Lack of health insurance and decline in overall health in late middle age.

BACKGROUND: The number of adults in their 50s and 60s in the United States who do not have health insurance is increasing. This group may be particularly vulnerable to the ill effects of being uninsured. METHODS: We conducted a prospective cohort study using files from the Health and Retirement Study, a national survey of adults who were 51 to 61 years old in 1992. We determined the risks of a major decline in overall health and of the development of new physical difficulties between 1992 and 1996 for participants who were continuously uninsured (uninsured in 1992 and in 1994), those who were intermittently uninsured (uninsured either in 1992 or in 1994), and those who were continuously insured. We used logistic regression to determine the independent effects of being uninsured on health outcomes after adjustment for base-line sociodemographic factors, preexisting medical conditions, and types of health-related behavior such as smoking and alcohol use. RESULTS: We analyzed data for 7577 participants. The 717 continuously uninsured participants and the 825 intermittently uninsured participants were more likely than the 6035 continuously insured participants to have a major decline in overall health between 1992 and 1996 (21.6 percent, 16.1 percent, and 8.3 percent of the three groups, respectively; P<0.001 for both comparisons). According to a multivariate analysis, the adjusted relative risk of a major decline in overall health was 1.63 (95 percent confidence interval, 1.26 to 2.08) for continuously uninsured participants and 1.41 (95 percent confidence interval, 1.11 to 1.78) for intermittently uninsured participants, as compared with continuously insured participants. A new difficulty in walking or climbing stairs was also more likely to develop in the continuously or intermittently uninsured participants than in the continuously insured participants (28.8 percent, 26.4 percent, and 17.1 percent of the three groups, respectively; P<0.001 for both comparisons). The adjusted relative risk of such a new physical difficulty was 1.23 (95 percent confidence interval, 1.02 to 1.47) for the continuously uninsured participants and 1.26 (95 percent confidence interval, 1.01 to 1.54) for the intermittently uninsured participants. CONCLUSIONS: The lack of health insurance is associated with an increased risk of a decline in overall health among adults 51 to 61 years old.

Health insurance and access to care for symptomatic conditions.

BACKGROUND: The uninsured receive less medical care than the insured. However, it is not known whether the uninsured are less likely to seek medical care for highly "serious" or "morbid" symptoms. METHODS: Participants in the National Access to Care Survey were asked whether they had experienced any of 15 highly serious or morbid symptoms. Those who did were asked whether they received medical care and, if care was not received, whether care was thought to have been necessary. RESULTS: A total of 574 respondents (16.4%) reported 794 new serious or morbid symptoms. Of these, 499 people (86.9%) had health insurance, and they reported 691 new symptoms; 75 (13.1%) lacked health insurance, and they reported 103 symptoms. The uninsured were less likely to have received medical care and more likely to say they did not receive care even though they thought it was needed (P = .001). Medical care was received for 45.4% of symptoms for the insured and 24.3% for the uninsured; care was not thought to have been needed for 41.0% of symptoms for the insured and 45.6% for the uninsured; and care was thought necessary but was not received for 13.6% of symptoms for the insured and 30.1% for the uninsured. In multivariate analysis, the uninsured were much less likely to have received care than the insured (adjusted odds ratio, 0.43; 95% confidence interval, 0.23-0.81). CONCLUSION: Lack of health insurance is a major barrier to receiving medical care, even for highly serious and morbid symptoms.

Limited English proficiency and Latinos' use of physician services.

Many Latinos have limited English proficiency and this may negatively affect their use of health care services. To examine this, the authors interviewed 465 Spanish-speaking Latinos and 259 English speakers of various ethnicities who presented to a public hospital emergency department with non-urgent medical problems to assess previous physician visits, sociodemographic characteristics, and level of English proficiency. The proportion of patients who reported no physician visit during the 3 months before study enrollment was not related to English proficiency. However, among the 414 patients who saw a physician at least once, Latinos with fair and poor English proficiency reported approximately 22 percent fewer physician visits (p = 0.020 and p = 0.015, respectively) than non-Latinos whose native language was English, even after adjusting for other determinants of physician visits. The magnitude of the association between limited English proficiency and number of physician visits was similar to that for having poor health, no health insurance, or no regular source of care.

Relationships between in-hospital and 30-day standardized hospital mortality: implications for profiling hospitals.

OBJECTIVE: To examine the relationship of in-hospital and 30-day mortality rates and the association between in-hospital mortality and hospital discharge practices. DATA SOURCES/STUDY SETTING: A secondary analysis of data for 13,834 patients with congestive heart failure who were admitted to 30 hospitals in northeast Ohio in 1992-1994. DESIGN: A retrospective cohort study was conducted. DATA COLLECTION: Demographic and clinical data were collected from patients' medical records and were used to develop multivariable models that estimated the risk of in-hospital and 30-day (post-admission) mortality. Standardized mortality ratios (SMRs) for in-hospital and 30-day mortality were determined by dividing observed death rates by predicted death rates. PRINCIPAL FINDINGS: In-hospital SMRs ranged from 0.54 to 1.42, and six hospitals were classified as statistical outliers (p <.05); 30-day SMRs ranged from 0.63 to 1.73, and seven hospitals were outliers. Although the correlation between in-hospital SMRs and 30-day SMRs was substantial (R = 0.78, p < .001), outlier status changed for seven of the 30 hospitals. Nonetheless, changes in outlier status reflected relatively small differences between in-hospital and 30-day SMRs. Rates of discharge to nursing homes or other inpatient facilities varied from 5.4 percent to 34.2 percent across hospitals. However, relationships between discharge rates to such facilities and in-hospital SMRs (R = 0.08; p = .65) and early post-discharge mortality rates (R = 0.23; p = .21) were not significant. CONCLUSIONS: SMRs based on in-hospital and 30-day mortality were relatively similar, although classification of hospitals as statistical outliers often differed. However, there was no evidence that in-hospital SMRs were biased by differences in post-discharge mortality or discharge practices.

Variations in family physicians' and cardiologists' care for patients with heart failure.

BACKGROUND: Improved understanding of the reasons for underuse of diagnostic tests and treatments for congestive heart failure (CHF) may be helpful for designing future interventions to improve quality of care. METHODS: To determine differences between family physicians' and cardiologists' practice styles for diagnosis and treatment of CHF, a random sample of family physicians and cardiologists were surveyed with standardized case scenarios. RESULTS: Survey respondents were 182 family physicians and 163 cardiologists. Family physicians were less likely than cardiologists to rate measurement of left ventricular ejection fraction as "very important" for patients with new CHF, less likely to order an echocardiogram or test for ischemia, and much less likely to identify diastolic dysfunction as a cause of CHF. Family physicians were more likely to prescribe digoxin when it was not indicated (diastolic dysfunction) and less likely to prescribe digoxin and an angiotensin-converting enzyme (ACE) inhibitor when they were indicated (moderately to severely reduced left ventricular ejection fraction). Family physicians expressed more concern over the risks of ACE inhibitors in patients with blood pressure of 100/70 mm Hg or serum creatinine of 2.0 mg/dL and were less likely to prescribe an ACE inhibitor in these settings. Family physicians overestimated the risks of warfarin use for atrial fibrillation and were therefore less likely to prescribe warfarin. CONCLUSIONS: Family physicians appear to have less understanding of CHF pathophysiology (ie, systolic versus diastolic dysfunction) and how treatment differs according to the underlying disease process. Overestimation of the risk of ACE inhibitor and warfarin use may result in underprescribing these medications.

Quality of care for Medicare patients hospitalized with heart failure in rural Georgia.

BACKGROUND: It is not known whether quality of care for congestive heart failure (CHF) at rural hospitals is similar to that in larger, urban hospitals. METHODS: We reviewed hospital charts for 310 Medicare patients hospitalized with CHF at six hospitals in rural Georgia. RESULTS: Of the 310 patients, 101 (33%) had left ventricular systolic dysfunction, and 60 (19%) had preserved systolic function. Information on left ventricular function was not available for 48% (range, 29% to 87% across the six hospitals). Among patients with systolic dysfunction, 77% were prescribed an angiotensin converting enzyme (ACE) inhibitor at discharge, and 73% were prescribed digoxin. However, the mean daily ACE inhibitor dose was only 48% of the recommended target dose. Only 30% of all patients with atrial fibrillation were prescribed warfarin. CONCLUSIONS: Overall quality of care for CHF at rural hospitals appears similar to that in other settings, though many patients may not receive evaluation of ventricular function.

Reading skills and family planning knowledge and practices in a low-income managed-care population.

OBJECTIVE: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees. METHODS: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression. RESULTS: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status. CONCLUSION: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Health literacy among Medicare enrollees in a managed care organization.

CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

Development of a brief test to measure functional health literacy.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Health literacy and the risk of hospital admission.

OBJECTIVE: To determine the association between patient literacy and hospitalization. DESIGN: Prospective cohort study. SETTING: Urban public hospital. PATIENTS: A total of 979 emergency department patients who participated in the Literacy in Health Care study and had completed an intake interview and literacy testing with the Test of Functional Health Literacy in Adults were eligible for this study. Of these, 958 (97.8%) had an electronic medical record available for 1994 and 1995. MEASUREMENTS AND MAIN RESULTS: Hospital admissions to Grady Memorial Hospital during 1994 and 1995 were determined by the hospital information system. We used multivariate logistic regression to determine the independent association between inadequate functional health literacy and hospital admission. Patients with inadequate literacy were twice as likely as patients with adequate literacy to be hospitalized during 1994 and 1995 (31. 5% vs 14.9%, p <.001). After adjusting for age, gender, race, self-reported health, socioeconomic status, and health insurance, patients with inadequate literacy were more likely to be hospitalized than patients with adequate literacy (adjusted odds ratio [OR] 1.69; 95% confidence interval [CI] 1.13, 2.53). The association between inadequate literacy and hospital admission was strongest among patients who had been hospitalized in the year before study entry (OR 3.15; 95% CI 1.45, 6.85). CONCLUSIONS: In this study population, patients with inadequate functional health literacy had an increased risk of hospital admission.

A revised measure of symptom-specific health care use.

The objective was to determine physicians' ratings of the clinical importance of common adult symptoms and to use these ratings to develop a new measure of symptom-specific use of health care services. We developed a list of common symptoms using the National Ambulatory Medical Care survey. We surveyed a random sample of internists, family physicians, general practitioners and emergency medicine physicians from the American Medical Association's Physician Masterfile and asked them to rate symptoms' seriousness, impact on quality of life and urgency of need for medical attention. The symptoms' prevalences were determined in a general population survey (National Access to Care Survey). Eleven items were classified as "serious" (median seriousness ratings of 7 or higher on scale from 1 to 10); most of these also were judged to have high impact on quality of life. Another 12 items that were not judged "serious" had median quality of life impact scores of 7 or higher and were classified as "morbid". Sixteen items did not meet criteria for either "serious" or "morbid" symptoms and were classified as "intermediate". Six other items had median seriousness and quality of life impact scores of 3 or less and were classified as "benign". A total of 24 of these items (7 "serious", 8 "morbid", 8 "intermediate" and 1 "benign") were selected to form the symptom-response measure. In the national survey, 26.3% reported one or more serious symptom, 30.6% reported one or more morbid symptom and 29.6% reported one or more intermediate symptom. This new instrument expands on earlier "symptom-response" measures by including a larger number and a broader spectrum of symptoms. This measure should be useful to assess differences in patterns of health care use for particularly serious or morbid conditions; such variations may indicate problems with access to medical care.

Ambulatory health care use by patients in a public hospital emergency department.

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.

Informatics, imaging, and healthcare quality management: imaging quality improvement opportunities and lessons learned form HCFA's Health Care Quality Improvement Program.

This article examines the use of population-based healthcare data at the interface among radiology, healthcare informatics, and health services research for the purposes of healthcare quality management. To illustrate these concepts, we draw on experience with Health Care Financing Administration's Medicare Health Care Quality Improvement Program (HCQIP). We present two HCQIP efforts that have identified opportunities to improve the delivery of imaging services, specifically studies of the diagnosis and management of congestive heart failure and cerebrovascular disease. The examples demonstrate from a population-level perspective that there are opportunities to enhance the quality of imaging practice by reducing the magnitude of imaging practice variability, implementing evidence-based guidelines, and optimizing the communication of imaging study findings to physicians who are responsible for subsequent diagnostic and therapeutic decisions. Additional research is required in specific clinical domains of radiology to determine if implementation of evidence-based imaging guidelines and enhanced clarity in the interpretation and communication of diagnostic imaging will improve health outcomes.

The relationship of patient reading ability to self-reported health and use of health services.

OBJECTIVES: This study examined the relationship of functional health literacy to self-reported health and use of health services. METHODS: Patients presenting to two large, urban public hospitals in Atlanta, Ga, and Torrance, Calif, were administered a health literacy test about their overall health and use of health care services during the 3 months preceding their visit. RESULTS: Patients with inadequate functional health literacy were more likely than patients with adequate literacy to report their health as poor. Number of years of school completed was less strongly associated with self-reported health. Literacy was not related to regular source of care or physician visits, but patients in Atlanta with inadequate literacy were more likely than patients with adequate literacy to report a hospitalization in the previous year. CONCLUSIONS: Low literacy is strongly associated with self-reported poor health and is more closely associated with self-reported health than number of years of school completed.

Understanding changes in health status. Is the floor phenomenon merely the last step of the staircase?

OBJECTIVES: Previous studies have found that health-status measures may be unable to detect clinically important changes for patients whose baseline health is poor (the "floor phenomenon"). It is not known whether this inability to detect change is confined to patients in very poor baseline health or whether the sensitivity of health-status instruments varies across the entire range of health states. The goals of this study were to see how changes in physical health, mental health, and overall health (1) depend on baseline (usual) health and (2) compare with patients' global assessment of changes in their health. METHODS: Stable, ambulatory patients presenting to the emergency department of a public hospital retrospectively rated their usual physical health (eight items), mental health (three items), and overall health (one item); their health on the day of study entry using these same items; and their global assessment of the change in their health compared with baseline. Complete information on these items was available for 1,005 patients. Baseline scores on the physical and mental health subscales and the overall health item were divided into five categories: 81 to 100 (best), 61 to 80, 41 to 60, 21 to 40, and 0 to 20 (worst). RESULTS: The mean difference in health from baseline to emergency department presentation decreased as the baseline health category worsened, as follows: physical health, -26.0, -35.9, -15.1, -9.5, +1.0; mental health, -23.0, -16.1, -9.6, 0.0, 6.6; overall health -64.0, -45.3, -28.4, -8.4, 10.4, respectively. However, patients' global assessment of health change showed the opposite trend; the proportion of patients rating their health as "much worse" than baseline increased as baseline health worsened. When only patients whose physical health score declined less than 10 points were analyzed, 14% of those in the best baseline health said their health was "much worse," whereas 74% of those with the worst baseline physical health said their health was "much worse" than baseline. CONCLUSIONS: These findings suggest that the sensitivity of health-status measures to change and the meaning of an incremental change in physical health or mental health vary depending on baseline health. This may result from noninterval properties of response options or from patients being at the lowest health state (the "floor") of individual questions. If health-status measures similar to this are to be used to compare the outcomes of treatment across diseases and for patients in a wide variety of baseline health states, weighting schemes may be needed to account for these effects.

Determinants of emergency department use: are race and ethnicity important?

STUDY OBJECTIVE: To determine whether race/ethnicity is an important determinant of emergency department use. METHODS: We conducted a cross-sectional survey in a public ED to determine self-reported ED visits over the preceding 3 months. The study group comprised consecutive ambulatory patients (N = 1,049) with nonemergency medical problems. RESULTS: Blacks, whites, and Hispanics were equally likely to report one or more visits to an ED in the 3 months before study enrollment. Blacks were the most likely to report two or more ED visits in the preceding 3 months (19.0%), followed by whites (13.5%) and Hispanics (11.4%) (P = .01; unadjusted odds ratio, 1.82 for blacks versus Hispanics). In multivariate analysis, older age (P < .001), health insurance coverage (P < .001), regular source of care (P < .001), and difficulty obtaining transportation to a physician's office (P = .011) were positively associated with two or more previous ED visits. After adjustment for these variables, race/ethnicity was not significantly associated with ED use (P = .23; adjusted odds ratio for blacks versus Hispanics, 1.48 [95% confidence interval, .95 to 2.30]). CONCLUSION: Race/ethnicity was not an important determinant of ED use after adjustment for age, health insurance coverage, regular source of care, and barriers to health care. Population-based studies of ED use should be conducted to further evaluate whether racial/ethnic differences in ED use exist that are not explained by differences in demographics, health, socioeconomic status, access to care, or other determinants of ED use.

Phase II of the AHCPR-sponsored heart failure guideline: translating practice recommendations into review criteria.

BACKGROUND: In 1992, under the sponsorship of the U.S. Agency for Health Care Policy and Research, RAND assembled an expert panel to develop the Heart Failure Clinical Practice Guideline. Phase II of the effort was intended to identify which of the guideline's recommendations the panel felt were suitable for use in retrospective utilization review and quality assessment programs and to develop review criteria, performance measures, and standards of quality for use in monitoring compliance with those recommendations. SELECTION OF RECOMMENDATIONS: Selecting guideline recommendations for translation into review criteria and ultimately into standards of care was a multistep process comprising (1) identification of 34 recommendations from the guideline, (2) rating them on the basis of importance to quality of care and feasibility of monitoring, (3) review by a subcommittee and the full guideline panel, (4) translation into review criteria, and (5) further review and input by panelists and peer and pilot reviewers. Finally, standards of care (the minimum proportion of cases expected to be in accordance with guideline recommendations) were determined to be 90%-95% for six of the final criteria and 75%-80% for the other two. CONCLUSION: Despite some reservations, physicians and other health care professionals agreed to be held accountable for following a core set of guideline recommendations for the treatment of heart failure. Substantial progress was made in identifying recommendations that panelists and reviewers were willing to endorse in utilization review activities, including adoption of improved documentation standards. The review criteria's major impact may be the knowledge that the criteria are in place and that care is being monitored based on those standards.

Shame and health literacy: the unspoken connection.

Illiteracy is a well known national crisis, yet relatively little research has focused on how low literacy affects patients' health care experiences. The purpose of this study was to determine the relationship between shame and low functional literacy in the health care setting. It hypothesized that many patients with low literacy may not admit they have difficulty reading because of shame. Patients who presented for acute care at a large, public hospital in Atlanta, Georgia were interviewed. A total of 202 predominately indigent African-American patients completed a demographic survey, the Test of Functional Health Literacy in Adults (TOFHLA) and answered questions about difficulty reading and shame. Of the 202 patients interviewed, 42.6% had inadequate or marginal functional health literacy. Patients with low literacy were more likely to be male (P < 0.05), have less than a high school education (P < 0.01) and be over the age of 60 (P < 0.01). Of those patients with low literacy, 67.4% admitted having trouble reading and understanding what they read. Almost 40% (n = 23) of patients with low functional literacy who acknowledged they have trouble reading admitted shame. Of the 58 patients who had low functional health literacy and admitted having trouble reading, 67.2% had never told their spouses, and 53.4% had never told their children of their difficulties reading. Nineteen percent of patients had never disclosed their difficulty reading to anyone. Many patients with reading problems are ashamed and hide their inability to read. Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers. Further research is needed to understand how providers should deal with the shame associated with low literacy.