Literacy and health 2014

Adult Literacy and its possible relation with health
related factors: Puerto Rico 2010
Dr. Orville M. Disdier Flores
1
Adult Literacy and its possible relation with some health aspects: Puerto Rico 2010 ©Dr. Orville M. Disdier
Version: 102114

Objectives
• Frame the historical context of literacy
statistics in Puerto Rico
• Present a brief summary of the results
obtained in the Literacy Survey of Puerto Rico:
Natural Year 2010 (LEA2010)
• Examine the possible relationship between
the adult literacy status and the health status
during the natural year of 2010
2

INTRODUCTION AND
BACKGROUND
3

Importance of Literacy in Society
• It is essential to…
– Eradicate poverty
– Reduce child mortality
– Curb population grow
– Achieve gender equality
– Ensure sustainable development, peace and
democracy
4
(UNESCO, 2011)

Literacy is a technology…
Walter Ong
“…technologies are never distributed
evenly among the population”.
Neil Postman (1992)
Clipart form: http://www.closedstacks.com.

What is the current literacy rate in Puerto Rico?
6
Clipart form: Microsoft Clipart, Power Point, 2007.

Literacy in Puerto Rico (1899‐2010)
“…the present can be understood only
with reference to its past.”
R.F. Hoxie (1906)
Clipart form:
http://images.search.yahoo.com/search/images;_ylt=A0oG7mP2XB5RUkMAgAtXNyoA?p=time+travel&fr=yfp‐t‐
701&fr2=piv‐web.

Historical Context of Literacy Statistics in
Puerto Rico (1899‐2010)
8

Illiteracy in Puerto Rico (1899‐2010)
• year 1899
• 953,243 habitants
• 79.6% literacy rate
• 1903 University of
Puerto Rico, Río Piedras
79.6%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1899
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000*
2010

• year 1930
• 1,543,913 habitants
• 24,244 enrollment in
adult schools (1914‐1915)
• $30,000 legislative
allocation to establish
adult schools (1919‐1925)
79.0%
65.5%
55.0%
41.4%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1899
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000*
2010

• year 1960
• 22 PRERA camps in 3
lines: literacy, English
teaching and special
courses
• 1 Auxiliary Secretary of
the Program of Education
Extension in the Public
Instruction Department
79.0%
65.5%
55.0%
41.4%
31.5%
24.7%
16.6%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1899
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000*
2010

• year 1990
• $3,515,464 assigned
budget by Legislature and
Federal Government for the
education of adult
population
• 2000 Literacy question
was not included in the 2000
Census.
79.0%
65.5%
55.0%
41.4%
31.5%
24.7%
16.6%
10.8% 11.5% 10.4%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1899
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000*
2010

Results summary of the Literacy Survey of
Puerto Rico: Natural Year 2010 (LEA2010)
13

Figure 1. Literacy rate by sex (2010)
14
8.6 7.5 8.0
91.4 92.5 92.0
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Male Female
___________________________________
Weighted Percentages.
n (male) = 2,436
n (female) = 4,042
Note: It was classified as literate anyone who met the following: answered “never”, “almost never” or “sometimes” to the required questions about difficulties in the
understanding of reading and difficulty to write. Not all the respondents completed the required questions.
0%
Masculino Femenino Ambos sexos
Percentage
Sex
Alfabetizado Analfabeta
Literate
Both sexes
Illiterate

Figure 2. Literacy rate by age (2010)
15
97.3 91.8 86.5 92.0
100
90
80
70
60
50
40
30
20
10
55 or more All ages
Literate Illiterate
_________________________________
Weighted Percentages.
n (18‐34) = 1,597
n (35‐44) = 2,082
n (55 or more) = 2,757
Note: It was classified as literate anyone who met the following: answered “never”, “almost never” or “sometimes” to the required questions about difficulties in the
understanding of reading and difficulty to write. Not all the respondents completed the required questions.
2.7
8.2 13.5 8.0
0
18 ‐ 34 35 ‐ 54 55 o más Todas las
edades
Percentage (%)
Age Group
Analfabeta Alfabetizado

Figure 3. Literacy rate by marital status (2010)
16
19.9 13.4
15.1 25.6
65.0 61.0
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
______________________________
Weighted percentages.
n (married or unmarried living as a married couple) = 3,385
n (divorced, widowed or separated) = 1,953
n (never married) = 1,120
Note: It was classified as literate anyone who met the following: answered “never”, “almost never” or “sometimes” to the required questions about difficulties in the understanding of
reading and difficulty to write. Not all the respondents completed the required questions.
0%
Literate Iliterate
Percentage
Literacy status
Never married
Divorced, widowed or separated
Married or unmarried living as married couple

Figure 4. Literacy rate by employment status (2010)
17
40.3
17.4
59.7
82.6
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Literate Illiterate
Percentage
Literacy status
Employed Unemployed
______________________________
Weighted percentages.
n (employed) = 2,541
n (unemployed) = 3,916

Is there any possible relationship between
Adult Literacy and Health Status?
18
Clipart form: Microsoft Clipart, Power Point, 2007.

According to some authors and researchers…
• Literacy goes further than the ability to read,
write and make mathematical operations; it
includes other dimensions such as the
capacity to maintain an adequate health
status (Bennett and colleagues , 2002).
• Literate people have a highest probability of
experimenting a better health status (Berkman and
colleagues, 2004).
– Lower prevalence of diabetes and hypertension
19

Other researchers have also found…
• Limited literacy contributes to reported poor health
status (Hoffman‐Goetz, Meissner & Thompson, 2009)
• Illiterate people are more likely to suffer mental
health conditions in comparison to literate people
(TenHave, Van Horn & Kumanyika, 1997).
• Literacy is critically important in the successful
treatment of several conditions, such as asthma.
– The reading level was an important predictor of
knowledge of asthma condition and its treatment.
(Williams et al, 1998).
20

Is there any relationship between adult literacy
status in adults who live in Puerto Rico and some
health factors?
21
Clipart form: http://www.marketingsociale.net/aree/24.htm.

METHODOLOGY
22

Methodology
• Literacy questions were realized as a
supplement for the PR‐BRFSS.
• 6,574 people who were 18 years old or more
and lived in Puerto Rico during 2010.
• Probabilities obtained through Prevalence
Odds Ratio (POR)
– Logistic regression models were used to calculate
the adjusted POR.
23

RESULTS
24

Figure 5. Prevalence of general health* perception by
literacy status, Puerto Rico 2010
p<0.001
POR = 3.8
25
Literate Illiterate
Poor/ Very poor Health
64.7
32.3
35.3
67.7
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Percentage
Literacy status
EExxcceellleenntt/eV/eMry ugoyo bd/uGeonoda /HBeualethna Pobre/Muy pobre
______________________________
Weighted percentages. The sample includes home phone and mobile phone number.
POR=Crude Prevalence Odd Ratio
*Would you say that in general your health is—
Note: It was classified as literate anyone who met the following: answered “never”, “almost never” or “sometimes” to the required questions about difficulties in the understanding of reading
and difficulty to write. Not all the respondents completed the required questions.

Figure 6. Prevalence of diabetes* by literacy status, Puerto
p<0.001
POR = 0.42
[58%]
27.0
73.0
Literate Illiterate
Diabetes, No Diabetes, Yes
No Sí Yes
Rico 2010
26
13.3
86.7
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Porcentaje
Literacy status
______________________________
*Have you ever been told by a doctor that you have diabetes?

Figure 7. Prevalence of physical activity* by literacy status,
Puerto Rico 2010
p<0.001
64.9
45.3 POR = 2.2
27
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
______________________________
*During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
54.7
35.1
0%
Literate Illiterate
Percentage
Literacy status
NPohysical activity, No YPehsysical activity, Yes

Figure 8. Prevalence of heart attack* by literacy status,
Puerto Rico 2010
28
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
______________________________
* Has a doctor, nurse, or other health professional EVER told you that you had any of the following? (Ever told) you had a heart attack, also called a myocardial infarction?
88.1
71.7
11.9
28.3
0%
Literate Illiterate
Percentage
Literacy status
No Yes
Weighted
p<0.001
Unweighted
p<0.001
Heart attack, No Heart attack, Yes

Figure 9 . Prevalence of current asthma* by literacy status,
Puerto Rico 2010
29
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
______________________________
* Adults who have been told they currently have asthma? This is a calculated variable using the responses from the following questions: a) Have you ever been told by a doctor, nurse, or other
health professional that you had asthma?; and b) Do you still have asthma?
91.3
87.8
8.7
12.2
80%
Literate Illiterate
Percentage
Literacy status
NAosthma, No Yes
Weighted
p<0.001
Unweighted
p=0.08
Asthma, Yes

Figure 10. Prevalence of overweight/obesity* by literacy
status, Puerto Rico 2010
Weighted
p<0.001
Unweighted
P=0.120
30
68.1 68.7
31.9 31.3
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Literate Illiterate
Percentage
Literacy status
Normal Overweight/Obese
______________________________
*Based on the Body Mass Index.

Figure 11. Prevalence of cigarette smoking* by literacy
status, Puerto Rico 2010
Weighted
p<0.001
Unweighted
15.1 16.0
84.9 84.0 p=0.980
31
100%
95%
90%
85%
80%
______________________________
*Have you smoked at least 100 cigarettes in your entire life?
75%
Literate Illiterate
Percentage
Literacy status
NSomoking, No YSems oking, Yes

Figure 12 . Prevalence of health plan coverage status* by
literacy status, Puerto Rico 2010
Weighted
p<0.001
Unweighted
p=0.630
32
90.2 90.1
9.8 9.9
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
______________________________
*Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
0%
Literate Illiterate
Percentage
Literacy status
NHoealth plan, No YHeesalth plan, Yes

Table 1. Literacy versus health factors and protectors: crude and adjusted Prevalence
Odds Ratios (POR) by age and sex (Adults, Puerto Rico 2010)
33
______________________________
All models evaluated the probability of literates versus illiterates of having the factor, condition
or illness.
POR = Prevalence Odds Ratio.
Factor POR
Crude
POR
Adjusted
General Health Perception
(Good, very good, excellent)
3.8
(p<0.001)
3.0
(p<0.001)
Living with diabetes (Yes)
58.3%
less probability
(p<0.001)
39.2%
less probability
(p<0.001)
Have performed exercises or
physical activity, not related to
work, in the last 30 days (Yes)
2.2
(p<0.001)
2.1
(p<0.001)

CONCLUSIONS
34

Conclusions
• Based on the presented results it is possible to
suggest that literate adults that reside in Puerto
Rico have:
1. Better general health
2. Lower diabetes prevalence
3. Lower overweight/obesity prevalence?
4. Lower asthma prevalence
5. Lower heart attack prevalence
6. Lower cigarette smoking prevalence
7. And also perform more physical activity
…in comparison with the illiterate adults.
35

• Literacy seems to be positively associated with
human health.
36

PUBLIC HEALTH LEADERSHIP?
37

38
Source: Rowitz, L. (2009). Public Health Leadership: Putting Principles into Practice (2nd Ed). Jones & Bartlett Publishers, Sudbury: Mass.

39
Source: Rowitz, L. (2009). Public Health Leadership: Putting Principles into Practice (2nd Ed). Jones & Bartlett Publishers, Sudbury: Mass.

Adult Education Program
Puerto Rico Department of Education
• Principal aim:
– To promote, facilitate and expand educative
opportunities and employability of this population
• Oriented to:
– Reduce illiteracy
– Develop academic skills required at work places
– Improve educational attainment of young people and
adults outside the school
– Develop skills in English, from 1st to 8th grade and 9th
to 12th grade
– Integrate technology in teaching‐learning process
40

Adult Education Program
Puerto Rico Department of Education
• Available in public schools and non‐profit installations
all around the island that had been approved by the
Puerto Rico Department of Education.
• Academic offer:
– To adults (16 or more years old) who are outside school
and want to continue or start with their studies
– Course schedules are: diurnal, evening, nocturnal and
Saturday
– Basic Education
– Secondary Education
– Conversational English

National Leadership Activities
U.S. Department of Education
• The Office of Vocational and Adult Education, Division of Adult
Education and Literacy (DAEL), oversees national leadership
activities, funded through Section 243 of the Adult Education
and Family Literacy Act (AEFLA).
• These activities strive to ensure that all youth and adult
students:
– Are ready for, have access to, and complete college and career
pathways
– Have effective teachers and leaders
– Have equitable access to high quality learning opportunities on
demand
– Benefit from an expanding research and evidence base

ADDITIONAL INTERVENTIONS?
43

44
“Studies of interventions to improve the health of persons
with low literacy have increased in number over the past 10
years but remain relatively uncommon”.
“Fewer studies have examined interventions designed to
mitigate the effects of low literacy on intermediate markers,
measures of disease incidence or prevalence, or use of health
services”.
“No research to date has examined how interventions affect
the general health status of persons with low literacy or
whether interventions can affect health care costs or health
disparities based on race, ethnicity, culture, or age”.

45

QUES T I O N S ?
46
Clipart form: http://www.garylellis.org/if‐you‐could‐ask‐jesus‐one‐question‐by‐gary‐ellis/.

References
Asociación de Ejecutivos de Ventas y Mercadeo de Puerto Rico (2011) Puerto Rico Internet Pulse 2010.
Departamento de Educación. Proyecto de alfabetización. Historia de la alfabetización en Puerto Rico. Estado Libre
Asociado de Puerto Rico. Retirado de http://www.dde.pr/dePortal/Comunidad/Adultos/AlfabetHistory.htm el
25 de agosto de 2011.
Departamento de la Guerra (1900). Informe sobre el Censo de Puerto Rico. Washington: Imprenta del Gobierno.
Retirado de http://www.estadisticas.gobierno.pr/iepr/LinkClick.aspx?fileticket=02D_v0VNgmM%3d&tabid=186
el 25 de agosto de 2011.
Hoxie, R. F. (Nov., 1906). Historical Method vs. Historical Narrative. Journal of Political Economy. 14(9), pp. 568‐572.
International Telecommunication Union (2012) Global ICT developments, 2001‐2011. http://www.itu.int/ict/statistics
Negociado del Censo (1992). Censo de Población y Vivienda de 1990. Resumen de características sociales, económicas y
de la vivienda. Washington: U.S. Government Printing Office. Retirado de
http://www.estadisticas.gobierno.pr/iepr/LinkClick.aspx?fileticket=CxAuqnr2Rgg%3d&tabid=186 el 25 de
agosto de 2011.
Universidad de Puerto Rico‐UPR (2011) La UPR‐Historia. Retirado de
http://www.upr.edu/?type=page&id=la_upr_historia&ancla=historia&r_type=items&r_id=0 el 25 de agosto de
2011.
Bennett J, Boyle PA, James BD, Bennett DA. (2012). Correlates of health and financial literacy in older adults without
dementia. BMC Geriatrics. Obtenido el 4 de diciembre de 2012, en http://www.biomedcentral.com/1471‐
2318/12/30.
Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and Health
Outcomes. (2004, January). Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–
University of North Carolina Evidence‐based Practice Center under Contract No. 290‐02‐0016). AHRQ
Publication No. 04‐E007‐2. Rockville, MD: Agency for Healthcare Research and Quality.
Hoffman‐Goetz L, Meissner HI, Thomson MD. (2009). Literacy and Cancer Anxiety as Predictors of Health Status: An
Exploratory Study. Journal of Cancer Education. 24:218‐224. DOI:10.1080/08858190902910871
TenHave TR, Van Horn B, Kumanyika S, et al. (1997). Literacy assessment in a cardiovascular nutrition education setting.
Patient Educat Counsel; 31(2):139‐50.
Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. (1998). Inadequate Literacy Is a Barrier to Asthma Knowledge
and Self‐Care. CHEST. 114:1008‐1015. Accessed March 6, 2014 from: <http://publictaions.chestnet.org/>

Thanks!
“Al educarse la razón también se educa la conciencia;
al educarse la conciencia, se induce al bien.”
Eugenio María de Hostos

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