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4-15-2014 A Tale of Two Cities: Health Literacy Between Two Western Healthcare Models Jaison Thomas Southern Methodist University, [email protected]
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Engaged Learning A Tale of Two Cities: Health Literacy Between Two Western Healthcare Models
Jaison Thomas
Special thanks to:
Engaged Learning Project SMU Dedman College Dr. Nora Gimpel Dr. Patti Pagels Dr. Teresa Strecker Xinqi Ren
Engaged Learning Project A Tale of Two Cities: Health Literacy Between Two Western Healthcare Models
Jaison Thomas
Abstract months. The survey did not include those Background: Health literacy, the ability to among the homeless population who are obtain, read and understand healthcare linguistically illiterate to prevent confusion in information, is the paramount indicator of an the results between health literacy and individual’s health; it determines how language literacy. To supplement the individuals request and understand assessments, a questionnaire was administered information necessary to make appropriate regarding participants’ relevant information health decisions. Perhaps most exemplifying such as age, gender, education, and access to insufficient health literacy are the homeless, healthcare. To maintain anonymity of the who in the United States, have varying access subjects, individuals and surveys were tracked to healthcare depending on state legislature. using initials and assigned numbers. However, select European countries, Results: The methodology highlighted health specifically Denmark, provide the homeless literacy rates among the respective populations. population with healthcare access. This The sample size utilized represents a 95% discrepancy raises the fundamental question of confidence level and confidence interval of whether increased healthcare access leads to 6.8%; analysis of the trends in health literacy improved health literacy. This project among the homeless populations provides investigates associations between the system requisite data to determine the health literacy of healthcare delivery and the health literacy efficiency of the healthcare delivery systems. of the population. Ultimately, the purpose of Surveys in Denmark produced an average the project is to explore this connection by REALM score of 62.5 and S-TOFHLA score comparing the health literacy of three of 10.9, indicating correlation of r=0.82. homeless populations, one served by the Among the Dallas sample population, an limited American model of healthcare, another average REALM score of 57.2 and S- by a universal American model, and the last TOFHLA score of 8.7 was observed; the under a Western European model. Boston sample population produced an Methods: The study was conducted in average REALM of 58.4 and TOFHLA of 9.1. homeless centers in Copenhagen, Denmark, Conclusion: Based upon the research, it was Boston, Massachusetts and Dallas, Texas. A reasoned that the readily available access to comparison proved to be the most effective healthcare among the Danish homeless way of isolating extraneous variables: there population led to higher rates of health literacy are approximately 5,000 homeless in over the health literacy of both the Boston and both Copenhagen and Dallas, both with urban Dallas individuals. Whereas the American populations of 1.2 million. Apart from these populations may receive a wider variety of similarities, the core difference was the system healthcare options—VA hospitals, county of healthcare available to both populations. hospital, charity clinics—the sporadic nature The project utilized surveys based on two of visits may prove to be unfavorable established methods of evaluating health compared to the more holistic access provided literacy: REALM and short-TOFHLA in Denmark. Any correlation—or lack assessments, having a correlation r=0.84. The thereof—lends vital information on how to study required the administration of the address the health needs of the homeless surveys to a sample size of 100 individuals: population. Ultimately, the access to eligible subjects include individuals aged 18 healthcare correlated strongly with improved and older who identified themselves as health literacy and health understanding. homeless for a minimum period of three
Introduction healthcare models, and to analyze the Nothing is a better indicator of gathered data in order to reveal trends in individuals’ health than their health health literacy. Within the current literacy. According to the American perspective of the American healthcare Medical Association, poor health model, there is an incomplete literacy is "a stronger predictor of a understanding of the causal link of person's health than age, income, health literacy to patient health. The employment status, education level, and project is interested in broadening this race" (NNLM). However, current understanding by comparing the models of healthcare administration and American model of healthcare to that of prevention identify ethnicity, race, and Denmark. In doing so, the project aims genetic dispositions as the leading to seek associations between the system markers of an individual’s prospective of healthcare delivery and the health health. Health literacy is defined as “the literacy of the population. Ultimately, degree to which individuals have the the purpose of the Engaged Learning capacity to obtain, process, and project is to explore this connection by understand basic health information and comparing the health literacy of three services needed to make appropriate homeless populations, two served by the health decisions” (Glassman); perhaps American models of healthcare—Dallas, most exemplifying unmet needs are the Texas; Boston, Massachusetts—and the homeless, who in the United States, have other that exists under a Western varied access to healthcare according to European model—Copenhagen, state legislature. In contrast, however, in Denmark. select European countries, specifically Denmark, the entire homeless population Background has access to a primary healthcare Health literacy is commonly physician (Squires). This raises the assessed with the Rapid Estimate of fundamental question of whether Adult Literacy in Medicine—Short Form increased healthcare access leads to (REALM-SF), the Single Item Literacy improved health literacy in a population. Screener (SILS), or the Test of Despite the importance of health Functional Health Literacy in Adults literacy, a recent analysis of PubMed (TOFHLA). Specifically, the REALM is databases reveals that less than two assessed on a scale from 0-66 with 0-14 percent of all articles pertaining to health indicating a lack of health literacy and literacy mentioned European populations. 42-66 indicating proficiency at a high This disparity strengthened the research school level (AHRQ). In order to problem, and points to the need for understand and effectively compare the further research of this topic. Dr. Nora health literacy of two populations in Gimpel, a professor at UT Southwestern, Denmark and the United States, it is shares this belief and indicated that her necessary to describe the two different department is interested in replicating healthcare environments. Though both the project as a pilot study for her countries are developed, western medical students. The project proposes democracies, they noticeably differ in an exploratory study to survey their delivery of health services to the comparable populations under different homeless populations.
The history of the Danish Healthcare in Denmark is based healthcare system is one marked not by upon the European model, where all sweeping reform but rather waves of persons are covered under the financial progressive, gradual changes from the responsibility of counties and 1970s to the middle of the last decade. municipalities (European Observatory). Due to an overwhelming aura of fiscal Recent figures indicate that Denmark federalism that exists in the Danish state, spends approximately 9.8 percent of its the path of healthcare reform followed GDP, or 30.7 billion US dollars, on one of decentralization and a healthcare services (Lewis). This reimbursement system (Pederson, translates into approximately 3,540 US Christiansen, Bech). Although Denmark Dollars per capita spent on healthcare in belongs to the group of national health Denmark (Health Spending). care systems, it is much like its ethnic Furthermore, in Denmark, municipalities cousins Sweden, Norway, and Finland in are responsible for health visitors, that the state run healthcare model is homeless health centers, and municipal decentralized into the county delivery dentists. Additionally, access to general system. Among Danes, fairly broad practitioners and hospital care is free for political consensus towards universal all Danish residents (European health avoided any political Observatory). This current Danish battlegrounds that have encompassed system was designed to ensure that all other Western counterparts. The 1970 people of Denmark are eligible to local government reform movements receive health services. Denmark reports reduced the number of counties and a 95 percent satisfaction with their municipalities and put in place a unified healthcare system. health service at the county level, Conversely, healthcare in the opening the path for universal health United States is not a system in the true delivery. sense as the government has not It is evident that Danes are organized national health insurance involved and concerned with health programs like most developed countries literacy. This concern is derived from in the world do. As a result, not all their trust and support of the Denmark Americans are automatically covered by health care system. "A country of 5.3 health insurance: access to healthcare million people, Denmark is known in among homeless populations is too often public management circles for having compromised by the immense scope of remarkable support for its public the healthcare structure (Shi). Healthcare institutions, such as healthcare. in the United States does not consist of Comparative surveys of 13 countries interrelated components that work conducted by the World Values Institute together coherently as a system should, and supplemented by Danish but is instead a kaleidoscope of Government-sponsored surveys show insurance and finance agencies along average confidence in Danish public with delivery and payment mechanisms. institutions, such as its healthcare system The World Health Organization (WHO) in the range of 65-70 per cent over the ranked the U.S. health care system as the last two decades" (Blume). highest in cost, first in responsiveness, 37th in overall performance, and 72nd
by overall level of health among 191 considered homeless. Studies conducted nations included in its research study show that vulnerable groups in Denmark, (World Health Statistics 2009). including the homeless, use hospital- In Massachusetts, health care based healthcare noticeably more often reform laws passed in 2006 aimed to than average Danes. In contrast, these provide health insurance to nearly all the same groups make use of their general state’s residents. The Massachusetts practitioners much less frequently; in a healthcare act – “An Act Providing survey, up to 70% of these individuals Access to Affordable, Quality, did not even know who their general Accountable Health Care” – was practitioners were (Del Zott). The introduced due to alarming rates of significance of these statistics is emergency room usage by uninsured highlighted when analyzing the situation Massachusetts residents as a source of with a health literacy aspect—homeless primary care. The homeless of members who frequent their GPs less Massachusetts are covered under the often are less likely to develop adequate provisions of this law due to their health literacy and in turn expose poverty status and presumed themselves to an increased risk of health unemployment. deterioration. In contrast to Denmark’s 9.8 Homelessness is an ongoing percent GDP spending on healthcare, in public health concern in both Boston and the United States up to 16 percent of the Dallas County. The Metro Dallas GDP is spent on healthcare, with 15% of Homeless Alliance 2011 Point-in-Time its GDP spent on healthcare in 2003: the Homeless Count and Census Report highest percentage among developed showed that on one given night there nations (Chua). In addition, the United were 5,783 homeless, including 4,626 States spends $5,635 per capita, twice adults, 1,106 children in family units and the per capita of developed countries. 51 unaccompanied children. These Ultimately, though the United States figures included 504 individuals pays more per head towards the categorized as chronically homeless, healthcare of its citizens, the result is a defined as any unaccompanied disabled delivery mechanism that fails to serve individual who has been continuously nearly as many individuals as its homeless for over one year. The report, European counterparts. Consequently, which provides a snapshot of individuals affected most by this homelessness in Dallas, showed health inefficiency are the underserved concerns as a contributing cause to populations, including the homeless. homelessness as well as a significant Though healthcare for unmet need among the homeless marginalized individuals in Denmark has (MDHA). The problem of Americans been studied in the past, research has without proper healthcare often failed to address how the and adequate health literacy continues to healthcare structure affects access to rise. Not surprisingly, the rates of both health delivery. In the Danish sense, chronic and acute health problems are although “homeless” is not concretely extremely high among the homeless defined, rough-sleepers and those population. “With the exception of without a home for 14 days or more are obesity, strokes, and cancer, homeless
people are far more likely to suffer from understanding of treatment, and use and every category of chronic health comprehension of preventative services. problem. Conditions which require Results from health literacy tests reveal regular, uninterrupted treatment, such as that functional health literacy scores tuberculosis, diabetes, hypertension, and essentially mirror the patient’s addictive disorders, are extremely knowledge of their illness; individuals difficult to treat or control” among those who score higher on health literacy without adequate housing (NCH). It is evaluations know more about their believe this tragic problem is illness and how to accurately care for exacerbated because the homeless themselves as compared to individuals neither have information on preventative who have lower or have mediocre scores. measures, nor do they possess the health Furthermore, lower scoring individuals literacy needed to understand and seek are more likely to answer incorrectly treatment. At present, there is one regarding the state and severity of their federally funded program, Health Care illness and how to recover. For example, for the Homeless (HCH) that is designed compared to individuals with adequate specifically to provide primary health literacy, patients with low health healthcare to homeless persons. More literacy on average do not understand programs similar to this are needed, as when to take “as needed” drugs, well as programs to increase health increasing their chance for accidental literacy among not just the homeless, but overdose or insufficient use. An increase the entire American population (NCH). in health literacy should improve these The Danish population’s facets of an individual’s life thus perception of their healthcare delivery as lowering health care costs (Andrus, well as the general consensus towards Roth). the effectiveness of the system was also studied as a component of the research Methods to be conducted in Denmark. There is Preface limited information available through The study was conducted in U.S. publications regarding Danish various homeless shelters and centers views on healthcare—a thorough throughout the research locations, understanding of the healthcare system Copenhagen during the summer of 2012, in Denmark is available by studying Dallas during winter of 2012-2013 and local records regarding policy towards Boston during the fall of 2013. The the delivery process. Records of subjects’ participation was on a purely spending towards healthcare are also voluntary basis – they were given more transparent with local information about the study and then the governmental records as opposed to option to take part in it. The developed information that is available online. survey strategy was based on two Significance established methods of evaluating health The significance of health literacy: REALM and Short-TOFHLA literacy is reflected in its implications: health literacy assessment surveys. The health literacy is a prime determinant in original TOFHLA’s sheer length hinders an individual’s self-reported health the project’s ability to complete the status, rate of compliance and project within the time parameters with a
satisfactory sample size. Consequently, was vital to the administration of health the project opted to utilize the S- proficiency surveys (REALM and S- TOFHLA (Short-TOFHLA), which can TOFHLA), which required verbal be administered in less than ten minutes exercises and communication between per subject. Furthermore, the REALM the subject and administrator. In addition and S-TOFHLA complement each other to facilitating the administration of the as health literacy surveys, having a high survey, the population’s knowledge of correlation of r=0.84 (Parker). English contributed to ease of travel, Setting allowed direct communication with The Engaged Learning project healthcare contacts, and offered the compared the healthcare model and opportunity to explore research demographics of Copenhagen, Denmark institutions for pertinent data and with Dallas, Texas and Boston, additional information sources. Massachusetts. Copenhagen was the Moreover, English as a prevalent most attractive choice for this project for language permitted researchers to collect multiple reasons, including the oral narratives from subjects that are practicality of carrying out inquiries. important in further exploring the Primarily, there are 3.8 homeless consequences of health literacy, and persons per 1000 citizens in Copenhagen, further humanized the study. which has an urban population of Furthermore, Southern Methodist approximately 1.2 million as of January University has strong connections with 2011 (Berensson). In a study completed the Danish Institute for Study Abroad— by Project UDENFOR, a private Danish DIS. This benefited the project due to social foundation, approximately 5,500 close affiliation with Danish research homeless people lived in Denmark, of individuals who are familiar with the which three-fifths or 3,300 live in the culture and customs of the local Copenhagen metropolitan area population and have a thorough (Udenfor). This homeless population is understanding of the public perception relevant because it provided the project of healthcare delivery. These individuals sufficient access to the intended at the DIS assisted in conducting population of study. Furthermore, the research about the Danish model of population of Copenhagen is nearly healthcare and disseminating relevant identical to that of Dallas in terms of data. total population as well as the homeless Although Canada may appear to population, which is estimated to be have been a plausible, alternative approximately 5,800 in 2011 (MDHA). location, its proximity to the United These similarities in the populations States created several problems. The provided the study a higher degree of project elected to forego Canada because control, which limited extraneous close interaction between the Canadian variables that could have biased the and American populations results in a results. transmission of healthcare knowledge Second, English is the via radio, television, newspapers, and predominant second language in direct access to U.S. health services. Denmark, spoken by over 86 percent of This diffusion diluted the effects of the the population (Eurobarometer). This two different healthcare models on their
populations, and subsequently, their and analyzed. Once the surveys were health literacy. Canada’s population was completed, each participant received a simply not isolated enough from the simple, easy-to-comprehend flier United States population to provide a detailing the benefits of health literacy discernable set of effects. and healthcare resources available to Design them. This service was provided to give Homeless shelters and centers in back to the community and allowed the the Dallas-Fort Worth and Boston area participants to have greater input in their were approached in order to compare own healthcare decisions. To maintain health literacy among the homeless the anonymity of the individual and populations. Professors Dr. Nora Gimpel eliminate bias, the surveys did not and Patti Pagels at UT Southwestern inquire the individual’s name but instead Medical School agreed to assist in tracked each set of surveys using an formally connecting researchers with assigned number. In order to ensure that homeless centers that they have worked no survey was repeated, birth dates and with through the Family and Community initials were documented from each Medicine Department. With the surveyed individual. In the Dallas homeless centers’ cooperation, surveys segment of the project, approximately 20 were administered to a sample size of people per week were surveyed whereas 100 individuals. This sample size the Boston segment required nearly 15 reflects a 95% confidence level, the most daily. common metric used by researchers, and In Copenhagen, the researchers a confidence interval (margin of error) of communicated with contacts at the 6.8 (Snedecor). The sample size was DIS—Danish Institute for Study appropriate given the three month period Abroad—and visited predetermined prior to traveling to Copenhagen. homeless centers and shelters. The Eligible study subjects included professors at DIS strengthened individuals aged 18 and older who connections to the homeless centers identified themselves as homeless and throughout Copenhagen and facilitated had been, as the Danish say, rough research at local institutions. These sleeping. However, the survey instructors—Jakob Hansen, Maj Vingum population did not include participants and Anders Moller Jakonsen—have who were linguistically illiterate to backgrounds in the study, organization, prevent confusion in the results between and provisions of public health in health literacy and language literacy. Northern Europe and its connection to Surveys were administered with consent the historical, social, economic, and and release forms according to their pre- political climates of the present determined instructions. To supplement healthcare system. The project also the assessments, a brief questionnaire worked in conjunction with instructors was given regarding participants’ in the field of Health Economics and relevant information such as age, gender, Health Policy in Europe to determine a and education received. connection between public health Upon the completion of a survey, delivery and the policy of Denmark. each administrator recorded the data in a Henceforth, the previous steps in Microsoft Excel file to be documented distributing and recording the surveys as
well as parameters for survey while scores above 60 reflect aptitude of participants were repeated. However, high school and beyond. due to the shortened time period of five weeks, approximately ten individuals The reason for REALM’s were surveyed daily, with each survey success and popularity is the speed with requiring roughly twenty minutes. which it can be administered, around 5 Initially, weekends were utilized minutes per subject. Furthermore, the for further independent research—the test has been used time and again and public records that reveal the healthcare has proven to remain accurate and systems of Boston, Dallas and produce reliable results. Copenhagen in more detail, talking with S-TOFHLA healthcare providers and reviewing available public information. The The Short Test of Functional information collected included, but was Health Literacy in Adults (S-TOFHLA) not limited to, expenditures, propensity is a 36-question, seven-minute timed test of various diseases, number and location that assesses an individual’s reading of hospitals or healthcare facilities, and skills. In its procedure, subjects are healthcare regulations. This information required to read health-related sentences, was obtained through primary sources which contain missing words; then they such as books, public ledgers, and local fill in the blanks by selecting the correct scholarly articles. During the finishing word from four choices. The authors of stages of the project, efforts shifted the test found a high correlation between toward compiling the data that was the STOFHLA and original TOFHLA as assembled through surveys with the well as the REALM, r=0.97 and r=0.84, information accumulated from primary respectively. Similar to the REALM, sources. Combining these data provided each question on this test grants one the project sufficient knowledge to score. Scores of 0-16 implies inadequate formulate graphs and detect possible health literacy, 17-22 are marginally trends between healthcare models and proficient, while scores of 23-36 have health literacy. adequate health literacy. (Chew) Description of Instruments REALM Results The Rapid Estimate of Adult Literacy in Medicine – REALM is a Data from the Copenhagen widely utilized health literacy interviews suggested a mean score of assessment tool. It is a word recognition 62.5 out of a potential 66 on the test, where subjects are presented with REALM and 10.9/14 on the S-TOFHLA 66 medical words in order of increasing – these values correspond to percentage difficulty. Subjects are asked to read scores of 94.69% and 77.86% through the list aloud by an examiner, respectively. The percentage values who records their score. Each word indicate a correlation r=0.8195 pronounced correctly is a point; scores compared to the correlation of r=0.84 of 0-44 represent literacy below the sixth that should be expected between the two grade level, scores from 45-60 indicate tests. Differences in grammatical proficiency at an eighth grade level, structure between Danish and English
may have caused confusion in part with access to healthcare venues. In fact, a the Danish population who needed to majority of the individuals surveyed had choose between articles and also no primary care physician and would singular tense verbs (has versus had). sporadically visit the emergency room Even so, the standard deviation of the when symptoms of disease progressed to participants was fairly low, with a range intolerable levels. Such encounters were of scores ranging from several perfect limited to once or twice every several scores in the REALM – 66 – to a low of years, a direct comparison to the annual 57. TOFHLA scores reflected similar visits enjoyed by their Danish deviations with scores ranging from counterparts. perfect – 14 – to a low of 8. The REALM distribution was skewed Surprisingly, the Boston study heavily to the left, indicating that more population had results very similar to the of the population was at or above Dallas sample population. The average average while the TOFHLA score REALM of the Boston sample distribution was fairly standardized. population was 58.4 with a S-TOFHLA Again, the discrepancy may stem from of 9.1. These values do not indicate a the nature of the tests themselves: significant difference from data collected because the REALM is a recognition and among the Dallas population. In fact, pronunciation based test, chances are although the Boston population had higher for improved scores. Conversely, supposedly higher access to healthcare, the S-TOFHLA tests for both it was not necessarily reflected in the recognition and application of health population’s health wellbeing. Homeless literacy terms—including a individuals in Boston were just as comprehension element in the test helps unlikely to visit primary care providers to normalize the distribution of scores. on a regular basis as their Dallas Nonetheless, both sets of tests proved to counterparts. This may adversely affect be remarkable given the fact that the their health wellbeing to a large extent population is homeless. and explain lower health literacy rates.
The study found a much different Interestingly, the pilot study of result among the Dallas homeless the Dallas homeless population also population. The surveyed population produced similar data. Of the individuals sample scored an average 57.2 on the surveyed, many had perfect scores on REALM and 8.7 on the S-TOFHLA: both the REALM and S-TOFHLA. The these values correspond to percentage extremely high distribution of scores scores of 88% and 62% on the REALM among the pilot population was alarming and S-TOFHLA, respectively. Data from as it threatened the entire foundation of the Dallas sample population was also the health literacy hypothesis that lower spread on a large range, with a high income individuals are susceptible to score of 65 and a low score of 16 on the lower health literacy rates. However, a REALM. These results are in line with correlation was quickly established: the what is perceived as the primary individuals in the pilot population all difference between the populations in originate from the Union Gospel regard to their health advocacy: adequate Mission homeless clinic – these
individuals already visit a healthcare conclusive evidence pointing to the establishment at a remarkably higher connection between access to health rate than most homeless individuals, on services and the subsequent health par with a middle-class American. Upon literacy of the individual or population. further interviewing, these individuals typically revealed that they had high Implications for Policy school level schooling or higher and were typically concerned about There is a notable disparity developing or exacerbating medical between the homeless who were Danish conditions. Ultimately, the connection citizens and the homeless who lacked elucidated the fact that these individuals Danish citizenship. Most discernible had higher health literacy rates, on par were the living conditions of the two with the general homeless population in populations. The former lived in a Copenhagen. homeless shelter complex with a variety of buildings -- including a dining hall, However, upon completing apartments, a job search center, and interviews with the Boston and Dallas nursing station. The latter, however, only populations, the average health literacy had a few facilities to visit, all of which rate was observed to decrease in were separate buildings that consisted of comparison to both the Union Gospel only a kitchen and living space. These pilot population as well as the were located throughout Copenhagen. In Copenhagen homeless population. The light of this discovery, it was speculated initial pilot was flawed in that it did not that the homeless who had citizenship systematically select homeless would have higher health literacy individuals from among the Dallas because of their improved conditions. population – only those who frequently However, upon surveying both groups, visited health centers and were aware of no such correlation is evident. This is their health consequences; the pilot did attributed to the full availability of serve its purpose in serving as a primary primary healthcare to both populations tool to work out potential kinks in the in Denmark. survey delivery prior to implementation in Copenhagen. Because the pilot The success of the homeless population frequented healthcare shelter complex is the result of mutual establishments at a comparable rate to cooperation between staff and the the Copenhagen population, the general homeless who reside. There are few staff Dallas population is expected to have a members, who work with the homeless lower health literacy rate exclusively on there to create a haven where there are the notion that their access to health three meals a day, full-time living and services is either non-existent or recreational areas, and employment hindered. However, according to this opportunities. This shelter complex is a logic, the Boston population should be simple idea: work to serve yourself and expected to hold higher health literacy. your community. Replicating this If the data from the Boston and Dallas foundation would be very beneficial to segments holds true to these communities elsewhere. expectations, there will be very strong
The Danish recycling policy is of visits may prove to be unfavorable innovative and beneficial, particularly compared to the more holistic access for the homeless population. People are provided in Denmark. Ultimately, any rewarded for returning used bottles – correlation—or lack thereof—lends vital glass, aluminum, or plastic. This is information on how to address the health prevalent in many developed countries; needs of the homeless population. however, the difference is that instead of bringing the recycled materials to a plant to be paid, one simply can collect bottles and return them to a special machine Limitations and Future Queries located in all major grocery stores in Denmark. The machine sorts the bottles One limitation to this project was and rewards the recycler with either that often, people were unwilling to store credit or cash. partake in the survey. Some felt embarrassed by it, while others saw little The success of this policy is reason to take the survey as there was no because it simplifies the recycling incentive. To amend this problem, process and reduces the work load of the researchers assured the subjects that recycler. Moreover, because the their anonymity would not be recycling machines are so easy to access, compromised. Additionally, subjects many homeless and impoverished people were offered them bottled water as an carry bags and clean the streets of empty incentive for completing the surveys. bottles and cans. In theory, they are receiving payment to clean the city and Future ventures include increase recycling. Implementing a performing this survey in cities with similar recycling system elsewhere easier access to healthcare than Dallas, would promote recycling while but less than Copenhagen. Such cities providing the homeless population a include London and New York. source of income. Furthermore, these cities have comprehensive public transportation, which allows for easier access to health Conclusion clinics and hospitals. Additionally, it would be interesting and supplemental to The project speculated that the investigate the role of doctors in readily utilized access to healthcare providing and teaching their patients, among the Danish homeless population especially those who have lower health leads to higher rates of health literacy literacy, to become more knowledgeable over the health literacy of both the about their health and treatment. This Boston and Dallas individuals. Whereas area of research would provide insight the Dallas population may receive a into how healthcare professionals view wider variety of healthcare options—VA the problem of low health literacy hospitals, county hospital, charity among patients, and what solutions there clinics— and Boston may have universal are to mitigate this problem. healthcare coverage, the sporadic nature References
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