OBJECTIVE: To review the relationship between literacy and health outcomes DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003 STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes Two abstractors reviewed each study for inclusion and resolved disagreements by discussion DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry The whole study team reconciled disagreements about information in evidence tables Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources Patients with low literacy were generally 15 to 3 times more likely to experience a given poor outcome The average quality of the articles was fair to good Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons CONCLUSIONS: Low literacy is associated with several adverse health outcomes Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions

/pdf/literacy-and-health-outcomes-4pmopsjgz6.pdf

Literacy and health outcomes

A theoretical model is proposed that relates the level of ingestion of diarrhoea-causing pathogens to the frequency of diarrhoea in the community. The implications of this model are that, in poor communities with inadequate water supply and excreta disposal, reducing the level of enteric pathogen ingestion by a given amount will have a greater impact on diarrhoea mortality rates than on morbidity rates, a greater impact on the incidence rate of severe diarrhoea than on that of mild diarrhoea, and a greater impact on diarrhoea caused by pathogens having high infectious doses than on diarrhoea caused by pathogens of a low infectious dose. The impact of water supply and sanitation on diarrhoea, related infections, nutritional status, and mortality is analysed by reviewing 67 studies from 28 countries. The median reductions in diarrhoea morbidity rates are 22% from all studies and 27% from a few better-designed studies. All studies of the impact on total mortality rates show a median reduction of 21%, while the few better-designed studies give a median reduction of 30%. Improvements in water quality have less of an impact than improvements in water availability or excreta disposal.

Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities.

Knowledge of the extent of vitamin A (VA) deficiency (D) is critical for identifying high-risk populations and mobilizing resources for prevention. Yet, all estimates are necessarily imperfect, often based on assumptions in the absence of data. In 1995, the World Health Organization estimated 254 million children to be VA-deficient and 2.8 million to have xerophthalmia. Subsequently, estimates were changed to 75-140 million and 3.3 million, respectively. Although both sets are consistent with a problem of enormous magnitude, the discrepancies also created uncertainty. The present analysis indicates there are approximately 127 million and 4.4 million preschool children with VAD (serum retinol 6 million women develop night blindness (XN) during pregnancy annually. Roughly 45% of VA-deficient and xerophthalmic children and pregnant women with low-to-deficient VA status live in South and Southeast Asia. These regions harbor >60% of all cases of maternal XN, three fourths of whom seem to live in India. Africa accounts for 25-35% of the global cases of child and maternal VAD; about 10% of all deficient persons live in the eastern Mediterranean region, 5-15% live in the Western Pacific and approximately 5% live in the Region of the Americas. VA prophylaxis seems to be preventing the number of deficient preschool children from increasing while probably reducing rates of blindness and mortality. Greater effort is needed to assess and prevent VAD and its disorders, particularly among pregnant and lactating women.

/pdf/extent-of-vitamin-a-deficiency-among-preschool-children-and-p7p0r02oyr.pdf

Extent of Vitamin A Deficiency among Preschool Children and Women of Reproductive Age

Physical height is an important economic variable reflecting health and human capital. Puzzingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox which is often called the Asian enigma. The primary contribution of this paper is to document that cross-country variation in sanitation statistically explains a large and important fraction of international height differences. Over a billion people worldwide and more than half of Indian households defecate openly without using a toilet or latrine, introducing germs into the environment that cause disease and stunt children's growth. I apply three complementary empirical strategies to Demographic and Health Survey data to identify the fraction due to sanitation: country-level regressions using collapsed DHS surveys; within-country analysis of differences between India's first and second DHS surveys; and econometric decomposition of the India-Africa height difference in child-level data. Open defecation, which is exceptionally widespread in India, accounts for much of the excess stunting in India.

/pdf/how-much-international-variation-in-child-height-can-38ia2unbek.pdf

How much international variation in child height can sanitation explain

The role of health education and sanitation in the control of helminth infections.

A general theory on the relationship between water supply and sanitation investments and health, the threshold-saturation theory, is proposed. The theory takes into consideration three variables: health status, socioeconomic status, and sanitation level, and attempts to encompass, for the first time in one general theoretical framework, numerous conflicting empirical findings. The two-tiered S-shaped logistic form of the relationship that is proposed assumes that at the lower end of the socioeconomic spectrum there is a threshold below which investments in community water supplies and/or excreta disposal facilities alone result in little detectable improvement in health status. Similarly, at the higher end of the socioeconomic scale, it is suggested that a point of saturation is reached beyond which further significant health benefits cannot be obtained by investments in conventional community sanitation facilities.

A preliminary attempt to validate this model using published data on sanitation level (defined as access to water supply), life expectancy, and adult literacy rates, for 65 developing countries, appears to provide preliminary support for the threshold saturation theory but further empirical validation is required before a quantitative predictive model can be developed.

Effect of investments in water supply and sanitation on health status: a threshold-saturation theory.

https://deepblue.lib.umich.edu/bitstream/handle/2027.42/24048/0000297.pdf;sequence=1

Correlates of life expectancy in less developed countries

The knowledge of leprosy epidemiology is still extremely limited as to basic epidemiologic characteristics. Only the infectious agent and the reservoir of infection have been firmly established. It is all the more surprising that very few studies of analytical leprosy epidemiology are reported in the literature. In order to contribute to the analysis of these characteristics, data are presented on the age and sex distribution of types of leprosy from the Pogiri Leprosy Control Project, a large leprosy control project in Andhra Pradesh, India. This data base includes records on biannual examination of some 160,000 household contacts of nearly 48,000 leprosy cases observed from five to nine years between 1962 and 1970. These data indicate a peak of leprosy prevalence and incidence in the age group 35-44 years. The sex differential in leprosy, observed in these data, appears more related to sex differences in social contact, as sex ratios of leprosy vary widely among different populations. Finally, the age distribution of tuberculoid leprosy shows a bimodal curve, with peaks at ages 10-14 and 35-44 years. The first peak appears related both to the occurrence of early and self-healing lesions in school children, and to the more frequent examination of school children. Additional observations are presented on type ratios of leprosy in single and multiple case households, and on per cent of single lesions for tuberculoid cases detected over time.

Leprosy case detection rates by age, sex, and polar type under leprosy control conditions

Berdasarkan data "Survei Prevalensi Kebutaan Gizi" tahun 1977, Lombok, Nusa Tenggara Barat, dinyatakan sebagai wilayah tinggi prevalensi xeroftalmia. Sebagai suatu wilayah dengan prevalensi xeroftalmia paling tinggi di Indonesia, banyak faktor risiko yang diidentifikasi bagi daerah ini, termasuk kejadian kecacingan, kekurangan frekuensi pemberian ASI pada anak yang masih menyusu; kekurangan "kamar cuci" di dalam rumah; variasi diet yang terbatas, tidak ada variasi konsumsi bahan pokok selain beras; dan kecilnya konsumsi sumber-sumber protein. Faktor risiko khusus xeroftalmi-korneal berkaitan dengan riwayat penyakit yang baru diderita si anak (campak dan infestasi berat kecacingan) dan kurang kalori protein berat. Sejak tahun 1978, Pemerintah Indonesia telah mengembangkan berbagai macam pendekatan untuk mengawasi (kontrol) xeroftalmia; sampai tahun 1982 telah mencapai 80% sasaran (anak Balita) dan telah menghasilkan penurunan prevalensi xeroftalmia di wilayah ini. Penurunan prevalensi ini dicapai tanpa penurunan secara proporsional faktor-faktor risiko terkait.

The change of prevalence of xerophthalmia on lombok, september 1977 - september 1983

A methodology is proposed for assisting health insurance policy analysts by developing a systems approach to health insurance information and literature. The general approach is to supply a link between the quantitative and qualitative information available, and the analytic needs of policy analysts. There is a great deal of information available, but traditional cataloging and indexing techniques do not adequately meet the policy researcher's and analyst's information needs. The most important of these once goals and limitations are identified, is knowledge of the interrelationships between program options in terms of expected results (problems, solutions) in a wide range of settings. The key element of the approach used is the concept of an information frame, based on considering health insurance as systems of issues, program options, problems, and solutions with interrelationships explicitly defined. This approach would provide initially qualitative identification of these interrelationships and make them available via a machine readable taxonomy of the components. With substantiating literature references, preliminary work on the building of the taxonomy is based on seven major health insurance issues, and over 70 program options, 325 problems, and 350 solutions so far identified for 170 of the problems. The implementation of this methodology would provide analytically structured information for policy analysts in a format not presently available. The multi-country information to be included would allow consideration of alternatives which might otherwise be neglected. The result would improve an important element of the analytic process, and reduce the lead time required for inquiries by health insurance policy analysts, legislators, health planners and administrators.

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Barbara H. Perry

Papers

Effect of investments in water supply and sanitation on health status: a threshold-saturation theory.

Correlates of life expectancy in less developed countries

Leprosy case detection rates by age, sex, and polar type under leprosy control conditions

The change of prevalence of xerophthalmia on lombok, september 1977 - september 1983

A systems approach to health insurance policy information: a preliminary taxonomy of health insurance issues, program options, problems and solutions.