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Current Research in Health Literacy
Research on Risk Assessment and Screening
Recognizing the signs of low health literacy:
It is important for researchers and policy makers to understand that low health literacy is not intuitively obvious at the individual level. Although evidence supports the often higher prevalence in certain subgroups typically labeled as having lower literacy levels such as the less educated, economically disadvantaged, and ethnic/racial minorities, anyone ;can suffer from low health literacy. For example, a business executive well versed in the best marketing approaches may not fully understand the importance of a screening colonoscopy let alone the instructions for how to accurately self-administer a bowel prep. Furthermore, many of those with limited health literacy skills have learned to adapt and compensate making it even more challenging to identify deficits.
The Role of Universal Precautions:
Due to the often high prevalence of low health literacy and challenge in easily identifying the low health literate individual, many researchers have suggested adoption of universal precautions. The idea behind universal precautions is to focus on clear communication with everyone as opposed to attempting to single out those who are thought to most benefit from specific efforts to improve communication.
As policy makers we, are in a key position to help improve health literacy and the accessibility of health information and healthcare in the United States. We should therefore be consistently and continually aware of the importance of health literacy and clear health communication and their role in the overall healthcare environment. From this vantage point, adopting a universal precautions approach has potential to improve the accessibility and comprehension of health-related information for individuals from all sectors of society. In fact, current research has highlighted several key areas in which policy change may have a positive impact:
- Readability and standardization of educational materials and other health documents (e.g. informed consent form)
- Health education in schools
- Public health and nutritional messages
- Access to care
- Insurance status
Interpreter and other culturally relevant services
Health Literacy Screening and Research Tools:
Research suggests that individuals are in fact amenable to having their health literacy skills assessed and this does not necessarily elicits feelings of shame or embarrassment (VanGeest J Health Commun 2010, Ryan Health Edu Research 2007). There are many existing tools that researchers have developed to measure health literacy and inform both research endeavors and health policies and programs. Some of the most commonly used instruments include:
- Newest Vital Sign (NVS): One of Pfizer’s most important contributions to the measurement of health literacy. Developed by Weiss et al., the NVS is a brief health literacy measure that utilizes information contained in a food label. It takes 3 minutes to administer on average and has been evaluated among various populations and in multiple clinical settings. Available in English and Spanish, this instrument has a reliability coefficient of 0.76 and in one study was shown to have high sensitivity and low to moderate specificity for identifying individuals with limited literacy skills; yet it was found to be less predictive of health outcomes [Osborn CY, Am J Health Behav 2007 Sep-Oct;31 Suppl 1:S36-46].
- Rapid Estimate of Adult Literacy in Medicine (REALM-S): One of the first screening tools developed. It is comprised of 66 questions designed to measure adult’s ability to recognize medical terminology and provides accurate estimates of reading levels. Takes approximately 1-2 minutes to administer and score. The REALM-S has high correlation (r=0.88-0.97) with other standardized general reading tests as well as strong test-retest reliability (r=0.99) [Davis TC, Fam Med 1993;25:391-5]. One criticism of this scale has been the number of items despite the relatively short administration time. In response, the REALM-S has been revised and adapted for use in different research settings, and shorter versions are available (REALM-R, REALM-SF).
- Short Test of Functional Health Literacy in Adults (S-TOFHLA): A commonly used measure of health literacy that consists of 36-items across 2 prose passages and 4 numeracy items. Combined administration time is 12 minutes. Respondents are categorized into inadequate, marginal, and adequate health literacy levels. A Spanish version is available. Reliability coefficients for the numeracy items and prose items are 0.68 and 0.97 respectively. Correlation between the S-TOFHLA and REALM-S is high at 0.80. Like the REALM-S, criticisms have included length of administration.
- The Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA): This 50 item scale developed by Lee et al. was patterned after the REALM-S and was designed to assess health literacy in Spanish-speaking adults. It correlates well with the S-TOFHLA (r=0.65) and was positively correlated with physical health status among study subjects. The instrument has good internal consistency (α=0.92) and test-retest reliability (r=0.86).
- Brief Health Literacy Screen (BHLS): Developed by Chew et al., this tool consists of 3 brief questions that ask respondents to rate their ability to perform several health literacy related tasks such as filling out medical forms, reading hospital materials, and learning about one’s medical condition. A Spanish version is available. Several studies have suggested that the question, “How confident are you filling out medical forms by yourself” may have the greatest accuracy in identifying limited and limited/marginal health literacy skills [Wallace LS, J Gen Intern Med 2006 Aug;21(8):874-7, Powers BJ, JAMA 2010 Jul;304(1):76-84]
- Subjective numeracy scale (SNS): Developed by Fagerlin et al., this self-report measure contains 8 items that assess one’s perceived ability to perform various mathematical tasks and preference for the use of numerical versus prose information. The SNS is significantly correlated with other objective measures of numeracy (r=0.63-0.68) and was perceived as less stressful and frustrating. On average it takes about 3 minutes to administer.
Research on Interventions to Address Health Literacy:
A review in 2009 by Clement et al. described studies that evaluated multi-faceted interventions aimed at improving health-related outcomes of individuals with limited literacy or numeracy skills. Results included interventions that targeted:
- Health professionals
- Literacy education
- Health education/management
About half of the identified studies measured direct clinical outcomes, and knowledge and self-efficacy were the most likely outcomes noted to improve. Another area that is gaining research attention is the use of media and health information technology to improve outcomes for low literate populations. Similarly, more research is emerging that emphasizes the importance of culturally-tailored and patient-centered approaches to intervention research. Wolff et al., recently described and challenged researchers to consider health literacy in terms of an individual’s “health-learning capacity” which encompasses a broader framework and constellation of cognitive and psychosocial skills that patients or family members rely upon to manage their health. Overall, consensus exists in the current literature regarding the need for additional and more extensive/rigorous research into the effectiveness, sustainability and costs associated with interventions targeting low health literate populations.