Health Literacy:

Is there a ‘rural’ link?

Ann Rathbun, Ph.D.

Morehead State University
Morehead, Kentucky
 What is health literacy?

D.
The degree to which individuals have
.

the
P h
n ,
capacity to obtain, process, and
b u
ath
understand basic health information
and services needed to make
n R
appropriate health decisions.
A n
©
HHS, 2000 & Institute of Medicine,
 Measuring Literacy in the
U.S.
NAAL
.


 National Assessment of Adult

h .D Literacy is
, P
a nationally representative assessment
of English literacy n
b u
Sponsored by thet h US Department of
Education Ra


n
The 2003 nassessment was the first one
A


©
completed in the U.S. since 1992
(National Adult Literacy Survey).

National Center for Education

Statistics, 2007
Literacy and Health Literacy
 The 2003 NAAL was the first-ever
D.
national assessment of adults ability
h .
P
to understand health-related materials
,
and forms.
u n
th b
R a

n
Six states purchased separate
samplesnto obtain detailed information
A
© the literacy of their adult
describing
populations: Kentucky, Maryland,
Massachusetts, Missouri,National
NewCenter
York,
for Education
Statistics, 2007
 Assessment of Skill Level
Upon completion of the assessment,
.


.D
participants were assigned a “level.”
h
, P
n
u as a list of

t h b
Each level is explained
sample tasks a that individuals at the
n R
various levels should be able to
A
perform.
n
©
American Institutes for Research,
2006
 4 Skill Levels
Below Basic
D.
.


 Basic
P h
Intermediate n ,
u


 Proficient
th b
R a
n n
© A
American Institutes for Research, 2006
 Literacy level & abilities
 Below Basic
D .
- Find and circle the date h . on an
appointment slipun,
P
- Identify what t h b
R a to do to get ready
for a
n n
A test (drink/eat)
medical
©
 Literacy level & abilities
Basic
.


- Read a pamphlet and hstate .D 2

reasons , P
u n
a person should
t h b be tested for a
R a
condition even though they do not
haveA n n
symptoms.
©
 Literacy level & abilities

Intermediate D.

h .
, P
- Determine ‘healthy weight’ on the
BMI u n
th b
chart
R a
n
- Read and interpret information
n
A
from a
©
drug label (interactions, when to
take in
relation to eating)
 Literacy level & abilities
 Proficient
D.
.
- Calculate health insurance costs
h
for a , P
u n
b
year based on information given
th
for
R a
n n
employees at a company
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- Search a complex document to find
the
 Individuals with low health
literacy skills are much more
likely to:
D.

h .
Skip prevention services (vaccines,
mammograms, pap tests, , P
n
u etc). (Weiss,
educational programs,
t h b
1999)
R a
n
Therefore are “sicker” when they do


A n
enter the healthcare system
 Have©chronic conditions and manage
them poorly (ex. HIV, diabetes, high blood
pressure)
 Individuals with low health
literacy skills are much more
likely to:
D .
Engage the healthcare system h .

,
through preventablenhospital
P visits
and admissions hbu
a t longer


n R
Stays are 2 days


A n
Higher healthcare costs.
Recent estimates ≈ $250 billion/year
© Projected costs ≈ the trillions


Vernon & Trujillo, 2007

 Who is at risk for
low health literacy?

D.
Those with overall poor literacy rates
.


 Older individuals Ph
n,

bu
Those with low levels of education

ath
Those who have been socialized to be
modest
n R

A n
Those who have been socialized to respect


©
the “white coat”
Anyone who does not “understand”
medical jargon!!!
 Health Literacy in the US
NAAL 2003
Majority of adults
D.
.


(65%) in the US
Ph
had INTERMEDIATE
n,
or PROFICIENT bu
health literacy ath
n R
36% of adults had
n


© A
Basic or Below
Basic health
literacy.
NCES, 2003
 Health Literacy in the US
NAAL 2003
Older adults (65+)
D.
.

 40% Intermediate or
Ph
Proficient
n,
 60% Basic or Below
b u
th
Basic

Education LevelR
a


n n
A
77% of those with some


©
high school or less than
a high school education
had Basic or Below
Basic health literacy.
NCES, 2003
 Percentage of High School Completion
by Age, Selected Appalachian Regions
and US Total, 2000
Source: 2000 Census Public Use Microdata Sample, PRB analysis

D.
Region Age 25-34 35-44
h .45-59 60+

, P
N Alabama 82.8
u n
83.4 82.0 60.4

th b
a
NE Tennessee 75.0 73.9 70.9 44.1

E Kentucky n74.9R 70.5 62.2 38.1

A n
©
SE Ohio 85.7 86.6 79.7 65.5

NE Pennsylvania 86.6 88.0 86.1 67.8

US Total 83.9 85.0 84.9 68.0

 Eastern Kentucky vs. U.S
Educational attainment, 2000

D .
.
25-34 35-44 45-59 60+

E Kentucky 74.9 70.5 P h62.2 38.1

n ,
bu
a th
US Total
n R
83.9 85.0 84.9 68.0

A n
©
Difference 9% 14.5% 22.7% 29.9%
 D.
h .
, P
u n
th b
R a
n n
This table does not show the same kind of results

© A
that we expected to find based on earlier
information regarding disparities high school
graduation rates in Appalachian Kentucky.
Data Classes

0.0-9.0%

11-27.1%

28-46.2%

D.
47.4-67.2%

h .
, P
68-98.1%

u n
th b
R a
n n
© A
Percent of Persons Who Live in Urban Areas: Kentucky by
County
Source: U.S. Census Bureau, Census 2000 Summary File 1, Matrices
P1, and P2.
 The Health of Kentucky:
A County Assessment

D.
Ranked each county in the state (n=120) by
.

health status.
Ph
n,
 The higher the rank, the worse the health

bu
status of individuals in that county.

ath
Factors were grouped into the following
categories:
n R
n
 Behavioral/social factors
A
©
 Demographics

 Health access, and

 Health outcomes.
Kentucky IOM, 2007
 D.
h .
, P
u n
th b
R a
n n
© A
 D.
h .
, P
u n
th b
R a
n n
© A
 D.
h .
, P
u n
th b
R a
n n
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 The purposes of this study
were to:
Look at
D.

h
Graduation rates by county .
, P

u n
Health status rank by county

th b
Population by county
R a
n n
© A
 Study purposes, cont.

D .
Discover if correlations exist between:
.
h and
High school graduationPrates
,


health status
u n
b
Population andhhealth status in
t
a


counties in
n Rthe state

A n
Population and high school graduation
©
rates in the state
 Methodology

Entered each county’s health statusD.


h .
ranking (KY IOM)
, P
u n
Entered each county’s rate of those
b


th
who did not complete high school (did
a
R
not graduate or obtain a GED)
n

A n
Entered total county population (sorted
©
into quartiles)
Quartile 1 Mean 7016

D.
.
Minimum 2266 (Robertson Co.)

h
P
Maximum 11,766

Quartile 2
n ,
Mean 14,810

u
Minimum 11,971

Quartile 3 th b
Maximum 17,649
Mean 25,472

R a Minimum 17,800
Maximum 33,144

n n
Quartile 4 Mean 363,403

A
Minimum 33,202

©
Maximum 693,604 (Jefferson
Co.)
 Results

D.
There is a significant difference

h .
P
between the health rank status
,
u n
and the percentage of high
th b
school graduates in a county and
R a
whether or not the county
n n
resides in Appalachia.
© A
 Results

D
There is a difference in high.

h .
P
school graduation rates based on
,
population.
u n
th b
R a
n n
© A
 Average percent of those lacking a high school degree in
relationship to population

D.
.
40
35

P h
30

n ,
u
25
20

th b
15
10
R a
5
n n
0

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1 2 3
Population Quartiles
4
Non-graduates and Population:
Where were the main
differences?
1 2 3
D. 4
h .
P
, 5.5
1 -1.0
u n 10.0*

th b
2 1.0
R a 6.6* 11.0*

3 n n-5.5 -6.6* 4.4

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4 -10.0* -11.0* -4.4
 Results

D.
There is a difference in health

h .
P
status based on population.
,
u n
th b
R a
n n
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 Differences in Health Status based on Population

80

D.
Average Health Rank

.
70
60

P h
,
50

n
40
30

b u
th
20

a
10

R
0

n
1 2 3 4

A n Population Quartiles

©
Health Rank and Population
Where were the main
differences??
D.
1 2
h . 4

, P
1
u n-5.9 27.2*

5.9 th
b
2
R a 33.2*

nn
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 Results

D.
There is a strong positive correlation

h .
P
(r=.77) between Health Rank and the
,
u n
percent of county population with no
hs diploma. th b
R a
In other words: As the percentage of
n


A n
those with no HS degree in a county
©
increased, so did health ranking
(meaning the health of that county is worse).
 Results

There is a correlation (r=.30)D.


h .
P
between population and health rank.
,
u n
This is not a strong correlation.
b



ath
Counties in the 1st and 2nd quartiles
n R
had a higher rank in IOM health
A n
rankings.
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 Recommendations

In order to effectively plan D.


h .
P
interventions sensitive to health
,
u n
barriers and disparities, county-level
th b
data on all health and health-related
R a
issues are necessary.
n n
2 examples of this were the KY IOM data
A


©
and the county graduation rates for
Appalachian Kentucky
 Recommendations

D.
Although county by county we do not have
.


Ph
health literacy data, you can make your
n,
own estimates by the accessing data for
b
your counties/county.u
ath
n R
A n
©
 Recommendations
Assess materials currently “in stock”
.


.D
printed materials for reading level.
h

, P
Revise materials based on findings.
u n

t h b
All printed and electronic written

R a
materials should be written at a 4 -
th

6 grade n
th
level.
A n
©
 Recommendations

Pre-test materials with audiences.D .



This is to avoid mistakesPin

.
h ordering
, that do not


u n
materials that are costly
b
meet the needshof the target population.
t “work;” don’t order
R a
If materials don’t
n n
them!! (see The Pink Book.)

© A
 Recommendations

Develop consumer empowerment D.


h .
P
workshops on “How to be a Better
,
Patient.”
u n
th b
This begins to bridge the gap in
a


R
provider-patient communication
n

n
http://www.cfah.org/hbns/PreparedPatient/Pr
http://www.cfah.org/hbns/PreparedPatient/P
A
©
 Recommendations

Work with healthcare providers: D .


h .
 Raise awareness, expose
, P to information
& training.
u n
b
AMA Foundationhkit ($35.00).
t
a


n R
A n
©