Executive Summary “Improving Health Begins with Understanding” A CIGNA Foundation Thought Leadership Forum

In 2007 CIGNA Foundation's Thought Leadership Forum hosted Improving Health Begins with Understanding, which reached these conclusions about literacy and health.

• People avoid what they don’t understand. Fear, shame, anxiety and confusion often drive personal health care decisions.
• Poor health literacy knows no demographic limits. Age, education, ethnicity, income, and gender are not reliable predictors.
• Demography does drive content. Different groups understand information in different ways.
• Reading literacy isn’t health literacy. Being able to read a professional journal doesn’t necessarily mean someone can understand the instructions on a prescription drug bottle.
• Fluency isn’t communication. Being able to speak a language doesn’t mean someone can understand a doctor’s instructions delivered in that language.
• Communication is multi-faceted. Printed material, audio/visual elements, electronic information and face-to-face interaction must all work together.
• Success will be slow and incremental. At first, improvements depend on listening, understanding and responding to people’s needs on a case by case basis.
• Failure is not an option. Poor health literacy is costing our country in terms of dollars and lost productivity, threatening not just our nation’s health, but our future.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions.
– Parker & Ratzan, 2001

http://newsroom.cigna.com/images/56/812520_Health_Literacy_Report.pdf

What is literacy in general?

“the ability to understand and employ
printed information in daily activities,
* at home, at work and in community,
* to achieve one’s goals, and
* to develop one’s knowledge and potential.”

International Adult Literacy Survey, 1993 - 1998

Since 1993 the Internet and other developments require us to ignore the “printed” in this definition.

The literacy skill levels

Skills were rated on levels one to five, lowest to highest, for prose, document, and numeracy.

Levels and skill descriptions
Level 1
cannot read or have extreme difficulty
2
use written material for limited purposes;
need simple language, clearly laid-out
3
everyday skills for day-to-day tasks, but
cannot cope with unfamiliar or complex information
4/5
comfortable and proficient


The international surveys conducted in 2003 explored deeper numeracy and problem-solving skills. Problem-solving skills tend to be slightly lower than prose and document literacy levels. Adult Literacy and Life Skills Survey


Literacy and the Brain

-Learning to read reprograms the mind
-Reading is new software program for thinking habits and solving problems:
• categories, chapters, indexes, tables, even chronology
-Reading structures are imposed over:
• visual language, oral language, sign language, with new rules, new culture

“Words do make a lasting impression, depending on the alphabet in which we read and write them.
Indeed, in Chinese text, reading engages different parts of the brain than English text. At the University of Hong Kong, linguist Li-Hai Tan and his colleagues reported in The Proceedings of the National Academy of Sciences that the reading problems of dyslexia also affect the brain differently depending upon the writing system.
In Nature Neuroscience, Georgetown University dyslexia expert Guinevere Eden and her colleagues tracked how literacy reorganizes the brain by studying neural changes in people between the ages of 6 and 22 years old as they learned to read and write English.”

The Wall Street Journal Online, Tech May 2, 2008
Read more at How the Brain Learns to Read Can Depend on the Language


Non-readers

• They use narrative form to help remember things –stories are told to retrieve information from memory.
• A reader’s way of thinking about and organizing information changes.
• The problem-solving method of a reader is different from that of a non-reader.

Problem-solving skill

The survey measures a person’s skill at unraveling and solving problems when they did not know a routine procedure. This skill involves:
• understanding of the problem or situation
• its step-by-step transformation
• based on planning and reasoning

Problem-solving skill is usually lower; it may be different system entirely if a person is not text-oriented.

In the health care field, legal mental capacity has been defined this way:

To be "mentally capable" means that a person must have the ability to understand information relevant to making a decision and the ability to appreciate the reasonably foreseeable consequences of a decision or lack of decision.

Now that we know that learning to read reprograms the brain and that different languages impose different habits of thought, this may be significant.

Literacy statistics

Levels Canada

Level 1----22
Level 2----26
Level 3----33
Levels 4/5-19

More information about literacy issues:
National Adult Literacy Database http://www.nald.ca/index.htm
LiteracyBC http://www2.literacy.bc.ca/

Who has literacy challenges?

Low literacy is more common in some specific groups than in Canadian society as a whole. These groups include

• seniors
• immigrants
• Aboriginal Canadians
• Francophones
• people entering the corrections system
• high school dropouts and graduates

A higher than average percentage of school dropouts are:

-born in Atlantic Canada
-born in Quebec (particularly female dropouts)
-Aboriginal
-spoke French in childhood
-have a disability
-have experienced learning difficulties in childhood

Learning disabilities include differences in a person’s perceptual or cognitive systems. People with low English literacy may have different thinking and problem-solving patterns especially if their first language was not English and they are not literate in that first language.

Other causes and sources

Many children could not learn due to
• Poverty, harassment, abuse, racial discrimination,
• Stress or anxiety such as being child of alcoholic

Many high school graduates and seniors have lost their reading skills through lack of practice of them. They seek information and entertainment from other media.

Short-term, temporary, and situational causes

Any of these causes can interfere with a person’s capacity to focus, concentrate, process information, and think clearly.

• personal or social stress or anxiety
• harassment or abuse, incl. phys. and sexual abuse
• Physical health problems, including head injury or trauma
• mental health problems

Tomorrow, some solutions for communicators…

Legal rights and literacy.

Do you really know your rights?

Canadian Charter of Rights & Freedoms, 1982,
http://laws.justice.gc.ca/en/const/annex_e.html#I

Guarantee of Rights and Freedoms
Rights and freedoms in Canada

1. The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.

Is literacy a right?

U.N. Universal Declaration of Human Rights, 1948, Article 26.
“Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory.”
A beautiful animated and musical version of the Universal Declaration of Human Rights is available at http://www.humanrightsactioncenter.org/

What is legal literacy?

Legal literacy means having the special literacy skills needed to understand legal language, concepts, and processes to be able to access rights in the justice system.

Charter of Rights - Legal Rights

Life, liberty and security of person
Secure against unreasonable search or seizure
No arbitrary detention or imprisonment
Rights upon arrest or detention
Rights during proceedings in criminal and penal matters

To be informed and able to act

A person involved with criminal justice must decide what to do at many points in the process. One of the main barriers they face is police jargon and legal language.
They are confronted with a mass of information that they must
1. understand
2. recall
3. act on in a timely way.


The need to communicate effectively


The Charter of Rights Section 10(b) requires communication of the right, not a rote repetition of it according to the courts. So police may have to show the court that a person
• received the needed information about Charter rights.
• showed an understanding of those rights at the time

When there is a sign that the accused does not understand the right to counsel, the police cannot rely on a mechanical recitation of the right to the accused. They must make reasonable efforts to make the right meaningful to the accused. The Charter of Rights Section 10(b) requires communication of the right, not a rote repetition of it.

• Unless they are clearly and fully informed of their rights at the outset, detainees cannot be expected to make informed choices and decisions about whether or not to contact counsel and, in turn, whether to exercise other rights, such as their right to silence.

• In order for an accused person to be informed of his rights, it is necessary that the accused be capable of understanding and appreciating the substance of the right to counsel and truly appreciating the consequences of giving up that right.

• The right of an accused to understand carries with it the obligation on police to ensure rights are understood by taking steps to facilitate communication.

• Providing reading material in a second language is not sufficient effort without any evidence whether the accused is literate in that language.

Low literacy and its impact on crime

Neighbourhoods with lower literacy rates have higher crime rates. And people who commit crimes are more likely to have lower levels of literacy. So are victims of crime. Witnesses with low literacy face many challenges when they are asked to provide statements or testify in court.


How is Canada’s prison population affected


• Almost 7 out of 10 prisoners in Canadian jails before 1996 had low literacy skills.

• Prison literacy programs raise a person’s self-esteem along with their literacy skills. The have reversed the literacy rates in prison in the past 15 years.

• The positive outcomes of literacy training include getting the skills needed for steady employment and reducing the chance that someone will re-offend. Improved literacy skills lower the likelihood of a return to prison.


In 1995, the Correctional Service of Canada reported that newly admitted offenders had an average education level of Grade 7, and that “70% of newly admitted offenders tested below a Grade 8 level in language and math” while 86% tested below Grade 10. (A Grade 9 education is considered a commonly accepted cut-off point for identifying adults with limited literacy. )


More tomorrow on literacy in general...

Footnotes

Supreme Court of Canada R. v. Evans [1991] 1 S.C.R. 869
Supreme Court of Canada R. v. Hebert, [1990] 2 S.C.R. 151
R. v. McAvena [1987] S.J. No. 166; [1987] 4 W.W.R. 15; 55 Sask.R. 161; 34 C.C.C. (3d) 461; 56 C.R. (3d) 303; 34 C.R.R. 130; 49 M.V.R. 243; 1 W.C.B. (2d) 354 (Sask. C.A.)
R. v. Michaud [1986] O.J. No. 1631; 45 M.V.R. 243 (Ont. Dist. Ct.)
Italy v. Seifert [2003] B.C.J. No. 471 2003 BCSC 351; 13 B.C.L.R. (4th) 356 [2003] B.C.T.C. 351 (BCSC)
R. v. Ly [1993] O.J. No. 268; 18 W.C.B. (2d) 581 (Ont. Ct. J.)
Long-term Care Facilities in Ontario: The Advocate's Manual (2nd edition). Advocacy Centre for the Elderly, 2001

A new logo for information literacy

A new, international, logo has been developed to represent information literacy.

The sponsor, Information Literacy Section of IFLA, for UNESCO, says:

The aim of creating this Logo is to make communication easier between those who carry out information literacy projects, their communities, and society in general. The Logo will be available free of charge and promoted as an international symbol of information literacy.

The American Library Association describes information literacy this way:

“To be information literate, a person must be able to recognize when information is needed and have the ability to locate, evaluate, and use effectively the needed information. The information literate individuals are those who have learned how to learn”

(ALA, 1998)

I prefer the perspective adopted by Sheila Webber at the Information Literacy Weblog:

"Information Literacy--
the adoption of appropriate information behaviour to identify, through whatever channel or medium, information well fitted to information needs, leading to wise and ethical use of information in society"

Edgar Luy Pérez, the artist, says of the design:

"The book, open and next to the circle [representing study], comprises with it a visual metaphor representing those people who have the cognitive tools to reach information in a nimble way, as well as the desire to share this ability."

Oral culture: people doing

Think on it:

In the absence of elaborate analytic categories that depend on writing to structure knowledge at a distance from lived experience, oral cultures must conceptualize and verbalize all their knowledge with more or less close reference to the human lifeworld, assimilating the alien, objective world to the more immediate, familiar interaction of human beings.
A chirographic (writing) culture and even more a typographic (print) culture can distance and in a way denature even the human, itemizing such things as the names of leaders and political divisions in an abstract, neutral list entirely devoid of a human action context.
An oral culture has no vehicle so neutral as a list. In the latter half of the second book, the Iliad presents the famous catalogue of the ships—over four hundred lines—which compiles the names of Grecian leaders and the regions they ruled, but in a total context of human action: the names of persons and places occur as involved in doings (Havelock 1963, pp. 176–80).

Orality and Literacy, Walter Ong
p. 42 (v) Close to the human lifeworld

Literacy Challenges to Delivering Administrative Justice

In May, I presented at the Council of Canadian Administrative Tribunal's 4th International Conference, in Vancouver, British Columbia - "Administrative Justice Without Borders".

I had been working with the CCAT for some 18 months on this issue. CCAT released a book at the conference on plain language and administrative practice. It will be available soon online.

Our handout at the conference was a 12-page summary of the previous publication by the Literacy and Access to Justice Project. That is is now available here. The 100-page original is available here.

Some pictures are here; not great pix because of the blinding Vancouver sun!