BACKGROUND/RATIONALE:
Studies have shown that people with poor health literacy skills have significantly worse health status, greater risk for hospitalization, less knowledge about their health conditions, and are less likely to use preventative services. Little is known about the prevalence of low health literacy skills among veterans who use the VHA or the effect poor health literacy skills may have on complex preventative behaviors, such as screening for colorectal cancer (CRC). Understanding the distribution of health literacy skills among veterans and their effect on preventive behavior is critical for improving patient education, reducing health disparities, and promoting patient-centered care.

OBJECTIVE(S):
The primary objectives for this study were to develop an estimate of the prevalence of health literacy at four geographically diverse VAMCs (Minneapolis, Portland, Durham, and West LA), and for specific groups based on age, race, education, and geographic location. The secondary objectives were to link health literacy estimates for those 50 to 75 years old to CRC screening data, examine variation in guideline concordant screening rates by health literacy levels, and identify how health literacy could mediate or moderate the effect of other variables on screening adherence.

METHODS:
This observational study used a time-sequential randomized design of 4868 veterans, stratified by age (<50, 50-75, >75), who had upcoming appointments in primary care clinics at the four study sites. Patients who were eligible (i.e., had at least 20/50 vision, spoke English fluently and were not demented) were asked to participate in a face-to-face structured survey with a study interviewer. The survey included demographic data, functional status, social support, measures of attitudes and beliefs about health care providers, health insurers, medical care and the Short-Test of Functional Health Literacy in Adults (S-TOFHLA). For those between ages 50-75, knowledge of and attitudes towards CRC screening were also measured.

FINDINGS/RESULTS:
Of the 1796 veterans who were eligible, enrolled in the study, and were assessed with the S-TOFHLA, the majority (84.3%) had adequate health literacy skills. Preliminary results show that slightly less than 16% had either inadequate (8.13%) or marginal skills (7.57%). In bivariate analyses, those with either inadequate and marginal skills were significantly more likely to be over 75, have less than a high school education, an annual household income less than $20,000, and be widowed than those with adequate skills. In bivariate analyses the S-TOFHLA did not vary significantly by race. In multivariate analyses, age, education, income, and race were significantly associated with inadequate or marginal skills after adjusting for study site. Contrary to our hypothesis, results showed that inadequate and marginal health literacy were significantly associated with adherence to CRC screening. Adequate health literacy was associated with non-adherence to CRC guidelines, but there were few significant associations between health status, patient satisfaction, tangible support or trust in providers and health literacy or adherence. Only physical functioning and social support were related to both health literacy and adherence.

IMPACT:
Findings from this study are expected to have a number of broad implications. Most importantly, this project can inform organizational changes aimed to improve the efficacy and efficiency of communication strategies and identify areas where interventions or system-level changes could be most effective; inform improvements in informed consent procedures, and patient education, discharge summaries and prescription instructions.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Griffin JM, Simon AB, Hulbert E, Stevenson J, Grill JP, Noorbaloochi S, Partin MR. A comparison of small monetary incentives to convert survey non-respondents: a randomized control trial. BMC medical research methodology. 2011 May 26; 11:81. [view]
2. Chew LD, Griffin JM, Partin MR, Noorbaloochi S, Grill JP, Snyder A, Bradley KA, Nugent SM, Baines AD, van Ryn M. Validation of screening questions for limited health literacy in a large VA outpatient population. Journal of general internal medicine. 2008 May 1; 23(5):561-6. [view]
3. Griffin JM, Partin MR, Noorbaloochi S, Grill JP, Saha S, Snyder A, Nugent S, Baines Simon A, Gralnek I, Provenzale D, van Ryn M. Variation in estimates of limited health literacy by assessment instruments and non-response bias. Journal of general internal medicine. 2010 Jul 1; 25(7):675-81. [view]

Journal Other

1. Azoulay L, Gralnek IM, Provenzale D, Talley J, Griffin JM. Evaluating the Impact of Health Literacy on Knowledge, Attitudes and Beliefs Toward Colorectal Cancer (CRC) and CRC Screening in Veterans. The VALUE Study: Veterans as Leaders in Understanding and Education. [Abstract]. Gastrointestinal endoscopy. 2012 Apr 1; 75(4):346-346. [view]
2. Azoulay L, Gralnek IM, Provenzale D, Talley J, Griffin JM. Reduced health literacy in Veterans is related to poor knowledge and negative attitudes toward colorectal cancer screening in the VALUE study: Veterans as Leaders in Understanding and Education. [Abstract]. Gastroenterology. 2012 May 1; 142(5):S-772. [view]

Reports

1. Griffin JM, Noorbaloochi S, Partin MR, Roth C, van Ryn. Determining the Prevalence of Health Literacy Among Veterans Final Report. Minneapolis, MN: 2006 Mar 30. [view]

Conference Presentations

1. Griffin JM, Friedemann-Sanchez G, Burgess DJ, Partin MR. Gender differences in colorectal cancer screening, attitudes and information preferences. Presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL. [view]
2. Griffin JM, Snyder A, Partin M, Nugent S, Grill J, Noorbaloochi S, van Ryn M, Saha S. Non-response bias in a study of health literacy. Paper presented at: Minnesota Health Services Research Annual Conference; 2007 Mar 6; Minneapolis, MN. [view]
3. Griffin JM, Snyder A, Partin MR, Nugent SM, Grill JP, Noorbaloochi S, van Ryn. Prevalence & variation of health literacy skills among veterans. Paper presented at: VA HSR&D National Meeting; 2006 Feb 17; Arlington, VA. [view]
4. Griffin JM, Snyder A, Partin M, Nugent S, Grill J, Noorbaloochi S, van Ryn. Prevalence and variation of health literacy skills among veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
5. Griffin M, Snyder A, Partin MR, Nugent S, Grill J, Noorbaloochi S, Saha S, van Ryn M. Prevalence and Variation of Limited Health Literacy Skills Among Veterans. Presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]

DRA: Health Systems, Aging, Older Veterans' Health and Care
DRE: none
Keywords: Behavior (patient), Cancer, Screening
MeSH Terms: none