Poor Literacy, Low Income May Deter Cancer Screening

CHICAGO—Poor reading ability and low income affect many aspects of health care, including cancer screening. Preliminary analysis of data from a study of new enrollees in a Medicare managed care program showed that women with low or inadequate functional literacy were less likely than literate patients to have a Pap smear, and those with yearly incomes below $20,000 were less likely to have mammography.

David W. Baker, MD, associate professor of medicine, Case Western Reserve University, Cleveland, presented the data at a symposium on reaching medically underserved populations sponsored by the Robert H. Lurie Comprehensive Care Center of Northwestern University.

The study was based on interviews and the Short Test of Functional Health Literacy administered to new female enrollees into Prudential SeniorCare Programs in Cleveland, Houston, Miami, and Tampa. The results showed that 11% of 3,260 women had marginal literacy and 25% had inadequate literacy.

While women with inadequate or marginal literacy were more likely to say they had never had mammography or had not undergone mammographic examination in the last 2 years, literacy was not the principal reason for failing to participate in breast cancer screening.

Of the 2,084 women with adequate literacy, 10% had never had a mammogram vs 14.3% of those with inadequate literacy; 19% of the literate women had not had a mammogram in the last 2 years vs 30.1% of the women with inadequate literacy.

Low income was more strongly associated with participation in mammographic screening than literacy, after data were adjusted for age and race. Women with a yearly household income less than $15,000 had a 2.95 odds ratio for never having a mammogram and a ratio of 2.99 for not having a mammogram in the last 2 years. Women with a yearly income below $20,000 had an odds ratio of 2.75 for never having a mammogram and 2.26 for not having a mammogram in the last 2 years.

The degree to which women underwent screening for cervical cancer, however, differed considerably by their literacy level. A total of 8.3% of women had never had a Pap smear. The number was nearly three times higher for women with inadequate literacy (14.3%) than for those with adequate literacy (5.4%).

After adjusting for age, income, and race, women with marginal or inadequate literacy were more than twice as likely to have never had a Pap smear. The odds ratio was 2.20 for women with inadequate literacy and 2.14 for women with adequate literacy.

Dr. Baker suggested, therefore, that information about literacy may help managed care plans improve participation in preventive care. Managed care programs may identify women in senior care plans who have marginal or inadequate literacy and “try aggressive interventions [directed at literacy] to get them in for screening,” he said, because literacy may be a marker for other factors, such as language barriers, cultural differences, and patient empowerment.

Dr. Baker said that researchers should determine the pathways by which literacy affects the use of health care services and health itself. “It is naïve for us to think we can address problems in literacy simply by giving individuals low-literacy materials. We need to develop more comprehensive interventions that will make a difference for these people,” he said.