Barry D. Weiss

Quick Assessment of Literacy in Primary Care: The Newest Vital Sign

PURPOSE Current health literacy screening instruments for health care settings are either too long for routine use or available only in English. Our objective was to develop a quick and accurate screening test for limited literacy available in English and Spanish. METHODS We administered candidate items for the new instrument and also the Test of Functional Health Literacy in Adults (TOFHLA) to English-speaking and Spanish-speaking primary care patients. We measured internal consistency with Cronbach’s α and assessed criterion validity by measuring correlations with TOFHLA scores. Using TOFLHA scores <75 to define limited literacy, we plotted receiver-operating characteristics (ROC) curves and calculated likelihood ratios for cutoff scores on the new instrument. RESULTS The final instrument, the Newest Vital Sign (NVS), is a nutrition label that is accompanied by 6 questions and requires 3 minutes for administration. It is reliable (Cronbach α >0.76 in English and 0.69 in Spanish) and correlates with the TOFHLA. Area under the ROC curve is 0.88 for English and 0.72 for Spanish versions. Patients with more than 4 correct responses are unlikely to have low literacy, whereas fewer than 4 correct answers indicate the possibility of limited literacy. CONCLUSION NVS is suitable for use as a quick screening test for limited literacy in primary health care settings.

BRIEF REPORT: Screening Items to Identify Patients with Limited Health Literacy Skills

AbstractBACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question. “How confident are you filling out medical forms by yourself?” was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P <.01) and also a greater AUROC than questions based on demographic characteristics. CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills.

Background: In nonindustrialized nations, illiteracy is independently associated with poor health. The objective of this research was to determine whether such a relation exists in the United States. Methods: One hundred ninety-three persons were randomly selected from a group of adult students enrolled in a publicly funded literacy training program. Subjects’ health status was measured with the Sickness Impact Profile (SIP), a behaviorally based measure of sickness-related dysfunction. Subjects’ literacy skills were also measured. Multivariate statistical techniques were then used to evaluate the relation between health status and literacy level and to adjust for confounding sociodemographic factors. Results: The physical health (measured by the SIP) of subjects with extremely low reading levels was poor compared with that of subjects with higher reading levels. The relation between reading level and physical health was statistically significant (P < 0.002), even after adjusting for confounding sociodemographic variables. Psychosocial health (measured by the SIP) was poor across all levels of reading skills and was comparable with the psychosocial health of populations with severe psychosocial disability. The relation between reading level and psychosocial health was statistically significant (P < 0.02) after adjusting for confounding variables. Conclusions: In the United States, illiteracy and poor health status are independently associated.

Practical Assessment of Adult Literacy in Health Care

Low literacy is a pervasive and underrecognized problem in health care. Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.

COMMUNICATING WITH PATIENTS WHO CANNOT READ

In 1992, the Department of Education tested 26,000 adults in the National Adult Literacy Survey to assess the literacy of the U.S. population in the English language.1 On the basis of the survey re...

Illiteracy among Medicaid Recipients and its Relationship to Health Care Costs

Poor literacy is associated with poor health status, but whether illiteracy is also linked to higher medical care costs is unclear. We characterized the literacy skills of 402 randomly selected adult Medicaid enrollees to determine if there was an association between literacy skills and health care costs. Each subjects literacy skills were measured with a bilingual (English/ Spanish) reading-assessment instrument. We also reviewed each subjects health care costs over the same one-year period. The mean reading level of this Medicaid population was at grade 5.6. Mean annual health care costs were

The Relationship Between Literacy and Health

4,574 per person. There was no significant relationship between literacy and health care costs. While there are compelling reasons to improve poor reading skills among Medicaid enrollees, illiteracy in this population does not appear to contribute to the high cost of providing government-sponsored care.

Literacy and Performance on the Mini-Mental State Examination

In non-industrialized countries, populations with the lowest literacy rates have the poorest health status. In the United States, however, there is no published research on whether illiteracy, independently of other sociodemographic factors, is related to health status. There are numerous plausible mechanisms by which such a relationship could occur. For example, published reports indicate that most information handouts, consent forms, and other materials for patients are written at reading levels too difficult for most American adults. These and other findings may have important implications in the health care of underserved populations.Research is needed to determine the health effects of impaired literacy skills among Americans, and to develop non-literacy-dependent methods for providing patient education, obtaining informed consent, and administering diagnostic tests.

Nontraumatic injuries in amateur long distance bicyclists

OBJECTIVE: Mini‐Mental State Examination (MMSE) scores are associated with age, education, and ethnicity. The objective of this research was to determine the relationship between MMSE and literacy.

Literacy Education as Treatment for Depression in Patients with Limited Literacy and Depression: A Randomized Controlled Trial

All 132 participants in a 500 mile, 8 day bicycle tour were surveyed by questionnaire to characterize the demographics and bicycling experience of the riders, and to determine the frequency and severity of non traumatic injuries they experienced. Riders who devel oped significant symptoms were interviewed and/or examined. Eighty-six percent of ride participants re sponded to the survey. The average age of the riders was 41.4 years (±11.7 years). They rode an average of 95.8 miles per week on a routine basis, but the majority were new to long distance touring. Most were healthy, but 5% had seri ous cardiovascular disease and bicycled as part of a rehabilitation program. The most common nontraumatic injury was buttocks pain (experienced by 32.8% of riders); four had skin ulceration of the buttocks. Knee problems occurred in 20.7% of riders; patellar pain syndromes and lateral knee complaints were the most common knee prob lems. One cyclist withdrew from the tour because of knee pain. Neck-shoulder pain occurred in 20.4% of the riders. Groin numbness and palmar pain or paresthesias each occurred in approximately 10%. Other less common problems were foot and ankle symptoms and sunburn.