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Health and Literacy

Overview
Poverty, Literacy and Health
What is Literacy?
What is Health Literacy?
Canadian Literacy Statistics
The relationship between literacy and health status
Direct Effects of Literacy on Health Status
Indirect Effects of Literacy on Health Status
Seniors and Literacy
Immigrants and Literacy
Aboriginals and Literacy
Literacy and the Disabled
What can Health Professionals do?
Reports, Resources and Websites
Summary


Overview

Literacy is a key determinant of health, making the relationship between literacy and health important. Canada is a multicultural nation with an ethnic and linguistic composition that is diverse and rapidly changing. With the evolution of computers and new technologies, in addition to the abundance of text based materials and increased organizational development and globalization, the basic literacy requirements for functioning in Canada’s knowledge-based economy are immense. Literacy affects many aspects of the human life including health, social status, income, employment and education. This review will outline the current Canadian research on the relationship between literacy and health, while providing literacy awareness education for health service providers as well as the general public.  

But health and literacy are crucial resources for everyday living and functioning, however, the strong connection between the two is often overlooked. Examples of literacy challenges that can result in daily health risks include the following:

  • Properly taking the appropriate dose of required medication
  • Giving the correct amount of medication to an ill child
  • Communicating the need for medical services such as referral to a health specialist
  • Safely operating an electric household appliance
  • Following the specific instructions for a diabetic or low-cholesterol diet
  • Completing and understanding medical forms and informed consent

To some people, these tasks may seem simple; however, to individuals with low literacy levels, these simple tasks can bring difficulties and result in potentially serious health risks. Needless to say, literacy skills play a critical role in acting upon health information and taking control over our total health. Low literacy skills have been reported to create many health-related barriers. Individuals with difficulties in literacy may have difficulties:

  • Accessing medical services and supports
  • Understanding health promotion and prevention education and are less likely to participate in prevention practices
  • Making knowledgeable decisions regarding their self-care practices as well as treatment of illness
  • Taking control over their own health as well as the health of their families and communities.

The Canadian Public Health Association established a National Literacy and Health Program (NLHP) in 1994. This program works to promote awareness to health professionals regarding the links between literacy and health. NLHP has partnered with a number of national organizations to provide resources and education in an attempt to raise awareness, and in turn, improve the literacy levels of Canadians. Essentially, the NLHP provides resources to health professionals to help them serve their low literacy skill clients more efficiently by providing health professional with easy-to-read health information and the skills necessary to communicate clear and simple instructions. To learn more about the National Literacy and Health Program and the resources offered, visit the NLHP website at http://www.nlhp.cpha.ca/

Research evidence exists to support the relationship between literacy and overall health status (Health Canada, 2003; The Canadian Public Health Association, 2005; Perrin, 1998; Literacy BC, 2005). The relationship between literacy and health status is complex. Negative effects of low literacy levels on health are evident in many health related areas such as life expectancy, utilization of preventative services, accidents, parenting skills and lifestyle practices. Literacy barriers affect an individual’s access to education, decent jobs and sufficient income. Limits can be placed on people’s overall opportunities, control over their lives, and access to resources as well as their ability to make well informed decisions over their lifestyle. Low literacy levels on behalf of the parent, may create difficulties in providing early childhood education, which in turn may impact overall child development. Individuals with low literacy skills are more likely to live and work in unsafe conditions and suffer the associated health consequences; in addition, they are more likely to experience a high degree of stress. Access to health services and health information may be limited for those individuals with low literacy skills due to their difficulties reading and understanding health information. They may be unaware of the services available to them and the process involved in gaining access to these services.

Seniors, immigrants, and Aboriginal people are three distinct groups that have been identified in having generally low literacy skills in Canada (Statistics Canada, 2003). In addition, individuals with learning disabilities, mental illness and those whose first language is something other than English are suggested to have poor literacy skills (Bowen, 2001). Awareness of such diverse groups is essential in supporting all the needs of the client.

Culture and language also play a role in the relationship between literacy and health (Rootman, 2004 http://www.centreforliteracy.qc.ca/publications/lacmf/vol17no2/8-10.htm) . Differing cultural groups view health and literacy differently; they have different experiences with literacy and health, as well, unique opportunities may arise for improving their literacy levels and overall health. Furthermore, language barriers may exist and provide a significant barrier in accessing medical services and health information (Bowen, 2001).  Culture and language can have a significant impact on health and literacy and should not be ignored. Results of the 2003 International Adult Literacy Skills Survey reported that 45% of adults who scored a level one (lowest level) on the literacy skills component were immigrants (IALSS, 2003). Further, the literacy performance by Aboriginal populations was significantly lower than the general population. This is of concern, indicating that literacy may be impacting the health of immigrants and Aboriginal Canadians considerably. Canada must take the impact of culture and language on health and literacy seriously.

In general, Canadians with low literacy have poorer overall health (IALSS and Statistics Canada, 2003). Low literacy puts an individual at risk for medication misuse and misinterpreted health information. Individuals with low literacy levels have been reported to make avoidable and unnecessary visits for medical services and wait longer to request medical attention. Not only do the negative impacts of low literacy levels put an individual at risk of poor overall health, they also add to the increasing health care costs.

Needless to say, literacy plays a significant role in an individuals overall health and this relationship must not be overlooked. It is important that health professionals have a clear understanding of the relationship between literacy and health so they can better help their clients. An awareness of the diverse groups with low literacy skills, including Aboriginals, seniors and immigrants, is important in providing appropriate health care services. It is hoped that this document will educate health care providers as well as the public surrounding the issues of literacy and health status and offer suggestions on how to better support the low literate population in Canada.

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Poverty, Literacy and Health

Poverty plays a significant role in both literacy and health (Literacy BC, 2005). Poverty can adversely affect literacy and vice versa.  Socio-economic factors such as poverty, pose a considerable barrier for learning. The early years of development play an enormous role in shaping the way an individual thinks, behaves and learns. Major foundations for learning are built in the early years of development, including major educational base in reading, writing, and arithmetic, but also major socialization skills and lifestyle practices (eating, smoking, hygiene, etc.). If these foundations are not established, individuals may have difficulties in many areas of their life in the future years.

 

Literacy and poverty are closely related elements that often occur in a continuing cycle. The lack of sufficient income often leads to the lack of adequate nutrition. Numerous studies have reported that children who go to school hungry have difficulty concentrating, which significantly impacts their ability to learn. Especially in the early grades, good concentration is key to establishing the foundations for reading, writing and mathematics skills. A child that misses those foundations is at a disadvantage as reading and writing become a central mode of teaching in the later years. Poor academic performance can lead to feelings of frustration, low self-esteem and high school drop out rates. Dropping out of school early has the potential to lead to low paying jobs, poverty and the associated health risks. This becomes a continuous pattern that is difficult for individuals to escape. (Goldsmith, 2002 http://www.canadian-health-network.ca/servlet/ContentServer?cid=1039795126850&pagename=CHN-RCS%2FCHNResource%2FCHNResourcePageTemplate&c=CHNResource&lang=En

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What is Literacy?

 

In Canada, there are numerous definitions for literacy as a result of the considerable changes over the past few decades.

According to United Nations Educational, Scientific and Cultural Organization (1970) “a person is functionally literate when he/she has acquired the knowledge and skills in reading and writing which enable him/her to engage effectively in all those activities in which literacy is normally assumed in his/her culture or group”.

 

The Centre of Literacy in Quebec defines literacy as “a complex set of abilities to understand and use the dominant symbol systems of a culture – alphabets, numbers, visual icons - for personal and community development. The nature of these abilities, and the demand for them, vary from one context to another.

It is an essential foundation for learning through life, and must be valued as a human right.” (Centre of Literacy, 2005) http://www.centreforliteracy.qc.ca/def.htm

The most commonly used definition of Literacy is that used by the International Adult Literacy Survey (IALS) and Health Canada that defines literacy as the “ Ability to understand and employ printed information in daily activities – at home, at work and in the community – to achieve one’s goals and develop one’s knowledge and potential” (OEDC & Statistics Canada, p.12, paragraph 1) http://www.centreforliteracy.qc.ca/health/finalsum/bd/backdoc.pdf

Essentially, the term literacy means more than the ability to read and write. Literacy involves the ability to communicate effectively in everyday life and the ability to search for and understand information.  It is with literacy skills that individuals can begin self-directed and self-taught learning. If the foundations for literacy development are for some reason not built at a young age, the impact may be felt in health status, social status, income, education, employment, and other areas.

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What is Health Literacy?

 

The United States Department of Health and Human Services defines health literacy as “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (http://www.hrsa.gov/quality/healthlit.htm)

Health literacy means more than just the ability to read and write. Health literacy includes the ability to read, write, speak, listen, talk, and obtain a level of conceptual knowledge regarding health information that allows an individual to make informed decisions to enhance their health.

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Canadian Literacy Statistics

In 2003, the International Adult Literacy and Skills Survey (IALSS) was conducted in Canada to measure the Canadian proficiency in four areas prose literacy, document literacy, numeracy and problem solving (Statistics Canada, 2003). Over 23,000 individuals from across all provinces and territories, aged 16 and over, participated in the 2003 IALSS. The same survey was administered in 1994 and generally, there has been little change in the literacy performance of Canadian adults between 1994 and 2003. The survey is scored based on a five level system. Level three in literacy is considered to be the desired threshold, or in other words, the minimum level in which an individual can understand and use information based on Canada’s ever changing knowledge society and information economy. Highlights of the 2003 International Adult Literacy and Skills Survey report are as follows:

  • 42% of Canadians aged 16 to 65 performed below the level three minimum on the literacy component of the survey. This amounts to approximately 9 million Canadians that are reading below the minimum literacy standard. When those aged 66 and over are included in the statistics, the proportion with low literacy increases to nearly one-half (48%).
  • The literacy performance by Aboriginal populations was significantly lower than the general population.
  • 82% of seniors 65 years and above scored below level three on the literacy component.
  • The proportion of individuals scoring at level one on the literacy component tended to increase with age.
  • Of the seven countries that participated in the survey, Canada was ranked third behind Norway and Bermuda in having the highest literacy skills.
  • 50% of Canadian adults who score a level one on the literacy component have less than a high school education and 12% were unemployed.
  • 45% of the Canadian adults who scored a level one on the literacy component were immigrants.
  • 28% of Canadian adults who scored a level two on the literacy component have less than a high school education and 8% reported to be unemployed.
  • Almost 21% of the Canadian adults who scored a level two on the literacy component were immigrants.
  • Adults who indicated their self-reported health status as poor health scored lower on the document literacy component of the survey.

For more detailed information on the results of the 2003 International Adult Literacy and Skills Survey, click on the following link http://www.nald.ca

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The Relationship between Literacy and Health Status

Literacy is an important skill in maintaining and promoting overall health. This is of concern when almost 50% of the Canadian adult population is not performing at the minimum literacy standard (Statistics Canada, 2003). The ability to communicate and learn via oral language as well as through text-based material is crucial in preventing, diagnosing and treating illness. Oral language is essential in communication between a patient and health care professional. The patient must clearly express their health concerns and describe their symptoms, in addition to understanding their treatment plan and being capable of voicing concerns and asking questions. Health promotion is frequently conducted via written text such as billboards, pamphlets, posters, etc. Therefore, the ability to read and understand such health promotion materials is essential in attaining and practicing health knowledge and health promotion behaviours.

The link between literacy and health status is complicated. Essentially, literacy directly impacts health knowledge, which in turn impacts health status and can make it difficult to access health-related services. It may be difficult for health professionals to assess the literacy level of their patients, as people with low literacy skills may be good at compensating for their lack of literacy. A document by Gilles (2005) for the Public Health Agency of Canada http://www.canadian-health-network.ca/servlet/ContentServer?cid=1059684393879&pagename=CHN-RCS%2FCHNResource%2FCHNResourcePageTemplate&c=CHNResource&lang=En  has highlighted factors associated with limited literacy skills. Knowledge of these factors is important as they can function as warning signs for health professionals. The following are factors or warning signs associated with low literacy levels and include:

  • Patient has difficulties speaking English.
  • Patient is an older adult/senior as many seniors did not have the opportunity to finish their education and have the highest rate of low literacy levels according to the 2003 IALSS.
  • Patient has not completed high school.
  • Live in poverty conditions and lack important resources such as income, social support, etc.
  • Patient avoids filling out medical forms and questionnaires.
  • Patient asks others to read materials for him/her or brings an individual with him/her to an appointment for the purpose of reading or translation.
  • Misunderstands medical directions/advice such as medication schedules, diet, frequency of medical visits.
  • Shows signs of frustration, confusion or anxiety while reading or being spoken to.
  • Frequently returns for health-related services.
  • Makes excuses about vision or other problems in order to avoid reading
  • Reads slowly and choppy with obvious effort.

Sufficient evidence exists to support the relationship between literacy and overall health status (Perrin, 1998; Goldsmith, 2002; Rootman & Ronson, 2003; Gilles, 2005). This relationship is an important matter and concerns all healthcare providers including physicians, nurses, psychologists, pharmacists, dentists, optometrists, etc. If communication between health provider and patient is not clear and instructions to the patient are not understood and/or helpful, patients are put at risk for potentially serious harm. Research has reported that Canadians with low literacy skills are more likely to have poorer overall health, lower life expectancy, and higher rates of chronic disease, compared to those Canadians with a high level of literacy (Perrin, 1998; Health Canada 2000; Statistics Canada, 2003).

Literacy effects health in both direct and indirect ways. The direct effects are probably the most obvious. However, the indirect effects of literacy on health are possibly less obvious, but can be potentially more profound.

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Direct Effects of Literacy on Health

 

It is well known that literacy is directly related to poor health status (Perrin, 1998; Roberts, & Fawcett, 1998; Goldsmith, 2002; Gilles, 2005).

Incorrect use of medications - Low literate patients are at highest risk of harm as a direct result of the inability to read and understand prescription information, food labels, safety warnings, or any text-based instructions. Incorrect use of medications, including prescription dose and compliance is of major concern for patients with low literacy levels. Incorrect use of medication may be a result of the inability to read or comprehend the doctor’s instructions or the instructions on a prescription bottle.

Inability to comply with medication regimes may be a result of the inability to understand verbal instructions and/or the inability to read and understand text-based instructions. In addition to putting the patient at risk of harm, poor medication compliance adds a cost to drug benefit plans and medical insurance companies when prescriptions are misused.

Seniors are at high risk of poor medication compliance due to the high percentage of low literacy seniors in Canada (Statistics Canada, 2003). Seniors typically take more than one medication prescribed by more than one doctor, thereby adding to the risk of information confusion.

A study by Kalichman, Ramachandran and Catz (1999) investigated whether literacy ability is a predictor of medication compliance for HIV and AIDS patients. Their finding identified that individuals with low literacy skills were more likely to miss their antiretroviral medication doses compared to individuals with higher literacy skills.   

Safety risks in the home, the community and the workplace also pose a concern for individuals who have poor literacy skills. Individuals with difficulties reading and comprehending precautions, safety warnings and instructions for proper use such as on chemical labels, mechanical equipment, household electrical appliances, etc. are at risk of harming themselves and others (Health Canada, 2003 - Perrin, 1998).

Difficulties accessing health information and medical services are also directly affected for those individuals with low literacy levels. Individuals with poor literacy skills have reported difficulties accessing health information and medical services. Health information and educational materials are primarily presented in text-based printed format. Typically, health information is written at a grade ten or higher reading level, making it very difficult for low literacy level individuals to understand (The Centre for Literacy of Quebec, 2001). A study by Gilles & Quigley (2004) reported interview responses expressing how low literacy skills reduced access to required health care services. Between the abundance of information and resources available on the Internet, or in books or magazines, people are able to seek advice or gather health-related information without the direct help of a medical professional. Such materials include self-help books and “how to” guides for example. For individuals in rural and remote communities where there is limited access to health professionals, these self-accessed resources play a vital role in health education. For those individuals with low literacy skills, the benefits of such materials are reduced and possibly non existent.

Individuals with difficulties in literacy may find it difficult to navigate through the health system. For example, they may have trouble finding the correct department, asking for referrals and they may not be knowledgeable in all services available.

A study by Parker et al (2003) reported that individuals with a low level of literacy have less knowledge of general health conditions and treatment procedures as compared to individuals with a higher level of literacy. This study reinforces the impact that literacy can have on accessing health information and medical services. Individuals with difficulties accessing services and health information are going to be less knowledgeable in health-related symptoms, prevention, disease and treatment.

Reduced Health Service Utilization by low literate individuals has been reported in a number of studies (Scott, Gaznararian, Williams, & Baker, 2002; Woloshin, Schwartz, Katz, & Welch, 1997). People with low-literacy levels tend to use less preventative services such as blood pressure checks, PAP tests, compared to individuals with higher literacy levels (Scott et al, 2002). A study conducted on 22,448 women in Ontario concluded that women whose main language was one other than English were less likely to receive important preventative health services such as breast examination, mammogram and PAP tests (Woloshin, Schwartz, Katz, & Welch, 1997). This is of concern as many conditions can be avoided and/or disability can be significantly reduced when early identification practices and treatment are utilized. Appropriate and timely utilization of medical services may be reduced in low literacy individuals. Some low literacy individuals may use health related services more frequently, however some may wait the longest possible to seek medical attention, resulting in worse health and added health care costs.

Although data is limited in both Canada and the United States, given the current research, the Institute of Medicine (2004) suggests that a relationship is present between low literacy levels, health care utilization and health care costs in the United States.

Difficulties effectively interacting and verbally communicating with health care professionals are another direct effect of poor literacy skills (Woloshin, Schwartz, Katz, & Welch, 1997; Perrin, 1998; Rootman, 2004). One contributing fact to difficulties interacting and communicating between a patient and health care professional is the presence of a language barrier. If the patient and health care professional do not speak the same language clearly and understandably, difficulties may arise in effectively communicating.

Summary of Direct Effects of Literacy on Health Status

  • Difficulty understanding and using health information such as advise on self-care, medication instruction, safety warnings and food labels.
  • Difficulty accessing medical services, both preventative and acute care services.
  • Difficulties interacting and communicating with health care professionals.

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Indirect Effects of Literacy on Health

Individuals with limited literacy skills often have reduced access to well-paying jobs. In turn, they are at greater risk of poverty and its associated stress and health risks (Health Canada, 2003; Perrin, 1998; Gilles, & Quigley, 2004). Literacy has an indirect impact on an individuals living and working conditions. Low-literacy individuals are more likely to work in dangerous and possibly unsafe environments compared to individuals with strong literacy skills (Statistics Canada, 2003). A Roberts & Fawcett (1998) reports from the indicated that between 22-50% of adults with low literacy skills live in low-income households compared to 8% of high literacy adults.

Research suggests that literacy is related to personal health practices and lifestyle (Perrin, 1998; Goldsmith, 2002). People with low literacy levels are less likely to practice home safety practices and take part in physical activity. Further, low-literate individuals are more likely to smoke and have a poor nutritional diet (Goldsmith, 2002; Health Canada, 2003).

Literacy has a significant impact on education and income (Statistics Canada, 2003). In Canada, the most effective predictor of the level of literacy an individual possesses is their level of educational attainment. In general, the longer an individual has attended school, the higher their literacy score. Because literacy is an important factor in employability, literacy increases career opportunity and reduces the chances of an individual being unemployed since it is a requirement for many jobs. Further, high literacy skills have been positively correlated with higher employment earnings (OECD & Statistic Canada, 2000) and conversely, individuals with limited income have been reported to be more likely to have limited literacy skills (Weiss, 1994). There is a strong relationship between literacy and education, income and employment. Canadians with high levels of literacy are more likely to have a higher life expectancy, be employed and live in a safe and secure neighborhood (Health Canada, 2000 http://www.canadian-health-network.ca/servlet/ContentServer?cid=1057876015677&pagename=CHN-RCS%2FCHNResource%2FCHNResourcePageTemplate&c=CHNResource&lang=En

Individuals with low literacy skill levels are more likely to live in low quality housing, work in unsafe work conditions, experience high stress, take part in less physical activity, lack a secure food supply and experience feelings of isolation and social exclusion (Health Canada, 2000; Gilles, & Quigley, 2004).

Literacy skills provide an individual with the opportunity to make informed decisions about where they want to live and how to go about making the change and protecting themselves from potential hazards. Individuals with low literacy skills have been reported to have increased smoking rates (Health Canada 2000), decreased physical activity (Health Canada, 2000), increased T.V. watching (Statistics Canada, 2003), increased stress and feelings of isolation and social exclusion (Perrin, 1998; Gilles, & Quigley, 2004) and poorer diet (Health Canada, 2000) compared to individuals with high literacy skills.

Summary of Indirect Impacts of Literacy on Health:

  • Living in poverty
  • Living in low quality housing
  • Working in dangerous and unsafe environments
  • Feelings of isolation and social exclusion
  • Experience less physical activity
  • Eat poor diet
  • Experience frequent high stress
  • Barriers in nurturing healthy child development

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Seniors and Literacy

Low-literate seniors are a high-risk group for decreased health status as seniors tend to have higher rates of low literacy (Statistics Canada, 1995; Roberts & Fawcett, 1998). The 2003 International Adult Literacy and Skills Survey (IALSS) indicate that 82% of Canadian seniors, aged 65 and older, have literacy skills lower than the minimum level to function effectively in Canada’s knowledge and information based society (Statistics Canada, 2003). This is a concern for health professionals as seniors may not understand the advice or instructions health professionals provide. Further, due to their low level of literacy skills, Canadian seniors may not have the language skills necessary to ask important questions or voice significant concerns. Seniors are at high risk of medication errors as many seniors take more than one type of medication prescribed by more than one physician. According to Tamblyn & Perreault (1998), seniors make up approximately 12% of the Canadian population and they receive between 28-40% of all prescriptions (Tamblyn, & Perreault, 1998). Medication non-compliance is expected to become an even bigger problem as baby boomers age and require more medications. Low literacy levels of seniors is an important factor to consider in the health care setting. It is important that seniors be part of the decision-making process that involves their treatment procedures and health concerns. Further, extra effort may be required to communicate the medication regime and follow up on compliance.

Health Canada has created a medication kit that outlines techniques to improve communication between health providers and seniors specifically directed at how to help seniors use their medication safely. The following are a selection of techniques offered to help seniors understand their medication regime as well as administer it safely:

Use clear verbal communication

Use common words

Frequently check to see if the patient understands

Organize the information

Couple verbal communication with written information

Explain to the senior what it means by “take as directed”

Explain the physical characteristics of the pills when talking about a specific medication

For more detailed information refer to the Health Canada document at http://www.phac-aspc.gc.ca/seniors-aines/pubs/med_matters/pdf/med_matters_e.pdf

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Immigrants and Literacy

The most recent census data indicates that approximately 18.4% of Canada’s population is immigrants (Statistics Canada, 2005).

According to the 2003 International Adult Literacy Skills Survey, Canadian immigrants tend to have lower literacy scores than the general Canadian adult population (Statistics Canada, 2003). This is understandable considering for many immigrants, English may not be their language of origin and thereby they may have difficulties communicating and understanding. In some instances, words and thoughts in another language and culture are not able to be directly translated in English to result in an identical meaning. Therefore, it is important that Canadians attempt to meet the diverse health needs of Canada’s newcomers by providing translated and culturally appropriate health materials, if possible. In addition, literacy support specifically directed at the immigrant population may help raise the literacy level in this population.

Literacy is an important issue for immigrants in Canada because poor literacy skills have been linked to adverse outcomes in education, income, employment and health status (Goldsmith, 2002; Statistics Canada, 2003). Literacy plays a significant role in employment success and contribution toward community economic development. Individuals with low literacy skills are more likely to be unemployed, work under poor working conditions for a low wage, and live in low income households, compared to individuals with high literacy skills (Canadian Council on Social Development, 1998).

Literacy education designed specifically for Canadian immigrants, is essential in integrating newcomers into Canadian society. Proficient literacy skills among Canada’s immigrant population would allow for easier access for services, education and employment opportunities, and in turn, improvement in overall health status.

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Aboriginals and Literacy

Aboriginal health status, education levels and literacy rates are considerably different than the overall Canadian population (Statistics Canada, 2003; Perrin, 1998). It is well published that the health of Aboriginal Canadians is significantly worse than the general population on a large number of health measures. The educational attainment and level of literacy skills are also significantly lower than the overall Canadian population. Interestingly, research has demonstrated the strong link between education and literacy skills, and overall health status (See the Health and Literacy Section). Therefore, education and literacy may be playing a considerable role in the poor overall health status apparent in the Aboriginal populations in Canada. Research specific to education, literacy and health status among the Canadian Aboriginal population is scarce and urgently needed.

According to the Aboriginal People Survey 2001, the percentage of Aboriginals with less than a high school education has declined in the past 5 years, meaning that more Aboriginal people are finishing secondary school. The percentage of First Nations with less than a high school education has remained the same at 52% between 1996 and 2001. However, the percentage of Inuit between the ages of 20-24 with a high school education has decreased from 66% in 1996, to 59% in 2001. The percentage Métis with less than a high school education of the same age group dropped from 47% in 1996 to 42% in 2001 (Statistics Canada, 2003).

Aboriginal postsecondary enrollment, retention and completion rates are significantly lower compared to the non-Aboriginal Canadian population (Malatest, 2002). A number of barriers have been identified with respect to Aboriginal participation in post secondary education. These include, 1) distrust among the Aboriginal community towards the education system as a result of residential school and other historical events, 2) lack of preparation at the elementary and secondary level, 3) feelings of social discrimination, isolation and loneliness when attending post secondary institutions, 4) financial barriers, 5) lack of knowledge of Aboriginal traditions and cultures at the post secondary level, and 6) family responsibilities that make attending school difficult (Malatest, 2002).

Academic preparation at the elementary and secondary level is essential in setting up success at the post-secondary level. Studies have shown that Aboriginal students are not on par with their expected grade level and are showing poor academic progress at the elementary school level (Minthorn-Biggs, 2004; Hull, Philips, Polyzoi, 1995).

Research into Canadian Aboriginal literacy levels is limited. The 2001 International Adult Literacy Skills Survey indicated that the literacy scores of Aboriginal adults are significantly lower than scores of the general Canadian population (Statistics Canada, 2003). This is of serious concern as research shows that the lower level of literacy an individual has the poorer their health status (Perrin, 1998).

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Literacy and the Disabled

Although research on the literacy levels among individuals with disabilities is limited, it has been reported that individuals with disabilities have generally low literacy levels compared to individuals without a disability (Statistics Canada, 2003; Kapsalis, 1999). Many disabilities can considerably eliminate or impede an individual’s capability to learn the foundations of reading, writing and communication. Therefore, these individuals are at greater risk for poor literacy development. Barriers to literacy development have been investigated among individuals with disabilities. Lack of assessable literacy programming, learning disabilities, environmental barriers, negative personal emotion and the disapproving attitudes of others have all been expressed as barriers to literacy among the disabled (Carpenter, & Readman, 2004; Neil Squire Foundation, 1999).

Statistics Canada (2003) has reported that approximately one in seven Canadians over the age of 15 years have a disability. The disability rate is even higher in the Canadian Aboriginal population, where approximately one in five have a disability. The overall Canadian disability rate is approximately 12.4%, representing 3.6 million Canadians (Statistics Canada, 2003).

A study by Kapsalis (1999) investigated the effects of disability on Literacy using data from the International Adult Literacy Skills Survey. This study indicated that 77% of individuals with learning disabilities and 48% of individuals with physical disabilities function at a literacy level below the level 3 minimum Canadian standard (Kapsalis, 1999). To read the entire document, visit the following website http://www.nald.ca/lil/english/litinfo/printdoc/effect/effect.pdf

Moreover, individuals with a disability have been reported to have a higher proportion of individuals with less than a grade nine education (Rioux, Zubrow, Stutt Bunch, Millar, 2003), have a lower income (Rioux, Zubrow, Stutt Bunch, Millar, 2003), live in a low-income households and have lower paying jobs compared to the general population (Macht, 2000). Although a causal relationship can not be assigned to these links, one can suggest that low literacy is a contributing factor. Low literacy rates among the disabled Canadian population is of concern due to the strong link between low literacy level and poor overall health status.

A study by Carpenter & Readman (2004), investigated the barriers to literacy activities facing people with physical disabilities. Twenty seven participants of diverse disabilities were involved in the study. A number of barriers were identified. Firstly, the majority of participants expressed a series of negative emotional responses when questioned about their literacy competence. Feelings of low self-worth, shame, embarrassment are examples of the emotions articulated. Secondly, 46% of participants expressed how the attitudes of others influences their access to programs, information and technology. Negative labels were placed on many individuals, giving them low expectation and value. 77% of participants indicated they had a negative experience at elementary and/or high school. School was a difficult place to learn for most and sometimes teachers were unable to help. Many participants voiced the important link between literacy and opportunity for education, employment, reclaimed self-esteem and communication. The literacy ability among these participants was poor. 92% of participants indicated they have difficulties with the technical components of reading and comprehension. 88% expressed difficulties in writing. This study indicated that individuals with physical disabilities may have literacy needs that are often overlooked and comparable to other marginalized populations.

For more detailed information about the study, refer to the full report at the following link. http://www.nald.ca/lil/english/litinfo/printdoc/barriers/barriers.pdf

The following links below are Canadian literacy and disability reports that provide more comprehensive information regarding the disability and literacy situation in Canada.

Macht, J. (2000). Literacy and Disability. http://www.nald.ca/fulltext/litdis/litdis.pdf

Tips for Communicating with people who are Hard of Hearing.
http://www.nald.ca/ava/english/textonly/aboutTO/4.htm

Tips for Communicating with people who are visually impaired.
http://www.nald.ca/ava/english/textonly/aboutTO/5.htm

Hornberger, C. (2003). Literacy for Persons with Disabilities.
http://www.nald.ca/fulltext/Lit4Dis/Ritread/RitRead.pdf

For facts on Literacy and Disability, visit the Literacy Alberta website at http://www.literacyalberta.ca

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What can Health Professionals do?

Recognize that literacy is a major health issue and create a respectful and accommodating environment for people with low literacy skills.

Develop partnerships with local literacy organizations.

Train staff on how to identify and refer patients to literacy services.

Write clearly in an easy-to-read format when using text-based materials.

Look for ways to make health information more user-friendly and easier to access.

Ensure health education is provided through multiple modalities (written, pictures, verbal) in a manner that is simple and easy-to-read/understand.

Make sure the patient understands the information the health professional is providing.

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Reports, References and Websites

1. Rootman, I., Gordon-El-Bihbety, D., Frankish, J., Hemming, H., Kaszap, M., Langille, L., Quantz, D., Ronson, B. (2004) .The National Literacy and Health Program Needs Assessment and Environmental Scan. Available at http://www.nlhp.cpha.ca/clhrp/needs_e/needs_e.pdf

2. Rootman, I., & Ronson, B. (2005). Literacy and Health Research in Canada. Available for review at http://www.nlhp.cpha.ca/lithlthe/lithlth.pdf

3. Rootman, I. (2004). Critical Issues in Literacy and Health. Available at
http://www.centreforliteracy.qc.ca/publications/lacmf/vol17no2/8-10.htm

4. Bowen, S. (2001). Language barriers in access to health care, Ottawa: Health Canada. Website unavailable

5. Gilles, D., Quigley, A. (2004). Taking off the Blindfold: Seeing how literacy Effects Health: A Report of the Health Literacy in Rural Nova Scotia Research Project. Available at
http://www.nald.ca/healthliteracystfx/pubs/takngoff/takngoff.pdf

Summary:

The Health Literacy in Rural Nova Scotia Research Project explored the relationship between health and literacy in three counties in rural Nova Scotia. The objectives of the project was to 1) learn about how adults with low literacy skills use health information and services and 2) find strategies for change that build on the services and supports currently available in the communities. A total of 46 adults were interviewed and ranged in age from 18-55 years. Several major themes were identified from the interviews with the 46 study participants. These included

  • Social isolation,
  • Lack of transportation
  • Limited opportunities for employment, recreation, health care, education and social support.

The interview responses in this study demonstrated the broad impacts that low literacy levels can have on an individual’s life, health and daily functioning. Participants expressed how their low literacy levels reduced their access to health services that they need, in addition to medical advice and health information. The links between literacy and education, employment, economic and social status and health were repeated consistently. The stories of the participants in this study reinforced the evidence that literacy influences an individual’s physical, mental and social well-being.

As a result of the interview responses, a number of priorities were set to help improve the situation in rural Nova Scotia.

  • Increase awareness and support for literacy
  • Reduce barriers to attending literacy programs
  • Early identification and intervention of learning disabilities
  • Address the impact of physical and emotional health on learning
  • Support reading program and children’s literature in schools
  • Increased awareness of literacy among health professionals and service providers
  • Make health information more assessable to everyone
  • Utilize pharmacists to provide oral instructions
  • Community initiatives to reduce poverty
  • Support the health care needs of those with limited income
  • Ensure that children have healthy, supportive and secure environments to develop
  • Increase funding for early prevention programs in health and education
  • Support Family literacy programs
  • Address social exclusion and isolation when planning programs and services

6. Perrin, B. (1998). How does literacy affect the health of Canadians? A profile paper. Presented to Health Canada. Website Unavailable

7. Roberts, B. & Fawcett, G. (1998) At Risk: A Socio-economic Analysis of Health and Literacy among seniors. Available at http://www.nald.ca/FullTEXT/nls/ials/atrisk/cover.htm

8. The Vaniar Institute of the Family. (1998). Literacy: the family role in a learning culture. Available at
http://www.vifamily.ca/library/transition/281/281.html#5

9. Goldsmith, A. (2002). A vital Link: How literacy Influences Health. Available at
http://www.canadian-health-network.ca/servlet/ContentServer?cid=1039795126850&pagename=CHN-RCS/CHNResource/CHNResourcePageTemplate&c=CHNResource&lang=En

10. The Canadian Public Health Association - National Health and Literacy Program Website is available at http://www.nlhp.cpha.ca/

11. Gilles, D. (2005). Beyond Words: The Health-Literacy Connection at http://www.canadian-health-network.ca/servlet/ContentServer?cid=1059684393879&pagename=CHN-RCS/CHNResource/CHNResourcePageTemplate&c=CHNResource&lang=En

12. Perrin, B. (1998). How does literacy affect the health of Canadians? A profile Paper. Ottawa: health Promotion and Programs Branch, Health Canada. Website Unavailable

13. OECD & Statistics Canada. (2000). Literacy in the Information Age: Final Report of the International Adult Literacy Survey. Ottawa: Statistics Canada. Available at www.oecd.org

14. Rootman, I., & Ronson, B. (2003). Literacy and Health Research in Canada: Where have we been and where should we go? Available at http://www.ualberta.ca

15. Roberts, P. & Fawcett, G. (1998) At Risk: A Socioeconomic Analysis of Health and Literacy among Senior. Statistics Canada. Available at
http://www.nald.ca/FullTEXT/nls/ials/atrisk/atrisk.pdf

http://epe.lac-bac.gc.ca/100/200/301/statcan/intl_adult_literacy_89-552-e/no05/89-552-MIE5.pdf

16. Kalichman, S., Ramachandran, B., Catz, S. (1999). Adherence to Combination Antiretroviral Therapies in HIV Patients of low health literacy. Available athttp://www.blackwell-synergy.com/doi/abs/10.1046/j.1525-1497.1999.00334.x

17. Weiss BD, Blanchard JS, McGee DL, Hart G, Warren B, Burgoon M, Smith KJ (1994).Illiteracy among Medicaid recipients and its relationship to health care costs. Journal ofHealth Care for the Poor and Underserved, 5(2):99-111.

18. Parker RM, Ratzan SC, Lurie N. Health literacy: A policy challenge for advancing high quality health care. Health Aff 2003;22(4):147.

19. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40(5):395-404.

20. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press, 2004.

21. Organization for Economic Co-operation and Development, Statistics Canada. Literacy, Economy and Society: Results of the First International Literacy Survey. Organisation for Economic Co-operation and Development – Paris, Minister of Industry – Ottawa, 1995.

22. The Centre of Literacy of Quebec. (2001). Health Literacy Project, Phase 1: Needs Assessment of the Health Education and Information Needs of Hard-to-Reach Patients Part 1 Background Document on Literacy and Health.
http://www.centreforliteracy.qc.ca/health/finalsum/bd/backdoc.pdf

23. The Canadian Public Health Association provides a series of courses on Literacy and Health issues directed at health professionals as well as the general public. For more information about these courses and how to access them, please see the Canadian Public Health website.

24. Literacy and Health: A Manitoba Perspective is available for review at http://www.mb.literacy.ca/publications/lithealth/ack.htm

25. Woloshin, S., Schwartz, L., Katz, S., & Welch, G. (1997). Is language a barrier to the use of preventive services? Available at
http://www.blackwell-synergy.com/doi/abs/10.1046/j.1525-1497.1997.00085.x

26. Tamblyn, R., Perreault, R. (1998). Encouraging the Wise Use of Prescription Medications by Older Adults. In Canada Health Action: Building on the Legacy. Papers Commissioned by the National Forum on Health, Volume 2: Determinants of Health—Adults and seniors), Sainte-Foy, Québec: Editions MultiMondes, 213–285.

27. Kalichman, S., Ramachandran, B., Catz, S. (1999). Adherence to combination antiretroviral therapies in HIV patients of low health literacy. Journal of General Intern Medicine, 14, 267-273. Available at http://www.blackwell-synergy.com/links/doi/10.1046/j.1525-1497.1999.00334.x/full/

28. Canadian Council on Social Development. (1998) The Value of Words: Literacy and Economic Security in Canada.

29. Movement for Canadian Literacy. (2004). Literacy in Canada: It’s time for action. Website Unavailable

30. Carpenter, & Readman. (2004). Barriers to participation in Literacy activities facing people with physical disabilities. National Literacy Secretariate.
http://www.nald.ca/lil/english/litinfo/printdoc/barriers/barriers.pdf

31. Kapsalis, C. (1999). The effect of disability on literacy skills. Nepean, ON: Data Probe Economic Consulting Inc. Available at http://www.nald.ca/lil/english/litinfo/printdoc/effect/effect.pdf

32. Neil Squire Foundation (1999). A Pan Canadian study significant disabilities. Vancouver

33. Rioux, M., Zubrow, E., Stutt Bunch, M., & Millar, W. (2003). Atlas of literacy and Disability. Canadian Abilities Foundation; Toronto.

34. Shohet, L. (2002). Health and Literacy: Perspectives in 2002. Available at
http://www.staff.vu.edu.au/alnarc/onlineforum/AL_pap_shohet.htm

35. Bow Valley College and Neil Squires Foundation. (2005). Learner Stories: Literacy and Disabilities Study. Available at http://www.nald.ca/ava/english/litinfo/print.htm

Canadian Literacy and Health Websites

Literacy Alberta
http://www.literacyalberta.ca

Movement for Canadian Literacy
http://www.literacy.ca/

National Adult Literacy Database
http://www.nald.ca

ABC Literacy Foundation Website

Literacy Partners of Alberta
http://www.mb.literacy.ca/resources/intro.asp

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