Health Literacy: How, When and Why to

measure

Kristie Hadden, PhDAssistant Professor

Director UAMS Center for Health Literacy

Partnership for Health Literacy in ArkansasSeptember 19, 2014

Overview of health literacy measures

Issues in measurement of health literacy

Demonstration and use of measures

Objectives

Quality improvement Intervention development and implementation

Targeting to groups Tailoring to individuals

Research1. How are health literacy and xyz outcome related?2. If health literacy improves, will XYZ outcome

improve?3. If we target/tailor an intervention for low health

literacy, will XYZ outcome improve? Why else?

Why measure health literacy?

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

What is Health Literacy?

Healthy People 2020

Health Literacy: A Prescription to End Confusion.Institute of Medicine. 2004

Individual “risk factor” (Nutbeam, 2010)

Public health “asset” (Nutbeam, 2010)

Provider health literacy (“other side”)

Conceptualizations of Health Literacy

Below Basic—circle date on appt slip Basic—read pamphlet and determine symptoms

of a disease Intermediate—vaccine schedule Proficient—calculate share of health insurance

cost from table

Literacy Levels

Reading Navigation Numeracy Understanding verbal information Asking questions What else?

What should we be measuring?

Print prose

Continuous text Health brochures

Components of Health Literacy

Print prose Print document

Non-continuous text Forms Diagrams Maps

Components of IndividualHealth Literacy

Print prose Print document Quantitative/numeracy

Numbers with or without text Dosages Appointment scheduling Treatment frequency, time

Components of IndividualHealth Literacy

Print prose Print document Quantitative/numeracy Oral (auditory)

Verbal instructions Conversations for shared decision making

Components of IndividualHealth Literacy

Print prose Print document Quantitative/numeracy Oral (auditory) Internet

Finding health information on the web Completing online forms Using online tools

Components of IndividualHealth Literacy

Current Measurement: Individual

Health Literacy Skills Instrument (HLSI )

ProseDocumentQuantitativeOralInternet

Current Measurement: Individual

McCormack et al, 2010

HLSI-SF

HLSI

Rapid Estimate of Adult Literacy in Medicine (REALM)

Current Measurement

Davis et al, 1993

REALM-SF Form  

Menopause Antibiotics Exercise Jaundice Rectal Anemia Behavior  Instructions for Administering the REALM-SF  1. Give the patient a laminated copy of the REALM-SF form and score answers on an unlaminated copy that is attached to a clipboard. Hold the clipboard at an angle so that the patient is not distracted by your scoring. Say: "I want to hear you read as many words as you can from this list. Begin with the first word and read aloud. When you come to a word you cannot read, do the best you can or say, 'blank' and go on to the next word." … 

REALM

Test of Functional Health Literacy in Adults (TOFHLA)

Current Measurement

Parker et al, 1995

TOFHLA

Newest Vital Sign (Weiss, 2005)

http://www.pfizer.com/health/literacy/public_policy_researchers/nvs_toolkit

Current Measurement: Individual

Screening questions

ShortEasySelf administeredIdentifies those at risk only

Current Measurement: Individual

Health literacy screening questions

Brief (3) questions (Chew, 2004)

**One question from the Brief (Wallace, 2006; Chew, 2007; Sarkar, 2010)

“Single Item Screener” (Morris, 2006)

Current Measurement: Individual

1. How often do you have problems learning about

your medical condition because of difficulty understanding written information? [always, often, sometimes, occasionally, or never]

2. How often do you have someone (like a family member, friend, or hospital worker) help you read hospital materials? [always, often, sometimes, occasionally, or never]

3. **How confident are you at filling out medical forms by yourself? [Extremely, quite a bit, somewhat, or not at all]

Chew’s 3 Health Literacy Screening Items

Performance (validated against STOFHLA) “…single screening question may be able to

identify 80% of adult patients with inadequate health literacy.” (Chew, 2004)

“One screening **question is sufficient for detecting limited and marginal health literacy in clinic popluations” (Wallace et al, 2006; Chew et al, 2007;Ohl et al., 2010)

including Spanish (Sarkar et al, 2010) and validating against NVS (Stagliano et al, 2013)

Chew’s 3 Health Literacy Screening Items

“How often do you need to have someone help you when you read instructions, pamphlets, or other written material form your doctor or pharmacy?” [1-Never, 2-Rarely, 3-Sometimes, 4-Often, 5-Always]

“Single Item Literacy Screener” (Morris, 2006)

Performance (validated against STOFHLA) “The SILS performs reasonably well … is very brief and therefore

practical for use during a routine clinical encounter” (Morris et al., 2006, p. 5).

  “The SILS could be self-administered or clinician/researcher

administered, which provides flexibility in [its] application for research purposes and in most clinical settings” (Al Sayah et al., 2012, p. 49).

“The single questions consistently yielded patient response times less than 1 minute” (Carpenter et al., 2013, p. 142). “If the single item literacy screener can be administered in less than 1 minute, then this is the most feasible of the instruments with the best performance for identifying lower health literacy” (Carpenter et al., 2013, p. 144).

“Single Item Literacy Screener” (Morris, 2006)

Quality improvement Intervention development and implementation

Targeting to groups Tailoring to individuals

Research1. How are health literacy and xyz outcome related?2. If health literacy improves, will XYZ outcome

improve?3. If we target/tailor an intervention for low health

literacy, will XYZ outcome improve? Why else?

Why to measure health literacy?

IRB determination? When people are informed When shame and embarrassment can be

mitigated When people understand why it is being

measured When some good will come from the

measurement When people are not under extreme stress

When to measure health literacy?

Without IRB consideration.

When there is no plan in place to address health literacy problems.

When more harm can come from shame than benefit from intervention.

When and why NOT to measure health literacy?

UAMS Regional Programs

Plans at UAMS clinical programs and hospital

BRFSS?

Other?

Who is screening?

“The answer depends on the question”

References

Carpenter, C., Kaphingst, K., Goodman, M., Lin, M., Melson, A., & Griffey, R. (2014). Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency department. Academic Emergency Medicine, 21(2), 137-146.

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. Family Medicine, 36(8), 588-594.

Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A. ... VanRyn, M. (2008). Validation of screening questions for limited health literacy in a large VA outpatient population. JGIM: Journal of General Internal Medicine, 23(5), 561-566. doi:Article

Miller, M. J., Allison, J. J., Schmitt, M. R., Ray, M. N., Funkhouser, E. M., Cobaugh, D. J. ... LaCivita, C. (2010). Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies. Journal of Health Communication, 15(4), 413-427.

Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The single item literacy screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, 1-7.

Osborn, C. Y., Weiss, B. D., Davis, T. C., Skripkauskas, S., Rodrigue, C., Bass, P. F., III, & Wolf, M. S. (2007). Measuring adult literacy in health care: Performance of the newest vital sign. American Journal of Health Behavior, 31, S36-S46.

Paasche-Orlow, M. K., & Wolf, M. S. (2008). Evidence does not support clinical screening of literacy. Journal of General Internal Medicine, 23(1), 100-102.

Powers, B. J., Trinh, J. V., & Bosworth, H. B. (2010). Can this patient read and understand written health information? JAMA: Journal of the American Medical Association, 304(1), 76-84.

Salgado, T., Ramos, S., Sobreira, C. , Canas, R., Cunha, I., Benrimoj, S., & Fernandez-Llimos, F. (2013). Newest Vital Sign as a proxy for medication adherence in older adults. Journal of the American Pharmacists Association: JAPhA, 53(6), 611-617.

Sarkar, U., Schillinger, D., Lopez, A., & Sudore, R. (2011). Validation of self-reported health literacy questions among diverse english and spanish-speaking populations. JGIM: Journal of General Internal Medicine, 26(3), 265-271.

Schwartz, K. L., Bartoces, M., Campbell-Voytal, K., West, P., Monsur, J., Sartor, A., & Neale, A. (2013). Estimating health literacy in family medicine clinics in metropolitan Detroit: A MetroNet study. Journal of the American Board of Family Medicine: JABFM, 26(5), 566-570.

Stagliano, V., & Wallace, L. S. (2013). Brief health literacy screening items predict newest vital sign scores. Journal of the American Board of Family Medicine: JABFM, 26(5), 558-565.

Wallace, L. S., Cassada, D. C., Rogers, E. S., Freeman, M. B., Grandas, O. H., Stevens, S. L., & Goldman, M. H. (2007). Can screening items identify surgery patients at risk of limited health literacy? Journal of Surgical Research, 140(2), 208-213.

Wallace, L. S., Rogers, E. S., Roskos, S. E., Holiday, D. B., & Weiss, B. D. (2006). Brief Report: Screening items to identify patients with limited health literacy skills. JGIM: Journal of General Internal Medicine, 21(8), 874-877.

Wallston, K., Cawthon, C., McNaughton, C., Rothman, R., Osborn, C., & Kripalani, S. (2014). Psychometric properties of the brief health literacy screen in clinical practice. JGIM: Journal of General Internal Medicine, 29(1), 119-126.

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P. ... Hale, F. (2005). Quick assessment of literacy in primary care: The Newest Vital Sign. Annals of Family Medicine, 3(6), 514-522.