by Eduardo J. Sanchez, MD, MPH, Commissioner, Texas DSHS
Every physician recognizes that factors such as income, race, and ethnicity are strongly linked to disparities in morbidity and mortality outcomes. Addressing these health disparities chal-lenges us to think broadly and deeply about the complex
interactions affect-ing society and health.
In advanced nations, it is social factors rather than pathogens and viruses at the root of health inequalities. One of the most important, yet often overlooked, of those factors is health literacy.
The public health improvements of a century ago – such as improved sanitation, safer food supply – did not rely on individual decisions. However, 50% of premature mortality today is attributable to behavior and lifestyle choices.(1) I believe two changes must occur if we are to reduce the early onset of chronic diseases and premature mortality:
• A better-informed public needs to ac-tively participate in health promotion and disease prevention; and
• Healthcare providers need more train-ing and communications skills to ef-fectively bridge barriers caused by lan-guage, culture, or educational differences.
Research shows that most medical in-formation on the Internet is written at a 12th grade level, whereas the average American reads at the eighth or ninth grade level, and the average Medicaid recipient reads at a fifth grade level. The National Adult Literacy Survey in 1993 showed that roughly half of adult Amer-icans have limited literacy skills. In fact, most adults with poor literacy are white, native-born Americans. For healthcare providers, it is crucial:
• To communicate to all patients using basic terms free of jargon;
• To listen well; and
• To close the communication loop by ensuring the patient’s comprehension.
Literacy skills predict individual health status better than race or ethnicity, age, income, or employment status.(2) Estimates of the medical costs of low literacy in the United States, which leads to poor adherence and increased hospitalization, are as much as $73 billion annually – comparable to the annual costs for smoking.(3)
On the other side of the equation, we know that improving high school graduation rates and increasing college attendance will provide health as well as economic benefits.
Less educated individuals are more likely to engage in unhealthy behaviors such as smoking, drinking to excess, poor dietary habits, and lack of exercise. Unhealthy behaviors result in the chronic diseases and higher mortality rates that generate many health disparities we want to eliminate.
The impact of unhealthy lifestyles among such a large percentage of the adult population helps drive the costs of medical care beyond the reach of more and more families. We know that less-educated persons are less likely to have medical insurance. In fact, 40% of those without a high school diploma are uninsured compared to 10% of college graduates.(4)
I emphasize the overlapping nature of health and education because the overall death rate for people ages 25 to 64 with more than 12 years education is roughly three times lower than that for people with less than 12 years of education. People with less than 12 years of education are more likely to die of a chronic disease earlier than are those with more years of education.(5)
According to the Texas Education Agency, 84% of Texas high school students graduate. The graduation rate for African-Americans is 82%. For Hispanics, the graduation rate is 78%. That is not a huge difference, but each year that the graduation rate for African-Americans and Hispanics stays below the average in San Antonio and across Texas, more kids will fall short of their potential, especially in a county like Bexar where the population is 54% Latino. This situation has consequences not only in terms of the economic opportunity they will lose in their lifetimes, but also, I stress again, in terms of their health.
The links between education and health are obvious when we think about them. Lack of health literacy is linked to an increase in unhealthy behaviors that directly contribute to growing health disparities. The failure to graduate more blacks and Latinos creates widening gaps in income that limit access to quality medical care.
At the same time, lower graduation rates limit the potential to diversify the workforce, which could help close the cultural gap between physician and patient, lessen disparities, and improve health outcomes.
We face a glaring shortage of African-American and Hispanic physicians, nurses, and other healthcare professionals in Texas and across the country.
Overall, Hispanics, blacks, and Native Americans represent more than a third of the Texas population, yet comprise fewer than 6% of physicians and 9% of nurses.
By 2030, Hispanics and blacks will comprise 63% of the Texas population, and the number of black and Hispanic physicians will need to increase dramatically to correspond to the numbers in the general Texas population. But first we must boost high school graduation rates and admissions into our colleges and universities.
Differences in educational achievement may be the core disparity we need to address.
The medical community can contribute to this effort on two fronts. First, as community leaders, we can communicate the clear health benefits as well as social and economic benefits that come with better schools, higher graduation rates, and expanded opportunities for higher education.
Second, providers can work to ensure that our communications to patients and the public at large are clear and readily understood. Research suggests even well-educated adults prefer health materials written in a format that is easier to read and comprehend.(6) The Institute of Medicine, the World Health Organization, and numerous state and federal agencies have made the issue of health literacy a priority. I hope we are really at the beginning of a cycle of research and training that will improve our ability to understand and be understood.
Roughly 1,000 children are born every day in Texas. How many will grow up to be healthy, well-educated, productive adults?
Research suggests that knowledge, power, prestige, and social connections are important health factors, in part because people from higher social classes have been given more training, more opportunity, more resources, and more skills to deal with life’s problems.
By the same token, worse health among lower income people may relate to less ability to problem-solve, and therefore less ability to gain access to resources. The long-term results from pilot programs teaching problem-solving skills to pre-school children from disadvantaged backgrounds show not only higher graduation rates but also healthier lifestyle choices as young adults.(7)
I believe the foundation for health is a caring, nurturing, stimulation-rich environment for all children. Coupling higher educational attainments with nurturing home environments leads to healthier lifestyles and greater life expectancies. The final link is for health providers to understand the difference between communicating information and the comprehension of that information, and to do whatever it takes to close the gap.
Dr. Sanchez is currently commissioner for the Texas Department of State Health Services. He has an-nounced plans to step down in early October.
Notes
1. Alder, et al. “Socioeconomic Disparities in Health,” Health Affairs, Vol 21, Number 3, 2002
2. Wilson, “The Crucial Link between Literacy and Health,” Annals of Internal Medicine, Vol 139, Number 10, November, 2003
3. Ibid
4. Alder, op. cit.
5. CDC National Center for Health Statistics, Vital Statistics Vol 53, Number 5, Deaths, 2002 (615.6 deaths per 100,000 vs. 207.9 deaths) http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_05.pdf
6. Dr. Rima Rudd, Harvard School of Public Health, The Source – The Newsletter of the Harvard Center for Cancer Prevention, October 2004.
7. Phelan and Link, “When Income Affects Outcome: Socioeconomic Status and Health,” Research in Profile, Issue 6, February 2003, Robert Wood Johnson Foundation.
