CHICAGOPoor reading ability and low income affect many aspects
of health care, including cancer screening. Preliminary analysis of
data from a study of new enrollees in a Medicare managed care program
showed that women with low or inadequate functional literacy were
less likely than literate patients to have a Pap smear, and those
with yearly incomes below $20,000 were less likely to have mammography.
David W. Baker, MD, associate professor of medicine, Case Western
Reserve University, Cleveland, presented the data at a symposium on
reaching medically underserved populations sponsored by the Robert H.
Lurie Comprehensive Care Center of Northwestern University.
The study was based on interviews and the Short Test of Functional
Health Literacy administered to new female enrollees into Prudential
SeniorCare Programs in Cleveland, Houston, Miami, and Tampa. The
results showed that 11% of 3,260 women had marginal literacy and 25%
had inadequate literacy.
While women with inadequate or marginal literacy were more likely to
say they had never had mammography or had not undergone mammographic
examination in the last 2 years, literacy was not the principal
reason for failing to participate in breast cancer screening.
Of the 2,084 women with adequate literacy, 10% had never had a
mammogram vs 14.3% of those with inadequate literacy; 19% of the
literate women had not had a mammogram in the last 2 years vs 30.1%
of the women with inadequate literacy.
Low income was more strongly associated with participation in
mammographic screening than literacy, after data were adjusted for
age and race. Women with a yearly household income less than $15,000
had a 2.95 odds ratio for never having a mammogram and a ratio of
2.99 for not having a mammogram in the last 2 years. Women with a
yearly income below $20,000 had an odds ratio of 2.75 for never
having a mammogram and 2.26 for not having a mammogram in the last 2
The degree to which women underwent screening for cervical cancer,
however, differed considerably by their literacy level. A total of
8.3% of women had never had a Pap smear. The number was nearly three
times higher for women with inadequate literacy (14.3%) than for
those with adequate literacy (5.4%).
After adjusting for age, income, and race, women with marginal or
inadequate literacy were more than twice as likely to have never had
a Pap smear. The odds ratio was 2.20 for women with inadequate
literacy and 2.14 for women with adequate literacy.
Dr. Baker suggested, therefore, that information about literacy may
help managed care plans improve participation in preventive care.
Managed care programs may identify women in senior care plans who
have marginal or inadequate literacy and try aggressive
interventions [directed at literacy] to get them in for
screening, he said, because literacy may be a marker for other
factors, such as language barriers, cultural differences, and patient
Dr. Baker said that researchers should determine the pathways by
which literacy affects the use of health care services and health
itself. It is naïve for us to think we can address
problems in literacy simply by giving individuals low-literacy
materials. We need to develop more comprehensive interventions that
will make a difference for these people, he said.