Healthcare Disparities

1. Racial Disparities in Cancer-Related Health
Literacy and Communication Skills
Roblin DW1, Mazor KM2, 3, Cutrona S2, 3, Torres-Stone R2,
Robinson BE1, Williams AE4, Gaglio B5, Wagner J3
3. Center for Health Research / Southeast, Kaiser Permanente Georgia
4. University of Massachusetts Medical School
5. Meyers Primary Care Institute
6. Center for Health Research / Hawai’i, Kaiser Permanente Hawai’I
7. Division of Research, Kaiser Permanente Mid-Atlantic States
HMO Research Network Annual Conference
Seattle, WA
May 2, 2012
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2. Background
• Competence in verbal and print literacy has important
implications for:
– Patient-provider communication
– Treatment adherence
– Health outcomes.
• On average, African American adults have lower health
literacy than Caucasians.
– Comparisons of average literacy levels by race are confounded by
lower levels of education achieved by African Americans.
– Average literacy increases with higher levels of educational
achievement.
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3. Objectives
• Primary objectives
– Ascertain the independent effects of oral and print literacy by race
and level of education
– Ascertain if race moderates the relationship between education and
literacy
• Secondary objectives
– Ascertain the independent effects of race and education or literacy
on communication skills (frequent internet use, preference for
listening vs. reading of new health information, difficulty
understanding rapid speech)
– Ascertain if race moderates the relationship between education or
literacy and communication skills
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4. Conceptual Model
• Educational disadvantage has historically burdened
African Americans relative to Caucasians in the US.
– Under-resourcing of public schools
– Under-resourcing of the domestic learning environment
• Implications of public under-resourcing of public
education on educational achievement compounded by
domestic under-resourcing and support of learning.
– Personal selection and institutional selection leading to lower
levels of educational attainment
– Lower quality of learning environment for equal levels of
educational attainment
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5. Conceptual Model
• Higher levels of educational attainment, however, mitigate
earlier effects of disparities in the learning environment.
– Selection: Motivation of students who progress to higher levels
– Resourcing: Resourcing differentials less associated with race
• Implications
– Disadvantaged students are less likely to progress to higher levels
of education than advantaged students.
– Performance gap between disadvantaged and advantaged students
narrows with higher levels of educational achievement.
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6. Methods
• Data were obtained from 2-hour in-person assessments
conducted at Kaiser Permanente Georgia (KPGA) in 2010
– Study goal: Develop psychometrically valid scale of oral (i.e.
verbal or spoken) cancer-related health literacy
– 40-70 year old enrollees (N=279 completed)
– KPGA enrollees selected using a stratified random sample
• Strata defined by area-based race and educational attainment
– Item construction
• Oral assessment: “Same” or “different” responses to paraphrased statements
following viewing of 1-3 minute videoclips
• Print assessment: “Same” or “different” responses to paraphrased statements
following reading of 1-3 paragraph vignettes
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7. Methods
• Literacy measures
– Health literacy – Oral: 45 items summarized into a single scale
scored from 0 (low) to 100 (high)
– Health literacy – Print: 21 items summarized into a single scale
scored from 0 (low) to 100 (high)
– REALM (Rapid Estimate of Adult Literacy in Medicine): number
of 66 items pronounced correctly (ranged from 10 to 66 in the
study population)
• Communication skills measures
– “Frequent” internet use: 5-7 days per week vs. 0-4 days
– Preference for hearing vs. reading new information on cancer
prevention
– Difficulty understanding rapid speech
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8. Methods
• Linear analyses of variance of oral literacy, print literacy,
and REALM scores
– Primary independent variables: self-reported race, education, and
their interaction
Race
b(1)
c(1)
Literacy:
-- Oral
Education
a(1) -- Print
--REALM
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9. Methods
• Logistic analyses of variance of frequent internet use,
preference for hearing vs. reading, difficulty
understanding rapid speech
– Primary independent variables: self-reported race,
education/literacy, and their interaction
Race b(2)
c(2)
Education Communication Skills:
Literacy: -- Frequency of Computer Use
-- Oral -- Preference for Spoken vs.
a(2) Printed Words
-- Print
-- Ability to Understand Rapid
-- REALM Speech
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10. Results
• Within levels of educational attainment, greatest
differences in average health-related literacy by race were
at the lower levels.
– Differences decreased, but did not disappear, at higher levels of
education.
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11. Results
• Education had a significant, graded association with oral
and print literacy and REALM scores [a(1) path]
• African Americans had significantly lower oral health
literacy [b(1) path]
• Race moderated the relationship between education and
oral and print literacy and REALM scores [c(1) path]
– HLO: -8.9 for HS or less (p=0.05)
– HLP: -11.0 for some college (p=0.02)
– REALM: -4.1 for HS or less (p=0.06)
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12. Results
• Low levels of education, oral or print literacy, and
REALM scores were significantly associated with less
frequent weekly computer use [a(2) path]
– Race had no significant independent [b(2) path] or moderating
[c(2)] effects
• Low levels of education and REALM scores were
significantly associated with more difficulty understanding
rapid speech
– Race had no significant independent or moderating effects
• No significant associations of education, oral or print
literacy, REALM scores or race with preference for
hearing vs. reading materials on new cancer prevention
services.
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13. Conclusions
• Adults with lower levels of educational attainment
(particularly HS education or less) have lower levels of
health-related literacy.
– With comparable levels of educational attainment, African
Americans have lower levels of health-related literacy than
Caucasians.
• Legacy costs of educational disparities
• “Education policy is also health policy”.
• Educational attainment and health literacy, to some extent,
are related to communication skills.
– Adjusting for education, race has no association.
– Low educational attainment or literacy particularly affected
internet use.
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14. Conclusions
• Limitations:
– Small sample size
– Limited number of covariates
• Educational quality
• Family history
– Selection effects
• Individuals with history of cancer, personal or familial, likely to have
participated
• Strengths:
– Unique dataset with batteries of validated measures
– Systematically developed computer-based assessment ensuring
high quality data
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15. Acknowledgements
• Funding
– NCI, 5U19CA079689 for the HMO Cancer Research Network
(EH Wagner, PI) and subproject 3 “Health Literacy and Cancer
Prevention: Do People Understand What They Hear?” (KM
Mazor, PI)
• Project Team
– UMass / MPCI: Kathleen Mazor, Terry Field, Joann Wagner,
Mary Costanza, Rosalie Torres-Stone, Sarah Cutrona
– KPGA: Douglas Roblin, Jody Calvi, Brandi Robinson
– KPHI: Andrew Williams, Vinutha Vijayadeva
– KPCO: Bridget Gaglio
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