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
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
Decreased knowledge and
comprehension
Hypertension and diabetes – con’t
Patients with inadequate literacy were less likely
to know:
• Blood pressure of 130/80 is normal (p<0.001)
• Blood pressure of 160/100 is high (p<0.001)
• Exercise lowers BP (p<0.001)
• Canned vegetables are high in salt (p=0.001)
• Losing weight lowers BP (p<0.001)
• Normal blood glucose level is between 70-140
(p=0.003)
• If you feel shaky, sweaty and hungry, it usually
means your blood glucose is low (p=0.001)
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% <6th grade reading level
• Poor literacy correlated with poor
knowledge of asthma and improper MDI
technique, even after adjusting for
education and other sociodemographic
variables (p<0.01)
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 (p<0.01)
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])
Poorer compliance rates
Antiretroviral therapy – con’t
Individuals with lower literacy were more
likely to indicate that the reasons for
non-compliance with antiretrovirals
were:
• Being confused (p<0.01)
• Feeling depressed (p<0.05)
• Wanting to cleanse their body (p<0.05)
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 (p<0.0001)
• 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
(p<0.0001)
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 (p=1.00), starting age (p=1.00)
or frequency (p=0.57)
• Socioeconomic differences (income as
surrogate?)
• Cultural differences?
• Availability of community services?
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 (p<0.001)
-heard of sigmoidoscopy or colonoscopy (p<0.001)
-know the correct starting age (p<0.001)
-know correct frequency of sigmoidoscopy
(p<0.0001) and colonoscopy (p<0.01)
• Patients with adequate literacy were more likely to
have had a FOBT (p=0.006), sigmoidoscopy or
colonoscopy (p<0.0001)
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 (p=0.000)
-no mammogram in the previous 2 years
(p=0.17)
-never had a pap smear (p=0.002)
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
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 <7.2;
adjusted OR 0.57, 95% CI 0.32-1.00, p=0.05)
and more likely to have poor glycemic
control (hemoglobin A1C >9.5%, adjusted OR
2.03, 95% CI 1.11-3.73, p=0.02)
• For each 1-point decrement in STOFHLA
score, the hemoglobin A1C value increased
by 0.02 (p=0.02)
Poorer health status
Type II diabetes – con’t
• Patients with inadequate functional
health literacy were more likely to have
retinopathy (adjusted OR 2.22, 95% CI
1.19-4.57, p=0.01)
• Inadequate functional health literacy
was also associated with other
complications of diabetes, but the
associations did not reach statistical
significance
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 (p<0.05)
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 (p=0.02) even after
adjusting for race, age and study site.
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 (p<0.002, p<0.02, p<0.02,
respectively)
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 (p=0.0006)
• Functional health literacy was not a
significant predictor of physical or mental
health as measured by the SF-12
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,
p<0.001), even after adjusting for health status
and various sociodemographic indicators.
Increased health care costs
• 402 Medicaid recipients enrolled in a statedirected 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 (p=0.43)
Increased health care costs
Con’t
• 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 selfempowerment.
• More research is needed on the impact of
low literacy and health care costs
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
Summary
•
•
•
•
•
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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
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
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