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The Impact of Graduation Rates on Health Literacy

Leslie M. Eickelberger Morehead State University Morehead, Kentucky

Ann Rathbun, Ph.D. Morehead State University Morehead, Kentucky

What is health literacy?

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

© Rathbun & Eickelberger, 2008 HHS, 2000 &

Institute of Medicine,

NAAL

Measuring Literacy in the U.S.
National Assessment of Adult Literacy is a nationally representative assessment of English literacy Sponsored by the US Department of Education The 2003 assessment was the first one completed in the U.S. since 1992 National Center for (National Adult Literacy Survey). Education Statistics, 2007
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The NAAL

The 2003 NAAL was the first-ever national assessment of adults ability to understand health-related materials and forms. Six states purchased separate samples to obtain detailed information describing the literacy of their adult populations: Kentucky, Maryland, for Education National Center Statistics, York, Massachusetts, Missouri, New 2007 and Oklahoma.
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Assessment of Skill Level

Upon completion of the assessment, participants were assigned a “level.” Each level is explained as a list of sample tasks that individuals at the various levels should be able to American Institutes for Research, perform.
2006

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American Institutes for Research, 2006

4 Skill Levels

   

Below Basic Basic Intermediate Proficient

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Literacy level & abilities

Below Basic - Find and circle the date on an appointment slip - Identify what to do to get ready for a medical test (drink/eat)

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Literacy level & abilities

Basic - Read a pamphlet and state 2 reasons a person should be tested for a condition even though they do not have symptoms.

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Literacy level & abilities

Intermediate - Determine ‘healthy weight’ on the BMI chart - Read and interpret information from a drug label (interactions, when to take in © Rathbun & Eickelberger, 2008 relation to eating)

Literacy level & abilities

Proficient - Calculate health insurance costs for a year based on information given for employees at a company - Search a complex document to find the
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Who is at risk?
   

Those with overall poor literacy rates Older individuals Those with low levels of education Those who have been socialized to be modest Those who have been socialized to respect the “white coat” Anyone who does not “understand” medical jargon!!!
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Health Literacy in the US NAAL 2003

Majority of adults (65%) in the US had INTERMEDIATE or PROFICIENT health literacy 36% of adults had Basic or Below Basic health literacy.
NCES, 2003
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Health Literacy in the US NAAL 2003

Older adults (65+)

40% Intermediate or Proficient 60% Basic or Below Basic

Education Level

77% of those with some high school or less than a high school education had Basic or Below Basic health literacy.
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NCES, 2003

Individuals with low health literacy skills are much more likely to:

Skip prevention services (vaccines, mammograms, pap tests, educational programs, etc). (Weiss,
1999)

Therefore are “sicker” when they do enter the healthcare system

Have chronic conditions and manage them poorly (ex. HIV, diabetes, high blood
pressure)
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Individuals with low health literacy skills are much more likely to:

Engage the healthcare system through preventable hospital visits and admissions
Stays are 2 days longer  Higher healthcare costs.  Recent estimates ≈ $250 billion/year Vernon  Projected costs ≈ the trillions & Trujillo, 2007

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Appalachia
>Appalachia encompasses 200,000 square miles, 410 counties >The struggle continues to secure basic food and shelter >Although poverty rates have improved, the region continues to have higher rates of poverty than the nation.

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Lichter & Campbell, 2005

Appalachian Sensibilities
   

Family Community Independence, self reliance Oral tradition
Toborg, Meyer, & Denham, 2001

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Location:

Kentucky – The Bluegrass State
south central United States along the west side of the Appalachian Mountains

  

Capital is Frankfort Population was 4,041,769 (2000 U.S. Census
Bureau)

Industry Providers:
  

Manufacturing Services Government
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Kentucky

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Mission of NAHEC

To make health education broadly accessible, effective, and sustainable.

This organization shall meet its mission by:

• Advancing health literacy through collaborative relationships with organizations that share a commitment to health knowledge.
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NAHEC Core Values
Quality of life for all is improved by: • Increasing health literacy, especially to the underserved.

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Percentage of High School Completion by Age, Selected Appalachian Regions and US Total, 2000
Source: 2000 Census Public Use Microdata Sample, PRB analysis

Region N Alabama

Age

25-34 82.8 75.0

35-44 83.4 73.9

45-59 82.0 70.9

60+ 60.4 44.1

NE Tennessee

E Kentucky
SE Ohio NE Pennsylvania US Total

74.9
85.7 86.6 83.9

70.5
86.6 88.0 85.0

62.2
79.7 86.1 84.9

38.1
65.5 67.8 68.0

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Eastern Kentucky vs. U.S Educational attainment, 2000
25-34 35-44 45-59 60+

E Kentucky US Total Difference

74.9 83.9 9%

70.5 85.0

62.2 84.9

38.1 68.0

14.5% 22.7% 29.9%

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This table does not show the same kind of results that we expected to find based on earlier information regarding disparities high school graduation rates in Appalachian Kentucky.
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2.

3.

Examine high school graduation rates across the state of Kentucky. Compare graduation rates to health status rank in Appalachian and nonAppalachian counties. Discover the correlation (if any) between high school graduation rates and health status in Appalachian and non-Appalachian counties in the state.
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The purposes of this study were to:

The Health of Kentucky: A County Assessment
Kentucky IOM, 2007

Ranked each county in the state (n=120) by health status.  The higher the rank, the worse the health status of individuals in that county. Factors were grouped into the following categories:  Behavioral/social factors  Demographics  Health access, and  Health outcomes.
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The Health of Kentucky: A County Assessment

Smoking is Kentucky's greatest challenge

More than 23% of all deaths in Kentucky are attributable to smoking. 115/120 counties have smoking rates below the national average.

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Kentucky IOM, 2007

The Health of Kentucky: A County Assessment

Kentucky is at or below the national average for:
 

low birth weight babies and infant mortality. Infectious diseases (HIV, hepatitis, and tuberculosis)

Kentucky is above the national average for:
   

diabetes Physical activity CVD Rathbun cancer death©rates & Eickelberger, 2008

Hypotheses
HO1 : In the state of Kentucky, Appalachian counties have lower graduation rates than non-Appalachian counties. HO2 : In the state of Kentucky, Appalachian counties have a worse health status than non-Appalachian counties. HO 3: There is a correlation between health rank and having a high school diploma in © Rathbun & Eickelberger, 2008 Kentucky.

Methodology

Entered each county’s health status ranking (KY IOM) Entered each county’s rate of those who did not complete high school (graduation or GED) Sorted all counties into Appalachian or Non-Appalachian counties
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Methodology

Entered each county’s total population (and sorted into categories) Entered each county’s percent of rural area (and sorted into categories) Compared means (ANOVA) and calculated correlations (Pearson’s R) in order to accept or reject © Rathbun & Eickelberger, 2008

Results

HO1: Accepted
Interpretation: Rates of high school graduation are lower in Appalachian counties than in non-Appalachian counties in Kentucky.

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Results

HO2: Accepted
Interpretation: Health status (by rank) is worse is Appalachian counties in Kentucky than in non-Appalachian counties.

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Results

HO3: Accepted (with conditions) Interpretation: Although there is a correlation between health rank and having a high school diploma, the strength of the correlation is only “fairly strong” (r=.74). As the health rank get worse in a county, the percentage of those in the county who did not complete high school is larger.
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Recommendations

In order to effectively plan interventions sensitive to health barriers and disparities, county-level data on all health and health-related issues are necessary.

2 examples of this were the KY IOM data and the county graduation rates for Appalachian Kentucky
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Recommendations

Although your state may not have health literacy data, you can make some estimates by accessing data in your state. Resource for county by county health data for each state in the U.S.

http://www.communityphind.net/StateLinks.cfm

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Recommendations

Yin, H. S., Forbis, S. G.,  & Dreyer, B. P. (2007). Health Literacy and Pediatric Health. Current Problems in Pediatric and Adolescent Health Care, 37(7), 258-286. Terrific manuscript that covers a variety of topics related to practice and programming issues for adolescents (and their adult caregivers) with low health literacy.
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Policy Recommendations

Assess materials currently “in stock” printed materials for reading level.

Revise materials based on findings.

All printed and electronic written materials should be written at a 4th6th grade level.

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Policy Recommendations

Pre-test materials with audiences.

This is to avoid mistakes in ordering materials that are costly that do not meet the needs of the target population. If materials don’t “work;” don’t order them!! (see The Pink Book.)

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Policy Recommendations

Develop consumer empowerment workshops on “How to be a Better Patient.”

This begins to bridge the gap in provider-patient communication http://www.cfah.org/hbns/PreparedPatient/Pr http://www.cfah.org/hbns/PreparedPatient/P

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Where to access and download this presentation © Rathbun & Eickelberger, 2008 www.arathbunblog.blogspot.com