Iris van der Heide

The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Is retirement good for your health? A systematic review of longitudinal studies

BackgroundSeveral studies regarding the effect of retirement on physical as well as mental health have been performed, but the results thereof remain inconclusive. The aim of this review is to systematically summarise the literature on the health effects of retirement, describing differences in terms of voluntary, involuntary and regulatory retirement and between blue-collar and white-collar workers.MethodsA search for longitudinal studies using keywords that referred to the exposure (retirement), outcome (health-related) and study design (longitudinal) was performed using several electronic databases. Articles were then selected for full text analysis and the reference lists of the selected studies were checked for relevant studies. The quality of the studies was rated based on predefined criteria. Data was analysed qualitatively by using a best evidence synthesis. When possible, pooled mean differences and effect sizes were calculated to estimate the effect of retirement on health.ResultsTwenty-two longitudinal studies were included, of which eleven were deemed to be of high quality. Strong evidence was found for retirement having a beneficial effect on mental health, and contradictory evidence was found for retirement having an effect on perceived general health and physical health. Few studies examined the differences between blue- and white-collar workers and between voluntary, involuntary and regulatory retirement with regards to the effect of retirement on health outcomes.ConclusionsMore longitudinal research on the health effects of retirement is needed, including research into potentially influencing factors such as work characteristics and the characteristics of retirement.

Health literacy of Dutch adults: a cross sectional survey.

BackgroundRelatively little knowledge is available to date about health literacy among the general population in Europe. It is important to gain insights into health literacy competences among the general population, as this might contribute to more effective health promotion and help clarify socio-economic disparities in health. This paper is part of the European Health Literacy Survey (HLS-EU). It aims to add to the body of theoretical knowledge about health literacy by measuring perceived difficulties with health information in various domains of health, looking at a number of competences. The definition and measure of health literacy is still topic of debate and hardly any instruments are available that are applicable for the general population. The objectives were to obtain an initial measure of health literacy in a sample of the general population in the Netherlands and to relate this measure to education, income, perceived social status, age, and sex.MethodsThe HLS-EU questionnaire was administered face-to-face in a sample of 925 Dutch adults, during July 2011. Perceived difficulties with the health literacy competences for accessing, understanding, appraising and applying information were measured within the domains of healthcare, disease prevention and health promotion. Multiple linear regression analyses were applied to explore the associations between health literacy competences and education, income, perceived social status, age, and sex.ResultsPerceived difficulties with health information and their association with demographic and socio-economic variables vary according to the competence and health domain addressed. Having a low level of education or a low perceived social status or being male were consistently found to be significantly related to relatively low health literacy scores, mainly for accessing and understanding health information.ConclusionsPerceived difficulties with health information vary between competences and domains of health. Health literacy competences are associated with indicators of socio-economic position and with the domain in which health information is provided.

Preferences for Vaccination : Does Health Literacy Make a Difference?

Purpose. The purpose of this study is to examine to what extent health literacy is associated with parental preferences concerning childhood vaccination. Methods. A cross-sectional study was conducted among 467 Dutch parents of newborns aged 6 weeks (response rate of 37%). A self-reported questionnaire was used to measure health literacy by means of Chew’s Set of Brief Screening Questions, as well as parental preferences for rotavirus vaccination by means of a discrete choice experiment. Five rotavirus-related characteristics were included (i.e., vaccine effectiveness, frequency of severe side effects, location of vaccination, protection duration, and out-of-pocket costs). Panel latent class models were conducted, and health literacy and educational level were added to the class probability model to determine the association between health literacy and study outcomes. Results. Lower educated and lower health literate respondents considered protection duration to be more important and vaccine effectiveness and frequency of severe side effects to be less important compared with higher educated and higher health literate respondents. While all respondents were willing to vaccinate against rotavirus when the vaccine was offered as part of the National Immunization Program, only lower educated and lower health literate parents were willing to vaccinate when the vaccine was offered on the free market. Conclusion: Health literacy is associated with parents’ preferences for rotavirus vaccination. Whether differences in vaccination decisions are actually due to varying preferences or might be better explained by varying levels of understanding should be further investigated. To contribute to more accurate interpretation of study results, it may be advisable that researchers measure and report health literacy when they study vaccination decision behavior.

Health literacy and informed decision making regarding colorectal cancer screening: a systematic review

Making an informed decision about participation in colorectal cancer (CRC) screening may be challenging for invitees with lower health literacy skills. The aim of this systematic review is to explore to what extent the level of a persons health literacy is related to their informed decision making concerning CRC screening. We searched for peer-reviewed studies published between 1950 and May 2013 in MEDLINE, EMBASE, SciSearch and PsycINFO. Studies were included when health literacy was studied in relation to concepts underpinning informed decision making (awareness, risk perception, perceived barriers and benefits, knowledge, attitude, deliberation). The quality of the studies was determined and related to the study results. The search returned 2254 papers. Eight studies in total were included, among which seven focused on knowledge, four focused on attitudes or beliefs concerning CRC screening, and one focused on risk perception. The studies found either no association or a positive association between health literacy and concepts underpinning informed decision making. Some studies showed that higher health literacy was associated with more CRC screening knowledge and a more positive attitude toward CRC screening. The results of studies that obtained a lower quality score were no different than studies that obtained a higher quality score. In order to obtain more insight into the association between health literacy and informed decision making in CRC cancer screening, future research should study the multiple aspects of informed decision making in conjunction instead of single aspects.

Health literacy and primary health care use of ethnic minorities in the Netherlands

BackgroundIn the Netherlands, ethnic minority populations visit their general practitioner (GP) more often than the indigenous population. An explanation for this association is lacking. Recently, health literacy is suggested as a possible explaining mechanism. Internationally, associations between health literacy and health care use, and between ethnicity and health literacy have been studied separately, but, so far, have not been linked to each other. In the Netherlands, some expectations have been expressed with regard to supposed low health literacy of ethnic minority groups, however, no empirical study has been done so far. The objectives of this study are therefore to acquire insight into the level of health literacy of ethnic minorities in the Netherlands and to examine whether the relationship between ethnicity and health care use can be (partly) explained by health literacy.MethodsA questionnaire was sent to a sample of 2.116 members of the Dutch Health Care Consumer Panel (response rate 46%, 89 respondents of non-western origin). Health literacy was measured with the Health Literacy Questionnaire (HLQ) which covers nine different domains. The health literacy levels of ethnic minority groups were compared to the indigenous population. A negative binomial regression model was used to estimate the association between ethnicity and GP visits. To examine whether health literacy is an explaining factor in this association, health literacy and interaction terms of health literacy and ethnicity were added into the model.ResultsDifferences in levels of health literacy were only found between the Turkish population and the indigenous Dutch population. This study also found an association between ethnicity and GP visits. Ethnic minorities visit their GP 33% more often than the indigenous population. Three domains of the HLQ (the ability to navigate the health care system, the ability to find information and to read and understand health information) partly explained the association between ethnicity and GP visits.ConclusionsIn general, there are no differences in health literacy between most of the ethnic minority groups in the Netherlands and the indigenous Dutch population. Only the Turkish population scored significantly lower on several health literacy domains. Some domains of health literacy do explain the association between ethnicity and higher frequency of GP visits. Further research is recommended to understand the pathways through which health literacy impacts health care use.

Individual care plans in chronic illness care: aims, use and outcomes

Introduction : During the last decade, individual care plans (ICPs) have been introduced in healthcare in many countries. ICPs are used in different settings and for different purposes. In chronic illness care, ICPs are implemented to improve patient-centeredness, i.e. to ensure that decision-making about treatment and care and the actual delivery of care is based on patients’ self-assessed needs and personal goals, and is tailored to their preferences and competencies. In addition, ICPs are implemented to support patients’ self-management. In terms of the Chronic Care Model (Wagner et al., 1998), these two purposes refer to interventions in different components: delivery system design and self-management support. With this paper we aim to provide more insight in the use of ICPs in chronic illness (primary) care in the Netherlands and in other European countries: to what extent and for which purpose have they been implemented, for which target populations and which outcomes have been achieved? Methods : Data were collected in three ways: 1. by a patient survey among a nationwide sample of 1602 patients with a (medically diagnosed) chronic disease registered in 82 general practices in the Netherlands, 2. by surveys among patients with COPD, diabetes type 2 or cardiovascular disease/high risk and their primary care providers participating in pretest-posttest evaluation studies of several ICP-related interventions in the Netherlands, and 3. by a survey among country experts of 31 European countries and subsequent site visits to regional integrated care programs or practices targeting patients with multi-morbidity in several European countries as part of the ICARE4EU-project (www.icare4eu.org). Results : Overall, the use of ICPs in Dutch chronic illness primary care in 2011 was low (9%), with slightly higher percentages of ICP-use found among patients with diabetes or COPD (13%), both diseases for which disease management programs have been implemented in the Netherlands. A low implementation level was also reported in studies from Norway and the UK. More recently, Dutch care groups who facilitated training and support for primary care providers to start working with ICPs succeeded in increasing the use of ICPs in their disease management programs for COPD, diabetes and cardiovascular disease/high risk (up to 36% of the participating patients). Primary care physicians and nurses reported various reasons to decide whether or not to develop an ICP with a specific patient. Some reported to use an ICP with patients with very complex health conditions, whereas others used ICPs with patients whom they perceived to be better prepared for self-management. These different reasons suggest that primary care providers use ICPs for different purposes. Several evaluation studies show that patients with whom an ICP had been developed experienced better chronic illness care (as assessed by the PACIC-questionnaire) than patients without an ICP. However, improvements in self-management were usually not found. One study showed no difference in outcomes between diabetes patients with a low or high (pretest) activation level (PAM). In 24 of the 31 countries included in the ICARE4EU-survey, integrated care programs were found in which the use of ICPs was reported. In the POTKU-project, which aimed to improve patient-centeredness of chronic illness primary care in Middle Finland, patients with an ICP reported to receive better chronic illness care (PACIC-scores) than patients without an ICP. But also in this project the implementation of ICPs lagged behind expectations, which -like in the Dutch evaluation studies- was attributed to poor integration of the ICP with the health information system, lack of time and patient characteristics. Highlights : - The implementation of ICPs in chronic illness care in European countries is still low, which seems partly due to impeding factors in the organization of the care (e.g. health information systems, allocation of staff time). - Healthcare providers seem to use ICPs for different purposes, which is reflected in their selection of patients with whom they develop an ICP. - ICPs have the potential to improve patient-centeredness: patients with an ICP report to receive care that is more guided by their personal goals and preferences than patients without an ICP. - There is currently insufficient evidence that ICPs also improve chronically ill patients’ self-management. Conclusion : There is a gap between policy aspirations and clinical practice of the use of ICPs in chronic illness care in the Netherlands and in other European countries. Factors in the organization of primary care (e.g. time investment, supportive environments) need to be addressed to improve implementation. ICPs may improve patient-centeredness rather than patients’ self-management in chronic illness care.

PS14 - 4. Associations between health literacy, diabetes knowledge, self-management and health among adults with type 2 diabetes in The Netherlands

Since self-management support is a crucial element of diabetes care, it is important to obtain a better understanding of how individuals’ health literacy skills and diabetes knowledge are related to involvement in self-management and health status.