Short Test Of Functional Health Literacy In Adults Research Articles

Application of the Cloze Procedure to Evaluate Comprehension and Demonstrate Rewriting of Pharmacy Educational Materials

Written materials are commonly used to communicate pharmacy-relevant information to patients. However, they are often composed at a level that limits comprehension, mitigating a well-intended effect. To (1) use the cloze procedure (a test designed to assess reading comprehension) to evaluate an individual's understanding of a pharmacy-relevant educational pamphlet; (2) compare results of the cloze procedure with the reading comprehension component of the Short Test of Functional Health Literacy in Adults (S-TOFHLA); and (3) use results to demonstrate rewriting of the educational pamphlet. The cloze procedure was applied to a pharmacy-relevant educational pamphlet describing safe medication practices. A total of 162 subjects were recruited from university faculty, staff, and students; a local adult literacy center; and community senior centers. Subjects completed a background interview, the S-TOFHLA, and cloze procedure for the pharmacy-relevant educational pamphlet. S-TOFHLA and cloze procedure scores were described and compared. Cloze procedure responses were used to demonstrate revision of the pamphlet. Of the 154 subjects analyzed, mean +/- SD age was 56.5 +/- 20.4 years. Subjects were predominantly white (93.5%), female (71.4%), and college graduates (42.2%). Mean score on the S-TOFHLA was 92.1%. A majority (95.5%, 147/154) of subjects demonstrated adequate functional health literacy. In contrast, mean score on the cloze procedure was 53.3%. Internal consistencies of the S-TOFHLA and the cloze procedure were 0.92 and 0.90, respectively. Scores on the cloze procedure and the S-TOFHLA were highly correlated (r = 0.71, p < 0.001). Performance on the cloze procedure indicated that 55.2% of subjects required supplemental teaching. In this highly educated, health-literate sample, a majority did not understand the pharmacy-relevant educational pamphlet despite adequate performance on a standard measure of health literacy. The cloze procedure can be used to assess comprehension of educational materials, solicit feedback from intended users, and guide the revision of educational materials.

Health literacy skills of kidney transplant recipients

Although low health literacy can affect patients' treatment decision making, comprehension of health information, and medication adherence, little is known about health literacy skills of kidney transplant recipients. To examine the relationship among kidney transplant recipients' health literacy levels, transplant knowledge, and graft function. Cross-sectional study of 124 adult kidney transplant recipients. Health literacy was assessed via the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine-Transplantation (REALM-T). Data on recipients' transplant numeracy, knowledge needs, and demographics were collected via semistructured interviews. Multivariable linear regressions were used to assess the relationship between health literacy and graft function. Most kidney recipients (91%) had adequate health literacy (S-TOFHLA); however, 81% were unfamiliar with at least 1 kidney transplant-related term (REALM-T). The 5 least familiar terms were sensitization (50%), urethra (45%), trough level (41%), blood urea nitrogen (32%), and toxicity (31%). Numeracy levels varied: 21% knew the likelihood of 1-year graft survival; 29% knew that half of kidney recipients have problems with the transplant in the first 6 months; 68% were aware of the risk of death within the first year after transplantation; and 86% knew the normal range for creatinine in kidney recipients. Patients with lower health literacy (REALM-T) had higher creatinine levels. Transplant providers should intervene with better patient education materials to improve patients' health literacy, which may improve patients' medication adherence or transplant outcomes.

Health Literacy Skills of Kidney Transplant Recipients

Although low health literacy can affect patients' treatment decision making, comprehension of health information, and medication adherence, little is known about health literacy skills of kidney transplant recipients. To examine the relationship among kidney transplant recipients' health literacy levels, transplant knowledge, and graft function. Cross-sectional study of 124 adult kidney transplant recipients. Health literacy was assessed via the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine-Transplantation (REALM-T). Data on recipients' transplant numeracy, knowledge needs, and demographics were collected via semistructured interviews. Multivariable linear regressions were used to assess the relationship between health literacy and graft function. Most kidney recipients (91%) had adequate health literacy (S-TOFHLA); however, 81% were unfamiliar with at least 1 kidney transplant-related term (REALM-T). The 5 least familiar terms were sensitization (50%), urethra (45%), trough level (41%), blood urea nitrogen (32%), and toxicity (31%). Numeracy levels varied: 21% knew the likelihood of 1-year graft survival; 29% knew that half of kidney recipients have problems with the transplant in the first 6 months; 68% were aware of the risk of death within the first year after transplantation; and 86% knew the normal range for creatinine in kidney recipients. Patients with lower health literacy (REALM-T) had higher creatinine levels. Transplant providers should intervene with better patient education materials to improve patients' health literacy, which may improve patients' medication adherence or transplant outcomes.

Screening Questions to Predict Limited Health Literacy: A Cross-Sectional Study of Patients With Diabetes Mellitus

Limited health literacy is increasingly recognized as a barrier to receiving adequate health care. Identifying patients at risk of poor health outcomes secondary to limited health literacy is currently the responsibility of clinicians. Our objective was to identify which screening questions and demographics independently predict limited health literacy and could thus help clinicians individualize their patient education. Between August 2006 and July 2007, we asked 225 patients being treated for diabetes at an academic primary care office several questions regarding their reading ability as part of a larger study (57% response rate). We built a logistic regression model predicting limited health literacy to determine the independent predictive properties of these questions and demographic variables. Patients were classified as having limited health literacy if they had a Short Test of Functional Health Literacy in Adults (S-TOFHLA) score of less than 23. The potential predictors evaluated were self-rated reading ability, highest education level attained, Single-Item Literacy Screener (SILS) result, patients' reading enjoyment, age, sex, and race. Overall, 15.1% of the patients had limited health literacy. In the final model, 5 of the potential predictors were independently associated with increased odds of having limited health literacy. Specifically, patients were more likely to have limited health literacy if they had a poorer self-rated reading ability (odds ratio [OR] per point increase in the model = 3.37; 95% confidence interval [CI], 1.71-6.63), more frequently needed help reading written health materials (assessed by the SILS) (OR = 2.03; 95% CI, 1.26-3.26), had a lower education level (OR = 1.89; 95% CI, 1.12-3.18), were male (OR = 4.46; 95% CI, 1.53-12.99), and were of nonwhite race (OR = 3.73; 95% CI, 1.04-13.40). These associations were not confounded by age. The area under the receiver operating characteristic curve was 0.9212. Self-rated reading ability, SILS result, highest education level attained, sex, and race independently predict whether a patient has limited health literacy. Clinicians should be aware of these associations and ask questions to identify patients at risk. We propose an "SOS" mnemonic based on these findings to help clinicians wishing to individualize patient education.

Assessing Adult Health Literacy in Urban Healthcare Settings

To determine if health literacy is lower among those using the emergency department as compared to those using community health clinics. A comparison was done of the health literacy level of patients at a level-I adult and pediatric emergency department and 3 community health clinics. The second purpose of the study was to identify and assess predictors of low or adequate health literacy in order to better accommodate the communication needs of these patients. The study used a convenience, cross-sectional design. The settings for the study were varied. The emergency department was a level-I inner-city pediatric and adult trauma center with 45,000 annual visits. The 3 outpatient clinics were all members of a 44-clinic network of private, community health centers that serve 175,000 underserved patients annually. Overall, 536 patients were approached to complete an in-person survey that included a 15-item written questionnaire and the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a English- and Spanish-validated health literacy measure. Based on language spoken with healthcare providers, patients were given either the Spanish or English S-TOFHLA. The refusal rate was 25.7%, with 536 patients approached and 398 completing the survey. Three of the four sites had a refusal rate of 8% per site. The fourth site had a higher refusal rate at 38%. Overall, 20% of subjects had marginal or inadequate functional health literacy. There was a significant difference at p=18.42, df=3, p=0.001 among sites. Three of the sites had > or =78% of the participants scoring at the adequate level. The fourth site, however, only had 66% who scored at the adequate level, with 34% of the scores in the inadequate functioning level as compared with 14% for the emergency department and its adjacent clinic and 3% for the clinic located at the city's edge. Using logistical regression, there was an association between literacy level and education (t=2.653, sig 0.008) and age (t=-6.451, sig 0.001). Less-than-adequate functional health literacy was seen at 20% of all sites. The location of healthcare access was not as predictive of low functional health literacy as were demographic indicators, such as age and education levels.

Health Literacy in an Adult Dental Research Population: A Pilot Study

The purpose of this investigation was to gather data concerning the level of health literacy in adults who frequently volunteer for our clinical research programs. A convenience sample of 99 adults was recruited from our database of subjects taking part in an ongoing series of investigations. Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Additional demographic and socioeconomic data were collected by means of a questionnaire. The results indicated that 13 percent of the cohort of subjects scored in the "inadequate" or "marginal" categories as described by the criteria of the S-TOFHLA. Inadequate or marginal health literacy was associated with race, gender, and age. Unfortunately, the sample size was too small to determine the interaction of these variables. Dental faculty conducting clinical research investigations should be cognizant of the fact that a portion of adults, especially older adults, may have difficulty reading written instructions, informational letters of consent, prescriptions, and other documents. Researchers should make every effort to ensure that information provided in text form is provided in a manner that is easily understandable to the reader. Technical terminology and jargon should be avoided or if used, it should be explained in plain, simple language. If a potential subject is having difficulty, the investigator is obligated to take the additional time to educate the potential subject using alternative methods.

The Demographic Assessment for Health Literacy (DAHL): A New Tool for Estimating Associations between Health Literacy and Outcomes in National Surveys

To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly. The Prudential Medicare Study assesses the S-TOFHLA score, leading to a "reference standard" classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based). Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined. As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.

Cognition and health literacy in patients with hypertension.

Approximately half of the US population has marginal or inadequate health literacy, a measure highly associated with health outcomes. This measure is often linked to age and education, but recent evidence from patients with chronic heart failure suggests that much of age-related variability in health literacy can be explained by cognitive abilities (e.g., working memory, processing speed). We examined the role of cognitive and sensory abilities as mediators of age and education in determining functional health literacy among patients with hypertension. Four hundred ninety two community-dwelling adults diagnosed with hypertension (aged 21 to 92 years) participated. They were primarily female (73%), African-American (68%), and reported taking on average 7.8 prescribed medications. Before participation in a medication adherence intervention study, participants completed a battery of health literacy-related tasks. They completed tests that measured health literacy [Short Test of Functional Health Literacy in Adults (STOFHLA)], cognitive abilities (working memory, processing speed), sensory abilities (visual acuity and hearing), and physical health. Regression analyses showed that health literacy was related to age, education, and race (accounting for 24.4% of variance in STOFHLA scores). Cognitive ability accounted for an additional 24% of variance and greatly reduced the influence of age, education, and race (by 75%, 40%, and 48%, respectively). When controlling for cognitive and sensory variables, the association of age and education with STOFHLA scores was dramatically reduced. Thus, future interventions aimed at improving self-care for patients with low health literacy should aim to reduce demands on patients' cognitive abilities.

Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population. We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of "inadequate or marginal" health literacy based on the S-TOFHLA and 2) inadequate and the combination of "inadequate or marginal" health literacy based on the REALM. Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, "How confident are you filling out medical forms by yourself?" had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69-0.79) and 0.84 (95% CI: 0.79-0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting "inadequate or marginal" health literacy than for detecting inadequate health literacy for each of the 3 questions. A single question may be useful for detecting patients with inadequate health literacy in a VA population.

Validation of a Hebrew health literacy test

Objective To validate a questionnaire measuring health literacy in Hebrew, based on the Short-Test of Functional Health Literacy in Adults (S-TOFHLA). Methods Interviews were held with 119 Hebrew speaking patients immediately before undergoing colonoscopy in a gastrointestinal outpatient department in Israel. The Hebrew Health Literacy Test (HHLT) was partly translated from the S-TOFHLA and partly re-written in Hebrew to accommodate for the Israeli health system, language, and culture, and then used to assess respondents’ health literacy levels. Results Internal consistency (Cronbach's alpha) of the 12 items representing the health literacy scale was 0.98. Mean score of the health literacy scale was 7.84 ± 5.2 with a range of 0–12. Thirty-five respondents (29.4%) could not correctly answer more than two of the items on the scale (could not read or understand the questions), and 69 (58.0%) answered correctly 11–12 of the items. Those with lower levels of education, women, and the older respondents had significantly lower levels of health literacy. Levels of health literacy as measured with the HHLT and subjective levels of literacy were positively correlated ( r p = 0.671). Conclusion The HHLT seems to be a valid measure of health literacy and can be used for assessment of health literacy in Hebrew. Practice implications The availability of the test should encourage studies regarding the magnitude of the problem and ways to decrease ill effects of low health literacy in Israel.

Development of a reliable and construct valid measure of nutritional literacy in adults.

BackgroundResearch into the relation of literacy to health status has not included measures of nutritional literacy. This may be a critical area in the study of chronic conditions such as hypertension and diabetes, which can both relate to obesity and nutrition. This paper details the development and psychometric characteristics of the Nutritional Literacy Scale (NLS), offered as a measure of adults' ability to comprehend nutritional information.MethodsIn order to assess the internal consistency and construct validity of the NLS, demographic data, readability statistics, NLS scores and scores on the Reading Comprehension Section of the Short Test of Functional Health Literacy in Adults (S-TOFHLA) were collected in a cross-sectional study of 341 patients from two primary care practices.ResultsThe NLS score showed acceptable internal consistency of 0.84 by Cronbach's alpha coefficient. The Pearson correlation between the NLS and the S-TOFHLA was 0.61, supporting evidence for construct validity.ConclusionGiven the importance of proper weight and nutrition in the health of the public, as well as the absence of research on literacy skills as related to nutritional concepts, the NLS has the potential to add to the national research agenda in these areas.

THE NEWEST VITAL SIGN: COMPARING INSTRUMENTS TO SCREEN FOR LOW HEALTH LITERACY?

Background The Newest Vital Sign (NVS) is a new rapid screening instrument for low literacy in medical settings. No studies currently compare the NVS with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Purpose Compare the performance of the NVS to the S-TOFHLA and assess the operating characteristics of the NVS. Methods A convenience sample of patients at two federally qualified health centers (FQHCs) were interviewed and given two literacy assessments, the S-TOFHLA and the NVS. The S-TOFHLA is a reading comprehension and numeracy assessment with well-studied internal consistency, reliability, and validity. Scores range from 0 to 100, with scores less than 53 identifying poor health literacy. The NVS is a nutrition label that tests patients9 general literacy and numeracy skills with six questions. A score of 4 to 6 indicates adequate literacy. Results Of the 119 patients tested, the average age was 55 years old (35-55), 70% were female, 61% were African American, and 39% had not graduated from high school. Administration time was approximately 7 minutes for the S-TOFHLA and 5 to 7 minutes for the NVS. The internal consistency of the NVS was good (α = 0.81). The correlation between scores on the NVS and scores on the S-TOFHLA was 0.61 (p Conclusion The NVS showed a moderate correlation with the highly validated S-TOFHLA and did well as a screen predicting low literacy as defined by the S-TOFHLA in two FQHCs.

Correlates of Health Literacy in Patients With Chronic Heart Failure

Many older adults have inadequate health-related literacy, which is associated with poor health outcomes. Thus, it is important to identify determinants of health literacy. We investigated relationships between health literacy and general cognitive and sensory abilities, as well as education, health, and demographic variables, in a community sample of middle-aged and older adults. Participants were 314 community-dwelling adults (67% female, 48% African American) diagnosed with chronic heart failure recruited for a pharmacist-based intervention study to improve adherence to chronic heart failure medications. We adminstered demographic, health, education, cognitive (e.g., processing speed, working memory), and sensory measures, and the Short Test of Functional Health Literacy in Adults (STOFHLA), as part of the baseline condition of this study. STOFHLA scores were lower for participants who were older, less educated, male, African American, had more comorbidities, or scored lower on all cognitive ability measures. Hierarchical linear regression analyses showed that education and cognitive ability were independently associated with the STOFHLA measure and explained age differences in health literacy. The association of cognitive abilities and literacy has important implications for health literacy models and for interventions to reduce the impact of low health literacy on health outcomes. For example, medication instructions should be designed to reduce comprehension demands on general cognitive abilities as well as literacy skills.

Asthma Numeracy Skill and Health Literacy

To assess understanding of numerical concepts in asthma self-management instructions, a 4-item Asthma Numeracy Questionnaire (ANQ) was developed and read to 73 adults with persistent asthma. Participants completed the Short Test of Functional Health Literacy in Adults (STOFHLA), 12(16%) answered all 4 numeracy items correctly; 6(8%) answered none correctly. Participants were least likely to understand items involving risk and percentages. Low numeracy but not STOFHLA score was associated with a history of hospitalization for asthma. At higher STOFHLA levels there was a wide range of the total number of correct numeracy responses. Numeracy is a unique and important component of health literacy.

Literacy and Knowledge, Attitudes, and Behavior About Colorectal Cancer Screening

ABSTRACT This cross-sectional survey explored the association between functional health literacy and knowledge of, beliefs and attitudes about, and reported usage of colorectal cancer screening tests. The results indicate that functional health literacy, as assessed by the Short Test of Functional Health Literacy in Adults (STOFHLA), is not an independent predictor of colorectal cancer screening knowledge, beliefs, attitudes, or behavior. Latino ethnicity and education, however, often predicted screening responses, suggesting that efforts to improve communication about colorectal cancer screening with Latino patients and patients with low education clearly are needed to reduce the disparities in awareness and utilization of colorectal cancer screening tests. This study also explored influences on intended screening behavior. Physician recommendation was found to be a powerful motivator of intention to undergo colorectal cancer screening regardless of literacy level, indicating that interventions aimed at increasing physician recommendation of colorectal cancer screening may be an effective way of increasing screening rates.

English language competency of self-declared English-speaking Hispanic patients

Study objectives: Hispanic patients compose the largest minority population in the United States. The federal government mandates that health care providers be able to communicate with those patients who have limited English ability. The primary purpose of this study is to assess the English-language proficiency of self-declared English-speaking Hispanic patients in the emergency department (ED). The secondary purpose is to determine concordance between patients' tested English proficiency and perceived proficiency by nurses and physicians. We hypothesize that many patients who state that they are able to speak English do not in fact possess sufficient ability to communicate in English. Methods: A convenience study was conducted in an urban Level I pediatrics and adult trauma center with 45,000 annual visits. Participants included adult patients and parents of pediatric patients, all of whom spoke Spanish as their first language. Patients were selected according to their Hispanic names. Research assistants administered the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Short Test of Functional Health Literacy in Adults (STOFHLA) to assess the English comprehension of patients who stated that they spoke English. Score of seventh grade or higher on the REALM and 23 or higher on the STOFHLA was considered a level of English competency. Data were entered into SPSS software and analyzed for correlations. This study was institutional review board approved. Results: Three hundred fifty-four patients with Hispanic names were approached and asked whether they spoke English, Spanish, or both. One hundred five patients, all self-proclaimed English speakers, were enrolled in the study. Patients ranged from 18 to 89 years, with 37.1% (39/105) male patients and 62.9% (66/105) female patients. Forty-nine percent (49) of patients had completed only grade school; 66.3% (65 of 98) of self-proclaimed English speakers scored at or above a seventh-grade reading level on the REALM, and 72.0% (67 of 93) scored in the category of adequate or higher on the STOFHLA. There was a significant difference between patients' tested level of English competency and the physicians' and nurses' assessments of the patients' language competency ( P =.002). Conclusion: This study demonstrates that a significant number of patients who report English proficiency have an inadequate level of English comprehension. Furthermore, there is a discrepancy in the perceived English competency of the patients in the judgment of the physicians and nurses in the ED. This study demonstrates that emergency physicians and nurses are unable to judge a patient's language ability, and it suggests that a more liberal use of interpreters may be indicated.

Health literacy and knowledge of chronic disease

We sought to examine the relationship between health literacy and knowledge of disease among patients with a chronic disease. A total of 653 new Medicare enrollees aged 65 years or older who had at least one chronic disease (115 asthma, 266 diabetes, 166 congestive heart failure, 214 hypertension), completed both the in-person and telephone survey. Health literacy measured by the short test of functional health literacy in adults (S-TOFHLA) and demographic information were collected during the in-person survey. Knowledge of disease was assessed by questions based on key elements in educational materials during a telephone survey. Overall, 24% of patients had inadequate and 12% had marginal health literacy skills. Respondents with inadequate health literacy knew significantly less about their disease than those with adequate literacy. Multivariate analysis indicated that health literacy was independently related to disease knowledge. There are many opportunities to improve patients’ knowledge of their chronic disease(s), and efforts need to consider their health literacy skills.

Health literacy and performance on the Mini-Mental State Examination

The objectives of the study were to determine the relationship between functional health literacy and performance on the Mini-Mental State Examination (MMSE). New Medicare managed-care enrollees aged 65 years and older, living independently in the community in four US cities (Cleveland, Houston, Tampa, and Fort Lauderdale/Miami), were eligible to participate. In-home interviews were conducted to determine demographics and health status, and interviewers then administered the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the MMSE. We then determined the relationship between functional health literacy and the MMSE, including total scores, subscale scores (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction), and individual items. Functional health literacy was linearly related to the total MMSE score across the entire range of S-TOFHLA scores (R 2 = 0.39, p < 0.001). This relationship between health literacy and MMSE was consistent across all MMSE subscales and individual items. Adjustment for chronic conditions and self-reported overall health did not change the relationship between health literacy and MMSE score. Health literacy was related to MMSE performance even for subscales of the MMSE that were not postulated to be directly dependent on reading ability or education (e.g. delayed recall). These results suggest that the lower MMSE scores for patients with low health literacy are only partly due to 'test bias' and also result from true differences in cognitive functioning. 'Adjusting' MMSE scores for an individual's functional health literacy may be inappropriate because it may mask true differences in cognitive functioning.