Abstract
Objectives
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.
Methods
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.
Measurements and Main Results
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.
Conclusion
A single question may be useful for detecting patients with inadequate health literacy in a VA population.
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References
Institute of Medicine. Health Literacy: a Prescription to End Confusion. Washington DC: National Academic Press; 2004.
Kirsch IJA, Jenkins L, Kolstad A. Adult Literacy in America: a First Look at the Findings of the National Adult Literacy Survey. Washington DC: National Center for Education Statistics, U. S. Dept of Education; 1993.
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health literacy: report of the Council on Scientific Affairs. JAMA. 1999;281(6)552–7.
Davis TC, Arnold C, Berkel HJ,et al. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78(9)1912–20.
Williams MV, Baker DW, Parker RM,et al. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2)166–72.
Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4)1008–15.
Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12)791–8.
Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8)1278–83.
Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4)475–82.
Bass PF 3rd, Wilson JF, Griffith CH, et al. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77(10)1039–41.
Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5(6)329–34.
Parikh NS, Parker RM, Nurss J, et al. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27(1)33–9.
Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33–42.
Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6)391–5.
Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6)514–22.
Brandes WL, ed.. In: Literacy, Health and the Law: An Exploration of the Law and the Plight of Marginal Readers Within the Health Care System: Advocating for Patients and Providers. Philadelphia: Health Promotion council of Southeastern Pennsylvania, Inc; 1996.
Davis TC, Michielutte , Askov EN, et al. Practical assessment of adult literacy in health care. Health Educ Behav. 1998;25(5)613–24.
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004;36(8)588–94.
Wallace LS, Cassada DC, Rogers ES, et al. Can screening items identify surgery patients at risk of limited health literacy. J Surg Res. 2007;140(2)208–13.
Morris NS, MacLean CD, Chew LD, et al. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7:21.
Wallace LS, Rogers ES, Roskos SE, et al. Brief report: Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21(8)874–7.
Baker DW, Gazmararian JA, Sudano J, et al. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci. 2000;55(6)S368–74.
Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry. 2001;16(2)216–22.
Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44(8)763–70.
Jaeschke, Guyatt GH, Sackett DL. Users’ Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. JAMA. 1994;271(9)703–4.
Delong E, Delong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating curves: a nonparametric approach. Biometrics. 1988;44:837–45.
The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, Kansas: AAPOR; 2006.
Baker DW. The meaning and the measure of health literacy. J Gen Intern Med. 2006;21(8)878–83.
McGee S. Simplifying likelihood ratios. J Gen Intern Med. 2002;17(8)646–9.
Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21)1677–82. Dec 6.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the University of Washington. This study was funded by a grant from VA Health Services Research and Development Service, CRI 03-158 to the Center for Chronic Disease Outcomes Research (CCDOR). Dr. Griffin is also supported by a Merit Review Entry Program award from VA Health Services Research and Development Service. Dr. Katharine Bradley is supported by the Department of Veteran Affairs, Northwest Center of Excellence for Health Services Research and Development, Primary and Specialty Medical Care, and the Center for Excellence in Substance Abuse Treatment and Education.
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Chew, L.D., Griffin, J.M., Partin, M.R. et al. Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population. J GEN INTERN MED 23, 561–566 (2008). https://doi.org/10.1007/s11606-008-0520-5
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DOI: https://doi.org/10.1007/s11606-008-0520-5