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Optometry (2008) 79, 98-103

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atient literacy levels within an inner-cityptometry clinic

eoffrey W. Goodfellow, O.D., Ruth Trachimowicz, O.D., Ph.D.,nd Gregg Steele, O.D., Ph.D.

llinois College of Optometry, Chicago, Illinois.

AbstractBACKGROUND: This study compares the literacy levels of patients seeking primary optometric care atthe Illinois Eye Institute, located in a Chicago inner-city neighborhood, to the literacy demands ofavailable near point cards and patient educational materials.METHODS: The revised large print Slosson Oral Reading Test was administered to 100 primary carepatients 10 to 15 minutes after the instillation of mydriatic eye drops. In addition, the Flesch-KincaidGrade Level was calculated using the Spelling and Grammar component of the Microsoft® Wordsoftware package 2003 (Microsoft, Redmond, Washington) for available near point testing cards andpatient education materials used in this clinic from the American Optometric Association and theNational Eye Institute.RESULTS: A total of 37.4% of patients read 1 standard deviation or more below their age-expectedlevels. A total of 46.5% of patients read at or below an eighth-grade level. The literacy demands of thetested near point cards ranged from 2nd grade to 12th grade. The literacy demands of patient educationmaterials ranged from 7th grade to 12th grade.CONCLUSIONS: About one third to almost one half of the 100 patients in this sample from the Illinois EyeInstitute optometry clinic read below their age-expected level. Therefore, near point testing materials andpatient education materials may not be written at a suitable reading level to be effective in this population.Clinicians who provide eye care for patients in inner city settings should consider communicating importantinformation using nonwritten methods to those patients with low literacy levels.Optometry 2008;79:98-103

KEYWORDSLiteracy;Patient education;Communication;Nonverbal

communication

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During a “routine” eye examination, optometrists use manyaterials that rely on the patient’s ability to read and compre-

end written English language. This includes the use of chartso measure visual acuity, near point testing cards to evaluatehe vergence and accommodative systems, and educationalamphlets and fact sheets. Patient education materials maynclude handouts on topics such as treatment regimens forlepharitis, dry eye, cataracts, macular degeneration, amblyo-

Corresponding author: Geoffrey W. Goodfellow, O.D., Illinois Collegef Optometry, 3241 S. Michigan Avenue, Chicago, Illinois 60616.

aE-mail: ggoodfel@ico.edu

529-1839/08/$ -see front matter © 2008 American Optometric Association. Alloi:10.1016/j.optm.2007.03.015

ia, and other common visual conditions. Written materials areften provided to instruct patients on how to use a homemsler grid, instill eye drops and ointments, or recognize the

ymptoms of a retinal or vitreous detachment. However, ifhese reading materials are not appropriately matched to theatient’s reading level, examination findings may be affected,r decreased patient compliance may result. For example, alinician may misinterpret a patient’s struggle to read a nearoint card as a need for a higher bifocal power, or a patient’snability to read medication instructions may cause the incor-ect instillation of eye drops. Thus, poor reading ability can

ffect all aspects of optometric vision and health care.

rights reserved.

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99Goodfellow et al Clinical Research

Individuals with reduced reading skills are prevalent inll parts of society, all professions, and all socioeconomicroups; they are not limited to certain ethnic groups orultures.1,2 Illiteracy has been shown to be particularlyommon in our nation’s urban areas3 as shown in Chicago,here it was estimated that 63% of the people living thereerformed at lower literacy skill levels.4

How widespread is adult illiteracy in the Americanopulation? More than 30 million Americans (14% to 20%)ave reading skills below the fifth- to eighth-grade level,1,2

eaning that they may have difficulty understanding theront page of a daily newspaper, the instructions on someedicine labels, or the poison warning on a can of insecti-

ide. An additional 20% are functionally illiterate,5-7 mean-ng that they do not have the literacy skills needed tonteract fully as a family member (i.e., parents may benable to assist with their children’s homework or admin-ster medications safely), employee (i.e., difficulty readingquipment manuals or hazard signs), or citizen (i.e., diffi-ulty reading a voting ballot).

In addition to affecting an individual’s daily life, illiter-cy greatly affects the nation’s economy. Illiterate patientsore frequently delay needed medical treatment, have more

rouble understanding medication instructions, are morerequently hospitalized unnecessarily, and have more medicalharges.8 These increased charges are caused by more visits tomergency rooms, increased need for hospitalization caused byoorer health,8 failure to get appropriate early treatment, andore frequent misinterpretation of medical instructions.5,9 This

ranslates into $8 billion to $15 billion a year in excess hospitalosts alone.10 Additionally, $30 billion to $100 billion arepent yearly on increased health care, lost wages, overuse ofnemployment benefits, and basic skills remediation10—allttributable to functional illiteracy.

It is necessary to point out that illiterate patients are notecessarily unintelligent individuals. A patient may have anverage or above-average IQ and may speak articulately butay not have learned to read well.1 Therefore, health care

rofessionals should not assume a patient has a certainiteracy level based solely on profession, socioeconomicroup, ethnicity, or culture.1,2

Based on the information above, it is important thatducational and near point testing materials be written atreading level suitable to the patient to be effective. Theurposes of this study are (1) to examine the literacyevels of patients seeking primary optometric care at annner-city optometric clinic, (2) to determine the readingevel of near point testing materials and educationalaterials used within optometry, and (3) assess whether

atient literacy levels are matched appropriately withhese materials.

ethods

o determine patient literacy levels, the revised Slosson

ral Reading Test (SORT-R) was administered to 100

atients who presented to the Illinois Eye Institute (IEI)or comprehensive eye examinations in the Primary Eye-are Service. The IEI is located in inner-city Chicago andontains a predominantly African American patient base.atients were selected randomly from morning andvening clinic sessions throughout the week. Patientsounger than 14 years were excluded from the study. Allubjects signed an Illinois College of Optometry Institu-ional Review Board–approved informed consent form.

The SORT-R evaluates the ability of the examinee toead aloud 200 words arranged in ascending order of diffi-ulty. This test was chosen because it is widely used,ationally standardized, quick to administer, and has aoderate number of items at lower reading levels.11 TheORT-R offers validity with correlations to other reading

ests in the 0.90s and higher as well as test-retest reliabilitiesf 0.95 and above.12 To take advantage of patient waitingime during the normal examination sequence, the test wasdministered while patients were waiting for dilation. Toinimize any unintended effects of mydriasis or cyclople-

ia, the test was administered within 5 to 10 minutes afternstillation of mydriatic drops, and the large print version ofhe test was used.

The SORT-R is untimed, but patients are not given creditor words which they take longer than about 5 seconds toead aloud.12 The patient’s raw score on the SORT-R andhe patient’s age are used to look up the standard score inhe SORT-R testing manual. A standard score is referencedo a mean of 100 and a standard deviation of 15. A patient’standard score allows that performance to be compared withhose of other patients. Standard scores near 100 � 15

Table 1 Tested near point cards and educational brochures

Source

Near point cardsNear Point Card NPTICO95.05Near Reading Cards for the

Partially SightedDesigns for Vision

Nearpoint Rotochard Reichert OphthalmicInstruments (11999)

Reading Card Snellen Rating SMD Test Card/BC 11980Standard Test Types BC/11966

Educational brochuresBlepharitis AOA (FS9/991)Cataracts AOA (FS5/191)Chalazia and Styes AOA (FS14/695)Common Vision Conditions AOA (Q1-10/04)Don’t Lose Sight of Cataract NEI/NIH (94-3463)Don’t Lose Sight of

GlaucomaNEI/NIH

Dry Eye AOA (Q20-10/04)Flashes, Floaters, and

Vitreous DetachmentAOA (FS10/991)

Macular Degeneration AOA (Q22/998)Presbyopia AOA (Q9/896)Protecting Your Eyes from

UV RadiationAOA (VL2/794)

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100 Optometry, Vol 79, No 2, February 2008

ndicate that a patient’s reading level is age normal. Stan-ard scores below 85 (i.e., outside of 1 standard deviation)ndicate that a patient’s reading level is below normal forhat individual’s age.

The reading levels of 5 different near point cards and 11ducational brochures were determined using the Spellingnd Grammar component of the Microsoft® Word softwareackage 2003 (Microsoft, Redmond, Washington). Thisrogram is capable of calculating the Flesch-Kincaid Gradeevel score by analyzing the literacy level of word process-

ng text files based on the number of words, the number ofentences, the average sentence length, and the number ofyllables in each word. The Flesch-Kincaid Grade Levelcore is based on the assumption that 50% of personseading at a given grade level should be able to comprehendhe material.13

The 5 near point cards and 11 educational brochuresssessed are shown in Table 1, Figure 1, and Figure 2.hese materials are widely used in the IEI and affiliatedlinics. Clinic administrators originally selected the 11ducational brochures from the American Optometricssociation (AOA) and National Eye Institute/National

nstitutes of Health (NEI/NIH) because their health in-ormation is contemporary, readily available, fairly costffective, and presented at the most reasonable readingevel available.

igure 1 Nearpoint Rotochart by Reichert Ophthalmic Instruments (1

NPTICO95.05); Standard Test Types (BC/11966); Near Reading Cards for the Part

esults

he scores of the SORT-R were analyzed from 33 male and7 female patients ranging in age from 14 to 89 yearsmean, 52.6 years). The mean standard score on theORT-R was 88.1 � 24.8 with a range of 33 to 119 (seeigure 3). A total of 37.4% of patients read 1 standardeviation or more below their age-expected levels (i.e., hadtandard scores below 85). A total of 46.5% of patients readt or below an eighth-grade level (see Figure 4).

A t-test for independent groups indicated that the readingcores for men (84.2 � 29.2) and women (89.3 � 22.5) didot statistically differ (t[51.303] � 0.886; P � 0.38). A-way analysis of variance on the dataset using age as aovariate also indicated that gender had no affect on readingcores when the variable of age was held constant.

The relationship between standardized reading scoresnd age was evaluated by calculating the correlation coef-cient for these 2 variables. The correlation coefficient of.088 (P � 0.05) indicates that a statistically significantinear relationship does not exist between these 2 variables.

scatterplot also produces a regression line with a slopelose to 0 (see Figure 5).

The literacy demands of the tested near point cards andatient education materials are summarized in Table 2,igure 6, and Figure 7. The literacy demands of many of

Reading Card Snellen Rating (SMD Test Card/BC 11980); Near Point Card

1999); ially Sighted by Designs for Vision.

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101Goodfellow et al Clinical Research

hese materials exceed the literacy levels of the patients thatould be using these resources.

onclusions

hese results show that a significant proportion of primaryare patients in an inner-city optometry clinic read belowheir age-expected level. Furthermore, there is no apparentorrelation between reading level and gender or age in thisarticular inner-city population. This is in contrast to mosteneral literacy studies, which find that older adults, espe-ially those over 65, have limited literacy skills comparedith the remaining adults in the United States.2,9 Oneossible explanation for why such a large number of pa-ients read below their age-expected level is that patientsay be fatigued from their eye examination and not score asell on the SORT-R. There is also the limitation that the

iteracy levels of people seeking eye care may not beepresentative of all inner-city people.

Based on our findings, the reading level of the tested nearoint cards and educational materials was often not appro-riate for the patients of this inner-city optometry clinic.

igure 2 Blepharitis (FS9/991 by the AOA); Chalazia and Styes (FS14Q1-10/04 by the AOA); Don’t Lost Sight of Cataract (94-3463 by the NEI/OA); Flashes, Floaters, and Vitreous Detachment (FS10/991 by the AOA);rotecting Your Eyes from UV Radiation (VL2/794 by the AOA).

here is even the possibility that the reading level of the

arious materials in this study may be higher than docu-ented. Studies have found that the Flesch-Kincaid for-ula, the easiest and most available tool for determining

y the AOA); Cataracts (FS5/191 by the AOA); Common Vision Conditionson’t Lose Sight of Glaucoma (by the NEI/NIH); Dry Eye (Q20-10/04 by ther Degeneration (Q22/998 by the AOA); Presbyopia (Q9/896 by the AOA);

/695 bNIH); D

Figure 3 Frequency distribution of SORT-R standard scores.

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102 Optometry, Vol 79, No 2, February 2008

eading level, may calculate lower grade levels than othereadability formulas. Also, none of these formulas are ableo analyze the reading levels for charts or graphs that oftenccompany patient education materials.3

Figures 6 and 7 show that about one half of the patientsncluded in this study would be unable to read some of theested near point cards and may not fully understand most ofhe tested brochures. Therefore, it is important that therofession develop more lower-literacy demand materials toeet patients’ needs. This mismatch between patient liter-

cy and patient education materials is not unique to optom-try; studies throughout health care have shown a similarroblem.3,14-22

Figure 4 Frequency distribution of SORT-R grade equivalents.

igure 5 Scatterplot of SORT-R standard score and age data with linear

egression. t

To achieve maximum patient understanding, compli-nce, and well-being, optometric clinicians practicing innner-city settings should choose near point cards and edu-ational materials with low literacy demands, if available,nd emphasize nonwritten forms of communication or easyandwritten instructions.1,9 Alternate education strategies

igure 6 Percentage of subjects at or above grade equivalent for

Table 2 Flesch-Kincaid grade levels and percentage ofsubjects at or above grade equivalent for the tested nearpoint cards and educational brochures

Gradelevel

% at orabovegradeequivalent

Near point cardsNearpoint Rotochart by Reichert

Ophthalmic Instruments2.3 99

Near Reading Cards for the PartiallySighted by Designs for Vision

3.6 98

Reading Card Snellen Rating 5.8 88Near Point Card 11.7 31Standard Test Types 11.8 31

Educational brochuresDon’t Lose Sight of Glaucoma 7.0 71Don’t Lose Sight of Cataract 7.7 66Chalazia and Styes 9.4 42Dry Eye 9.9 35Blepharitis 10.3 34Protecting Your Eyes from UV

Radiation10.9 33

Presbyopia 11.3 32Cataracts 11.5 32Macular Degeneration 11.5 32Common Vision Conditions 11.6 32Flashes, Floaters, and Vitreous

Detachment11.9 32

ested near point cards.

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103Goodfellow et al Clinical Research

ay include videotapes or demonstrations.1,23,24 Most pa-ients can learn even complicated tasks if given enoughnstruction.25 With the patient’s permission, instructionsould also be provided to more literate family members oraretakers. To demonstrate sufficient understanding, clini-ians could have patients repeat instructions or demonstraterocedures while in the office.

It is difficult to assess the literacy level of patientsuring “routine” clinical encounters. Even requesting aatient’s “highest educational level attained” does notrovide reliable information regarding literacy. Espe-ially in inner cities, the last grade completed in schooloes not indicate actual reading ability.24 Nonetheless,tudies of the general population indicate a direct rela-ionship between educational attainment and key healthtatus indicators such as life expectancy, infant survival,nd maternal survival rates.5

Patients with lower literacy have been shown to receiveess preventative care, have less health knowledge, haveore chronic illness and are hospitalized more frequently

han other patients.25,26 As consumer-driven health careontinues to increase, this will only place further demandsn patients with literacy problems. A better match betweenhe readability of near point cards, educational materials,nd patient literacy skills would result in better health andore efficient care.27

cknowledgments

he authors wish to thank Drs. Sandra Block and Susanelly for their assistance with data analysis. Alissa Wong

nd Jennifer Tomich are also acknowledged for their assis-

igure 7 Percentage of subjects at or above grade equivalent forested educational brochures.

ance in gathering data for this project.

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