Rapid Estimate Of Adult Literacy In Medicine-Revised Research Articles

A-126 Social Determinants Measures: Dichotomous or Dimensional?

Abstract Objective: The study aimed to examine the use of dichotomous versus dimensional scores across two social determinant measures regarding their ability to predict cognitive and psychiatric outcomes in a diverse, urban, clinical sample. The goal was to better guide clinicians in the selection of appropriate research methodology pertaining to the use of cut-scores versus dimensional constructs. Method: The study included 215 adults referred for outpatient neuropsychological evaluation. Patients were classified into at-risk/low-risk groups based on predetermined Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R) and Adverse Childhood Experiences (ACE) cut-scores. Nine cognitive tests and two psychiatric self-report scales were administered. A series of hierarchical regression models were conducted to investigate the predictive power of dichotomous scores alone, and account for the incremental predictive power of dimensional scores. Results: For REALM-R, dichotomous scores alone accounted for significant variance, demonstrating robust predictive power across all cognitive tests (p < 0.001 to p < 0.05), but not for psychiatric outcomes. Dimensional scores provided significant incremental variance in five cognitive tests (p < 0.001to p < 0.05) during which the parameter estimate for the dichotomous scores was reduced to non-significance. Regarding ACE, dichotomous scores were positively associated with psychiatric symptoms (p < 0.001), but not with cognitive outcomes. The addition of dimensional scores did not predict significantly more variance. Conclusion: This study demonstrated the robust predictive power of dichotomous scores in REALM-R and ACE. Further, dimensional scores provided potent incremental predictive power for REALM-R and should be used to enhance clinical decision-making when applicable.

A-124 Racial Disparities in Health Literacy and Numeracy: The Role of Sociodemographic and Psychological Risk Factors

Abstract Objective: Health literacy and numeracy are commonly associated with health disparities and may disproportionately affect minoritized groups. This study assessed racial disparities in health literacy and numeracy and their association to sociodemographic and psychological risk factors among a mixed clinical outpatient sample. Method: Cross-sectional data from 198 patients who were administered the General Health Numeracy Test-Short Form (GHNT), Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), Adverse Childhood Experiences Checklist (ACE), Perceived Stress Scale (PSS), and Test of Premorbid Functioning-Predicted FSIQ (TOPF-FSIQ) were examined. Participant characteristics were compared by ethnoracial group status via chi-square and ANOVA tests. Multivariate regression models evaluated associations between health literacy and numeracy with sociodemographic and psychological risk factors across ethnoracial groups. Results: Subjects were 45% female/55% male, 48% White, 38% Black and 14% Hispanic, with a Mage of 44.7 (SD = 17.3) and Meducation of 13.5 years (SD = 2.8). Black subjects were older, less educated, and had lower TOPF-FSIQ than White subjects, whereas Hispanic subjects were younger with lower TOPF-FSIQ than White subjects. Black subjects had lower GHNT-6 and REALM-R scores than White subjects. No group differences in ACE or PSS were observed. In multivariate analyses, only lower TOPF-FSIQ was significantly associated with lower REALM-R, whereas lower TOPF-FSIQ, older age, and higher ACEs were significantly associated with lower GHNT. No significant interactions with ethnoracial group status were observed. Conclusion(s): Although health literacy and numeracy differed across ethnoracial groups, this effect was driven by lower TOPF-FSIQ for health literacy, in addition to lower age and higher number of adverse childhood experiences for health numeracy.

Psychometric Evaluation of Three Translated Measures of Functional Health Literacy among Jordanians.

Assessment of functional health literacy (FHL) is not integrated into clinical settings in Jordan possibly because relevant psychometric studies are lacking. The aim of this secondary analysis of data on family caregivers (N = 115) was to evaluate the internal consistency reliability and construct validity of three measures of FHL among Jordanians: the Short Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), and the Single Item Literacy Screener (SILS). Cronbach's alpha was excellent for the S-TOFHLA (.92), but suboptimal for the REALM-R (.67). In bivariate analysis, FHL measured by the S-TOFHLA and the REALM-R, but not the SILS, was positively associated with educational attainment (p < .05) and negatively related to self-reported anxiety (p < .05). Among Jordanians, psychometric rigor was fully demonstrated for the S-TOFHLA and partially for the REALM-R, but not for the SILS.

Good Literacy to Enhance Response in Diabetes Mellitus (GLITTER-DM).

The purpose of this study is to determine the effectiveness of individualized communication strategies and self-management action plans to improve A1c control at 3 months in patients with low health literacy. A prospective, open-labeled, pilot study was conducted on 23 patients with diabetes mellitus in a pharmacist-led ambulatory care clinic. Patients who had a Rapid Estimate of Adult Literacy in Medicine- Revised (REALM-R) score of 6 or less and an A1c greater than 7% upon study entry were included. The first group received the teach-back method, personalized actions, and follow-up phone calls to assess comprehension (N = 12). The second group was assigned to usual care (N = 11). Patients receiving literacy-appropriate interventions had greater A1c percent reduction (A1c difference of -2.0 ± 1.3 vs -1.0 ± 2.2; P = 0.02) and less hyperglycemic events per week (0.1 vs. 2.1; P = 0.04). There were no differences in the number of hypoglycemic events, testing frequency, medication-adherence rates, or hospitalizations and emergency room visits related to diabetes. Literacy-appropriate methods such as the teach-back method, personalized action plans, and telephone follow-ups may improve glycemic control in low health literate patients with diabetes. The findings from this study suggest that pharmacists may improve diabetes outcomes when managing patients who possess low health literacy using simplified teaching methods.

Health literacy and related health behaviour: a community-based cross-sectional study from a developing country

Abstract Objectives The concept of health literacy (HL) is globally evolving, and understanding its nature and impact is essential for disease prevention and treatment. Therefore, we aimed in this study to assess level of HL and predictors of inadequate HL in Jordanian population as an example case of a developing country. Method This cross-sectional study was conducted in a public tertiary hospital and community pharmacies in Jordan. All respondents answered a questionnaire, which included demographic data, Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), Short Test of Functional HL in Adults (S-TOFHLA), and All Aspects of HL Scale (AAHLS). Chi-square test and logistic regression analysis were conducted to determine the relationship and significant predictors for HL. Key findings Among 310 participants, REALM-R showed that around 27.1% had limited HL. Similar findings with S-TOFHLA and AAHLS were shown with a mean score 25.6 out of 35 (SD = 3.54, Range = 16–33) for AAHLS. Functional and critical HL were comparably low. Education level, age, living area and chronic conditions were significant predictors of HL (P &amp;lt; 0.05). Conclusions Health literacy was inadequate among Jordanians. Further research is required to assess the effect of inadequate HL on healthcare access and health outcomes. Health education programmes are required to improve HL particularly for patients with chronic diseases.

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans

ObjectivesIndividuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans. MethodsParticipants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics. ResultsApproximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4–3.8), unable to work (OR = 2.8, CI = 1.3–6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0–1.2). ConclusionLimited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels. Practice implicationsFuture studies are needed to understand the role of health literacy in an individual’s health behavior and the provision of effective healthcare.

Education and Decision-Making in Patients and Caregivers Considering Left Ventricular Assist Devices

Purpose Left ventricular assist device (LVAD) is a mainstay of therapy in end-stage heart failure, but presents a challenge in decision-making to patients and caregivers. The aim of this study is to assess patient education and understanding of LVAD therapy. Methods Consecutive candidates for LVAD therapy were enrolled for this study. Patients were excluded if they were unable to participate in baseline testing. Prior to LVAD implant, health literacy was assessed by Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) testing, a word-recognition test of 11 items. Cognitive function was assessed by St. Louis University Mental Status Exam (SLUMS), a brief oral and written exam. LVAD knowledge was assessed by a validated 20-item score. Results 21 patients were enrolled. The median age was 59 years and 62% of the patients were male. Most patients were institution naive, and only 47% had a documented prior advanced heart failure (HF) clinic visit. The majority of patients were on IV inotropes (85.7%) at the time of evaluation and many had indwelling aortic balloon pumps (42.9%). The median time to assessment following formal LVAD education was 1 day. 31% of patients had low health literacy based on REALM-R testing. Median SLUMS scores were in range of mild neurocognitive disorder (22.5; IQR 21, 25) (Fig. 1A). Baseline knowledge check demonstrated a low median score (45/100; IQR 35, 50) (Fig. 1B), and no patient reached a score of >70 (previously described average). Conclusion The majority of referrals for LVAD at our institution are late referrals of critically ill patients. Health literacy and cognitive scores are low in our patient population resulting in low knowledge check scores, despite systematic LVAD education. Patient specific LVAD education should address each patient's individual needs.

Assesse the Health literacy in Multiple Sclerosis patients

Background and objective: Health literacy is one of the major determinants of health and is one of the important factors in chronic diseases such as MS. The aim of this study was to evaluate the Health Literacy Association with health behaviors and health care utilization. Methods: This study was a cross-sectional study in which 100 patients with multiple sclerosis diseases selected by the convenience sampling in Qazvin hospital. Respondents completed the Rapid Estimate of Adult Literacy in Medicine, revised (REALM-R) and the Newest Vital Sign (NVS) instrument. For statistical analysis, we used logistic and ordinal regression and Kruskal-Wallis and Mann-Whitney tests. Results: Mean age of the subjects was 33/43±8/53 years. On the NVS, 63% of respondents had a high likelihood of inadequate literacy and 26% had borderline health literacy and 11% had adequate health literacy. On the Realm-r, 7% had inadequate literacy and 93% had adequate health literacy, Using logistic regression the frequency of alcohol consumption and using cigarette (p<0/05) and level of education (p-value=0/045) were associated with higher odds of having inadequately health literacy as assessed by the Realm-r. There was a significant correlation between Realm-r health literacy (p value=0/007) and NVS (p-value=0/005) with visits to the emergency room (ER), and hospitalizations in the last 6 months. Conclusion: Based on the results of the current study it is necessary to pay more attention to the health literacy level of the affected people and promote it in health programs and health promotion. Paper Type: Research Article.

Screening Hospitalized Patients for Low Health Literacy: Beyond the REALM of Possibility?

As patient-centered education efforts increase, assessing health literacy (HL) becomes more salient. The verbal Brief Health Literacy Screen (BHLS) may have clinical and feasibility advantages over written tools, including the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and Short Test of Functional Health Literacy in Adults (S-TOFHLA); however, the BHLS's utility among inpatients remains unresolved. Hospitalized adults were enrolled; HL was assessed using three tools. Categorical comparisons used chi-square; area under the receiver operating characteristic curve was calculated (reference: REALM-R). The prevalence of low HL among participants ( n = 260) was higher for the BHLS than S-TOFHLA (29% vs. 17%, p < .001) and higher for the REALM-R than both the BHLS (44% vs. 29%, p = .004) and S-TOFHLA (44% vs. 17%, p < .001). The areas under the receiver operating characteristic curve were .58 for BHLS and .66 for S-TOFHLA. The different prevalence of low HL among the participants based on each tool likely reflects the complexity of measuring HL and differing domains captured by each tool. The BHLS can be considered a viable inpatient HL screening tool, given its increased feasibility and verbal administration.

Abstract C12: An examination of intention to donate biospecimen among women considering consent models and health care discrimination

Abstract The purpose of this study is to examine the influence of different consent models on the intention to donate a biospecimen for use in secondary research, accounting for having experienced racial health care discrimination. Specifically, the influence of the notice, broad consent, and study-specific consent models is explored. Biospecimen donation is important for the advancement of medical cancer research. Discrimination may impede biospecimen donation. The analyses presented offer some indication of the type of consent model that may have the strongest potential to minimize negative effects of health care discrimination on intentions to donate biospecimen. In this study, self-identified non-Hispanic White and non-Hispanic Black women age 35 and older were recruited to complete a survey that was primarily self-administered. The Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) component of the survey was administered by trained research staff. In addition to baseline questions, the survey included a randomized component, which involved participants seeing three brochures explaining each of the consent models in a randomized order. Participants were asked to indicate their intentions to donate following exposure to each of the models and asked to pick their preferred model after having viewed all three. Preliminary chi-square analyses suggest discrimination negatively influences willingness to consent to donate. Specifically, there is a significant difference by general intention to donate as well as intention to donate to multiple studies, Washington University studies, and studies in which Protected Health Information (PHI) is attached to the sample. Of note, those having experienced health care discrimination are significantly different regarding general intentions to donate from those who had not experienced health care discrimination in intentions to donate after receiving brochures about both notice (p=0.0101) and broad consent (p=0.0002) models. Also, participants who reported experiencing health care discrimination are significantly different from those who had not reported experiencing health care discrimination for intention to donate to multiple studies and if PHI was attached to the sample across all consent model types - notice, broad, and study-specific. In each case, noticeably smaller percentages of those who reported experiencing at least some health care discrimination indicated intentions to definitely consent to donate. These preliminary findings suggest health care discrimination can negatively affect the potential benefits of cancer research via hindering biospecimen donation. In additional analyses, we will be able to determine the influence of additional sociodemographic factors on the relationship between the experience of health care discrimination and intentions to donate biospecimen. Ultimately, reducing the likelihood and actual occurrences of health care discrimination through addressing the root causes of health care discrimination is an important goal. Examining the influence of consent model types on the relationships between health care discrimination and intentions to donate biospecimen can provide cues as to models of information to provide that can minimize the impact of discrimination on biospecimen donation. Appropriate models of information to provide may vary by study type. Citation Format: Karyn Stewart, Katherine Brown, Bettina Drake, Sarah Gehlert, Leslie Wolf, James Dubois, Hannah Perkins, Sarah Lyons, Melody Goodman, Kimberly Kaphingst. An examination of intention to donate biospecimen among women considering consent models and health care discrimination. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C12.

Do Subjective Measures Improve the Ability to Identify Limited Health Literacy in a Clinical Setting?

Existing health literacy assessments developed for research purposes have constraints that limit their utility for clinical practice, including time requirements and administration protocols. The Brief Health Literacy Screen (BHLS) consists of 3 self-administered Single-Item Literacy Screener (SILS) questions and obviates these clinical barriers. We assessed whether the addition of SILS items or the BHLS to patient demographics readily available in ambulatory clinical settings reaching underserved patients improves the ability to identify limited health literacy. We analyzed data from 2 cross-sectional convenience samples of patients from an urban academic emergency department (n = 425) and a primary care clinic (n = 486) in St. Louis, Missouri. Across samples, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), Newest Vital Sign (NVS), and the BHLS. Our analytic sample consisted of 911 adult patients, who were primarily female (62%), black (66%), and had at least a high school education (82%); 456 were randomly assigned to the estimation sample and 455 to the validation sample. The analysis showed that the best REALM-R estimation model contained age, sex, education, race, and 1 SILS item (difficulty understanding written information). In validation analysis this model had a sensitivity of 62%, specificity of 81%, a positive likelihood ratio (LR(+)) of 3.26, and a negative likelihood ratio (LR(-)) of 0.47; there was a 28% misclassification rate. The best NVS estimation model contained the BHLS, age, sex, education and race; this model had a sensitivity of 77%, specificity of 72%, LR(+) of 2.75, LR(-) of 0.32, and a misclassification rate of 25%. Findings suggest that the BHLS and SILS items improve the ability to identify patients with limited health literacy compared with demographic predictors alone. However, despite being easier to administer in clinical settings, subjective estimates of health literacy have misclassification rates >20% and do not replace objective measures; universal precautions should be used with all patients.

Cognitive dysfunction and poor health literacy are common in veterans presenting with acute coronary syndrome: insights from the MEDICATION study.

BackgroundPatient nonadherence to cardiac medications following acute coronary syndrome (ACS) is associated with increased risk of recurrent events. However, the prevalence of cognitive dysfunction and poor health literacy among ACS patients and their association with medication nonadherence are poorly understood.MethodsWe assessed rates of cognitive dysfunction and poor health literacy among participants of a clinical trial that tested the effectiveness of an intervention to improve medication adherence in patients hospitalized with ACS. Of 254 patients, 249 completed the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) survey, an assessment of risk for poor literacy, and the St Louis University Mental Status (SLUMS) exam, a tool assessing for neurocognitive deficits, during ACS hospitalization. We assessed if SLUMS or REALM-R scores were associated with medication adherence.ResultsBased on SLUMS score, 14% of patients were categorized as having dementia, and 52% with mild neurocognitive disorder (MNCD). Based on REALM-R score of ≤6, 34% of patients were categorized as at risk for poor health literacy. There was no association between poor health literacy and medication nonadherence. Of those with MNCD, 35.5% were nonadherent, compared to 17.5% with normal cognitive function and 6.7% with dementia. In multivariable analysis, cognitive dysfunction was associated with medication nonadherence (P=0.007), mainly due to an association between MNCD and nonadherence (odds ratio =12.2, 95% confidence interval =1.9 to 243; P=0.007). Cognitive status was not associated with adherence in patients randomized to the intervention.ConclusionCognitive dysfunction and risk for poor health literacy are common in patients hospitalized with ACS. We found an association between MNCD and medication nonadherence in the usual care group but not in the intervention group. These findings suggest efforts to screen for MNCD are needed during ACS hospitalization to identify patients at risk for nonadherence and who may benefit from an adherence intervention.

"Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management.

PurposeHealth literacy is lower in minorities and older adults, and has been associated with nonadherence to medications, treatment, and care in people living with human immunodeficiency virus (HIV). Likewise, African Americans with HIV are more likely to be nonadherent to their HIV medications, less likely to keep their clinic appointments related to HIV treatment and care, and more likely to die during hospitalizations than their ethnic counterparts. The present study explored the preferences of older African Americans with HIV for a health literacy intervention to promote HIV management.Patients and methodsIn this qualitative study, 20 older adult African Americans living with HIV were recruited from an HIV/acquired immunodeficiency syndrome outpatient clinic in the southeastern region of the US. Using patient-centered participatory design methods, semi-structured individual interviews were conducted to determine patient preferences for intervention development and design. Health literacy was also measured using the Rapid Estimate of Adult Literacy in Medicine – Revised (REALM-R).ResultsFour major themes emerged related to intervention development and design: keep health information simple; use a team-based approach for health education; tailor teaching strategies to patients’ individual needs; and account for patients’ low experience, but high interest, in technology. Forty-five percent of the study population had low health literacy based on the revised Rapid Estimate of Adult Literacy in Medicine.ConclusionFuture interventions that target minorities and older adults living with HIV should consider patients’ learning needs, sex-specific and mental health needs, and delivery approaches, in order to increase uptake and improve disease management and health outcomes.

Health literacy and the digital divide among older Americans.

Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy. The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older. We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans. Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users). Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and self-reported confidence filling out medical forms. Only 9.7% of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9% of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95% CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95% CI 0.47 to 0.77]). Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide.

Levels of health literacy in a community-dwelling population of Chinese older adults.

Lower levels of health literacy have been associated with adverse health outcomes, especially for older adults. However, limited research has been conducted to understand health literacy levels among Chinese American older adults. The PINE study is an epidemiological cohort of 3,159 community-dwelling Chinese older adults, 95% of whom do not speak or read English. Chinese older adults' health literacy levels were examined using the Chinese version of the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test. Kruskal-Wallis test and chi-square statistics were used to identify significant differences by sociodemographic and self-reported health characteristics. Pearson and Spearman correlation coefficients were used to examine correlations between personal characteristics and health literacy level. The mean age among this sample of Chinese older adults was 72.8 years (SD = 8.3, range = 60-105) and the mean REALM-R test score was 6.9 [SD = 2.3, range (0-8)]. Health literacy was positively associated with education, marriage status, and number of people living with. Older age, being female, greater number of children, years in the United States, and preference for speaking Cantonese or Taishanese were negatively associated with health literacy. Health literary was not associated with self-reported health status or quality of life. In this Chicago Chinese population, older adults had reasonable levels of health literacy in Chinese. Future longitudinal research is needed to understand risk/protective factors associated with health literacy level in Chinese older adults.

Improving prescription auxiliary labels to increase patient understanding

ObjectivesTo develop new, easy-to-understand prescription auxiliary labels, assess patient understanding of both new and existing labels, and compare the effectiveness of existing labels with the newly developed ones. DesignCross-sectional study. SettingSemistructured interviews. ParticipantsConvenience sample of adults from minority populations who were currently taking or had previously taken a prescription medication and could understand English. InterventionEasy-to-understand prescription auxiliary labels were developed. Both these newly created labels and existing labels were shown to participants. Participants’ health literacy levels and understanding of the information provided on the labels were determined. The reading difficulty of the auxiliary labels was determined using a Lexile Score. Main outcome measuresInterpretation and understanding of prescription auxiliary labels. ResultsThe study included 120 participants with a mean age of 40 years (SD = 14). All existing prescription auxiliary labels yielded less than 50% “excellent” interpretations except for those indicating “Take with food” and “Do not chew or crush.” The newly designed labels were better understood compared with existing labels. Some existing labels yielded Lexile scores above the sixth-grade reading level. There was an association between higher levels of education (χ2 = 20.86, P = 0.02) or higher REALM-R (Rapid Estimate of Adult Literacy in Medicine, Revised) scores (χ2 = 26.79, P = 0.02) and better interpretation of auxiliary labels. ConclusionSimpler auxiliary labels with improved patient comprehension can be developed. Auxiliary label understanding and interpretation is low for commonly used labels. Pharmacies should consider using existing manufacturer auxiliary labels that meet the criteria for patients with low literacy.

Effects of Health Literacy and Polypharmacy on Medication Adherence

To determine if health literacy has an effect on medication adherence in patients taking fewer than five prescriptions (no polypharmacy), and those taking five or more prescriptions (polypharmacy). Retrospective cohort. The Primary Care Residents' Clinic at Virginia Commonwealth University Health System (VCUHS). Those who received a Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) assessment at the clinic between June 1, 2009, and June 30, 2010, and utilized the VCUHS outpatient pharmacies to fill their prescriptions. A total of 648 individuals were identified. The degree of health literacy and level of medication adherence were analyzed per patient by accessing the clinic's electronic health records. The number of medications each patient filled was determined using VCUHS outpatient pharmacy databases. To determine if there are any associations among the degree of health literacy, the level of medication adherence, and the amount of medications a patient is taking. There was a significant association found between the level of medication adherence and the degree of polypharmacy. We found no association between the degree of health literacy and the level of adherence to a prescribed medication regimen. Additionally, there was no relationship between the degree of polypharmacy and health literacy. Those patients with more medications were also found to have lower levels of medication adherence and vice versa. Our study does not show an association between health literacy and medication adherence nor between health literacy and polypharmacy. Thus, potential changes to improving health literacy may not have a significant effect on adherence.

Evaluating the Brief Health Literacy Screen

To the Editors: We commend Wallston et al. on their work, demonstrating that the Brief Health Literacy Screen (BHLS) is a useful tool in identifying hospitalized patients with low health literacy.1 Given that about one-quarter of adults in the US have low health literacy2 and that physicians often have difficulty identifying their patients’ health literacy status,3 it is imperative that clinicians have a tool that accurately identifies patients who have low health literacy. The work of Wallston et al. demonstrating the validity of the BHLS in both the hospital and clinic setting is valuable, especially since many of the written health literacy assessment tools are difficult to use in the clinical setting. It is particularly important to have a concise and easily administered verbal screening tool, because it can easily be integrated into the clinic or hospital intake screen and does not require patients to read and respond to a written questionnaire. Since over one-third of US adults have basic or below basic literacy4 and we have found that more than one in four inpatients have insufficient vision,5 it is extremely important that we have a verbal screening tool that does not rely on patients’ vision or reading fluency. These results are encouraging, especially since studies at our institution have found less promising results when evaluating the performance of the BHLS. In early preliminary analysis of a study we are doing comparing the verbal BHLS to both the short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) written screening tools, we have not observed a similar correlation between the BHLS and S-TOFHLA as was found by Wallston et al. One possibility for why our results may differ is that the patient population of our studies is very different. Wallston et al.’s study population was predominantly white, while our study’s population was predominantly African American. There was also was a higher educational attainment among participants in the Wallston study than in our study. Since Wallston et al. found that having more education and being of the white race was associated with higher health literacy scores, it is quite possible that our results are less promising because the tools may perform better in populations with high health literacy. Given these observations, it is even more important to further evaluate the utility of the BHLS in diverse patient populations, including those with low health literacy.

Residents' ability to identify patients with poor literacy skills.

To determine whether residents could identify patients with poor literacy skills based on clinical interactions during a continuity clinic visit. The authors hypothesized residents would overestimate patients' literacy abilities and fail to recognize many patients at risk for poor literacy. The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) was administered to screen patients for potential literacy problems. Residents were asked "Do you feel this patient has a literacy problem?" and answered yes or no. Continuity adjusted chi-square was used to test for overestimation of literacy abilities by residents. REALM-R scores and residents' evaluations of literacy were available for 182 patients. The residents believed 10% of patients (18) had literacy problems based on their clinical interactions. Only three patients passing the literacy screen were incorrectly identified as at risk for literacy. Of the 90% of patients (164) the residents perceived to have no literacy problem, 36% (59) failed the literacy screen. Resident physicians overestimated the literacy abilities of their patients. A significant portion of these residents' patients may not have the skills to effectively interact with the health care system and are at increased risk for adverse outcomes.