22 March 2008

"Flush tissue with stool": the problem of low health literacy in Canada

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information. ~ How low literacy can affect your health (Canadian Council on Learning)

Last January I wrote about a particularly atrocious example of patient information, a poop test brochure, which, among other things, advised the reader to "flush tissue with stool." Have you ever tried flushing a toilet using a stool, let alone trying to repeat the step "on the next two subsequent bowel movements?" It's not easy, let me tell you.

Every time some hapless patient is forced to struggle through the opaque vocabulary and convoluted syntax of the Coloscreen brochure published by Helena Laboratories in Beaumont, Texas, you can almost see the illiteracy ratio and mortality rate starting to rise on the charts. Whoever wielded the applicator stick that smeared this rank prose specimen into print has a lot to answer for, as has the Winnipeg health clinic that decided it was appropriate to give to patients [1]. For we have become a country of the reading challenged, where even Robert Service's unpretentious, galumphing strophes, which my Grade 4 class once recited with pleasure, are becoming artifacts of another age. For school kids hooked on Halo and Twitter, The Cremation of Sam McGee will soon be as obscure as Horace's Alcaics; although I see that someone has posted a video of McGee on YouTube. Perhaps this will become a trend: literary works preserved for the print-allergic population as YouTube presentations — bardic recitation in the digital realm. An abomination like the poop test brochure is not the kind of challenge we really want. A health brochure's business is to communicate important facts that will help guide a person to make good health decisions. How did we reach such an impasse: that we can produce neither texts that communicate nor readers who comprehend them?

A vision for a health literate Canada
This month another study is bringing bad news about Canadians' ability to read. "Low health literacy is a serious and costly problem," says a recent report from the Canadian Public Health Association. A vision for a health literate Canada was released on March 3, 2008. A CPHA Expert Panel found that a majority (more than 55%) of Canadian adults do not have the skills to understand information about their own health or to make daily health-related decisions. The low levels of health literacy in Canada are "critical" and a countrywide strategy is needed to solve the problem.

The panel's findings were drawn from a 2003 analysis of 23,000 Canadians by the Canadian Council on Learning, which offers its own take on the problem in a March 6 report on its website, How low literacy can affect your health. See also another CCL report dated February 28, 2008, Health literacy in Canada: a healthy understanding.

Videosphere vs. Graphosphere
What is the nature of this literacy problem, which is certainly not unique to Canada? It seems likely that Fahrenheit 451's flame throwers will never be required. As young people's desire to read is assiduously burned off in what Régis Debray calls the era of the videosphere, and as cultural and political discourse becomes increasingly infused by and confused with the ruminant world of the cartoon or the video game, elites will not crease their linen worrying about proletarian revolution. In a typically quirky but thought-provoking essay published in the New Left Review [2], Debray laments the loss of the graphosphere, the era of printing that made possible the Enlightenment and progressive social change. In his schema this passing age is being replaced by the era of the image, the videosphere, in which the book is knocked off its pedestal and replaced by widescreen, gridlinked digital culture. Debray offers an arresting image of the possible political consequences of the drift from the printed word to digital prattle:
A practical example: to find out what is going on one has to watch TV, and so stay at home. A bourgeois house arrest, for beneath "a man’s home is his castle" there always lurks, "every man for himself." The demobilization of the citizen begins with the physical immobilization of the spectator.
Very much like Ray Bradbury's dystopia. And today's video-capable mobile devices could act like a digital equivalent of ankle bracelets to keep our minds virtually immobilized. According to Debray, the Internet, its access devices, and the jet plane are good for internationalization, but they are lethal for progressive politics and international solidarity. They enlarge the sphere of individual relations but privatize them at the same time; they particularize even as they globalize. And it is the isolated, atomized individual who makes the ideal consumer and the credulously passive subject of the state.

A digression: lexemes and publishing extremes
Strange, then, that even as some thinkers mourn the loss of literacy and the end of solidarity, consumers at all levels of the literacy scale are buying extraordinary amounts of reading material, some of it even subversive of the ruling order. I find it difficult to reconcile the massive size of the English-language publishing industry and the continuing problem of low literacy. To illustrate, a brief note by Daniel Soar in the London Review of Books for 7 Feb 2008 cites the annual turnover of the British publishing industry as £2.8 billion. That's 900,000 books flying off British bookshop shelves every day, or one book for every nine loaves of bread sold in the UK. A lot of bread, however you look at it. In Canada book sales are healthy as well. The overall value for Canadian consumer book sales for 2006 was $1.59 billion. The Association of American Publishers reported that U.S. publishers had net sales of $25 billion in 2007. Book sales were up 3.2% over 2006, with a compound growth rate of 2.5% per year since 2002.

The average person has never been so well educated. Look at the size of an adult's working vocabulary today. According to the linguist David Crystal [3] it's 50,000 words. That represents the average adult's active vocabulary in present-day Britain. The estimate of passive vocabulary (words that can be recognized but would not be used in speech or writing) is roughly 25 per cent larger. Modern vocabularies are simply enormous. There are approximately 400,000 lexemes (actually differing words, not including various forms of the same word) in the Oxford English Dictionary which make up Modern English vocabulary. A reasonably well-educated person with a working vocabulary of about 50,000 words is thus actively employing about 12 per cent of the word stock of the language. By comparison, Shakespeare was working with a word stock of 150,000 lexemes. The size of his vocabulary is approximately 20,000 lexemes. This means that Shakespeare was using something over 13 per cent of the total word stock available to him. That total was probably much higher than his contemporaries, and it was certainly well ahead of the linguistically conservative King James Bible, which has only 8,000 lexemes. But it's extraordinary to think that the average educated working person in most English-speaking countries has a larger active vocabulary than the Bard himself. Obviously social status plays an important role here, something that Crystal does not discuss. Those buyers of books and users of dictionaries are less likely to be from the low-income strata of society.

Health literacy facts
But let's get back to the facts about health literacy. Whatever we may think of Debray's lofty theorizing and the remarkable vocabularies of the average adult, the fact remains that four out of ten Canadians still struggle with low literacy. And we have solid research to show how this affects the health of Canadians. What do we now know about the state of health literacy in this country?
  • 11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs. (CCL, 2007)

  • When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale, which is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information. (CCL, 2007).
  • Canadians aged 16 to 65 who rate their health as excellent or very good have the highest levels of proficiency in health literacy. People who rate their health as fair or poor have the lowest levels of proficiency. People with the lowest health literacy skills are more than three times as likely to report fair or poor health. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)
  • A recent American study examined mortality rates of a group of 3,260 adults over age 56 in four metropolitan areas and found that those with inadequate and marginal health literacy levels had a 50% higher mortality rate over a five-year period than those with adequate skills. Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

Dr. Irving Rootman, chair of CCL's Health and Learning Knowledge Centre and co-chair of the expert panel, provides the following grim statistics in his PowerPoint presentation: Health Literacy and Public Health [PPT]:
  • Over 800 studies have found that health-related material for patient education far exceeds the reading levels of the average adult.
  • A recent study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11.

  • Low health literacy is a barrier to effective self-management of chronic disease. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management.

Despite the excellent work of CPHA and CCL, I'm afraid I don't have much hope that our literacy rates will greatly improve without serious social change. After all, quickly sending their own clear message about the depth of their commitment to such change, the Conservative government wasted no time in cutting nearly $20 million from adult literacy programs back in 2006. The unerringly empathetic John Baird, the minister overseeing the cut, explained at the time: "I think if we're spending $20 million and we have one out of seven folks in the country that are functionally illiterate, we've got to fix the ground floor problem and not be trying to do repair work after the fact." Funny, but I thought doing gimcrack repairs was the government's answer to most of Canada's social problems — either that or just cutting costs and programs outright, at least the type that don't get noticed at a G8 summit. One of Harper and Co.'s bright ideas for fixing the ground floor problem of health literacy has been to cut the Canadian Health Network website, which specializes in plain-language consumer health information. By the way, CHN has a good article on Canadian health literacy: Beyond words: the health-literacy connection. But you'd better look now, because whether you can read or not, it won't be available from CHN come April Fool's Day.

The role of the media
The media aren't much help either. For all their health beats, ambulance chasing, and obesity scares, by excluding or marginalizing other perspectives — notably, a more explicitly political analysis of the origins of illness — the media play a significant part in actually narrowing public debate about health, illness and medicine, and they are not helping to fix Mr. Baird's ground floor problem either. A Social Science and Medicine article [4] that looks specifically at Canadian newspapers goes on to conclude:
The absence of any discussion about social gradients in health indicates that newspapers do not find the central observation driving the population health perspective in public policy newsworthy. Even the stories that we have classified as being concerned with the social environment largely fail to discuss broad issues of the welfare state in relation to health—housing and housing policy, child development and related issues of education and child care, the social relations of work environments (as opposed to exposures to physical hazards), community design and urban infrastructure, etc. Implicit in the obsession with issues of health care is the notion that this aspect of the welfare state is singularly important to maintaining and improving human health. Debates as to whether investments in the health care sector come at the expense of investments elsewhere within the welfare state (in education, housing, income supplementation, etc.) rarely appear in Canadian newspapers. Newspapers appear to do little to advance levels of critical health literacy on broad determinants of health in Canada.
A tissue of equivocations
If we are to avoid the bourgeois house arrest of Régis Debray's isolated, passive consumers of the videosphere, we must not approach the issue of health literacy in passive isolation. It is well known that the determinants of literacy include: education, early childhood development, aging, living and working conditions, personal capacity/genetics, gender and culture [5]. These are basically the same as the social determinants of health. Literacy should be framed within an empowering paradigm that highlights opportunities and choices for people. Unfortunately, the way the media deal with the issue has been devoid of empowerment. The blatant fostering of disease-laden imagery (e.g., “stamping out the epidemic of illiteracy”) is one such counterproductive example. It is not helpful either when literacy is promoted — wittingly or unwittingly — as the predominant solution to Canada’s economic woes. What the public often gets from journalists and politicians is a tissue of equivocations.

Literacy or the lack of it should not be separated off from its social context. Nor can the solution to poor literacy be found in some bureaucratic, gimcrack program. Perhaps John Baird was right. We should stop throwing money into programs that are not truly connected to broader efforts to change the determinants of health. But he is wrong to think that anything will change without a radical program to reduce social and economic inequity in Canada.

Like the problem of homelessness in Canada, the baleful reality of illiteracy has been studied very thoroughly. As many experts familiar with the facts will admit, we have known for years what the reports are telling us over and over again. Is it any surprise, for example, to be told that "daily reading appears to be a strong determinant of health literacy?" Good heavens, Francis Bacon was saying that "reading maketh a full man" four centuries ago.

The recommendations of the most recent report are what one might expect: we need a comprehensive, coordinated, cooperative, and integrated pan-Canadian strategy on health literacy, involving all levels of government. We also need educators, bureaucrats, and health professionals who are able to communicate in plain language [6]. And, as always, more research is required. There is nothing new here. Rather than more paper, Canadians need leadership that is truly responsive to people's needs, with the political will to increase social inclusion, reduce income disparities, and uphold everyone's right to equitable health care, housing, education, and employment opportunity. As the Expert Panel conclude, "The question is: are we willing as a country to make the investment that is required to create a health literate Canada?"

Test your health literacy (from the Canadian Council on Learning website)

Can you correctly answer this example question?

Imagine your child is 11 years old and weighs 85 pounds. According to the chart below, how many 80 mg tablets of Tempra can you administer to your child in a 24-hour period and in what dosage?


1. Rootman I. Health literacy: where are the Canadian doctors? CMAJ. 2006 Sep 12;175(6):606.

2. Debray R. Socialism: a life-cycle. New Left Review. 2007 Jul-Aug;46:5-28.

3. Crystal D. The stories of English. London: Penguin; 2004.

4. Hayes M, Ross IE, Gasher M, Gutstein D, Dunn JR, Hackett RA. Telling stories: news media, health literacy and public policy in Canada. Soc Sci Med. 2007 May;64(9):1842-52.

5. Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S62-77.

6. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

Health literacy reports
Canadian Council on Learning.

Health literacy in Canada: A healthy understanding, February 2008. This report reveals that daily reading outside of work is associated with higher health literacy scores.

Health Literacy in Canada: Initial Results from the International Adult Literacy and Skills Survey (IALSS), September 2007. Provides Canadians with a country-wide snapshot of health literacy.

Canadian Public Health Association.

A Vision for a Health Literate Canada, February 2008. The CPHA Expert Panel on Health Literacy found a majority of Canadian adults do not have the skills needed to respond to daily health information demands. Low health literacy is associated with poor health and the Panel estimates that the situation in Canada is critical.

The Ontario Health Promotion E-Bulletin of 20 March 2008 provides an excellent list of Canadian resources on health literacy.

Recent articles in mainstream media on health literacy
The Toronto Star, March 4, 2008 Alarm raised on health literacy, by Meghan Ogilvie, http://www.thestar.com/living/article/309115

CBC March 4, 2008 Canadians illiterate about health, report says, http://www.cbc.ca/health/story/2008/03/04/health-literate.html

I like to think that when I fall,
A rain-drop in Death's shoreless sea,
This shelf of books along the wall,
Beside my bed, will mourn for me.

Robert Service, Bookshelf