National Healthcare Disparities Report, 2007

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Chapter 2 (continued)

Focus on Health Literacy

Healthy People 2010's Objective 11-2 is to improve Americans' health literacy, defined as the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions.¹¹⁷ In 2003, the first-ever national assessment of health literacy was conducted—the Health Literacy Component (HLC) of the National Assessment of Adult Literacy (NAAL). The HLC assesses responses to health-related tasks presented in written form. These tasks fall into three categories: clinical, prevention, and navigating the health system.

The HLC tasks require familiarity with health-related words, experience with written materials such as drug labels and health insurance forms, or knowledge of how the health care system works. The HLC did not measure the ability to obtain information from nonprint sources.

In addition to racial and ethnic differences, the elderly are less likely than younger populations to have a proficient level of health literacy. The 2003 Health Literacy Component of the NAAL showed that over one-quarter of adults age 65 and over had "below basic" health literacy.¹¹⁸ There is evidence that inadequate health literacy is linked to all-cause mortality and cardiovascular mortality among the elderly.¹¹⁹

The HLC measures the English health literacy of adults in the United States. Four million adults had language barriers or cognitive or mental disabilities that prevented them from taking the NAAL, and therefore they are not included in the results presented below. The NAAL captures no information on these adults' literacy in another language.

The NAAL groups adults without language barriers into four performance levels:

Below basic—This performance level indicates that a person can understand no more than the most simple and concrete skills (e.g., circle the date of a medical appointment on a hospital appointment slip). Thirty million adults were found to have below basic health literacy; 7 million of these were unable to answer the simplest of questions and were determined to be nonliterate in English.
Basic—This performance level indicates that a person can perform the skills necessary for simple and everyday activities (e.g., give two reasons a person with no symptoms of a specific disease should be tested for the disease, based on information in a clearly written pamphlet). Forty-seven million adults were found to have basic health literacy.
Intermediate—This performance level indicates that a person can perform the skills necessary for moderately challenging activities (e.g., identify three substances that may interact with an over-the-counter drug to cause a side effect, using the information on the over-the-counter drug label). One hundred and fourteen million adults were found to have intermediate health literacy.
Proficient—This performance level indicates that a person can perform the skills necessary for more complex and challenging activities (e.g., find the information required to define a medical term by searching through a complex document) needed to manage health and prevent disease. Twenty-six million adults were found to have proficient health literacy.

Figure 2.46. Adults in each health literacy level, by race and ethnicity, 2003

Source: National Assessment of Adult Literacy, Health Literacy Component, 2003.

Key: API=Asian or Pacific Islander; AI/AN=American Indian or Alaska Native.

Note: Adults are defined as people 16 years of age and over living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3% in 2003) are excluded from this figure. All adults of Hispanic origin are classified as Hispanic, regardless of race. The API category includes Native Hawaiians, Black includes African American, and Hispanic includes Latino.

Only 12% of adults had proficient health literacy (Figure 2.46). In other words, nearly 9 in 10 adults may lack the skills needed to manage their health and prevent disease.
Asian/Pacific Islanders and Whites were the most likely to have proficient health literacy. A very small proportion of Black, Hispanic, and AI/AN adults reached the proficient health literacy level.
Two-thirds of Hispanic adults, over half of Black adults, and almost half of AI/AN adults did not reach the intermediate level.

Figure 2.47. Adults: Likelihood of having below basic health literacy as compared with Whites, 2003

Bar chart shows percentage of adults with a likelihood of having below basic health literacy as compared with Whites. Ratio of subpopulation/White. Black, 2.7; Hispanic, 4.6; API, 1.4; AI/AN, 2.8; More than one Race, 1.

Source: National Assessment of Adult Literacy, Health Literacy Component, 2003.

Key: API=Asian or Pacific Islander. AI/AN=American Indian or Alaska Native.

Hispanic adults were 4.6 times more likely than White adults to have below basic health literacy (Figure 2.47).
Black and AI/AN adults were almost three times more likely than White adults to have below basic health literacy.

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Summary Tables

Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian>	NHOPI	AI/AN	>1 Race	Hispanic
Cancer
Women age 40 and over who received recommended breast cancer screeningⁱⁱⁱ	=	↓		=	=	↓
Rate of breast cancer diagnosed at advanced stage^iv	↓	↑		↑		↑
Cancer deaths per 100,000 population per year for breast cancer^v	↓	↑		↑		↑
Diabetes
Composite: Adults with diabetes who had hemoglobin A1c measurement, retinal eye exam, and foot exam in the past year^vi	=					↓
Hospital admissions for lower extremity amputations in patients with diabetes per 1,000 population^vii	↓	↑				↓
End Stage Renal Disease
Hemodialysis patients with adequate dialysis^viii	=	↑		=	=	↑
Dialysis patients registered on the waiting list for transplantation^ix	=	↑		=		↓
Heart Disease
Adults who were obese given advice about exercise	=				=	↓
Current smokers age 18 and over receiving advice to quit smoking^vi	=					↓
Composite: Hospital care for heart attack patients^x	=	=				=
Deaths per 1,000 adult admissions with acute myocardial infarction (heart attack)^xi	↑	=				=
Composite: Hospital care for heart failure patients^x	↑	=			↓	↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: National Health Interview Survey, 2005.

^iv Source: Surveillance, Epidemiology, and End Results Program, 2004. This source does not provide rate estimates for Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

^v Source: National Vital Statistics System-Mortality, 2004. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

^vi Source: Medical Expenditure Panel Survey, 2004.

^vii Source: National Hospital Discharge Survey, 2002-2004. This source did not collect information for >1 race. Missing rates preclude analysis by ethnicity.

^viii Source: CMS End Stage Renal Disease Clinical Performance Measures Project, 2005.

^ix U.S. Renal Data System, 2003. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

^x Source: CMS Quality Improvement Organization Program, 2005. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander, American Indian and Alaska Native. These contrasts compare each group with non-Hispanic Whites.

^xi Source: HCUP State Inpatient Databases disparities analysis file, 2004. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander. These contrasts compare each group with non-Hispanic Whites.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued)

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
HIV and AIDS
New AIDS cases per 100,000 population 13 and overⁱⁱⁱ	↓	↑		=		↓
Maternal and Child Health
Pregnant women receiving prenatal care in first trimester^iv	↓	=		=		↓
Infant mortality per 1,000 live births, birth weight <1,500 grams^iv	↓	=		=		↓
Children 19-35 months who received all recommended vaccines^v	=	↑		=	=	↓
Hospital admissions for pediatric gastroenteritis per 100,000 population^vi	↑	↑				=
Children 2-17 with advice about healthy eating^vii	=	=			=	=
Children 2-17 with untreated dental caries^viii	↓					↓
Hospital admissions for asthma per 100,000 population under 18^vi	↓	=				↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: Centers for Disease Control and Prevention, 2005. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander, American Indian and Alaska Native. These contrasts compare each group with non-Hispanic Whites.

^iv Source: National Vital Statistics System-Natality, 2004. This source did not collect information for >1 race.

^v Source: National Immunization Survey, 2005.

^vi Source: HCUP State Inpatient Databases disparities analysis file, 2004. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander. These contrasts compare each group with non-Hispanic Whites.

^vii Source: Medical Expenditure Panel Survey, 2004.

^viii Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1999-2004. This source collects data for Mexican Americans, not Hispanics.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Key to Symbols Used in Quality of Health Care Tables:
= Group and comparison group receive about same quality of health care or have similar outcomes.
↑ Group receives better quality of health care than the comparison group or has better outcomes.
↓ Group receives poorer quality of health care than the comparison group or has worse outcomes.
Blank cell: Reliable estimate for group could not be made.

Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued)

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
Mental Health and Substance Abuse
Adults with major depressive episode in the past year who received treatment for the depression in the past yearⁱⁱⁱ	↓					↓
Suicide deaths per 100,000 population^iv	↑	↑		=		↑
People age 12 and over who needed treatment for substance abuse who received such treatmentⁱⁱⁱ	↑					=
Respiratory Diseases
People 65 and over who ever received pneumococcal vaccination^v	↓	↓				↓
Composite: Hospital care for pneumonia patients^vi	↓	↓		=		↓
Rate antibiotics prescribed at visits with a diagnosis of common cold per 10,000 population^vii	=
Tuberculosis patients who complete course of treatment within 12 months of treatment initiation^viii	↑	↑		↓		↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005.

^iv Source: National Vital Statistics System-Mortality, 2004. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

^v Source: National Health Interview Survey, 2005.

^vi Source: CMS Quality Improvement Organization program, 2005. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander, American Indian and Alaska Native. These contrasts compare each group with non-Hispanic Whites.

^vii Source: National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2003-2004. This source did not collect information for >1 race. Missing rates preclude analysis by ethnicity.

^viii Source: CDC National TB Surveillance System, 2003. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued)

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
Nursing Home, Home Health, and Hospice Care
Long-stay nursing home residents who were physically restrainedⁱⁱⁱ	=	↓		↓		↓
High-risk long-stay nursing home residents with pressure soresⁱⁱⁱ	↓	↑		=		↓
Low-risk short-stay nursing home residents who have pressure soresⁱⁱⁱ	↓	↓		=		↓
Home health care patients who get better at walking or moving around^iv	=	=	=	↓	=	=
Home health care patients who had to be admitted to the hospital^iv	↓	↑	=	=	=	↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: CMS Minimum Data Set, 2005. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander. Contrasts compare each group with non-Hispanic Whites.

^iv Source: CMS Outcome and Assessment Information Set, 2005.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Key to Symbols Used in Quality of Health Care Tables:
=Group and comparison group receive about same quality of health care or have similar outcomes.
↑ Group receives better quality of health care than the comparison group or has better outcomes.
↓ Group receives poorer quality of health care than the comparison group or has worse outcomes.
Blank cell: Reliable estimate for group could not be made.

Table 2.1b. Socioeconomic Differences in Effectiveness of Care

Core Report Measure	Income Differenceⁱ				Educational Differenceⁱⁱ		Insurance Differenceⁱⁱⁱ
	< 100%		100-199%	200-399%	<HS	HS Grad	Uninsured
Cancer
Women age 40 and over who received recommended breast cancer screening^iv		↓	↓	↓	↓	↓	↓
Cancer deaths per 100,000 population per year for breast cancer^v					↓	↓
Diabetes
Composite: Adults with diabetes who had hemoglobin A1c measurement, retinal eye exam, and foot exam in the past year^vi		↓	↓	↓	↓	↓
Heart Disease
Adults who were obese given advice about exercise^vi		↓	↓	↓	↓	↓	↓
Current smokers age 18 and over receiving advice to quit smoking^vi		=	=	=	=	=	↓
Maternal and Child Health
Pregnant women receiving prenatal care in first trimester^vii					↓	↓
Infant mortality per 1,000 live births, birth weight <1,500 grams^vii					↓	↓
Children 19-35 months who received all recommended vaccines^viii		↓	↓	↓
Children 2-17 with advice about healthy eating^vi		↓	↓	↓			↓
Children 3-6 with a vision check^vi		↓	=	↓			=

ⁱ Compared with persons with family incomes 400% of Federal poverty thresholds or above.

ⁱⁱ Compared with persons with any college education.

ⁱⁱⁱ Compared with persons under 65 with any private health insurance.

^iv Source: National Health Interview Survey, 2005.

^vi Source: Medical Expenditure Panel Survey, 2004.

^vii Source: National Vital Statistics System-Natality, 2004. This source did not collect information for >1 race.

^viii Source: National Immunization Survey, 2005.

Key: HS=high school.

Table 2.1b. Socioeconomic Differences in Effectiveness of Care (continued)

Core Report Measure	Income Differenceⁱ			Educational Differenceⁱⁱ		Insurance Differenceⁱⁱⁱ
	< 100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Mental Health and Substance Abuse
Adults with a major depressive episode in the past year who received treatment for the depression in the past year^iv	=	=	=	↓	=
Suicide deaths per 100,000 population^v				↓	↓
People age 12 and over who needed treatment for substance abuse who received such treatment^iv	=	=	=	=	=
Respiratory Diseases
Persons 65 and over who ever received pneumococcal vaccination^vi	↓	=	=	↓	↓

ⁱ Compared with persons with family incomes 400% of Federal poverty thresholds or above.

ⁱⁱ Compared with persons with any college education.

ⁱⁱⁱ Compared with persons under 65 with any private health insurance.

^iv Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005.

^vi Source: National Health Interview Survey, 2005.

Key: HS=high school.

Table 2.2a. Racial and Ethnic Differences in Patient Safety

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
Postoperative Complications
Composite: Adult surgery patients with postoperative complicationsⁱⁱⁱ	↓			=		↓
Other Complications of Hospital Care
Composite: Bloodstream infections or mechanical complicationsⁱⁱⁱ	=
Deaths per 1,000 discharges following complications of care^iv	↑	↓				=
Complications of Medications
Elderly with inappropriate medications^v	=					=

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: Medicare Patient Safety Monitoring System, 2005.

^iv Source: HCUP State Inpatient Databases disparities analysis file, 2004. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pacific Islander. These contrasts compare each group with non-Hispanic Whites.

^v Source: Medical Expenditure Panel Survey, 2004. This source did not collect information on Asians and NHOPIs separately but in aggregate as Asian and Pacific Islander. This source did not collect information for >1 race.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Table 2.3a. Racial and Ethnic Differences in Timeliness and Patient Centeredness

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
Timeliness
Adults who sometimes or never can get care for illness or injury as soon as wantedⁱⁱⁱ	↓	↓			=	↓
Emergency department visits in which the patient left without being seen^iv	↓
Patient Centeredness
Composite: Adults who sometimes or never received patient centered careⁱⁱⁱ	↓	↓			↓	↓
Composite: Children who sometimes or never received patient centered careⁱⁱⁱ	=	=			=	↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: Medical Expenditure Panel Survey, 2004. This source did not collect information for >1 race.

^iv Source: National Hospital Ambulatory Medical Care Survey - Emergency Department, 2004-2005. Missing rates preclude analysis by ethnicity.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native

Table 2.3b. Socioeconomic Differences in Timeliness and Patient Centeredness

Core Report Measure	Income Differenceⁱ			Educational Differenceⁱⁱ		Insurance Differenceⁱⁱⁱ
	< 100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Timeliness
Adults who sometimes or never can get care for illness or injury as soon as wanted^iv	↓	↓	↓	↓	↓	↓
Emergency department visits in which the patient left without being seen^v						↓
Patient Centeredness
Composite: Adults who sometimes or never received patient centered care^iv	↓	↓	↓	↓	↓	↓
Composite: Children who sometimes or never received patient centered care^iv	↓	↓	↓			=

ⁱ Compared with persons with family incomes 400% of Federal poverty thresholds or above.

ⁱⁱ Compared with persons with any college education.

ⁱⁱⁱ Compared with persons under 65 with any private health insurance.

^iv Source: Medical Expenditure Panel Survey, 2004. This source did not collect information for >1 race.

^v Source: National Hospital Ambulatory Medical Care Survey - Emergency Department, 2004-2005. Missing rates preclude analysis by ethnicity.

Key: HS=high school.

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