The Impact of

Graduation Rates on
Health Literacy

Leslie M. Ann Rathbun, Ph.D.

Eickelberger Morehead State
Morehead State University
University Morehead, Kentucky
Morehead, Kentucky
 What is health literacy?
 The degree to which individuals have
the
capacity to obtain, process, and
understand basic health information
and services needed to make
appropriate health decisions.

HHS,
© Rathbun & 20002008
Eickelberger, & Institute of Medicine,
 Measuring Literacy in the
U.S.
 NAAL
 National Assessment of Adult Literacy is
a nationally representative assessment
of English literacy
 Sponsored by the US Department of
Education
 The 2003 assessment was the first one
completed in the U.S. since 1992
National Center for Education
(National Adult Literacy Survey).
Statistics, 2007

© Rathbun & Eickelberger, 2008

 The NAAL
 The 2003 NAAL was the first-ever
national assessment of adults ability
to understand health-related materials
and forms.
 Six states purchased separate
samples to obtain detailed information
describing the literacy of their adult
populations: Kentucky, Maryland,
National Center for Education
Massachusetts, Missouri,Statistics,
New 2007 York,
and Oklahoma.
© Rathbun & Eickelberger, 2008
 Assessment of Skill Level
 Upon completion of the assessment,
participants were assigned a “level.”

 Each level is explained as a list of

sample tasks that individuals at the
various levels should be able to
perform. American Institutes for Research,
2006

© Rathbun & Eickelberger, 2008

 4 Skill Levels
American Institutes for Research, 2006

 Below Basic
 Basic
 Intermediate
 Proficient

© Rathbun & Eickelberger, 2008

 Literacy level & abilities
 Below Basic
- Find and circle the date on an
appointment slip
- Identify what to do to get ready
for a
medical test (drink/eat)

© Rathbun & Eickelberger, 2008

 Literacy level & abilities
 Basic
- Read a pamphlet and state 2
reasons
a person should be tested for a
condition even though they do not
have symptoms.

© Rathbun & Eickelberger, 2008

 Literacy level & abilities
 Intermediate
- Determine ‘healthy weight’ on the
BMI
chart
- Read and interpret information
from a
drug label (interactions, when to
take in
relation to eating)
© Rathbun & Eickelberger, 2008
 Literacy level & abilities
 Proficient
- Calculate health insurance costs
for a
year based on information given
for
employees at a company

- Search a complex document to find

the
© Rathbun & Eickelberger, 2008
 Who is at risk?
 Those with overall poor literacy rates
 Older individuals
 Those with low levels of education
 Those who have been socialized to be
modest
 Those who have been socialized to respect
the “white coat”
 Anyone who does not “understand”
medical jargon!!!
© Rathbun & Eickelberger, 2008
 Health Literacy in the US
NAAL 2003
 Majority of adults
(65%) in the US
had INTERMEDIATE
or PROFICIENT
health literacy
 36% of adults had
Basic or Below
Basic health
literacy.
NCES, 2003
© Rathbun & Eickelberger, 2008
 Health Literacy in the US
NAAL 2003
 Older adults (65+)
 40% Intermediate or
Proficient
 60% Basic or Below
Basic

 Education Level
 77% of those with some
high school or less than
a high school education
had Basic or Below
Basic health literacy.
NCES, 2003
© Rathbun & Eickelberger, 2008
 Individuals with low health
literacy skills are much more
likely to:
 Skip prevention services (vaccines,
mammograms, pap tests,
educational programs, etc). (Weiss,
1999)
 Therefore are “sicker” when they do
enter the healthcare system
 Have chronic conditions and manage
them poorly (ex. HIV, diabetes, high blood
pressure)
© Rathbun & Eickelberger, 2008
 Individuals with low health
literacy skills are much more
likely to:
 Engage the healthcare system
through preventable hospital visits
and admissions
 Stays are 2 days longer
 Higher healthcare costs.

 Recent estimates ≈ $250 billion/year

Vernon & Trujillo, 2007
 Projected costs ≈ the trillions

© Rathbun & Eickelberger, 2008

 Appalachia
>Appalachia encompasses
200,000 square miles, 410
counties
>The struggle continues to
secure basic food and shelter
>Although poverty rates have
improved, the region
continues to have higher rates
of poverty than the nation.

© Rathbun & Eickelberger, 2008 Lichter & Campbell, 2005

 Appalachian Sensibilities
 Family
 Community
 Independence, self reliance
 Oral tradition
Toborg, Meyer, & Denham,
2001

© Rathbun & Eickelberger, 2008

 Kentucky – The Bluegrass
State
 Location:
 south central United States along the west side
of the Appalachian Mountains
 Capital is Frankfort
 Population was 4,041,769 (2000 U.S. Census
Bureau)
 Industry Providers:
 Manufacturing
 Services
 Government

© Rathbun & Eickelberger, 2008

Kentucky

© Rathbun & Eickelberger, 2008

 Mission of NAHEC
 To make health education broadly
accessible, effective, and
sustainable.
 This organization shall meet its mission
by:
• Advancing health literacy through
collaborative relationships with
organizations that share a
commitment to health knowledge.
© Rathbun & Eickelberger, 2008
 NAHEC Core Values

Quality of life for all is improved by:

• Increasing health literacy, especially
to the underserved.

© Rathbun & Eickelberger, 2008

 Percentage of High School Completion
by Age, Selected Appalachian Regions
and US Total, 2000
Source: 2000 Census Public Use Microdata Sample, PRB analysis

Region Age 25-34 35-44 45-59 60+

N Alabama 82.8 83.4 82.0 60.4

NE Tennessee 75.0 73.9 70.9 44.1

E Kentucky 74.9 70.5 62.2 38.1

SE Ohio 85.7 86.6 79.7 65.5

NE Pennsylvania 86.6 88.0 86.1 67.8

US Total 83.9 85.0 84.9 68.0

© Rathbun & Eickelberger, 2008
 Eastern Kentucky vs. U.S
Educational attainment, 2000
25-34 35-44 45-59 60+

E Kentucky 74.9 70.5 62.2 38.1

US Total 83.9 85.0 84.9 68.0

Difference 9% 14.5% 22.7% 29.9%

© Rathbun & Eickelberger, 2008

This table does not show the same kind of results
that we expected to find based on earlier
information regarding disparities high school
graduation rates in Appalachian Kentucky.

© Rathbun & Eickelberger, 2008

 The purposes of this study
were to:
 Examine high school graduation
rates across the state of Kentucky.
2. Compare graduation rates to health
status rank in Appalachian and non-
Appalachian counties.
3. Discover the correlation (if any)
between high school graduation
rates and health status in
Appalachian and non-Appalachian
counties in the state.
© Rathbun & Eickelberger, 2008
 The Health of Kentucky:
A County Assessment
Kentucky IOM, 2007
 Ranked each county in the state (n=120) by
health status.
 The higher the rank, the worse the health
status of individuals in that county.
 Factors were grouped into the following
categories:
 Behavioral/social factors

 Demographics

 Health access, and

 Health outcomes.
© Rathbun & Eickelberger, 2008
© Rathbun & Eickelberger, 2008
© Rathbun & Eickelberger, 2008
© Rathbun & Eickelberger, 2008
 The Health of Kentucky:
A County Assessment

 Smoking is Kentucky's greatest

challenge
 More than 23% of all deaths in Kentucky
are attributable to smoking.
 115/120 counties have smoking rates
below the national average.

© Rathbun & Eickelberger, 2008 Kentucky IOM, 2007

 The Health of Kentucky:
A County Assessment
 Kentucky is at or below the national
average for:
 low birth weight babies and infant mortality.
 Infectious diseases (HIV, hepatitis, and
tuberculosis)
 Kentucky is above the national average
for:
 diabetes
 Physical activity
 CVD
 cancer death©rates
Rathbun & Eickelberger, 2008
 Hypotheses
HO1 : In the state of Kentucky, Appalachian
counties have lower graduation rates than
non-Appalachian counties.

HO2 : In the state of Kentucky, Appalachian

counties have a worse health status than
non-Appalachian counties.

HO 3: There is a correlation between health

rank and having a high school diploma in
Kentucky. © Rathbun & Eickelberger, 2008
 Methodology
 Entered each county’s health status
ranking (KY IOM)
 Entered each county’s rate of those
who did not complete high school
(graduation or GED)
 Sorted all counties into Appalachian
or Non-Appalachian counties

© Rathbun & Eickelberger, 2008

 Methodology
 Entered each county’s total
population (and sorted into
categories)
 Entered each county’s percent of
rural area (and sorted into
categories)
 Compared means (ANOVA) and
calculated correlations (Pearson’s R)
in order to accept or reject
© Rathbun & Eickelberger, 2008
 Results
 HO1: Accepted
Interpretation: Rates of high school
graduation are lower in Appalachian
counties than in non-Appalachian
counties in Kentucky.

© Rathbun & Eickelberger, 2008

 Results
 HO2: Accepted
Interpretation: Health status (by rank) is
worse is Appalachian counties in
Kentucky than in non-Appalachian
counties.

© Rathbun & Eickelberger, 2008

 Results
 HO3: Accepted (with conditions)
Interpretation: Although there is a
correlation between health rank and
having a high school diploma, the strength
of the correlation is only “fairly strong”
(r=.74).
As the health rank get worse in a county,
the percentage of those in the county who
did not complete high school is larger.
© Rathbun & Eickelberger, 2008
 Recommendations
 In order to effectively plan
interventions sensitive to health
barriers and disparities, county-level
data on all health and health-related
issues are necessary.
 2 examples of this were the KY IOM data
and the county graduation rates for
Appalachian Kentucky

© Rathbun & Eickelberger, 2008

 Recommendations
 Although your state may not have health
literacy data, you can make some
estimates by accessing data in your state.

 Resource for county by county health data

for each state in the U.S.

 http://www.communityphind.net/StateLinks.cfm

© Rathbun & Eickelberger, 2008

 Recommendations
 Yin, H. S., Forbis, S. G.,  & Dreyer, B. P.
(2007). Health Literacy and Pediatric
Health. Current Problems in Pediatric and
Adolescent Health Care, 37(7), 258-286.

 Terrific manuscript that covers a variety of

topics related to practice and
programming issues for adolescents (and
their adult caregivers) with low health
literacy.
© Rathbun & Eickelberger, 2008
 Policy Recommendations
 Assess materials currently “in stock”
printed materials for reading level.
 Revise materials based on findings.
 All printed and electronic written
materials should be written at a 4th-
6th grade level.

© Rathbun & Eickelberger, 2008

 Policy Recommendations
 Pre-test materials with audiences.
 This is to avoid mistakes in ordering
materials that are costly that do not
meet the needs of the target population.
If materials don’t “work;” don’t order
them!! (see The Pink Book.)

© Rathbun & Eickelberger, 2008

 Policy Recommendations
 Develop consumer empowerment
workshops on “How to be a Better
Patient.”
 This begins to bridge the gap in
provider-patient communication
 http://www.cfah.org/hbns/PreparedPatient/Pr
http://www.cfah.org/hbns/PreparedPatient/P

© Rathbun & Eickelberger, 2008

 Where to access and download this
presentation
www.arathbunblog.blogspot.com
© Rathbun & Eickelberger, 2008