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February 20, 2007

Health Literacy

One real failure in the discussion over health policy is that it takes place largely among educated elites. So while I may not think patients have the training and judgment to always assume a leading role in their health decisions and others do, we're too often thinking of folks basically like us. Here's who we're not thinking about:

In a 2004 report, the Institute of Medicine defined health literacy as the ability to obtain and understand basic health information and services needed to make informed decisions. Low health literacy, the institute noted, affects an estimated 90 million Americans, who struggle to understand what a doctor has told them or to comply with treatment recommendations as essential as taking the proper dose of medication. A 1999 report by the American Medical Association found that consent forms and other medical forms are typically written at the graduate school level, although the average American adult reads at the eighth-grade level.[...]

A comprehensive national assessment of adult literacy conducted in 2003 by the U.S. Department of Education found that 43 percent of adults have basic or below-basic reading skills -- they read at roughly a fifth-grade level or lower -- and 5 percent are not literate in English, in some cases because it is not their first language.

So forget, for a moment, whether individuals have the interest or time to take charge of their treatment regimens. If 43 percent of Americans are reading at a fifth-grade level of lower, how many even have the capability? And how much damage will be done -- as in the article's example of a women who sought to save face and accidentally consented to a hysterectomy -- if we don't take these educational inequities seriously?

February 20, 2007 in Health and Medicine | Permalink


I'm not sure I go along with your first question. There's a difference between reading level and ability to make an informed judgment. If the information necessary to make that judgment is only available in written form, then yes, you end up with the situation you describe in the second question, which needs to be addressed. By, for example, the medical establishment incorporating non-written instructional methods into explaining diagnoses and treatment protocols. Visual aids help, even for very literate people. And given all the relevant information about various procedures, people tend to know what's right for them.

Posted by: Headline Junky | Feb 20, 2007 2:47:29 PM

One real failure in the discussion over health policy is that it takes place largely among educated elites.
Would Matt Yglesias or Spencer Ackerman qualify as educated elites? From the posting regarding their squirrel attack:

No problem, said Spencer, it's an emergency room, you don't need to pay. I said I thought that was wrong, you can get emergency service for free if you're indigent, the merely uninsured need to pay.

Posted by: poofla | Feb 20, 2007 3:38:14 PM

As long as educated elites are in charge of an issue like this nothing will get done. They are truly clueless when it comes to fixing problems like this. Just like trade, wages, unions, and a whole host of other issues they just can't be trusted on. Places like Harvard and Yale don't give you information on these subjects, they give you elitist propaganda and call it information. They have 20 billion dollar endowments and still give special access to former allumni pretending they need the money it helps them raise. The people who go to the elite universites as such simply can't be trusted. They've been taught to believe in their own divine superiority, whether they know it, acknowledge it, or not.

Posted by: soullite | Feb 20, 2007 4:36:24 PM

What would taking this ability deficit mean in terms of taking it seriously?

I'm saying, whatever the deficit of skills is, how should we respond? Surely not to ignore them, but then, how to include them in the decision-making regarding future reform and revision to our health care system?

I'm missing someting in your post, Ezra.

Posted by: JimPortlandOR | Feb 20, 2007 4:52:33 PM

Numerous case studies suggest that the best way to get the health care "system" to respond is to change the way you pay it. Doctors who get paid per procedure do more procedures. Doctors who own MRIs order more MRIs.

So let's get Medicare to pay for time-consuming -- but understandable -- discussions of risks and options!

There -- wasn't that easy? What's next?

(In all seriousness, we won't get much traction on this issue unless clinicians or hospitals have very good reason to believe it is in their short-term best interest.)

Posted by: tinman | Feb 20, 2007 6:37:28 PM

If 43% of our population can only read at the 5th grade level, health care is not our biggest problem.

Posted by: Kevin Rooney | Feb 21, 2007 2:26:37 AM

If 43% of the adult population is reading at 5th grade level or below, health care could still be our biggest problem, but gosh. Anything on the methodology for where that number comes from?

Posted by: paul | Feb 21, 2007 11:38:01 AM

In the Republican worldview every American needs to be an expert on investing and on medicine. Yet, given that a typical American has many many other things to worry about it seems unproductive to require that all Americans become investing geniuses and medical treatment and pharmacology mavens.

Republicans have a hard time fending off the argument that we'd all be better off in a system where

1) Americans don't end up penniless in retirement if they make poor investment choices or have poor investing luck

2) Americans don't end up with poor health care because they aren't medical professionals and don't have the expertise to manage their own care.

Most Americans aren't competent to make good medical treatment choices ... they'd rather leave that to medical professionals. Most Americans aren't competent to make good investment choices ... they'd rather leave that to investing professionals.

Given a choice I've got to believe that Americans would choose a system of shared risk and insured outcomes instead of being left to fend for themselves in complex, confusing, jargon-filled areas of knowledge. It really is asking too much to expect that every American become a medical and finance expert just so they have a hope of getting good medical care and an adequate retirement.

Posted by: Curt M | Feb 21, 2007 12:04:43 PM

Linda Gottfredson of the University of Delaware gave an interesting talk at AEI on the subject.

Posted by: Ted | Feb 21, 2007 10:01:56 PM

It's not just that the poor lack the education to make informed healthcare decisions. There is strong evidence that lack of education correlates with poor overall health. Moreover--and this is the important and surprising point-- there is good argument to be made that more spending on education could do more to improve the health of the poor than more spending on healthcare.

A recent essay in JAMA about spending priorities makes a provocative argument. Steven H. Woolf, a physician at Virginia Commonwealth University, writes:

"With all of medicine's advances, mortality rates over the past century have declined at a consistent, modest rate of 1% per year. Throughout these decades, however, age-adjusted black mortality rates have been 30% higher than those of whites . . .

"Closing so wide a gap has the potential to save more lives than the modest year-to-year reductions achieved incrementally by biomedical advances," Woolf continues. " By some estimates, for every life saved by such advances, 5 lives would be saved if blacks experienced the mortality rates of whites and 8 lives would be saved if adults with lesser education experienced the mortality rates of college-educated adults.Addressing the root cause of these disparities conveys benefits beyond the health sector.

Education, for example, not only promotes better health choices but also enhances job opportunities, improving earnings and access to health insurance. . .

A study that took these broader societal benefits into consideration estimated that reducing grade school class sizes would add QALYs to students' lives and generate net savings for society ($168 000 per graduate; P. A. Muennig, MD, MPH, Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, unpublished data, January 2007).

Seldom can medical advances do as much for health and society and save money.
If this is true, the US strategy to reduce disease should emphasize the alleviation of social distress at least as much as medical advances, but reverse priorities dominate government today.

Budget pressures . . . along with political concerns, have caused the government to reduce funding for social programs . . . Social distress is worsening—severe poverty increased by 20% between 2000 and 2004—while trillions of dollars are spent on health care."

I'd add to what Woolf says only by noting that spending on public education has been flat for too long(even while the number of children in the U.S. climbs.) Meanwhile spending on healthcare sprirals, in part Woolf suggests, because too many oxen would be gored if we contained healthcare spending and used some of the money saved for public education:

"those who stand to lose, such as federal agencies and research laboratories that will receive less funding, specialties and facilities that will perform fewer procedures, industries that will forfeit profits, politicians who will disappoint constituents, and taxpayers who must subsidize publicly financed programs" [would howl}. "Such tensions pit 2 prevailing ethics against each other—American individualism vs the utilitarian commitment to the common good—and the resulting deadlock has, for years, mired the status quo in place."

Woolf concludes: "What now moves the issue beyond a debate in ethics, however, is the hard reality of the health care crisis. Those who would be morally content to preserve self-interests at the expense of greater disease must now confront the looming economic ramifications. As the hardship from spiraling health spending intensifies . . . pressure may build to eschew self-interest and deploy health dollars in ways that more wisely maximize benefit."

You can find Woolf's whole essay on www.gooznews.com, Feb 07.

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