Health Literacy and Urbanicity Among Cancer Patients

Low health literacy is an extensive problem in the United States. Approximately 80 million adults (36%) have limited health literacy.1, 2 Low health literacy is increasingly recognized as an important individual-level predictor of poor overall health and higher mortality among seniors.1, 3, 4 Research indicates those with low health literacy may have difficulty understanding, obtaining, and retaining health information.5 Low health literacy is also associated with under-utilization of preventive health care services, increased use of emergency services and hospitalizations, and worse physical functioning and mental health.1, 5–8 Broadly defined, the term “health literacy” encompasses an array of skills required to understand health and to function in a health care environment. The Institute of Medicine defined health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”9 The American Medical Association states that health literacy is a “constellation of skills that constitute the ability to perform basic reading and numerical tasks for functioning in the health care environment and acting on health care information.”10 Health literacy has been found to be an important factor for cancer prevention and control.3, 11 Adults with limited literacy obtain less information from cancer prevention and control materials and may be less likely to be screened for cancer.11 For instance, a review of the literature found that low health literacy is associated with a lower probability of mammography screening.1, 4 Low literacy is also associated with a 1.6 times higher odds of being diagnosed at a later stage of prostate cancer and having an inadequate understanding of complex information about cancer.11, 12 Low health literacy may hinder cancer patients’ ability to understand consent forms, follow medication directions, and manage their disease.3, 5, 11 Previous research has examined the association between health literacy and sociodemographic factors, including income, education, racial and ethnic minority status, age, and recent immigration to the United States.1, 3, 5, 11, 13 Health literacy has also been associated with lack of insurance coverage.2 Results from the National Assessment of Adult Literacy (NAAL) showed that, among US adults without health insurance, 28% had low (below basic) health literacy.2 Relatively less attention has been paid to the relationship between health literacy and place of residence (urbanicity). Previous research has indicated that living in rural and non-metropolitan areas is associated with higher incidence of late-stage lymphoma and prostate cancer and lower survival rates among lymphoma patients.14, 15 Studies have shown that rural residence is also associated with lower cancer screening rates, later diagnosis stage, as well as a higher incidence of lung, prostate, colon, and cervical cancer in specific US regions.14, 16–18 Whether health literacy may explain, at least partially, these associations is unknown. Rural areas are disproportionately represented among US counties designated as medically underserved and have fewer physicians, specialists, and hospitals per capita than their urban counterparts.19, 20 One study reported no difference in health literacy between rural and urban residents.13 Instead, the results of that study suggested a U-shaped curve with lower literacy levels in urban and rural areas and higher health literacy in suburban areas.13 Characteristics typically associated with low health literacy (eg, poverty, inadequate or lack of health insurance, and the absence of a usual source of care) are more concentrated among residents of rural areas and could result in worse health outcomes and health care access for rural cancer patients independent of health literacy levels.18–20 Health literacy research has called for further investigation into sociodemographic characteristics as potential mediators, rather than confounders of relationships between health literacy and other variables such as health care utilization and health outcomes.6, 7 Cancer patients residing in medically underserved or rural areas may have lower income and education levels than patients in more urbanized areas. These socioeconomic factors could be associated with lower health literacy levels among rural patients compared to those living in more urbanized regions. Therefore, socioeconomic status could explain, at least to some extent, the relationship between rural residency and lower health literacy levels. This study attempts to fill the gaps in knowledge regarding the relationship between urbanicity and health literacy by a) investigating the association between rural residence and health literacy in a population-based sample of cancer patients in Wisconsin, and b) testing whether education, income, and other sociodemographic factors mediate this relationship.