1. Health Literacy and
Relevant Cancer
Screening: The story of
middle class African
Americans
BROWN BAG PRESENTATION
AUGUST 20, 2015
CALANDRA WHITTED

2. 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

3. 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)

4. 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)

5. 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)

7. 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)

8. 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.

9. 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”

10. 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.

11. 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)

12. 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.

13. 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)

14. Health Literacy Interventions
RAISE HEALTH LITERACY
•Brochures/leaflets
•Photographs
•Education sessions
•Audio/Video
REDUCE IMPACT OF HEALTH
LITERACY
•Patient Navigation
•Clear communication from
providers
•Lay health workers

15. 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).

16. 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

17. Ethical Considerations
Study 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

18. 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)

19. 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

20. 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)

21. 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

22. 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

23. Prostate
Odds Ratio CI
Health Literacy 0.979 0.183-5.241
• Health literacy level was not significantly associated with prostate
cancer screening

24. 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

25. 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

26. 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

27. 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.

28. 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.

29. 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, MPH
Acting United States Surgeon General
December 2006

30. References
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outcomes. Jama, 288(4), 475-482.
Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. health, 11, 12.
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Chaudhry, S. I., Herrin, J., Phillips, C., Butler, J., Mukerjhee, S., Murillo, J., ... & Krumholz, H. M. (2011). Racial disparities in health
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31. References
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32. 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.

33. Questions