Consequences of Inadequate Functional Health Literacy

1
Consequences of Inadequate Functional Health
Literacy

• Can be divided into 7 categories
• Decreased knowledge and comprehension
• Poorer compliance rates
• Lack of understanding and use of preventive
  health services
• Poorer self-reported health
• Poorer health status
• Increased hospitalizations
• ? Increased health care costs

2
Decreased knowledge and comprehension

• Hypertension and diabetes
• 402 patients with hypertension and 114 patients
  with diabetes at two urban public hospitals
  (Grady, UCLA)
• Knowledge questionnaire normal and levels,
  lifestyle modifications, drugs, symptoms and
  complications
• TOFHLA - 49 and 44, respectively, had
  inadequate FHL
• Functional health literacy was strongly
  associated with knowledge of illness

3
Decreased knowledge and comprehension

• Hypertension and diabetes cont
• Patients with inadequate literacy were less
  likely to know
• Blood pressure of 130/80 is normal (plt0.001)
• Blood pressure of 160/100 is high (plt0.001)
• Exercise lowers BP (plt0.001)
• Canned vegetables are high in salt (p0.001)
• Losing weight lowers BP (plt0.001)
• Normal blood glucose level is between 70-140
  (p0.003)
• If you feel shaky, sweaty and hungry, it usually
  means your blood glucose is low (p0.001)

4
Decreased knowledge and comprehension

• Asthma
• 483 patients with asthma at ER and asthma clinic
  at Grady
• 20-item questionnaire to assess asthma knowledge
  and ability to properly use an MDI
• REALM 40 lt6th grade reading level
• Poor literacy correlated with poor knowledge of
  asthma and improper MDI technique, even after
  adjusting for education and other
  sociodemographic variables (plt0.01)

5
Decreased knowledge and comprehension

• HIV/AIDS
• 228 patients with HIV or AIDS
• TOFHLA -18 had inadequate functional health
  literacy
• Patients with inadequate functional health
  literacy were less likely to understand the
  meaning of their CD4 counts, viral load tests,
  and were more likely to have misconceptions about
  HIV therapy and safe sex practices (plt0.01)

6
Poorer compliance rates

• Antiretroviral therapy
• 182 HIV/AIDS patients in the community taking
  triple-drug antiretroviral therapy
• TOFHLA adapted to be relevant to HIV population
• Lower TOFHLA scores were found to be a predictor
  of noncompliance with antiretroviral drugs during
  the previous 2 days after adjusting for age,
  ethnicity, income, HIV symptoms, substance abuse,
  social support, emotional distress and attitudes
  toward primary care providers (OR 3.9 1.1,
  13.4)

7
Poorer compliance rates

• Antiretroviral therapy cont
• Individuals with lower literacy were more likely
  to indicate that the reasons for non-compliance
  with antiretrovirals were
• Being confused (plt0.01)
• Feeling depressed (plt0.05)
• Wanting to cleanse their body (plt0.05)

8
Lack of understanding and use of preventive
health services

• Mammography I
• 445 low-income, low-literate predominantly
  African-American women at outpatient clinics LSU
  who had not had a mammogram in the previous year
• REALM 47 had less than 7th grade literacy
  level
• Lower reading ability correlated significantly
  with less mammography knowledge (plt0.0001)
• Of those who read at the 3rd grade level or less,
  61 did not know why mammograms were recommended,
  compared with 88 of those who read at a high
  school level or higher (plt0.0001)

9
Lack of understanding and use of preventive
health services

• Mammography II
• 126 Latinas attending 3 community clinics in
  Philadelphia
• STOFHLA -31 had inadequate and 18 had marginal
  literacy
• Literacy was not related to knowledge about
  mammography (p1.00), starting age (p1.00) or
  frequency (p0.57)
• Socioeconomic differences (income as surrogate?)
• Cultural differences?
• Availability of community services?

10
Lack of understanding and use of preventive
health services

• Colorectal Cancer Screening
• 126 patients over age 50 attending 3 community
  and 2 university-based primary care practices in
  Philadelphia
• STOFHLA
• Patients with adequate literacy were more likely
  to have
• -heard of FOBT (plt0.001)
• -heard of sigmoidoscopy or colonoscopy (plt0.001)
• -know the correct starting age (plt0.001)
• -know correct frequency of sigmoidoscopy
  (plt0.0001) and colonoscopy (plt0.01)
• Patients with adequate literacy were more likely
  to have had a FOBT (p0.006), sigmoidoscopy or
  colonoscopy (plt0.0001)

11
Lack of understanding and use of preventive
health services

• Vaccines/Mammogram/Pap in older patients
• 2722 Medicare patients age 65-79 in an HMO in 4
  cities
• STOHFLA
• After adjustment for sociodemographic variables
  and health status, patients with inadequate
  literacy had higher rates of
• -never had influenza vaccination (p0.000)
• -no mammogram in the previous 2 years (p0.17)
• -never had a pap smear (p0.002)

12
Poorer self-reported health

• 2659 patients at Grady and UCLA
• TOFHLA
• Patients with inadequate functional health
  literacy were 2x more likely to report their
  health as poor at all both sites regardless of
  spoken language

13
Poorer health status

• Type II diabetes
• 408 pts at 2 primary care clinics at SF General
  Hospital
• STOFHLA, hemoglobin A1C levels and complications
  of diabetes
• Patients with inadequate functional health
  literacy were less likely to have tight glycemic
  control (hemoglobin A1C lt7.2 adjusted OR 0.57,
  95 CI 0.32-1.00, p0.05) and more likely to have
  poor glycemic control (hemoglobin A1C gt9.5,
  adjusted OR 2.03, 95 CI 1.11-3.73, p0.02)
• For each 1-point decrement in STOFHLA score, the
  hemoglobin A1C value increased by 0.02 (p0.02)

14
Poorer health status

• Type II diabetes cont
• Patients with inadequate functional health
  literacy were more likely to have retinopathy
  (adjusted OR 2.22, 95 CI 1.19-4.57, p0.01)
• Inadequate functional health literacy was also
  associated with other complications of diabetes,
  but the associations did not reach statistical
  significance

15
Poorer health status

• HIV/AIDS
• 228 patients with HIV or AIDS
• TOFHLA
• Patients with adequate health literacy were
  significantly more likely to have undetectable
  viral loads (plt0.05)

16
Poorer health status

• Prostate Cancer
• 212 men at a prostate cancer clinic
• REALM
• Lower literate men were more likely to have
  advanced stage prostate cancer at presentation
  than those with higher reading abilities (p0.02)
  even after adjusting for race, age and study
  site.

17
Poorer functional health status

• 193 primarily younger patients from a publicly
  funded literacy training program
• Test of Adult Basic Education/Mott Basic Language
  Skills Program mean reading level was grade
  7.17
• Sickness Impact Profile (SIP) 136 items covering
  12 categories of daily activity including
  mobility, body function and self-care, social
  interaction, communication, emotional behavior,
  work
• Mean physical, psychosocial and total SIP scores
  were significantly related to reading level, even
  after adjusting for potential confounding
  variables (plt0.002, plt0.02, plt0.02, respectively)

18
Poorer health status

• Comorbidity burden and physical and mental health
  status
• 1301 patients at 4 community and 1
  university-based primary care practices
• STOFHLA
• Charlson Comorbidity Index (CCI)
• SF-12 PCS-12 and MCS-12
• After adjusting for confounders, functional
  health literacy remained a significant positive
  predictor of CCI score (p0.0006)
• Functional health literacy was not a significant
  predictor of physical or mental health as
  measured by the SF-12

19
Increased hospitalizations

• 958 low-income patients at ERs and walk-in
  clinics
• TOFHLA
• Hospital information system used to
  retrospectively determine number of
  hospitalizations and visits to walk-in clinic in
  the previous 2-year period
• Patients with inadequate health literacy were
  twice as likely to be hospitalized compared with
  those who with marginal or adequate health
  literacy (31.5, 16.4 and 14.9, respectively,
  plt0.001), even after adjusting for health status
  and various sociodemographic indicators.

20
Increased health care costs

• 402 Medicaid recipients enrolled in a
  state-directed managed care plan in Arizona and
  receiving care through one providing practice
• Instrument for the Diagnosis of Reading (IDL)
  mean reading level grade 5.6 (s.d. 2.7)
• Charges assessed included hospital, physician and
  ancillary charges for services rendered on-site
  or off-site
• After adjusting for confounding sociodemographic
  variables, no significant relationship between
  reading level and cost of medical care over 1
  year (p0.43)

21
Increased health care costs

• Cont
• Medicaid population inherently controls for
  income and employment status. However, this
  study did not control for number or type of
  comorbidity. Low literate patients may have a
  greater number or more severe comorbidities yet
  underuse medical care because of access and
  navigation barriers, poorer compliance or a sense
  of lack of self-empowerment.
• More research is needed on the impact of low
  literacy and health care costs

22
Summary

• Inadequate functional health literacy is
  associated with
• poorer knowledge about disease
• poorer compliance with therapy
• inadequate knowledge and use of preventive
  services
• poorer health outcomes
• increased hospitalizations
• ? health care costs

23
Summary

• The mechanism for poorer health in patients
  with inadequate literacy is likely multifactorial
  and includes increased difficulty with
• applying for and navigating the health care
  system
• understanding and communicating with provider
• understanding management of disease
• understanding medication and test instructions
• compliance
• perceiving need for preventive services

24
What can we do?

• Acknowledge that the problem exists be aware of
  the prevalence and consequences
• Identify individuals in your practice
• Assist those with reading difficulties
• -verify their understanding by asking them to
  repeat instructions back to you
• -verify they are taking their medications as
  prescribed
• -use low-literacy educational material available
  from many government agencies, National Institute
  for Literacy, AHA, ACS, and many other agencies
• -suggest referral to literacy center

25
Acknowledgement

• Funding/Support
• Agency for Health Care Quality and Research,
  Minority Supplement to Grant R01 HS10299-02
• FOCUS on Health Leadership for Women, Clinical
  Investigator Award 2001-2002
• Mentorship
• Judy A. Shea, PhD
• Research Assistants
• Megan Krumholz
• Francisco Dominguez, MD