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Health Literacy Research The Next Generation


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Title: Health Literacy Research The Next Generation

Health Literacy Research The Next Generation
  • University of Arkansas Health Literacy Research
  • Grand Rounds
  • July 22, 2013
  • Terry Davis, PhD
  • Professor of
  • Medicine and Pediatrics

  • Research funding
  • Agency for Healthcare Research and Quality
  • American Cancer Society
  • American College of Physicians Foundation
  • McNeil Pharmaceutical
  • Unrestricted educational grant
  • Advisory Board for icons on OTC pain medication
  • National Cancer Institute
  • Stocks
  • Johnson Johnson
  • Abbott Laboratories

Literacy and HealthcareWhat We Know
  • Patient literacy linked to health knowledge,
    behavior, outcomes navigation skills
  • The majority of U.S. adults struggle with health
    information and tasks
  • Literacy levels in U.S. are getting worse
  • The demands and expectations of the healthcare
    system are increasing

AR ranks 39th in literacy and 48th in overall
health, 44th obesity , 38th infant mortality and
43rd in preventable hospitalizations
United Health Foundation, Department of Education
Literacy Definition (Requirement) Expands With
Increasing Demands Of Society
Judgment/ Interpretation
  • at a level needed to function on the job and in

National Literacy Act, 1991 S. White, Project
Director NAALS 2016
Low Literacy is a National Problem(National
Adult Literacy Survey)
Adults with Level 1 Literacy Skills
  • 21 U.S. Adults are Level 1
  • 48 level 1 and 2 lack sufficient
  • literacy skills to function in society
  • Hispanic 79 African-American 75

National Institute for Literacy 1998
Low Literacy Rates By County
Adults with Level 1 Literacy Skills
  • gt30
  • 20-30
  • 15 to 20
  • lt 15

22 Arkansas Adults are Level 1
National Institute for Literacy 1998
Literacy Forecast for 2030
Level 3 skills necessary for current economy
From the ETS report Americas Perfect Storm
Three Forces Changing Our Nations Future
written by Irwin Kirsch, Henry Braun, Kentaro
Yamamoto and Andrew Sum. The full report is
available from ETS at
1st National Assessment of Health
LiteracyAssessed functional skills in clinical,
preventive, and navigational tasks
n19,000 U.S. Adults
(quantitative literacy)
12 (13)
Below Basic
14 (22)
53 (33)
Below basic Hispanic
41 Native American 25 Adults gt 65 29
22 (33)
Average HS grad
National Assessment of Adult Literacy
(NAAL) National Center for Educational
Statistics, U.S. Dept. of Education, 2003.
Health Literacy Tasks
152 tasks (28 health related)
  • Below Basic Circle date on doctors appt. slip
  • Basic Give 2 reasons a person with no symptoms
    should get tested for cancer based on a clearly
    written pamphlet
  • Intermediate Determine what time to take Rx
    medicine based on label
  • Proficient Calculate employee share of health
    insurance costs using table
  • 67 probability individual can perform task

Medication Error Most Common Medical Mistake
1.5 M adverse events (patient error gt700,000)
  • 2 out of 3 patients leave MD visit with Rx
  • 3.9 Billion Rx filled in 2010
  • Up 50 - 60 in 10 years
  • 82 adults take at least one med
  • Elderly fill 20 Rx/year, see 8 physicians
  • 1 in 6 pediatric Rx not dosed correctly
  • gt100,000 OTC meds (gt600 contain acetaminophen)
  • Most labels and inserts are in English only

U.S. Census Bureau, 2009 PDR for
Non-Prescription Drugs, Dietary Supplements and
Herbs (2007) IMS Health 2005 IOM 2006.
Calculation A Hidden ProblemUnderstanding Food
  • You drink this whole bottle of soda. How many
    grams of total carbohydrates does it contain?
  • 67.5 grams
  • 32 answered correctly
  • 200 primary care patients
  • 73 private insurance
  • 67 at least some college
  • 78 read gt 9th grade
  • 37 math gt 9th grade

Rothman R, Am J Prev Med, 2006
  • Its easy to make a mistake

Health Literacy 1st Viewed as Patient Deficit
Emphasis Shifts to Health System
  • IOM Report (2004)
  • 90 million adults have trouble understanding and
    acting on health information
  • Healthy People 2010.and 2020
  • Improve health communication (plain language
  • Joint commission (2007)
  • Patients must be given information they
  • Health literacy is a safety issue

US DHHS, May 27, 2010. (
Baby Step Research
  • Our teams story of putting 1 foot in front of
    the other
  • Curiosity -gt Assessing Problems -gt Interventions

1st study Are These Clear?
All short and seemingly simple. Not regulated by
FDA or State Boards of Pharmacy.
Davis T , Bass P, Wolf M , Parker R. J Gen Intern
Med. 2006
What Does This Picture Mean?
  • Somebody is dizzy
  • Dont touch this stuff
  • Take anywhere
  • Chills or shaking
  • Having an experience with God

Wolf M, Davis T, Parker R, Bass P. Am J
Health-System Pharmacy. 2006
Does Adding the Words Help? 1 in 10 Adults
Struggle With Decoding
  • Use extreme caution in how you take it
  • Medicine will make you feel dizzy
  • Take only if you need it

8 of patients with low literacy understood this
Correct Interpretations by Literacy
Labels lt 6th Grade 7th-8th Grade gt 9th Grade p value
78 86 86 NS
42 65 60 lt0.001
37 73 66 lt0.001
4 36 35 lt0.001
0 6 14 lt0.001
Davis T , Bass P, Wolf M , Parker R. J Gen Intern
Med. 2006
Improving Targets Top 10 Warning Labelsn500
LSU NW patients
Simplified text 2.6 X more likely to be
correctly interpreted , simplified text icon
3.3 times more likely.
Wolf M , Davis T, Bass P, Parker R. Arch Intern
Med, 2010.
Rx Label Instructions
  • Can patients understand how to take meds after
    reviewing label instructions on actual pill

Minimum Federal oversight for Rx labels. State
Boards of Pharmacy regulate labeling but provide
little guidance Davis T, Wolf M, Bass P, Parker
R. Ann Intern Med, 2006.
How would you take this medicine?
n395 patients in 3 states 48 lt9th grade
reading, averaged 1.4 meds
  • 46 did not understand instructions 1 labels
  • 38 with adequate literacy missed at least 1
  • lt10 attended to warning labels

Davis, Wolf, Bass, Parker. Ann Intern Med, 2006.
Show Me How Many Pills You Would Take in 1 Day
Rates of Correct Understanding vs.Demonstration
Take Two Tablets by Mouth Twice Daily
Wolf M, Davis T, Parker R. Patient Educ Couns.
Lessons Learned
  • Labels simple, but not necessarily clear
  • Ability to read the Rx label does not guarantee
    correct interpretation
  • Mistakes are more likely the more meds patients
  • Some pts over complicate- take meds more times
    daily than necessary
  • Approximately half of physicians dont mention
    dose, timing, duration, and possible side effects
    of meds.
  • Instructions need to be tested with patients

More Precise Labels Aid ComprehensionInstruction
s that require interpretation are poorly
n 375 pts LA, NW, NY
High Low
Metformin, 1000 mg
Take 1 pill by mouth every 12 hours. 61 30
Take one tablet by mouth twice daily. 90 70
Take 2 pills by mouth every day. Take 1 with breakfast and 1 with supper. 88 78
Glyburide, 5 mg
Take two tablets by mouth twice daily. 71 33
Take 2 pills in the morning and 2 pills in the evening. 92 76
Take 2 pills by mouth at 8 am and 2 pills at 6 pm. 90 76
plt0.001, plt0.01
Davis, Bass, Parker, Wolf. J Gen Intern Med,
Correct Interpretation of Standard vs. Patient
Centered Label
N500 (LSU NW), Low Lit 52, AA 64, Avg. 3
Standard PCL PCL Graph
  • Take 2 pills by mouth Take 2 pills in
    the morning Take 2 pills in the morning twice
    daily and 2 pills at bedtime and 2
    pills at bedtime
  • 77 84 88
  • Take 1 pill by mouth Take 1 pill in the morning,
    Take 1 pill in the morning,
  • 3 times daily 1 pill at noon, and 1 pill at
    noon, and
  • 1 pill in the evening 1 pill in the evening
  • 44 91 91

Wolf M ,Davis T, Parker R. Medical Care. 2011.
Patient Centered Label Can Improve
Understanding and Adherence
RCT in 11 FQHCs. 429 pts w DM and/or
HTN. Average 5 meds Mean age 52, 28 W, 39 low
Standard Label PC Label
Understanding 59 74
Adherence (3 months) 30 49
State Board of Pharmacy in CA passed
legislation for this label
OTC Health Literacy Challenge
Wal-Mart has 80 sq. feet of pain meds Most people
not aware of active ingredient or its importance
Recent OTC Research with Drs. Wolf Parker Few
consumers aware of active ingredient
  • Majority of consumers dont read OTC instructions
  • People have their own schematic for taking OTCs
  • Would revised label increase awareness,

DHHS National Action Plan Road Map to Improve
Health Literacy
  • Aim Make health information and services easier
    to understand and use
  • 7 Goals and high priority strategies
  • Develop and disseminate health information
  • that is accurate, accessible, and actionable.
  • Promote changes in healthcare delivery system
  • Build partnerships, develop guidance, change
  • Increase research, and evaluation of interventions

US DHHS, May 27, 2010. (
Research in Rural and Community Health Centers
  • Few studies conducted in rural areas
  • In 2012 HRSA required meaningful use of EHR

Health Literacy and Cancer Screening
  • 5 year quasi experimental evaluation in 8 FQHCs
  • Test the effectiveness of health literacy
    interventions to improve initial and repeat use
    of CRC and breast cancer screening
  • Explore patient, provider and system factors that
    facilitate or impede initial and repeat
  • We added cost effectiveness

1 RO1 CA115869-01A2 10/01/07-9/30/12
Study Clinics Locations and Characteristics
  • Gilliam (183)
  • 3 parent FQHCs ( 5 satellites)
  • Baseline screening rates are extremely low
  • 5-9 mammography
  • 1-2 CRC
  • Patients lack adequate insurance
  • 59 of FQHC patients have no insurance
  • 11 have private insurance
  • CDC. http//
  • DeWalt DA, J Gen Intern Med. 2004. 191228-1239
  • Medicare Interactive, http//www.medicareinteracti
  • New choice Health
  • http//

Colorectal CancerBaseline Interview Findings
N961, 77 F 67 AA, 56 Lit 89 PCP visit prior
  • Almost all patients (96) had heard of CRC
  • 91 would want to know if they had CRC
  • Only 39 had received a physician recommendation
  • 29 had been given a kit
  • 28 previously completed an FOBT
  • Over half (57 )not rescreened in gt 3
  • Most common reasons for not getting screened
  • 29 put it off
  • 25 didnt think it was needed

Davis T, Arnold C, et al. J Rural Health. 2012
CRC Screening Barriers Among Rural vs. Urban FQHC
Rural Urban
Believe helpful to find CRC early 90 66
Received MD rec 36 46
Received FOBT Info 15 32
Completed FOBT 22 46
Confident complete FOBT 16 4
plt.0001, p0.03 Davis TC, Rademaker
A, Bailey SC, et al. Contrasts in Rural and Urban
Barriers to Colorectal Cancer Screening. Am J
Health Behavior. May 2013 37(3)289-98.
Doctor Giving FOBT Kit Dramatically Increases
Patient Completion

Baseline survey
Risk Ratio of Patient Completing FOBT Risk Ratio of Patient Completing FOBT Risk Ratio of Patient Completing FOBT
Low literacy Adequate literacy
MD recommended CRC 4 4
MD ever given FOBT kit 49 11
Davis T, Arnold C, Rademaker, Wolf M, et al. J
Rural Health. 2012
Breast CancerBaseline Interview Findings
  • 98 of all patients had heard of breast cancer
  • 84 seen advertisements that encouraged getting
  • 82 had received prior recommendation
  • (78 AL vs. 59 LL) knew someone who had breast
  • 93 said they knew what a mammogram was of these
    100 defined it correctly
  • Most common misconception
  • 71 believed screening mammogram needed to begin
    before age 40
  • 77 had ever had a mammogram

The Influence of Family
  • 88 said if there was one person who told them
    to get tested they would.
  • Those included
  • 38 Child
  • 19 Mother
  • 14 Sister

Making Information and Services Easy to Obtain,
Understand, and Use
  • Recommendation
  • FOBT no cost mammogram
  • Pamphlets (5th grade)
  • Short videos that tell story
  • Simplified FOBT instructions (3rd grade)
  • Nurse manager to teach support with follow-up

FOBT Screening Completion by Study Arm
Initial n961 Repeat n561
By Arm By Arm By Arm
EUC HL HL Nurse p-value
Initial FOBT returned 39 57 61 .02
2nd year FOBT returned 36 33 51 lt.001
p-values adjusted for age, race, gender, and
literacy- take clustering by clinic into account
Initial Screening Cost Incremental cost of HL
per additional person screened 250 over
EUC Incremental cost of Nurse arm over EUC 1337
Repeat (Annual) Screening Cost Incremental
cost of Nurse arm over EUC 2811 CRC baseline
1-2 CRC screen - 14 needed diagnostic
colonoscopy - 8 patients
had polyps removed
Mammography Completion
n 1181 Mammogram
By arm By arm By arm
EUC HL Nurse p value
Initial 56 52 66 .04
Repeat 11 7 47 lt.0001
  • Incremental cost of nurse arm per additional
    person screened compared to HL was 2,644
  • Mammography baseline 10-12
  • Breast Cancer screen - 10 patients had breast

Adjusted for race, marital status, literacy, and
self-efficacy Adjusted for race, education,
marital status, seen doctor, and ever had a
  • Community clinics focus on service not research
  • Challenging to find qualified RAs in rural areas
  • Hiring RAs from clinic staff is a Catch 22
  • High physician turnover in rural areas
  • Follow-up calls are feasible but phones commonly
    disconnected then reconnected.
  • Mailed reminders and FOBT kits years 2 and 3 not
  • Patients lose FOBTS / forget to complete.
  • At LSU Wait for diagnostic colonoscopy up to a

LSU Colonoscopy Referrals
Lessons Learned from Study
  • Strong ongoing relationship with CEOs and clinic
    is essential.
  • Including providers patients in material
    development is key.
  • Clinic in-service helps inform and enlist staff.
  • RA giving recommendation and FOBT before PCP
    visit is feasible and well received by providers
    and patients.
  • Playing videos revealed RA and patient barriers
    pamphlets and FOBT kits were easier to use as
    teaching tools
  • Nurse follow-up call to motivate and problem
    solve screening completion was time consuming.
  • Unlike mammography, patients did not seem to feel
    pride when completing FOBT

FQHC Patients
Nurse Manager
Wisdom Gained ..the ah hasLife is dynamic -
things changed since grant written in 2007
  • In 2007 concern over reaching poor and rural
    patients by phone. (now 87 U.S. adults have a
    cell phone)
  • FQHC patients can be reached by phone cells may
    be disconnected but reconnected at first of next
    month. Several attempts to reach patients are
    often needed.
  • When grant written, colonoscopy was viewed as
    test to be promoted.
  • Now increasing emphases on practical, CRC
    screening using FOBTs. (It is the 1st line
    screening reported in numerous studies abroad and
    in large US health systems.)
  • ACS, USPSTF professional organizations have
    updated their recommendations for CRC screening
  • Now recommend immunochemical tests that have
    superior sensitivity such as the FIT
  • In 2012 HRSA requires reporting CRC screening as
    standard performance measures and meaningful use
    of EHR.

Engage Patients in Self-Management American
College of Physicians Guides
  • Guides focused on
  • Patient not disease
  • Need to know and do
  • Help patients change health behavior
  • Increase knowledge and confidence managing
  • Solve self-care problems
  • Over 5 million distributed nationally
  • Customer Service -800-338-2746 ext 2600

Brief Self-Management Counseling
  • 4-Step Approach
  • 1. Introduce Guide
  • Ask Is there anything you would like to
    do this week to improve your health?
  • 2. Help Patient Set Action Plan (short-term
    achievable goal-pt chooses )
  • 3. Assess confidence - 7 on 10 point scale
  • 4. Check on progress
  • Maintain, modify or set new action plan

Brief video to train clinic staff
Lorig, J Am B Fam Med, 2006. Davis T, Seligman H,
Dewalt D, Arnold C, et al. J Prim Care Community
Health. 2012
Patients Recalled Action Plans Changed
Behavior And Problem Solved
225 patients, LSU, UNC, UC-SF Med Clinics (76
minority DM 9yrs BMI 36 A1C 8.6)
2 Week Calls - Recall AP Behavior sustained Other behavior 96 75 56
17 Week Visits - Recall AP Behavior sustained Other behavior 88 67 45
  • Most patients (89) chose diet and exercise
  • Equally effective with low and high literacy

Wallace, Seligman, Davis, Schillinger, Arnold,
DeWalt, et al. In press DeWalt, Davis,
Schillinger, Seligman, Arnold, et al. In press.
Will Plan Work in Community Clinics?Test of 2
Approaches to DM Self-ManagementCarve In vs.
Carve Out
  • 9 FQHCs in Missouri, 666 patients, mean age 55
    30 African American, 33 low literacy, A1c
    8.5, SBP 140

Carve-In Clinic identifies patient champion to
review guide and engage patients in action
planning. Carve-Out Assumes clinics cannot
sustain Clinic distributes guides, refers
patients to offsite DM Counselor DM Counselor
reviews guide engages patient in action planning
Touch Points
Carve Out More Feasible and Effective
  • At 1 year carve out patients more likely to
  • Recall telephone calls 79 vs 46 plt.001
  • Set action plans 4.6 vs 1.8 plt.001
  • Find intervention helpful 7/10 vs 4/10 plt.001
  • Want to continue 76 vs 62 plt.001
  • Achieve glycemic control (hbA1Clt7) 48 vs
    21 plt.001

Challenges Conducting Research in Distant
Community Clinics
  • Challenging to hard wire interventions robust
    implementation methods needed
  • Efforts of Diabetes Champion varied widely b/t
  • Buy in from PCPs is key
  • Staff and physician turnover after orientation
  • Need to find low cost ,reliable, effective
    outreach strategies

Health Literacy Funding OpportunitiesIOM Health
Literacy Model Guides Interventions
2004 PAR NIH (13 institutes) issued program
announcements focused on Understanding and
Promoting Health Literacy (re-issued 2013-2016),
Addressing Health Disparities (2013-2016) and
Mobile Health Tools to Promote Communication
Adding Literacy as a Variable is Easy
  • The most commonly used tests
  • REALM (Rapid Estimate of Literacy Medicine)
  • TOFHLA (Test of Functional Health Literacy)
  • NVS (Newest Vital Sign)
  • These are sometimes referred to as tests of
    health literacy
  • Qualitative
  • How confident are you filling out medical forms
    by yourself?
  • Extremely Quite A Bit Somewhat A Little Bit
    Not At All
  • ( 0 ) ( 1 ) ( 2 ) ( 3 )
    ( 4 )

Tests and ordering instructions are in resources
at the end of the presentation.
Health Literacy Research Ideas
  • Expand technology for patient outreach
  • Cell phones for automated calls /texts, EHR
  • Make health numeracy easier to interpret and act
  • Address current health care challenges
  • Hospital discharge, health insurance
  • Add cost effectiveness if possible
  • Dont forget your consent form
  • Can patients read and understand it
  • Is it formatted for reading ease?
  • Is the information included manageable or

Consumer TechnologiesGoing (Gone) Mobile
Recent Growth of Mobile Health Apps
2010 4,921 201213,600 2013 97,000 Rx Mgmt 450
Android activates 1.5 million phones a day 87 US
adults own cell phone. 1 in 3 use it for health
information. Latinos, African Americans, people
lt 50 and college educated, most likely to gather
health information this way.
Research2Guidance. Mobile Health Market Report
2013-2017 (Vol . 3) March 4, 2013.
IOM Focused on HL Health Insurance
  • Choosing and using health insurance is
    unnecessarily complex.
  • Trust levels for health insurers are very low.
  • People dread shopping for health insurance
    (paying taxes is preferable)
  • They dont understand the product (car insurance)
  • They dont know the terms
  • Coinsurance
  • Benefit maximum
  • These complex concepts must be used to estimate
    cost for services.
  • Do co-pays count towards the deductible or the
    out-of-pocket maximum?
  • Allowed amount
  • Out-of-pocket maximum

ehealth, Inc., New Survey Shows Americans Lack
Understanding of Their Health Coverage and Basic
Health Insurance Terminology, January 3, 2008,
available at http//
Whats Our Action Plan? Address the Red
Health Literacy
  • Rx and OTC labels and Med Guides standardize
    and make easier to see, navigate, understand and
    act on
  • Find low cost sustainable outreach strategies to
    improve cancer screening chronic disease
  • Health insurance - get to Apple Store approach!
  • Make cost transparent. Clarify smart use.
    Patiently offer help when customers buy it or are
    confused or overwhelmed trying to use it.
  • Employ new technologies but remember technology
    is a tool - it does not replace a nice,
    knowledgeable person helping you. Health is

Are We Prepared?
A Perfect Storm is Approaching Intersection of
low literacy and the increasing demands of health
Whats Our Bridge to Action?
  • How does this talk stimulate your thinking?
  • What strategies could AR develop and test to make
    health information/ services more user-friendly?
  • What research opportunities exist?

Useful HL Resources
IOM Reports on Health Literacy
  • Health Literacy Improving Health, Health
    Systems, and Health Policy, 07/13
  • Oral Health Literacy, 02/13
  • How Can Health Care Organizations Become More
    Health Literate? 07/12
  • Promoting Health Literacy to Encourage Prevention
    and Wellness, 12/11
  • Improving health Literacy Within a State, 11/11
  • Health Literacy Implications for Health Care
    Reform, 07/11
  • Innovations in Health Literacy Research, 03/11
  • The Safe Use Initiative and Health Literacy,
  • Measures of Health Literacy, 12/09
  • Health Literacy, eHealth, and Communication
    Putting the Consumer First, 03/09
  • Toward Health Equity and Patient-Centeredness
    Integrating Health Literacy, Disparity Reduction,
    and Quality Improvement, 02/09
  • Health Literacy A Prescription to End Confusion,

AHRQ Toolkits(Agency Healthcare Research and
  • Hospital Discharge
  • Project RED (ReEngineered Discharge) (2013)
  • Informed Consent (2009)
  • Health Literacy Universal Precautions(2010)
    (clinic based system)

More Toolkits
  • Pharmacy Assessment Tools and Training
  • AHRQ (2007) Strategies to improve communication
    between pharmacy staff and patients training
  • Website Design
  • HHS (2010) Health literacy online a guide to
    writing and designing easy to use health web

Resources For Healthcare Organizations
  • Institute of Medicine (2012 ) Ten attributes of
    Health literacy Healthcare Organizations
  • Health Literacy Environment of Hospitals Health
    Centers (2006 )
  • The Joint Commission (2007) What did the doctor
    say ? Improving health literacy to protect
    patient safety
  • National Qualify Forum (2009) Health Literacy a
    linchpin in achieving national goals for health
    and healthcare.
  • Communication Climate Assessment Tool (2010)
  • Wynia M American Journal of Medical Quality

Health literacy Websites
  • CDC
  • NIH
  • UNC
  • Rima Rudd (Harvard School of Public Health)
  • Helen Osborne

Helpful Websites For Nurses
  • Health Literacy Tools, Reports, and Research
  • Carolina Geriatric Education Center
  • CDC Expert Panel Report HL for Older Adults

Patient Education Development
  • CMS (2011) Toolkit for making written materials
    clear and effective
  • https//
  • NCI (2003) Clear and simple developing effective
    print materials for low literacy readers
  • http//
  • Arnold CL, Davis TC, Ohene Frempong J, et al
    Assessment of newborn screening parent education
    materials. Pediatrics. 2006117320-5.
  • Seligman HK, Wallace AS, DeWalt DA, et al
    Developing low-literacy patient educational
    materials to facilitate behavior change. Am J
    Health Behav. 2007 Sep-Oct31 Suppl 1S69-78.

Patient Education Materials
  • Institute for Healthcare Advancement
  • 7 easy to read, easy to use guides to better
  • What To Do
  • When Your Child Gets Sick
  • When Youre Having a Baby
  • For Teen Health
  • American College of Physicians
  • Helpful Ways To Lose Weight
  • Caring For Your Heart
  • End of Life Decision Making
  • Volandes AE (2010) Medical Decision Making.
  • For Healthy Teeth
  • When Your Child Has Asthma
  • When Your Child Is Heavy
  • For Senior Health
  • Living With Diabetes
  • Living With COPD

Literacy Tests Used in Healthcare Research
  • The most commonly used
  • REALM (Rapid Estimate of Literacy Medicine)
  • TOFHLA (Test of Functional Health Literacy)
  • NVS (Newest Vital Sign)
  • These are sometimes referred to as tests of
    health literacy
  • Qualitative
  • How confident are you filling out medical forms
    by yourself?
  • Extremely Quite A Bit Somewhat A Little Bit
    Not At All
  • ( 0 ) ( 1 ) ( 2 ) ( 3 )
    ( 4 )

Tests and ordering instructions are in resources
at the end of the presentation.
List 1 List 2 List 3
fat flu pill dose eye stress smear nerves germs meals disease cancer caffeine attack kidney hormones herpes seizure bowel asthma rectal incest fatigue pelvic jaundice infection exercise behavior prescription notify gallbladder calories depression miscarriage pregnancy arthritis nutrition menopause appendix abnormal syphilis hemorrhoids nausea directed allergic menstrual testicle colitis emergency medication occupation sexually alcoholism irritation constipation gonorrhea inflammatory diabetes hepatitis antibiotics diagnosis potassium anemia obesity osteoporosis impetigo
0-18 correct lt 3rd grade 19-44 correct
4th-6th grade 45-60 correct 7th-8th
grade 61-66 correct high school
Davis, Fam Med, 1993
  • Your doctor has sent you to have a ____________
  • a. stomach
  • b. diabetes
  • c. stitches
  • d. germs
  • You must have an __________ stomach when you come
    for ______.
  • a. asthma a. is.
  • b. empty b. am.
  • c. incest c. if.
  • d. anemia d. it.
  • The X-ray will ________ from 1 to 3 _________ to
  • a. take a. beds
  • b. view b. brains
  • c. talk c. hours
  • d. look d. diets

Scoring 0-16 Inadequate func.
HL 17-22 Marginal func. HL 23-36 Adequate
func. HL
Parker, J Gen Intern Med, 1995
  • Questions
  • If you can have 60 grams of carbs for a snack -
    how much ice cream can you have?
  • Score 1 point for each correct answer
  • 0-1 Inadequate literacy
  • 2-3 Marginal literacy
  • 4-6 Adequate literacy

Cautions for Assessing Health Literacy Clinically
  • Testing patient literacy level alone will NOT
    confirm ability to navigate, act, understand, and
    act on health information and manage care
  • To get the most accurate measure of health
    literacy, use teach back
  • No evidence that literacy testing improves health
    care delivery or outcomes when testing is done
    strictly for clinical use
  • Universal precautions (plain language) are
    recommended to make materials user-friendly

Ordering Information
  • REALM and REALM-Teen
  • http//
  • NVS
  • http//
  • WRAT
  • http//

Original Citations for Tests
  • Davis TC, et al. Rapid Estimate of Adult Literacy
    in Medicine A shortened screening instrument.
    Fam Med 199325(6)256-60.
  • Bass PF, et al. Residents' ability to identify
    patients with poor literacy skills. Acad Med.
    2002 Oct77(10)1039-41.
  • Arozullah AM, et al. Development and validation
    of the Rapid Estimate of Adult Literacy in
    Medicine (REALM) Short Form. Medical Care.
    2007 45(11)1026-33.
  • REALM-Teen
  • Davis TC, et al. Development and validation of
    the Rapid Estimate of Adolescent Literacy in
    Medicine (REALM) Teen A tool to screen
    adolescents for below-grade reading in health
    care settings. Pediatrics. 2006 1181707-14.

Original Citations for Tests cont
  • NVS
  • Weiss BD, et al. Quick assessment of literacy in
    primary care the newest vital sign. Ann Fam Med.
    2005 Nov-Dec3(6)514-22.
  • Qualitative Assessment
  • Chew LD, et al. Validation of screening questions
    for limited health literacy in a large VA
    outpatient population. J Gen Intern Med. 2008
  • Parker RM, et al. The test of functional health
    literacy in adults a new instrument for
    measuring patients literacy skills. J Gen Intern
    Med. 199510537-41.
  • Baker DW, et al. Development of a brief test to
    measure functional health literacy. Patient
    Education and Counseling. 19993833-42.

RED (Re-Engineered Discharge Toolkit) Addresses
Low Health Literacy
  • Aim effectively prepare patients for hospital
  • RN Discharge Advocate works with inpatients to
  • Educate them with individualized instruction
    booklet (also sent to PCP)
  • Arrange follow-up appointments
  • Confirm medication reconciliation
  • Avg total time 87 min per patient ( 42 min w
    /patients, 45 min reviewing EMR, communicating w/
    medical team preparing discharge booklet)
  • Clinical PharmD calls patients 2-4 days after
    discharge to review meds and reinforce discharge
  • Avg total time 26 min per patient (10-19 min
  • 65 of patients had at least 1 med problem

AHRQ March 2013
EACH DAY follow this schedule for your medicines
RED Template for Meds
What time of day do I take this medicine? Why am I taking this medicine? Medicine name Amount How many do I take? How do I take this medicine?
Only if you need it for
RED Template for Follow-up Appointments
John Doe What is my main medical problem? Chest
Pain When are my appointments?
Wednesday August 8 at 1130 a.m. Thursday, August 16 At 320 p.m. Wednesday September 12 At 900 a.m.
Dr. Mark Avery Primary care doctor Dr. Anita Jones Rheumatologist Dr. Lin Wu Cardiologist
100 Main st. 2nd floor Anytown ST 100 Pleasant Rd, Suite 105 Anytown, ST 100 Park Rd, Suite 504 Anytown, ST
For a follow up appointment For your arthritis To check your heart
Office phone number (555) 555- 5555 Office Phone (555) 555-5555 Office Phone (555) 555-4444
Project RED (ReEngineered Discharge)Effective
and Cost Effective
  • Randomized control trial 30 days after discharge
  • RED vs. standard discharge
  • 30 lower hospital use
  • 30 more likely to follow-up PCP
  • 34 lower cost
  • mean stay 2.7 days
  • 59 low literacy
  • mean age 50
  • 50 AA, 27 White

2007 National Quality Forum Safe Practice for
hospital discharge based largely on RED
Jack BW, Ann Intern Med 2009
A Fun Way to Spot Difficult
  • Vocabulary Profiler color codes words in English
  • 1000 most frequently used words (K1)
  • Second 1000 frequently used words (K2)
  • Academic words frequently used in academic texts
  • Words which are not found on the other lists (off

Red Yellow Warn You
Key Test References
  • Davis T, Kennen EM, Gazmararian JA, Williams MV.
    Literacy testing in health care research. In
    Schwartzberg JG, VanGeest JB, Wang CC, eds.
    Understanding health literacy Implications for
    medicine and public health. United States of
    America AMA Press 2005 157-179.
  • White S. Assessing the Nations Health Literacy
    Key concepts and findings of the National
    Assessment of Adult Literacy (NAAL). AMA
    Foundation, 2008.

National and State Literacy Health Data
  • National Assessment of Adult Literacy
  • http//
  • http//
  • United Health Foundation
  • Annie E. Casey Foundation
  • http//
  • CDC

Helpful References
  • Institute of Medicine (2004) Health Literacy A
    Prescription to End Confusion. In Nielson-Bohlman
    L, Panzer A, Kindig DA, eds. Washington, DC
    National Academy Press
  • Schwartzberg JG (2005) Understanding health
    literacy Implications for medicine and public
    health. AMA Press
  • Weiss BD (2003) Health Literacy A Manual for
    Clinicians. AMA Foundation
  • Doak CC (1996) Teaching Patients with
    Low-Literacy Skills, 2nd ed. JB Lippincott
  • US DHHS (2010) National Action Plan to Improve
    Health Literacy
  • The Joint Commission (2008) Strategies for
    Improving Health Literacy from The Joint
    Commission Perspectives on Patient Safety. The
    Joint Commission Oakbrook Terrace, Illinois

2013 Health Literacy Conferences
  • Institute for Healthcare Advancement
  • Irvine, California May 8-10
  • Health Literacy Institute (great conference)
  • Freeport, Maine June 2-5
  • Boston University Health Literacy Annual Research
    Conference (HARC)
  • Washington, D.C. October 28-29

  • Terry Davis, PhD
  • Department of Medicine and Pediatrics
  • LSU Health Shreveport
  • (318)675-8694
  • Research Associate
  • Robert C. Ross, BS
  • (318)675-4584

Plain Language Summary
  • Health literacy is a problem for people in
  • Health literacy is a problem for health care.
  • Research has made medicine labels easier to
  • Research has improved cancer screenings in rural
  • Cell phones and electronic medical records may be
    the next step to better health literacy.
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