Hello. I'm Dr. Felicia Hill-Briggs. I am Professor of Medicine and Physical Medicine and Rehabilitation in the School of Medicine at Johns Hopkins and professor of Health, Behavior, and Society in the School of Public Health. I'm also Senior Director of Population Health Research and Development for Johns Hopkins Healthcare and 2018 President of Health Care and Education for the American Diabetes Association. Today I will be presenting on the topic Tailoring Materials for Populations with Limited Health Literacy. By way of overview, I will start describing literacy adaptation in context with regard to social determinants of health and socioeconomic status and population trends. Then I will discuss the methodology for low literacy evaluation and adaptation. We will cover the information processing loop as an underpinning for the method, and then I will describe for you what I call the five-step LEAP process. Literacy in context. In this course, you will have had a great deal of discussion about social determinants of health, and here I utilize the World Health Organization's definition, which is the conditions in which people are born, grow, work, live, and age, and the wider set of forces and system shaping the condition of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. A related important construct is socio-economic status or class. Here is the American Psychological Associations definition. Socioeconomic status is the social standing or class of an individual or group. It is often measured as a combination of, and these are very important, education, income, and occupation. Examination of socioeconomic status often reveal inequities in access to resources plus issues related to privilege, power, and control. So when we think about literacy and the importance of literacy within this context, you will see those core aspects, education, occupation in common residents or geography, place, and education has been used for many decades as a proxy for socioeconomic status. There are two education-related measures that serve as proxies for socioeconomic status. The first is educational attainment, and this is the one that's been historically used most in data and analyses. This is the quantity of education attained measured as years of education completed. Literacy, however, is a measure of educational achievement or quality of education. Since the early 1990s, in neuropsychological research, it's been observed that in the United States, literacy is a better proxy for socioeconomic status than years of education completed. So in other words, quality is a better proxy than quantity, and one reason for this is that we are seeing a disaggregation of years of education from literacy. As our population obtains more years of education, we're also becoming less literate. In the decade from the early 1990s to the early 2000s, a decline in US literacy was seen on the National Assessment of Adult Literacy, and the significant changes that were seen in that decade were declines particularly in persons with some college education and above college education, in other words, the more highly educated. Here you'll see circled where the changes were both in prose and document literacy over the two decades, showing a decline from the early 1990s. This disaggregation of years of education from quality of education likely is a result of changes in our educational system with an overall lower quality of education seen throughout our US population. Other population trends in literacy that are important to note are regarding declines in literacy by race and education. Interestingly, from the decade between the early 1990s to the early 2000s, we saw declines in literacy among Whites, while gains were made in literacy by Blacks and Hispanics. This is to point out that there has been a recent trend toward lower quality of education impacting the population as a whole. Such that lower literacy, although we think of this as a topic of health inequity, now impacts the population more broadly than it has in the past. As a result of the population level need, the Plain Writing Act of 2010 became policy. The purpose of this act was to promote clear communication that the public can understand and use. Federal agencies, including our health agencies, the CDC and the National Institutes of Health, promoted plain language for all health information. It's important to note that when we talk about plain language and low literacy adaptation as methods to address the lower literacy we see in our population and our population subgroups, that this is an intervention that really falls under the category of a compensatory strategy. Meaning, here, we are able to adapt materials and information to meet low literacy needs in order to compensate for lower quality of education and reading grade levels in the US. That's quite different from an intervention approach that seeks to address the root cause of the problem, such as improving public education, for example. So we've covered literacy in context, literacy as a socio-economic status proxy, and our population trends suggest that knowing how to adapt public health information in order to be usable and understandable for people with lower literacy meets the needs not only of racial and ethnic minority groups, but meets the needs for the population as a whole.
