HOW OUR 'HEALTH LITERACY' AFFECTS OUR WELL-BEING

Saturday, March 20, 2004

Life isn't fair. People who are well educated and have a good job and a decent income are already ahead in the game, yet, in addition, they are statistically likely to enjoy better health and a longer life than people who don't have those advantages.

The conventional wisdom is the "poverty paradigm," the idea that people who are poor can't afford and don't get good medical care so their health suffers. It's certainly plausible.

But it doesn't match the facts very well, says Linda Gottfredson, who teaches in the School of Education at the University of Delaware. Much of her research focuses on the role of general intelligence in the workplace, and she proposes an alternative hypothesis: Caring for your own health over a lifetime is a difficult and demanding job, and not everyone is smart enough to do it well.

Put so bluntly, it sounds harsh, but surely none of you reading this would maintain that everybody -- absolutely everybody -- is smart enough to be a doctor. Yet we all are doing part of a doctor's job, even though we are our only patients.

Gottfredson's article on the relationship between intelligence and health, published in the Journal of Personality and Social Psychology is available at www.udel.edu/educ/gottfredson/reprints/2004fundamentalcause.pdf.

But to illustrate it, let me tell you a story. My husband Arthur was diagnosed with diabetes in 1965, when he was 27. He was very diligent about managing the disease, monitoring his blood sugar and adjusting insulin dosage for even slight changes in what he ate and what activities he planned. The most-read book in our house was the U.S. Department of Agriculture's big red book listing the nutritional values for any type of food one is likely to eat, since most prepared foods did not then have nutrition information on the label.

And for the next 23 years, he remained in excellent health -- until in 1988 he made a really stupid mistake.

We had spent a sabbatical year in China, which could have been a problem if he'd needed care, but he didn't, and he was fine when we got back. We brought back with us the supply of insulin we took to China. It was past its expiration date, and because we'd been traveling for the past several weeks, it hadn't been properly refrigerated.

He should have thrown it out. But he didn't think of that, or perhaps he did and just decided to save a little money. He started a fresh bottle which was no longer effective, and by the time he figured out what the problem was, his blood sugar had been uncontrolled for two or three weeks and he had lost two-thirds of his kidney function. His health deteriorated steadily and he died in 1996.

In contrast, a couple of years ago I observed a diabetes management class at Kaiser. One of the exercises was to take cardboard cutout pictures of food -- a salad, a slice of pizza -- with nutrition information on the back, and assemble them into a meal that fit their diet.

Many of the people in the class found this simple exercise extraordinarily difficult. One woman couldn't tell whether a food item had more carbohydrate or protein. Another thought "diet" referred only to solid food, so she was very careful about what she ate but failed to consider the consequences for her diabetes of the four to six cans of Coke she drank every day.

What are their chances of getting through 23 years with no mistakes and no problems? Sadly, not very good.

The relation between social class (typically measured by education, occupation and income) and health is "remarkably general," Gottfredson writes. "With few exceptions, it is found for all major diseases and causes of death and for all ages, sexes, races, decades and countries." Also, when access to health care improves, health differences related to social class get wider, not narrower.

Health researchers are understandably reluctant to characterize patients' difficulties with complicated drug regimens or other treatment as the result of low intelligence, but they do attempt to measure something called "health literacy" that closely resembles general intelligence. People with inadequate health literacy are far more likely to have trouble determining how many pills to take, or when their next appointment is scheduled than others. They are also less likely to understand their illness fully, or to seek preventive care or screening for cancer (even when it is free).

Health literacy predicts health outcomes, Gottfredson says, even after social class is controlled for. And in a study of Medicaid patients, poor health literacy was associated with more frequent or more severe medical problems, at a much higher cost.

If the "poverty paradigm" is right, then spending more on health care for the poor is good policy. If it's wrong, the money will be wasted, and it's more important to work on how to ensure people are able to make effective use of the medical care they do get.