italy, Spain, Cyprus and France did not include this domain in their assessment Scores ranged from 294 (Japan) to 275 (Poland) U.S. scores were: Lower than in 14 countries Not significantly different than in 4 other countries Higher than no other country (Italy, Spain, Cyprus and France did not participate ) * Officially problem solving in technology-rich environments (PS-TRE) Japan Finland Australia Sweden Norway Netherlands Austria Denmark Czech Rep. Korea, Rep. of Germany Canada Slovak Rep. Flanders-Belgium U.K. Estonia United States Ireland Poland Italy Spain Cyprus France PS-TRE

51.  Literacy: both paper & pencil and computer versions  Numeracy: both paper & pencil and computer versions  Problem solving in technology-rich environments: only on computer  Reading components: only paper & pencil  All countries were required to administer literacy and numeracy assessments  The U.S. assessed all four domains 51 THE DIRECT ASSESSMENT FOCUSES ON FOUR DOMAINS: PPT slide provided courtesy of AIR

53. AN EVEN HIGHER PROPORTION OF U.S. ADULTS ARE AT THE LOWEST LEVELS (LEVEL 1 AND BELOW LEVEL 1) OF NUMERACY.

54.  In general, would you say that your health is excellent, very good, good, fair, or poor?  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?  Have you ever been diagnosed or identified as having a learning disability?  Do you have any kind of medical insurance or are you enrolled in any kind of program that helps you pay for your health care?

55. SOURCES OF INFORMATION / PREVENTIVE MEASURES  How much (a lot, a little, some, or none) information about health issues do you get from...newspapers, magazines, Internet,  Radio  TV  Books or brochures  Family, friends, or coworkers?  Talking to health care professionals such as doctors, nurses, therapists, or psychologists?  In the past year, have you:  Gotten a flu shot?  Had your vision checked?  Visited a dentist?

56.  Literacy: both paper & pencil and computer versions  Numeracy: both paper & pencil and computer versions  Problem solving in technology-rich environments: only on computer  Reading components: only paper & pencil  All countries were required to administer literacy and numeracy assessments  The U.S. assessed all four domains 56 THE DIRECT ASSESSMENT FOCUSES ON FOUR DOMAINS: PPT slide provided courtesy of AIR