Literacy is for Life: Strengthening Adult Literacy is Key to Canada's Economic and Social Prosperity

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1 Literacy is for Life: Strengthening Adult Literacy is Key to Canada's Economic and Social Prosperity Submission to the Romanow Commission on the Future of Health Care in Canada Literacy and Health: Making the Connection "Many times you don't understand what the health people tell you and you're petrified so don't ask questions. A lot of times you just stay home with that ache or pain just because you're too embarrassed to go to a doctor."1 "Taking positive action to provide all Canadians with the opportunities they need to obtain a solid education and achieve adequate literacy skills is one of the best ways to foster healthy citizens and a prosperous, competitive nation.." 2 April, 2002 The Movement for Canadian Literacy The Movement for Canadian Literacy (MCL) is a national non-profit charitable organization representing literacy coalitions, organizations and individuals from every province and territory. Since 1978 MCL has worked to: inform the federal government and the general public about issues related to adult literacy in Canada; provide a national forum for provincial and territorial literacy organizations to work together to ensure that every Canadian has access to quality literacy education; strengthen the adult student/learner voice in Canada; and support the development of a strong movement of people and organizations involved with adult literacy education. Health and Literacy: Making the Connection Introduction National health surveys, international studies, a Federal-Provincial Ministerial Taskforce on Health 3, experts from Health Canada 4, and firsthand reports from health and literacy workers all confirm that there are strong correlations between literacy and health. 5 Low literacy is a major social policy issue. According to the International Adult Literacy Survey (IALS), 22% of Canadian adults have serious problems dealing with printed material, and another 26% "read, but not well". For these millions of Canadians, low literacy is a barrier to accessing health services and information. It can lead to or entrench unemployment and poverty, which are key determinants of poor health. It can make healthy lifestyle choices and practices, like following nutritional or exercise guidelines, more difficult to identify or adopt. Finally, as low literacy undermines the health of individuals and families, it places a strain on the healthcare system we all share. In this paper, MCL reviews the links between literacy and health, and makes the case that literacy issues must be considered in the on-going development of an effective, efficient and quality healthcare system. The issues: Low literacy is strongly correlated with poor health, and is interrelated with many other major health deter-

2 minants. People with low literacy have difficulty accessing health information and services. This gap in access to information and services ultimately increases costs to our healthcare system. People with low literacy skills are often members of poor or marginalized populations. These millions of Canadians must be assured of access to a quality healthcare system that does not discriminate on the basis of wealth. Low Literacy: A Key Determinant of Health Low literacy and poor health are interrelated at all stages of the life cycle. In fact, sources have repeatedly confirmed that low literacy has a negative impact on all aspects of health, including overall morbidity and mortality, accidents, and a wide range of diseases.6 (1) Low literacy is clearly linked to poverty, itself a major determinant of health. Low literacy, poverty and health problems are interrelated in a number of ways. Low literacy affects peoples' access to decent jobs and thus to adequate incomes. Poverty affects nutrition, prevention and treatment of illness, the extent of risky behaviors, stress and mental health. Poor health also affects peoples' ability to access and use literacy services. Literacy workers report that many students are hindered in their learning by health and other problems directly related to living in poverty. The combination of poverty, low literacy and poor health is more prevalent among certain populations, such as Aboriginal people, older adults, and immigrants. (2) Poverty and low literacy are barriers to healthy child development. Families need economic security in order to provide their children with the brightest possible futures. Many babies born into poor families have low birth weight, which increases their risk of developing health and learning problems. Poor children are more than twice as likely to have low levels of vision, hearing, speech, mobility, dexterity, cognition and emotion. Poverty leads to inadequate nutrition, and forces families into unsafe neighbourhoods and substandard housing. In turn, poverty and poor health are barriers to learning for children as well as adults. Experience in our early years shapes the way we learn, think, behave and respond to challenges for the rest of our lives. Low literacy makes it difficult for parents to access parenting information, maximize their children's early learning, and help them succeed in school. Older children and youth who have not developed a solid literacy base are at risk for school failure and drop-out, anti-social behaviour, poverty and risky lifestyles. (3) People with lower literacy skills are more likely to work and live in dangerous environments. Workers with low literacy skills have a higher than average rate of occupational injuries. This appears to be mainly because the types of jobs generally open to them. Jobs in the primary, resource and construction industries, for example, are more likely to be dangerous. Also, information about workplace health and safety is difficult to read and understand. Even if these workers are aware of workplace risks and their rights, they are unlikely to be in a position to assert themselves due to limited advocacy skills and the lack of job options. Home and neighbourhood environments are also more dangerous for people with low literacy skills, as poverty makes it more likely that they live in substandard housing with contaminants like moulds, lead or asbestos, or in unsafe areas with higher traffic volume, environmental hazards and crime.7 Poverty is also a major determinant of homelessness. Homeless Canadians suffer poorer health by almost any measure. They are more vulnerable to respiratory diseases, bacterial and viral infections and other serious effects from living on the streets.

3 (4) Literacy is closely linked to healthy lifestyle practices. Literacy barriers limit people's opportunities, resources, control over their lives, and ability to make informed choices about their lifestyles. People with low literacy are more likely to smoke or to make poor nutrition choices. They are less likely to wear seatbelts or bicycle helmets, to have their blood pressure checked, and for women, to breastfeed, do breast self-examinations, or obtain pap smears.8 (5) People with lower literacy skills are likely to be under more stress- a major health problem in its own right. For poor or undereducated adults, stress is a fact of life - dealing with the uncertainty that comes with poverty, coping with unemployment or a precarious labour market, ever increasing costs, and a lack of resources to ride out rough patches. For families, the pressure is even greater as parents struggle to give their kids the security they need to survive and to thrive. The resulting stress has been recognized as a major factor in depression, anxiety, and other mental health problems which themselves can lead to increased illness and disease.9 (6) Senior adults face serious literacy / health challenges. Almost 80% of seniors have some degree of literacy barriers, at a time of life when income is limited and health challenges are common. These literacy barriers impede seniors' abilities to access information, use prescriptions properly, or communicate effectively with their doctors. Health and Literacy: Accessing Services Poor literacy is a major barrier to accessing health information and services. Close to half of all adult Canadians have difficulty understanding complex print materials. It's not surprising that many Canadians have a difficult time deciphering information about medications, health practices, and safety risks. While it may be tempting to blame these problems solely on the low literacy skills of individuals, it is fairer and more constructive to also look at the barriers that they face in terms of access to health information and services. These barriers include poverty, cultural bias, language and literacy. People with low literacy skills (including people from cultural minorities) have trouble reading and understanding health information unless it is clearly presented and linked to their own realities. They tend to have less background health knowledge and vocabulary and therefore may not understand even information given verbally. They may not know about the services available to them, and may feel powerless and intimidated in relation to health professionals and institutions. Although some of these barriers are beyond the control of health providers, many health care professionals are making a difference by re-examining the way they communicate health information. Health Canada has taken steps to introduce plain language into prescription and nutritional labeling. Other initiatives train healthcare professionals to communicate effectively and clearly with their patients10. Addressing information barriers is a very important part of the solution to the literacy/health challenge, especially as many of the people affected are unlikely to participate in literacy training. MCL believes these measures must be supported and expanded. Health and Literacy: Costs to our Healthcare System Low literacy places a strain on the efficiency and cost-effectiveness of the healthcare system we all share. This is due in part to the generally poorer overall health of less-literate people, misuse of medication or misunderstanding of health information, and inappropriate use of health services, including emergency care. Also, because of low self-confidence and limited resources, people with low literacy skills often do not seek medical help until a health problem has reached a crisis state.11

4 According to one study conducted by the Journal of the American Medical Association, patients with the lowest literacy levels had average annual health care costs of $12,974 compared with $2,969 (US) for the overall population studied. In another study recorded by the Council on Scientific Affairs, of the 958 low-income patients the study followed over 2 years, patients with inadequate literacy were nearly twice as likely to have been hospitalized during the previous year (31.5% vs 14.9%), a relationship that persisted after adjustment for health status and various socio-economic indicators. 12 Literacy and Health: The Benefits of Working Together In addition to improved health for individuals, families and our healthcare system, there is much to be gained from addressing the links between literacy and health at a system-wide level. Partnerships between the health and adult education fields have great potential for furthering both agendas. From a health standpoint, the literacy delivery system is a useful channel for health departments and agencies to reach people at risk. As members of families and communities, literacy learners can act as a channel for health promotion among low income, immigrant and minority populations. From a literacy point of view, health issues provide a useful focus for learning and practicing reading, writing, speaking and math skills. Through learning about health issues, adult students develop skills and knowledge they can use to make healthy choices for themselves and their families. Over the long-term, system-wide connections linking literacy and health can improve health and save money. Given the complexity of the issues, interdepartmental cooperation within governments is vital. Although the lead responsibility for literacy is in the education and human resource development areas, there are benefits to ensuring that ALL departments develop policy with literacy in mind. This is especially true in the healthcare area, where literacy and health are clearly interrelated. Preserving Healthcare for All Canadians The healthcare system we build together must serve all Canadians. People with low literacy skills are often members of poor or marginalized populations. These millions of Canadians must be assured of access to a quality healthcare system that does not discriminate on the basis of wealth or geography. As the Commission works towards the goal of devising a model for high-quality, efficient, sustainable healthcare, it is crucial that this model serves the needs of Canada's low-income populations. For example, any move towards two-tiered health must not compromise the availability of high-quality public services that are free, effective, and available widely across the country. Health and Literacy: The Way Forward Making the connection between literacy and health is important to reinforcing and strengthening our health care system. As the Commission works to build a healthcare system that serves all Canadians well, we encourage you to consider the many links between literacy and health outlined in this paper. Low literacy is a key determinant of health. It can lead to poverty, which itself seriously undermines the health of individuals at all stages of the life cycle. It is a barrier to accessing crucial health care services and information related to prevention and treatment. And, because low literacy affects population health, it places a strain the healthcare system we all share. To better serve the health of Canadians and the vitality of our health care system, we urge the Commission to recognize and respect the links between literacy and health, and to incorporate literacy considerations into a renewed healthcare model for Canada.

5 1 Adult learner, from the grafitti wall at the Canadian Public Health Association (CPHA) Conference on Literacy and Health, May Federal Provincial Territorial Advisory Committee on Population Health, September Federal/Provincial/Territorial Advisory Committee on Health, For example, the National Literacy and Health Program within the Canadian Public Health Association promotes awareness of the links between literacy and health, see 5 For a list of suggested resources, see MCL's Factsheet on literacy and health at 6 "How does literacy affect the Health of Canadians?" Burt Perrin, Health Promotions Branch, Health Canada, Ibid, Perrin Ibid, Perrin Ibid, Perrin In partnership with 26 national health associations, the Canadian Public Heath Association raises awareness about the links between literacy and health and promotes the use of clear written and verbal communication of health information, through its National Literacy and Health Program. 11 Burt Perrin, Health Literacy: Report of the Council on Scientific Affairs.