Literacy and Health in Canada: Is It Really a Problem?
Rootman, Irving, Canadian Journal of Public Health
Canada is seen as an international leader in literacy and health largely as a result of the work carried out by the National Literacy and Health Program coordinated since 1994 by the Canadian Public Health Association. The article in this issue by Smith and Haggerty, however, raises the question of whether or not literacy and health is really a serious problem, at least in the context of health care. As reported in the article, the prevalence of low literacy among patients attending a Family Practice Centre in Montreal was found to be 9% - which is considerably lower than the authors had predicted (between 15% and 40% with a 5% margin of error).
One conclusion of this study might be that low literacy is in fact not a large problem in the context of health care. The authors themselves present arguments against reaching this conclusion too hastily. They note, for example, that the instrument that they used to measure literacy (the Rapid Estimate of Adult Literacy in Medicine (REALM)), "may have overestimated literacy, as patients able to correctly pronounce words may not have understood them."1 They also suggest that other more sensitive instruments, such as the Test of Functional Health Literacy in Adults (TOFHLA),2 "might have permitted them to detect more patients with literacy problems."1 And indeed, this is quite possible. Moreover, it is possible that even higher levels of literacy problems might be detected if instruments designed to measure aural and oral literacy (which do not exist at the moment) were applied. In addition, it should be noted that the study was done in only one clinic, in one city in Canada and may not reflect literacy levels among patients in other health care settings across the country. In fact, it may not entirely represent literacy levels in the clinic in which the study took place, as some potential respondents were eliminated. The authors also acknowledge that their sample was too small to detect a statistically significant association between literacy levels and self-reported health. Thus, it is clear that it is premature to conclude that the prevalence of literacy difficulties in health care settings in Canada is low throughout the country and in all kinds of settings, or that it does not have any health consequences for patients or others. Much more research of the type conducted by the authors is required before we can reach such a conclusion.
The authors give us some additional reasons for pursuing research on literacy and health. One of them comes from their important finding about the readability levels of the educational materials that were used in the practice that was studied. They found that the mean reading level of these materials was grade 11.5, which is certainly higher than the reading levels of people with low levels of literacy (which according to the International Adult Literacy Survey (IALS) represents 22% of the adult population3), and probably a challenge for those who are slightly more literate (e.g., those 28% who fall into the second lowest categoiy of the IALS). This suggests that, at minimum, we should be conducting studies regarding the readability levels of other health materials that people are exposed to in other health contexts, including public health ones. At the same time, it might be helpful to know what other kinds of literacy demands different health contexts place on people. This might include literacy demands that might be imposed by physicians, nurses, public health officials and others which require people to understand, interpret and make appropriate decisions based on oral communication of health information.
Another reason for further research comes from their finding that literacy levels did not decrease with age, at least among those with high school level education. As they note, this finding flies in the face of the findings of studies in the United States which found higher rates of low literacy among seniors,4 as well as research which has found dramatic declines in reading ability with age. …