At risk: A socio-economic analysis of health and literacy among seniorsPaul Roberts and Gail Fawcett
Centre for International Statistics,
Canadian Council on Social Development
More and more research demonstrates that social, demographic and economic factors and practices affect the health of a population. However, much less is known about literacy skills and practices among those with higher health risks. Understanding these relationships is important, since weak literacy skills may impede good health care practices and healthy lifestyle decisions. Literacy can therefore be considered an important policy issue for health promotion: enhancing literacy can help to achieve health promotion goals, and understanding literacy practices and patterns can assist in more effectively directing health messages to target populations.
Using Canadian data from the 1994 International Adult Literacy Survey (IALS), this research paper compares the health-related characteristics of seniors with their literacy skills and practices. The findings support the view that literacy skills and practices may serve as "barriers" in the attainment of good health.
The link between population health and the socio-economic environment
Traditionally, research on health has concentrated on the importance of a range of obvious health variables such as genetics, biomedical factors, lifestyle patterns, risk behaviours and health care. The importance of this research is undeniable, but it has become increasingly evident that socio-economic status is also one of the strongest predictors of health available.
Income, education, occupation and labour force status have now become the measures most frequently used by current researchers. These factors, however, are less useful when applied to studies of older adults. Occupational status is often problematic, as most seniors have left the labour force. Similarly, income cannot denote a clear causal path since poorer health can lead to reduced income, which can lead to poorer health, and so on. While data from the National Population Health Study (NPHS) confirms that those with upper-middle and upper income levels are more likely to enjoy very good to excellent health than those at lower levels of income, this gap is less pronounced among older age groups. Income is not a good predictor for seniors.
It appears that when seniors are the focus of research, education levels may be the strongest predictor of health. The NPHS shows that those with higher levels of education are much more likely than those with lower levels to be in very good to excellent health. This relationship is fairly constant in all age groups and is true for both women and men.
In general, the literature and the NPHS reveal that education and income are both strong predictors of health status, with education as the strongest predictor for seniors. However, education is not a proxy for literacy. Large numbers of people seem to lose their skills after spending time outside the formal education system. In particular, seniors are at great risk of losing skills due to diminished use of their literacy skills.
Past research suggests that among seniors whose health is at high risk, literacy levels may be very low; indeed, the combination of low literacy and chronic illness is particularly common among the elderly. The Canadian Public Health Association (1996) and the Ontario Public Health Association (1990) have recognized literacy as an essential aspect of health. They found that people with limited literacy skills have poorer health, however it is measured or defined, than those with higher literacy skills.
A public policy must examine how people use and acquire information in their daily lives. What are the implications of such low literacy levels for everyday living among older Canadians? The rest of this paper examines the role of literacy in a healthy lifestyle.
The link between health and literacy for seniors
One of the most obvious and critical areas where literacy skills can have a direct effect on a personís health is in the use of prescription drugs. The potential for medication errors is enormous among those unable to understand written directions properly, or among those who are unable to decipher the written text. Elderly patients will experience this problem to a much greater degree since they are more likely to use medication and take several drugs simultaneously.
Patients must also be able to understand appointment slips, consent documents and health educational materials. The problem for those with low literacy skills is that they may not be able to understand the information fully and apply it properly to their particular health situation. Other direct effects of low literacy on health can be the failure to comply with medical directions, errors in use of infant formula and difficulty in comprehending health and safety precautions. From a policy perspective, therefore, it would be helpful to know how seniors acquire information and what skill levels they possess for processing that information.
Literacy, age and education
The literacy data suggest that senior citizens are a particularly vulnerable group. For all three forms of literacy ability (prose, document and quantitative), literacy skill is higher in the younger age groups and lower among the elderly. For example, approximately 67% of people aged 16 to 24 years have literacy abilities at Level 3 or 4/5, compared with only about 21% of seniors (over the age of 65). In other words, eight in ten senior citizens have literacy skills at the two lowest levels, making seniors especially at risk in medical situations that may demand high literacy ability.
Using the three forms of literacy (prose, document and quantitative) found in IALS, we can observe that while not the same, there is a definite connection between literacy and education, with a very strong relationship between educational attainment and literacy levels within every age group. For people 65 years and older, 76% of those with the highest prose literacy level had completed high school or more. Similar results were found overall for both document and quantitative literacy.
Although the IALS database did not contain data on personal health, it has been shown that a personís education level is correlated with relative health risk. Since seniors with the lowest levels of literacy were more likely to possess lower education, it follows that seniors with weak literacy skills are also at relatively higher risk for health problems.
Information acquisition patterns
Understanding information is only one factor in effective communication. In many instances, individuals may not realize they have difficulty interpreting certain kinds of information because they do not typically use these types of information. Information acquisition patterns vary by literacy level. Eighty per cent of Canadian seniors with high literacy skills read newspapers or magazines every day compared with only 62% of those with lower levels of literacy. Reading books each day was less prevalent; just over 60% of people aged 65 and over with high prose literacy skills reported reading books on a daily basis, compared with 30% of low-literacy seniors.
Listening to radio, compact discs, tapes and records daily was also more common among those with higher levels of literacy. While these activities are most generally associated with listening to music, a variety of information is available in these forms. Books on tape, information on compact disc or record, and the traditional radio information programs all provide a venue for developing literacy skills and general knowledge.
Because of their activities, seniors with high levels of literacy have a greater propensity to be exposed regularly to a wide range of possible information sources. Low-literacy seniors, on the other hand, are less likely to be exposed to as wide a range of information sources each day; as a result, they are not as likely to have access to health-related information in their daily lives.
The vast majority of seniors, at all literacy levels, reported television viewing as an activity they engage in on a daily basis. The "literacy gap" in daily hours spent watching television or videos tends to narrow with those aged 65 and over. Seniors with low prose literacy (64%) are more likely than those with high literacy (50%) to watch two or more hours of television on a daily basis.
People with lower levels of literacy have less exposure to newspapers, magazines and books and more prolonged daily exposure to television. These differences have an impact on an individualís knowledge about what is going on in the world. Those with high levels of prose literacy were much more likely to derive their knowledge of current affairs from newspapers and magazines. For example, 93% of high-literacy seniors obtained some or a lot of their knowledge of current events from newspapers, compared with only 65% of seniors with low literacy levels. Both groups also gather information about current affairs from radio and television, and both high- and low-literacy seniors relied quite heavily on their family, friends or co-workers for at least some of their knowledge of current events (both 63%). This is a potentially vital source of information for many people. The quality and usefulness of the information, however, very much depends upon the literacy abilities of the contacts available to these senior citizens.
Getting help with reading in everyday life
In general, seniors with lower levels of literacy were less likely than those with higher levels to be able to deal with written information entirely on their own. For example, over 98% with prose literacy levels of 3 or 4/5 could read the instructions on a medicine bottle or recipe without assistance; however, only about 72% with prose literacy Level 1 reported that they were able to do this.
A significant finding is that a large number of older Canadians at the lowest literacy level require assistance dealing with information from government agencies, businesses and other institutions. Only a limited proportion of seniors (58%) with low literacy (Level 1) do not need assistance with information from government agencies, businesses and other institutions, and need no help to fill out forms such as applications and bank deposit slips. This suggests that many seniors cannot easily understand much of the material from these sources. Thus, information about health care or medical issues may miss a large number of the people most at risk because it is not targeted to their reading skills.
Adequacy of literacy skills
Although a sizeable minority of older Canadians are aware of their need for assistance in reading various types of materials in their daily life, data from IALS indicate that many overestimate their literacy skills. For example, about 66% of seniors who scored at Level 1 and 90% who scored at Level 2 on the document literacy test believe that they possess good to excellent reading skills (i.e. the equivalent of Level 3 or 4/5 skills). This suggests that large numbers of seniors do not know that their literacy abilities may be inadequate. One of the obvious dangers that might arise from this situation is the misunderstanding of instructions from medical personnel and pharmacists, as well as safety instructions or instructions on medicine bottles or medical supplies. For example, 74% of those 65 and over who must read instructions on medicine bottles or in recipes every day scored at the two lowest levels of prose literacy.
Literacy levels are also connected to the way older Canadians acquire health-related information. Often, current health information is covered in health columns in newspapers, and a newspaper story may alert people to ask questions of their medical doctor. While this information does reach the over 70% of seniors with high literacy levels, we find that about 40% of low-literacy seniors do not read the health section of their newspaper.
The connection between health and literacy demands more than just the ability to read information; it also requires that the people fully understand and absorb the health information that is provided to them. The literacy skills of many seniors, objectively measured using IALS, suggests that those with low literacy are unable to consistently perform many literacy tasks with a full understanding of their meaning. As well, these same low-literacy seniors are more likely to have to read medicine prescriptions on a daily basis and are less likely to be exposed to health-related information in newspaper health columns.
The findings presented here would seem to support literacy being considered an important policy issue area for health promotion. However, the evidence is indirect, for the most part, and suggests a pressing need to gain a more direct and detailed insight into these connections. Given the growing size of Canadaís senior population, the forecast of increased use of medications among senior citizens and the tendency of literacy abilities be weaker for seniors, there is a pressing need to consider literacy as an important policy issue for health promotion.