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Health Literacy, Access to Care and Outcomes of CareAlan Jotkowitz a & Avi Porath aa Ben-Gurion University of the Negev ,Published online: 15 Nov 2007.

To cite this article: Alan Jotkowitz & Avi Porath (2007) Health Literacy, Access to Care and Outcomes of Care, The AmericanJournal of Bioethics, 7:11, 25-27, DOI: 10.1080/15265160701638637

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Health Literacy, Health Inequality

times the shortest one, an interval of 49 years (WHO 2007).Second, the rural poor in developing countries cannot besaid to lack much health literacy in the systemic sense. Cer-tainly, the global poor are more likely to lack formal educa-tion (WHO 2002), and may often lack knowledge that couldenhance their health. In this usual sense, their health literacymay be insufficient for their needs. And certainly, povertyis strongly associated with greater childhood malnutrition,less access to clean water and sanitation, and greater indoorair pollution (WHO 2002). But do the global poor suffer froma wide differential between the complexities of their health-care systems and their understanding of it? Chad, one of thecountries where the least is spent on healthcare in the world,had a life expectancy at half the global maximum in 2005.Much of its rural populations have no access to healthcarefacilities whatsoever. Presumably, they have little difficultyin understanding this fact.

Addressing health inequalities and making complexhealthcare systems—and providers—easier to understandare both crucial goals. This is true both in developing and in-dustrialized countries. Marmot (2004) imagines a ride fromsoutheast Washington, DC, to Montgomery County, Mary-land, on the Washington Metro red line: life expectancy islonger by 20 years for the rich whites at the end of thisjourney than for the poor blacks at its beginning. If wetruly can address both goals at once in industrialized coun-tries, we should be thankful that efforts aimed at these twochallenges may thus converge. However, if we accept adefinition in which greater health illiteracy follows greatercomplexity in healthcare systems, we cannot consider healthliteracy to be a valid international surrogate for socioeco-nomic determinants of health. This should be clear if weare to avoid the conclusion that giving priority to health lit-

eracy gives us grounds to consider the worst-off patientsto be those who actually have a functioning healthcaresystem. �

REFERENCES

Low, A., L. Unsworth, A. Low, and I. Miller. 2007. Avoiding thedanger that stop smoking services may exacerbate health inequal-ities: Building equity into performance assessment. BioMed CentralPublic Health 7(1): 198.

Marmot, M. G. 2004. Status syndrome: How social standing affects ourhealth and longevity. New York, NY: Times Books.

Oliver, M. 1998. Theories in healthcare and research: Theories ofdisability in health practice and research. British Medical Journal317(7170): 1446–1449.

Powers, M., and R. Faden. 2006. Social justice: The moral foundationof public health and health policy. New York, NY: Oxford UniversityPress.

Volandes, A. E., and M. K. Paasche-Orlow. 2007. Health literacy,health inequality and a just healthcare system. American Journal ofBioethics 7(11): 5–11.

World Health Organization. 2006. Meeting the MDG drinking-water and sanitation target: The urban and rural challenge of thedecade. Available at http://www.who.int/water sanitation health/monitoring/jmp2006/en/index.html (accessed August 25, 2007).

World Health Organization. 2007. WHO statistical informationsystem (WHOSIS). Available at http://www.who.int/whosis/database/core/core select.cfm (accessed August 25, 2007).

World Health Organization. 2002. World health report 2002—reducing risks, promoting healthy life. Available at: http://www.who.int/whr/2002/en/index.html (accessed August 25, 2007).

Health Literacy, Access to Care andOutcomes of Care

Alan Jotkowitz, Ben-Gurion University of the NegevAvi Porath, Ben-Gurion University of the Negev

The field of academic bioethics was born with the delivery ofthe Lyman lectures at Harvard University by Joseph Fletcherin 1949. The lectures were later published as a monographentitled Morals and Medicine (Fletcher 1954). Fletcher’s uni-fying theme was the relationship between human freedomand medical ethics and focused on human rights in med-ical decision-making. The five chapters of the book cor-

Address correspondence to Alan Jotkowitz, Moshe Prywes Center for Medical Education, Ben Gurion University of the Negev, P. O. Box653, Beer-Sheva 84105, Israel. E-mail: ajotkowitz@hotmail.com

respond to five different human rights relating to health-care. The book serves as a cornerstone of the dominantprinciple in modern Western bioethics: unlimited humanautonomy.

Fletcher (1954) primarily focused on the ethical dilem-mas of the individual in his work, and other theologicallytrained pioneer bioethicists such as Immanuel Jakobovitz

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(1959) and Paul Ramsey (1970) also concentrated on theethics of individual patient care. In the 1970s, however,bioethicists expanded the rights paradigm to such notionsas the right to healthcare. Beauchamp and Childress (1994)base this right on the principles of collective social protec-tion and fair opportunity, and this right has been acceptedby most bioethicists as a major component of a just health-care system. Similar to their reluctance to quickly acceptautonomy as a dominant factor in the physician-patient re-lationship, the organized medical community, particularlyin the United States, has been slow to accept the ethical im-perative of the universal right to healthcare. However, in aremarkable document published by a collection of leadingmedical organizations in 2002, entitled The Physician Charteron Medical Professionalism (ABIM Foundation et al. 2002), themedical community recognized that, in addition to patientautonomy and acting in the patient’s best interest, pursu-ing social justice is one of the cardinal principles of medicalprofessionalism. Endorsed by more than 90 organizationsworldwide, the document states:

The medical profession must promote justice in the healthcaresystem, including the fair distribution of healthcare resources.Physicians should work actively to eliminate discriminationin health care, whether based on race, gender, socioeconomicstatus, ethnicity, religion or any other social category (ABIMFoundation et al. 2002, 243).

Universal access to healthcare has emerged as the defin-ing issue in the pursuit of Justice in an ethical healthcaresystem. Countries that do not guarantee universal health-care to their citizens, such as the United States, have evokedmuch criticism among some members of the bioethics com-munity. However, the question that arises in countries thatdo have universal health care coverage is whether that sys-tem guarantees fair and equitable healthcare.

Since its founding, for example, Israel has, by law, guar-anteed healthcare to all its citizens regardless of race, coloror religion. Israel is a very socioeconomic diverse coun-try that, in past decades, has absorbed more than one mil-lion new immigrants, primarily from the former SovietUnion. In a recent population-based study of more thanfour million Israeli citizens, we found that patients fromthe lower socioeconomic strata had greater access to healthcare, as manifested by more preventive healthcare amongdiabetic patients, but nevertheless had worse health out-comes (Jotkowitz et al. 2006). We postulated that lifestyledifferences and cultural and psychosocial influences mightpartially explain this result. However, it is certainly possiblethat limited health literacy might also play a role, as claimedby Volandes and Paasche-Orlow (2007), and that this mightplay an even larger role in the future due to the impact ofglobalization and the rapid movement of populations fromone country to another.

We believe that the principle of Justice should be ex-panded not to only ensure access to care but to strivefor equal outcomes among differing socioeconomic groupsas a moral imperative. The ethical debate on equality in

healthcare thus must progress beyond the vital but lim-ited issue of universal coverage. Overcoming the problemof limited health literacy is an important component of thisendeavor.

Volandes and Paasche-Orlow (2007) offer three sug-gestions on how this might be accomplished: 1) the as-sumption of limited health literacy among patients; 2)technology-supported communication, and 3) a more justpay-for-performance system. The “teach-back” model thatthey champion should be a component of the patient-interviewing courses now taught in most medical schools,and there has been a recent push in medical education toimprove crosscultural communication skills (Rosen et al.2004). Patient education in groups has been touted as apartial solution to some of these problems. We also agreewith their critique of current pay-for-performance programsthat may be biased against patients with low health literacyand their physicians which has the potential to discrimi-nate and lead to ’cherry–picking’ patients. In addition, aswe have shown (Jotkowitz et al. 2006), providing more doc-umented preventive care to certain populations does notnecessarily lead to better outcomes. We are skeptical, how-ever, about Volandes and Paasche-Orlow’s (2007) claims thatnew technology can solve the problem of health literacy. Be-fore this approach is advocated it needs to be rigorouslytested.

However important these innovations are, there arepractical limitations that must be addressed. In all healthcaresystems, whether fee-for-service or government-funded,there is increased pressure on physicians to see morepatients in a shorter time with the result that there is lesstime available for such vital activities as discussing patientpreferences and health education. Perhaps the real ethicalchallenge is to guarantee patients adequate time with theirhealthcare providers. In addition, we believe it is not possi-ble to discuss the issue of health literacy in a vacuum withoutalso dealing with the larger issue of literacy in general.

Volandes and Paasche-Orlow (2007) are right that Justicemandates that the medical community address the issue ofhealth literacy, but their solutions need to be practical at-tainable and well studied. �

REFERENCES

ABIM Foundation, American Board of Internal Medicine, ACP-ASIM Foundation, American College of Physicians-AmericanSociety of Internal Medicine, and the European Federation ofInternal Medicine. 2002. Medical professionalism in the new millen-nium: A physician charter. Annals of Internal Medicine 136(3): 243–246.

Beauchamp, T. L., and J. F. Childress. 1994. Principles of biomedicalethics. New York, NY: Oxford University Press.

Fletcher, J. 1954. Morals and medicine. Princeton, NJ: Princeton Uni-versity Press.

Jakobovitz, I. 1959. Jewish medical ethics. New York, NY: Bloch Pub-lishing.

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Jotkowitz, A. B., G. Rabinowitz, A. Raskin-Segal, R. Weitzman, L.Epstein, and A. Porath. 2006. Do patients with diabetes and lowsocioeconomic status receive less care and have worse outcomes?A national study. American Journal of Medicine 119:665–669.

Ramsey, P. 1970. The patient as person. New Haven, CT: Yale Univer-sity Press.

Rosen, J., E. S. Spatz, A. M. Gaaserud, et al. 2004. A new approachto developing cross-cultural communication skills. Medical Teacher26(2): 126–132.

Volandes, A. E., and M. K. Paasche-Orlow. 2007. Health literacy,health inequality and a just health care system. American Journal ofBioethics 7(11): 5–11.

Illiteracy Ain’t What It Used to BeHoward Trachtman, Schneider Children’s Hospital

As I go through my normal workday meeting and inter-acting with patients, parents, students, residents and col-leagues, certain phrases reappear in my conversations asleitmotifs. Now, with the article by Volandes and Paasche-Orlow (2007) fresh in my mind, I shudder to think howmany times I have said out loud or thought to myself, “Youdon’t have to be a rocket scientist to understand this.” Thetruth is I could not be more mistaken. It probably is easier tobuild a rocket from scratch than it is to competently navigatethrough our healthcare system.

Try making an appointment and climbing the phone-tree message prompts that inevitably guard access to thephysician’s office. Read a patient’s Bill of Rights, the stan-dard Health Insurance Portability and Accountability Actnotice, or an application for prescription drug coverage,and see if your non-legal eyes do not glaze over in com-plete incomprehension. Visit a physician to discuss treat-ment for your newly diagnosed disease that requires inten-sive therapy and that may recur, and see if you can keeptrack of the risks and benefits of initial and relapse therapyoptions. Review a current research report on the benefits ofprophylactic administration of clotting factors to childrenwith severe hemophilia (Manco-Johnson et al. 2007), andlet me know how well you disentangle protection againstprogressive joint injury from the impact of the costly infu-sions on skyrocketing health expenditures. Finally, imag-ine talking to your physician about diagnostic methods ormedical interventions that were science fiction less than 50years ago. Do you wish you had paid more attention inschool?

Volandes and Paasche-Orlow’s (2007) central point thatmany aspects of the health system are overly and needlesslyconvoluted and that this complexity interferes with goodclinical outcomes is well documented. They address struc-tural flaws in the healthcare system such as use of printed

Acknowledgement: The author expresses his thanks to Rachel Frank, RN, CNN, for her thoughtful comments about this essay.Address correspondence to Howard Trachtman, Schneider Children’s Hospital, Division of Nephrology, 269-01 76th Ave., New HydePark, NY, 11040. E-mail: trachtma@lij.edu

materials that presume advanced levels of literacy, limitedavenues of communication, and use of administrative ratherthan educational criteria in evaluating pay-for-performancequality improvement programs. The recent introduction ofa federally funded drug prescription program encounterednumerous administrative problems caused by a failure toaccount for the complicated needs of indigent elderly pa-tients with chronic disease (Winter et al. 2006). In addition,there is ample literature documenting that patients with lim-ited financial resources encounter barriers in their access tostandard healthcare. The absence of universal health insur-ance aggravates this inherent inequality in the United States.Poor patients are often not offered the same therapeutic op-tions, and even if they are, the diagnostic tests or treatmentsare not presented with same degree of urgency comparedto well-to-do individuals. This has been shown for the eval-uation of cardiac disease and treatment of cancer (Brownand O’Connell 2004; Wender 2007). These injustices doneto patients reflect problems that are external to them, actsperpetrated by healthcare practitioners. However, becauseVolandes and Paasche-Orlow (2007) approach health liter-acy from this perspective, I suggest that they focus too nar-rowly on the problem among socioeconomically deprivedpopulations instead of viewing this as a problem in whichall patients have a stake.

The fund of knowledge in the biosciences has grown ex-ponentially over the lifespan of the past generation. Volan-des and Paasche-Orlow (2007) assume that those who arethe least well-off and who have marginal material resourcesare the only people who are materially impacted by barriersto health literacy. The scope of medicine extends much far-ther into the fabric of society and penetrates deeper into thedaily lives of individuals resulting in a “medicalization” ofcontemporary life. This is because of the enhanced abilityof physicians to diagnose and treat illness. This dramatic

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