Can My Patient Read and Understand
Written Health Information? A systematic
review of literacy screening instruments
Ben Powers
Powers, MD
MD, MHS
Jane Trinh
Trinh,, MD
Hayden Bosworth, PhD
Academy Health
Boston MA
Boston,
June 27, 2010
Background
the degree to which individuals can
Health literacy: “the
obtain, process, and understand basic health
information and services needed to make appropriate
health decisions”
decisions
2003 National Adult Assessment of Health Literacy
– 14% of adults had below basic health literacy
– 22% had only basic health literacy
Low health literacy associated with:
–
–
–
–
–
disease knowledge
health care utilization
overall health status
chronic disease control
mortality
y
Institute of Medicine. Health literacy: A Prescription to End Confusion.
2003 National Assessment of Adult Literacy
Background
The
Standards
Th Current
C
t Reference
R f
St d d
– Test of Functional Health Literacy in Adults (TOFHLA)
50 reading
di comprehension
h
i questions;
ti
17 numeracy
questions
Up to 22min
– Shortened TOFHLA
36 reading comprehension questions; 4 numeracy questions
7-12 minutes to administer
– Rapid Estimate of Adult Literacy in Medicine
(REALM)
Recognition and pronunciation of 66 medical words
Up to 3minutes to administer
Should I screen for literacy?
The case against screening:
– Limited evidence on effective interventions
– ~50% with limited literacy are ashamed of their inability to read,
– Clear health communication and low literacy education material
should be available to all patients
The case for screening:
– Estimating local prevalence
– When physicians are notified of patients low literacy
literacy, they were
3x more likely to use recommended communication strategies
– 64% of physicians and 96% of patients believed screening
worthwhile
– Patients with limited literacy may particularly benefit from care
management interventions
Pignone et al. JGIM. 2005
Seligman et al. JGIM. 2005
Rothman et al. JAMA. 2004
Research Objective
Systematically evaluate practical clinical
tools for identifying
y gp
patients with low
literacy
– Accurate
– Reproducible
– Brief
– Acceptable
p
to the p
patient
Methods
Literature Search through Feb
Feb, 2010
–
–
–
–
Pubmed (including Medline)
Psychinfo
Experts
Bibliographies
Abstract Screening and Inclusion:
– Subjects >18 years old
– Used acceptable reference standard (REALM, TOFHLA, ss--TOFHLA,)
– Sufficient Information to calculate diagnostic test info (Sens, Spec, Likelihood Ratios)
Full text reviewed by two independent reviewers
Each Study Graded on Quality
Meta-analysis using univariate randomMetarandom-effects from the individual studies in
Comprehensive Meta
Meta--analysis
Methods
2522 studies identified for abstract review
2496 Excluded after abstract review
26 selected for full manuscript review and
abstraction
16 Excluded after full article review
- 7 special populations or circumstances
- 3 review articles
- 2 inadequate data
- 4 other
10 studies selected for inclusion
Likelihood Ratios
Sensitivity
1- Specificity
Combines the test
characteristics into a single
composite
measure
p
Allows rapid conversion
of a prepre-test probability to a
post--test probability
post
Results
10 Uniq
Unique
studies
included
evaluating
e st
dies incl
ded e
al ating 6 different
screening instruments
Multi-item screening tools:
Multi– Newest Vital Sign (NVS)
– Medical Term Recognition Test (METER)
Single--item screening questions:
Single
– Use of a surrogate reader
– Confidence with filling out medical forms
– Self
Self--rated reading ability
– Difficulty learning about health
Results: Newest Vital Sign
Newest Vital Sign:
– 6 questions based on
reading nutrition label
– 2-6 minutes to
administer
d i i t
– 3 separate studies
evaluating NVS in
primary care setting
p
Responses
Summaryy LR ((95% CI))
0-1
3.2 (1.9(1.9-5.4)
2-3
0.77 (0.34(0.34-1.8)
4-6
0.08 (0.02(0.02-0.45)
Results: Use of a surrogate
reader
“How often do you have someone help
yyou read hospital
p
materials?”
Response options: always, often,
sometimes rarely
sometimes,
rarely, or never
Has been evaluated in 5 separate studies.
Responses
Summary LR (95% CI)
Sometimes, Often, Always
2.9 (2.3(2.3-3.7)
Rarely
1.0 (0.80(0.80-1.3)
Never
0.53 (0.38(0.38-0.73)
Results: Confidence with medical forms
“How confident are you filling out medical
forms by
y yyourself?”
Response options: extremely, quite a bit,
somewhat a little bit
somewhat,
bit, or not at all
all.
Evaluated in 3 separate studies
Responses
Summary LR (95% CI)
A littl
little or no confidence
fid
5 0 (3.85.0
(3.8
(3 8-6.4)
6 4)
Somewhat confident
2.2 (1.5(1.5-3.3)
Quite a bit or extremely confident
0.44 (0.24(0.24-0.82)
Results: SelfSelf-rated reading
ability
“How would you rate your ability to read?”
Responses range from excellent
excellent, very
good, good, okay, poor, very poor, and
terrible
Evaluated in 2 separate studies
Responses
LR (95% CI)
Okay poor
Okay,
poor, very poor
poor, terrible
5 1 (3.25.1
(3.2
(3 22-8.3)
8 3)
Good
1.0 (0.61(0.61-1.8)
Excellent or Very good
0.16 (0.05(0.05-0.46)
Conclusions
Providers should be aware of prevalence and risks of
limited literacy
A single question about confidence with medical forms,
use of a surrogate reader, or selfself-rated reading ability
can accurately screen for limited literacy in a busy health
care setting
While clear health communication is important for all
patients, those with limited literacy may require more
time and attention to support adequate understanding
Acknowledgements
Funding Support: NCRR and Duke Mentored Clinical
Research Scholar Program KL2 RR024127RR024127-02
Primary Research Mentors:
– Eugene Oddone
Oddone,, MD
– Hayden
y
Bosworth,, PhD
Rational Clinical Exam:
– David Simel
Simel,, MD