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As a consumer education issue, health literacy asks what is needed for people to make rational informed decisions. As a consumer protection issue, it questions what information consumers can or would use and how they might use it. Unfortunately, health decisions by their basic nature often can involve information consumers can't or won't use, and no amount of education can help consumers where even the experts’ knowledge might be uncertain. Too often, the plethora of health-based decisions become emotional reactions where the hypothetical curves of information frustration and shopping exhaustion meet.
And thus a day begins for an aging health-motivated baby boomer consumer.
A few omega-3 fish oil pills help something-or-other in the body, though after a few years of regular consumption it is difficult to remember just what. There remains a dim memory of news reports based on research studies that might have been properly refereed that these pills are good for a long life, so the pills now are popped as a habit with the morning coffee. Calcium pills are swallowed for bone health, and vitamin D, too, since both compensate for the use of sun screen that is spread on face and arms before going outside to help retard skin damage from the sunlight. Vitamin B12 is taken for daytime energy; vitamin B6 will be used at bedtime to help get to sleep, along with an uncertain amount of melatonin. Or is it the other way around on the B vitamins?
There also is a daily aspirin, which the guy who plays the role of a doctor on the network TV morning news show said is good for everyone over 40-something. The medical reporter might be a real doctor and he didn't want to give a universal recommended dosage for everyone. However, the journalist anchor of the morning show kept asking for a dosage statement, saying at the end that everyone should take a “baby aspirin” despite the repeated caveats made by the doctor-reporter being interviewed. Unfortunately, there aren't real baby aspirin any more since aspirin is bad for babies. There are “half-dose” or “daily adult” aspirin in stores, with a warning label that says too much regular use of the product can cause stomach damage. The dietary supplement with a weird name that sounds like a character from Lord of the Rings was long believed to stave off the potential onset of Alzheimer's disease. However, NPR news reported a large-scale study that found it didn't have any positive effect, so it's no longer used.
It is easy for an intelligent, well-educated consumer of sound mind and body to get confused.
At one time, vitamin E was thought to be a miracle cure-all, sold in pills, ointments, skin creams, and shampoos. Then it was dangerous, and now its benefits are unclear. Drinking wine is good for the heart, though that might only be found in the doses experienced in the consumption levels of alcoholics. News reports of a recent study in a U.K. medical journal said alcohol consumption is associated with breast cancer, but other science news columnists assert that the research study is not valid. Coffee causes… other than stains that are impossible to get out of the carpet, it is hard to know just what.
Health literacy means education. Education means a degree of skepticism of information sources. And since even experts can disagree on pragmatic applications of the latest research, skepticism can become confusion. Ignorance becomes defended as a point of view.
The manufacture standards and medical claims of both prescription and over-the-counter drugs are regulated in the United States by the Food and Drug Administration (FDA). However, the products commonly known as supplements are not, something that many consumers apparently do not know or fully comprehend despite the government-mandated disclaimers on the supplements’ packages (Mason, Scammon, and Fang 2007). What many of these untested or unverified products can do for consumer health exists in the realm of maybe, might, or “believed in ancient times.” Despite that they are found on the shelves of reputable stores, the purity and efficacy of the packages of supplement products themselves might be uncertain and variable. Some people strongly believe in the value of these products as part of what they reference as “alternative medicine,” not knowing or caring that it is called alternative when it lacks objective research that establishes whether the products actually work as claimed. If a product's value was supported by research findings on its safety and efficacy, it wouldn't be an alternative. It would be medicine.
People believe what they want to believe. A medical doctor reports discussing with her mother a certain problem and what the treating doctor said are the recommended options. Mom didn't like the options, so she asked the nearest nurse for another opinion.
When I was living in New Zealand in 1999, news media breathlessly reported research findings that an extract from local green-lipped mussels, Lyrinol, had killed isolated cancer cells grown in a lab culture. Within days, before animal tests were authorized and long before human tests were even considered, Lyprinol capsules appeared on the shelves of many New Zealand chemists (what in the United States are called pharmacies). In the stores, the nonexpert clerks were overheard giving customers detailed instructions on how and when to take the capsules, with an added guess stated as a confident fact of a “proper” dose per day. In this case, the typical consumer's medical miscomprehension meant they needed protection, not information. Disclaimers would not have been read by cancer-fearing consumers.1
Even the knowledgeable, educated, and skeptical consumer's desire to be fully informed can come into conflict with information overload. Carbohydrates, fat, low-fat, non-fat, and other labels can have government-required guidelines for how the claims can be made, but consumers faced with purchase decisions need to understand the terms, which themselves can raise confusion on health trade-offs. Consumers then ask, “But how does it taste?” Labels can help some people sometimes in some cases, if they have the knowledge or motivation to use the information, which may or may not be in a format they can understand (e.g., Bui et al. 2008; Grobe, Manore, and Still 2007; Kemp et al. 2007). Consumers’ desires for labels could also be driven by paranoia, not of information needed for safety, serving more as a guide for their fears of what they might wish to avoid (e.g., Radas, Teisl, and Roe 2008). The health literacy research often looks at who is helped or cares, but at some point there is an intrinsic limit to the value of consumer education or label information.
Supposedly, health literacy also can be a guide for consumers beyond their personal safety when it acts as an impetus in the marketplace to help reduce costs. Consumers are to choose foods, drugs, insurance plans, and health care providers with an eye to maximize their personal benefits. However, consumers are not primary decision makers on many of these things, trusting the expertise of the doctor or other professional, not even considering that medical professionals are not always as rational in their decisions as we might like to presume. A plethora of numerous industry sales contacts with doctors have an influence (Wazana 2000); doctors might recommend or require a brand name drug despite the existence of generic equivalents, making the patient decide if the specific brand is worth the higher cost.
Most consumers probably do not know of FDA assurances that the generic drug manufacturers’ products are chemically identical to the brand name originals. Since any functional benefit of a brand name product is virtually nonexistent, in some ways a generic drug could be considered safer since it is less likely to be the target of illegal drug counterfeiters. But then, patients taking drugs to correct a medical problem or treat a life-threatening condition would not be easily convinced that a cheaper version of the familiar brand is “just as good” as the name they know and trust. Direct to consumer advertising of prescription drugs also can engender a misleading consumer trust in a brand name (Royne and Meyers 2008). Even before the existence of this new promotional tool that has become ubiquitous in the United States and New Zealand (the two countries where it is currently allowed), there was evidence that patients, and even some doctors, might be mislead about a brand's value apart from the scientific data on the matter (e.g., Avorn, Chen, and Hartley 1982).
And then there are the hidden costs of many consumers’ medical choices.
In the small print of a monthly purchased prescription, a short note was recently discovered: “price $799.99, you pay $25. Your insurance saved you $774.99.” Why the pharmacy placed this note on the label is unclear, since the store does not have financial ties to the health insurance provider. If the product is bought elsewhere, the patient copayment remains the same, so going to a more expensive store means an increase in what the insurance “saves” the buyer. And if a less expensive store is found, the patient does not see a reduction in insurance premiums.
Left unstated is the intrinsic problem of patient shopping under the U.S. health system: it requires a degree of prediction, and gambling that the predictions are accurate. For insurance, the individual or corporate purchaser is generally healthy, so there is a guess as to what would be needed later on. To make the system work, young healthy people must be convinced to pay for insurance with the expectation that it can be both available and affordable when needed in later years. At the personal visceral level, to borrow a metaphor style from the late adman Howard Gossage, convincing the healthy young people that paying for unnecessary insurance now will help them when they are older or injured is like convincing a small child that sex will someday prove more desirable than ice cream. And even if the healthy young people buy into the insurance argument, the worry can be whether the insurance company itself will last that long.
Consumer literacy is a basic consumer affairs issue going back to the start of the last century. Left unstated is whether health literacy is the solution for consumer problems, or whether it points out the limits of commercial freedoms being able to help maximize public health.