Reading, Health Literacy, and Public Health:

What You Don't Know

James M. Lee, Ph.D., M.P.H. Cleo Berninger, B.A.

There are no financial or monetary considerations in

this presentation

“Ha ha ha, Biff. Guess what? After we go to the drugstore and the post office, I’m going to the vet’s to get tutored.”

Learning Objectives

• Understand how low literacy impacts your client’s health, including mental health

• Identify and screen individuals who may have literacy needs

• Know how to locate and collaborate with a literacy service in Oklahoma

• Understand how to work more effectively with low literacy persons

“The invention of writing, which occurred

independently in distant parts of the world, at

many times even occasionally in the modern era,

must rank among mankind’s highest intellectual

achievements.”

“Without writing, human culture as we know it

today is inconceivable.”

- O.T. Zeng and W. Wang

“It seems to me that beginning with age two,

every child becomes a linguistic genius. Later

beginning with age five to six, this talent

begins to fade. There is no trace left in the

eight year old of this creativity with words

since the need for it has passed.”

- Korney Chukovsky, children’s poet

“THOSE WHO CAN READ SEE TWICE AS WELL.” MENANDER, 4th CENTURY BCE

• Health literacy is the ability to obtain, process, and understand basic health information and services to make appropriate health decisions needed to prevent or treat illness.

• Adult literacy is the ability to read, write, speak English, and compute and solve problems at levels of proficiency necessary to function on the job and in society.

• Functional literacy: possessing limited vocabulary and cannot read or write well enough to deal with everyday requirements of life in their own society.

A mother’s literacy level is one of the most significant predictors of a child’s future literacy- more significant than income level and employment status.

Children of adults who participate in literacy programs improve their grades and test scores, improve their reading skills, and are less likely to drop out of school.

For both men and women, more education means longer life. On average, a 25 year old college graduates can expect to live eight to nine years longer than their counterparts who have not completed high school.

1,000,000

Over one million adult Oklahomans do not have sufficient reading skills to actively participate in needed medical treatment or preventative health care.

43% of Oklahoma adults function at or below basic reading literacy skills.

• Over 400,000 adult Oklahomans cannot read a prescription label or this sentence.

• Over 700,000 adult Oklahomans did not understand when their next appointment was scheduled.

• Over 2,000,000 (78%) of adult Oklahomans misinterpret warning labels on prescriptions.

63-73% of prison inmates can’t read and are functionally illiterate

According to the United Health Foundation, Oklahoma ranked

in overall health in 2014

46th 47 48 49 50

Poor health literacy is a stronger predictor of a person's health than age, socioeconomic status, or ethnicity

Why 46th?

Diabetes Physical

inactivity High

cholesterol

Drug deaths

High rates of obesity

Lack of primary care

physicians

Low immunization

Lack of annual dental exams

High increase in foreign language

speakers

•Oklahoma is one of the states with the highest increase in foreign language speakers from 2000-2013, up 48 percent.

•122,088 individuals 18 and over who did not speak English “very well.”

•Spanish and Vietnamese were the most common languages.

CHANGING DEMOGRAPHICS One in five -- 61.8 million-- U.S. residents do not speak English at home

• Are more likely to skip important preventative measures such as mammograms, PAP smears, and flu shots.

• Make greater use of services designed to treat complications of disease and use less services designed to prevent complications.

• Have higher rate of hospitalizations and ER visits.

They enter the health care system when they are sicker- and this includes mental health

ADULTS WITH LIMITED HEALTH LITERACY:

PROFILE OF LOW LITERACY

• The majority are white and native born.

• They develop coping skills to hide their problems.

• They don’t think of themselves as poor readers.

• Two-thirds have never told their spouses.

• 19% have never told anyone.

• 66% to 75% of adults in the very lowest level said they could read and write “well” or “very well.” 93-97% of basic readers described themselves the same way.

Education Below Basic Basic Intermediate Proficient

Less than High School 49% 27% 23% 1%

High School Graduate/GED 15% 29% 53% 3%

Other College Attendance or Degree 6% 19% 65% 10%

Bachelor's Degree or Higher 3% 9% 58% 30%

Age Below Basic Basic Intermediate Proficient

16–49 11% 20% 56% 13%

50–64 13% 22% 53% 12%

65–75 23% 28% 44% 5%

Over 75 39% 31% 29% 1%

Ethnic Group Below Basic Basic Intermediate Proficient

White 9% 19% 58% 14%

Black 24% 33% 41% 2%

Hispanic 41% 24% 31% 4%

Other 13% 21% 54% 12%

2003 National Assessment of Health Literacy - National Assessment of Adult Literacy

77 Million Adults Have Basic or Below Basic Health Literacy

HOW DOES THIS EFFECT MENTAL HEALTH?

• 54-75% of low literacy adults are consumers of services in community

mental health centers.

• Adults diagnosed with psychotic disorders are more likely to have lower

literacy skills as compared to those diagnosed with PTSD or substance abuse.

• Three times more likely to be diagnosed with depression.

• Adults who received literacy training improved on standard depression

scales compared to a control group.

• 76% of homeless were below an 8th grade reading level.

• Poverty reduces brain power. It imposes a cognitive tax.

• A Princeton study showed that financial concerns have an immediate impact on the mental capacity of a low income person’s overall cognitive function, as much as a 13 point drop in IQ or loss of a whole night’s sleep.

• Standard psychological evaluations do not consider literacy levels.

Common treatment modalities generally assume basic or higher levels of literacy skills-

CBT, bibliotherapy, journaling, reading homework.

• Researchers recommended that services for the poor should take into account the total effect that poverty has on a person’s thought processes and behaviors.

Simpler aid forms, more guidance in filling out forms, training and educational programs that are more forgiving of absences.

….POVERTY AS A NEUROTOXIN

TO SCREEN, OR NOT TO SCREEN, THAT IS THE QUESTION

• Short Test of Functional Health Literacy (STOHFLA) Three questions: “How often do you have someone help you read hospital material?”

“How confident are you in filling out medical forms by yourself?”

“How often do you have difficulty learning about your medical condition because of difficulty understanding written information?”

• Wide Range Achievement Test

• Rapid Estimate of Adult Literacy in Medicine (REALM)- 66 item questionnaire.

• Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF)- 6 items.

Pulse check

● How to identify and screen

● How to locate and collaborate with a literacy service

● View to best practices on working with literacy clients

To screen or not to screen, that was quite a question: working toward

that via:

● RGHALS* as an example of best practices literacy service.

● The largest literacy service in the State of Oklahoma Member of

Oklahoma Literacy Coalition and ProLiteracy

*Ruth G. Hardman Adult Literacy Service, TCCL

Remaining objectives

Client Life Cycle - and how to achieve desired results*

● I was treated with respect by the staff.

● The staff gave me the time and attention I needed.

● I was treated fairly.

● The staff is concerned that I do well and helps me if I need it.

● The staff notices when I am doing well.

● The staff is calm when he/she talks to me.

● When I do something wrong the staff explains what I did wrong.

● I can trust the staff.

*Payne; with permission. Bridges Out of Poverty, Pg. 167

How do you achieve desired results?

“Research on client satisfaction indicates that a

customer makes up his/her mind about an organization in

the first 15 minutes after walking through the door. For

that reason alone planners should know what that

experience is. Survey questions that will get to the

experience of clients from the poverty culture are largely

about relational issues.”

Payne. With permission, pg. 167

The RGHALS Intake

Process: phone call, appointment, intake, assessment, engagement,

PowerPath, computer introduction, orientation & student agreement

Assessment tools

● BestPlus

● READ

● WRAT4

• Word Reading

• Sentence Comprehension

Adult learner samples from RGHALS intake

Adult learner samples from RGHALS intake

Engagement

“A ship is safe at shore - but that is not what it is designed for.” -Albert Einstein

The next year includes:

● Matching with a tutor

● Materials, strategy, accommodation

● Working one-on-one with a tutor

● Reassessment

Back to best practice

Any process can become stale, routine, heartless

and accidentally off-putting. An organization may

have the best tools and process structure but what

makes a difference? The human element. The spirit

in which something happens does make impact.

Show that you care.

Back to: ‘To screen, or not to screen”

YES: Identify those who may be low literacy by use of a

screening tool or via simple, direct inquiry:

● Do you need to brush up your reading skills?

● Do you feel like your eyes aren’t showing you what’s

really there?

● Do you want to help your children with homework?

● Do you feel confident with health forms or work-related

reading tasks?

What do you think the answer to be?

How to locate a literacy service

How to collaborate with a literacy service

Brain Break

WORKS CITED jimcarolylee@sbcglobal.net 918.740.3230

Arozullah, A. H., et al. (2007). Development and validation of a short-form, rapid estimate of adult literacy in medicine. Medical Care, 45(11), 1026-33. doi: 10.1097/MLR.0b013e3180616c1b

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. Health, 11(12). September 2004. Family Medicine. 36(8): 588-94.

Chew, L. D., Griffin, J. M., Partin, M. R., et al. (2008). Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population. Journal of General Internal Medicine, 23(5), 561–566. http://doi.org/10.1007/s11606-008-0520-5

Herring, A. (2012). Mental illness and limited literacy. Retrieved from: http://www.northeastern.edu/news/2012/10/mental-illness-and-limited-literacy/

Kelly, M. (2013). Poor concentration: Poverty reduces brainpower needed for navigating other areas of life. Retrieved from: http://www.princeton.edu/main/news/archive/S37/75/69M50/index.xml?section=topstories

Kelly, T. Mental health and literacy. LernNetwork.org. August 2013.

Krishan, S., von Esenwein, S. A., & Druss, B. G. (2012). The health literacy of adults with severe mental illness. Psychiatric Services, 63(4), 397-397.

Larson, G. “The Far Side.” Dogs tutored. Comic Strip.

Mani, A., Mullainathan, S., Shafir, E., & Zhao, J. (2013). Poverty impedes cognitive function. Science, 341(6149), 976-980.

Oklahoma Health Equity Campaign. (2015). Literacy and health equity. Literacy Resource Office.

---. (2015). Health literacy. Literacy Resource Office.

---. (2015) Journey to success. Literacy Resource Office.

U.S. Department of Health and Human Services. (2015). America’s health literacy: Why we need accessible health information. Retrieved from: http://health.gov/communication/literacy/issuebrief/

U.S. Department of Health and Human Services. (2015). Quick guide to health literacy and older adults. Retrieved from: http://health.gov/communication/literacy/olderadults/cognitive.htm

Wolf, M. (2007). Proust and the squid: The story and science of the reading brain. New York, NY: Harper.

ADDITIONAL READINGS • Clancy, C. (2009). An overview of measures of health literacy. Retrieved from: www.ncbi.nlm.nih.gov/books/NBK45375

• Kiernan, J. (2015). 2015’s the most and least financially literate states in America. Retrieved from: http://wallethub.com/edu/most-and-least-financially-literate-states/3337/

• Kloc, J. (2011). Reading Braille activates the brain’s visual area. Retrieved from: http://www.scientificamerican.com/article/the-reading-region/

• Gregoire, C. (2015). Study reveals sad link between poverty and children’s brain development. Retrieved from: http://www.huffingtonpost.com/2015/03/30/brain-development-poverty_n_6968758.html

• Ladd, H. & Fiske, E. (2011). Class matters. Why won't we admit it? Retrieved from: http://www.nytimes.com/2011/12/12/opinion/the-unaddressed-link-between-poverty-and-education.html?_r=0

• Luby, J., et al. (2013). The effects of poverty on childhood brain development: The mediating effect of caregiving and stressful life events. JAMA Pediatrics. 2013; 167(12): 1135-1142. doi:10.1001/jamapediatrics.2013.3139.

• Ostrander, M. (2015). What poverty does to the young brain. Retrieved from: http://www.newyorker.com/tech/elements/what-poverty-does-to-the-young-brain

• Paasche-Orlow, M. & Wolf, M. (2008). Evidence does not support clinical screening of literacy. J Gen Intern Med. 2008 January; 23(1): 100–102. doi: 10.1007/s11606-007-0447-2

• Sample, I. (2015). Brain development in children could be affected by poverty, study shows. Retrieved from: http://www.theguardian.com/science/2015/mar/30/brain-development-in-children-could-be-affected-by-poverty-study-shows

• Schnabel, J. (2014). Poverty and cognition: How the poor get poorer. Retrieved from: http://dana.org/News/Poverty_and_Cognition__How_the_Poor_Get_Poorer/

Short List

• Mullainathan, S. (2013). Scarcity: Why having too little means so much. New York, NY: Times Books.

● Payne, R., DeVol, P., & Dreussi Smith, T. (2009). Bridges

out of poverty: Strategies for professionals and

communities (Revised ed.). Highlands, TX: AHA! Process.

● Tirado, L. (2014). Hand to mouth: Living in bootstrap

America. New York, NY: G.P. Putnam’s Sons.

● Wolf, M. (2007). Proust and the squid: The story and

science of the reading brain. New York, NY: Harper.