1. Health Literacy: How, When and Why to measure
Partnership for Health Literacy in Arkansas
September 19, 2014
Health literacy interventions for patients and providers.”
Understand how health literacy is affected by both patient skills and health/provider demands.
Discuss how individual patients’ health literacy can be addressed.
Discuss how providers can address health literacy in practice.
Kristie Hadden, PhD
Assistant Professor
Director
UAMS Center for Health Literacy

2. Objectives Overview of health literacy measures
Issues in measurement of health literacy
Demonstration and use of measures

3. Why measure health literacy?
Quality improvement
Intervention development and implementation
Targeting to groups
Tailoring to individuals
Research
How are health literacy and xyz outcome related?
If health literacy improves, will XYZ outcome improve?
If we target/tailor an intervention for low health literacy, will XYZ outcome improve?
Why else?

4. What is 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.
Talk about “health information” and daily health decisions rather than diabetes booklet
Forms
Numbers
Verbal instructions
Knowing when an appt is
Where to go
Knowing what family history is important
Securing and keeping insurance
Paying medical bills
Taking right med, right time
Knowing what questions to ask providers and how to ask them
Health Literacy is complex
Healthy People 2020
Health Literacy: A Prescription to End Confusion.
Institute of Medicine. 2004

5. Conceptualizations of Health Literacy
Individual “risk factor” (Nutbeam, 2010)
Public health “asset” (Nutbeam, 2010)
Provider health literacy (“other side”)

6. Literacy Levels 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
Measuring Health Literacy
Proficient: Can perform complex and challenging literacy activities.
Intermediate: Can perform moderately challenging literacy activities.
Basic: Can perform simple everyday literacy activities.
Below Basic: Can perform no more than the most simple and concrete literacy activities.

7. What should we be measuring?
Reading
Navigation
Numeracy
Understanding verbal information
Asking questions
What else?

8. Components of Health Literacy
Print prose
Continuous text
Health brochures

9. Components of Individual Health Literacy
Print prose
Print document
Non-continuous text
Forms
Diagrams
Maps

10. Components of Individual Health Literacy
Print prose
Print document
Quantitative/numeracy
Numbers with or without text
Dosages
Appointment scheduling
Treatment frequency, time

11. Components of Individual Health Literacy
Print prose
Print document
Quantitative/numeracy
Oral (auditory)
Verbal instructions
Conversations for shared
decision making

12. Components of Individual Health Literacy
Print prose
Print document
Quantitative/numeracy
Oral (auditory)
Internet
Finding health information on the web
Completing online forms
Using online tools

13. Current Measurement: Individual

14. Current Measurement: Individual
Health Literacy Skills Instrument (HLSI )
Prose
Document
Quantitative
Oral
Internet
McCormack et al, 2010

15. 4/15/2017
HLSI-SF
NOTE: THE FIRST RESPONSE IS NOT THE RIGHT ANSWER, that is just where the cursor was when the screen shot was taken.
Advantages
Assesses multiple constructs
Print prose
Print document
Quantitative
Oral
Internet
Items are functional
Short administration time
Limitations
Has not been used in research
Not validated in pregnant women

16. HLSI

17. Current Measurement
Rapid Estimate of Adult Literacy in Medicine (REALM)
Davis et al, 1993

18. REALM Menopause Antibiotics Exercise Jaundice Rectal Anemia Behavior
4/15/2017
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." …
Advantage
Short
Limitations
Only measures verbal reading
Does not measure functional understanding
Validation sample 100% male

19. Current Measurement
Test of Functional Health Literacy in Adults (TOFHLA)
Parker et al, 1995

20. TOFHLA 4/15/2017 Advantage (S-TOFHLA) short administration time
(TOFHLA) measures both print literacy and numeracy
Most widely cited in recent literature
Limitations
Does not measure functional understanding of stimuli
Short version does not measure numeracy
Validation sample was not racially diverse

21. Current Measurement: Individual
Newest Vital Sign (Weiss, 2005)

23. Current Measurement: Individual
Screening questions
Short
Easy
Self administered
Identifies those at risk only

24. 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)

25. Chew’s 3 Health Literacy Screening Items
How often do you have problems learning about your medical condition because of difficulty understanding written information? [always, often, sometimes, occasionally, or never]
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]
**How confident are you at filling out medical forms by yourself? [Extremely, quite a bit, somewhat, or not at all]

26. 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)

27. “Single Item Literacy Screener” (Morris, 2006)
“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]

28. “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).

29. Why to measure health literacy?
Quality improvement
Intervention development and implementation
Targeting to groups
Tailoring to individuals
Research
How are health literacy and xyz outcome related?
If health literacy improves, will XYZ outcome improve?
If we target/tailor an intervention for low health literacy, will XYZ outcome improve?
Why else?

30. When 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

31. When and why NOT 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.
Fifty-one percent of patients had low literacy skills (<= sixth grade) and 27.9% were assessed as having marginal literacy (seventh-eighth grade). Half (47.6%) of patients reading at or below the third-grade level admitted feeling ashamed or embarrassed about their difficulties reading, compared with 19.2% of those reading at the fourth-sixth-grade level and 65% of those reading at the seventh-eighth-grade level (p < 0.001). More than 90% of patients with low or marginal literacy reported it would be helpful for the doctor or nurse to know they did not understand some medical words.

32. Who is screening? UAMS Regional Programs
Plans at UAMS clinical programs and hospital
BRFSS?
Other?
Fifty-one percent of patients had low literacy skills (<= sixth grade) and 27.9% were assessed as having marginal literacy (seventh-eighth grade). Half (47.6%) of patients reading at or below the third-grade level admitted feeling ashamed or embarrassed about their difficulties reading, compared with 19.2% of those reading at the fourth-sixth-grade level and 65% of those reading at the seventh-eighth-grade level (p < 0.001). More than 90% of patients with low or marginal literacy reported it would be helpful for the doctor or nurse to know they did not understand some medical words.

33. “The answer depends on the question”

34. References