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Health Literacy

Definition

Sorensen (2012) notes health literacy may be a robust demographic predictor of health outcomes as well as how patients use the health care delivery system. Health literacy is associated with health knowledge and health behaviors and within the past decade has received attention from prominent health care delivery organizations.

Healthy People 2020 incorporated health literacy into its objectives and HHS released a health literacy call-to-action plan in 2010. Health literacy criteria are included in the Joint Commission's accreditation of U.S. health care facilities. In addition, there is significant international interest in health literacy research and practice.

Low health literacy is associated with a variety of barriers to improving health such as higher rates of hospitalization, less frequent use of preventive services and increased patient costs (Baker et al., 2002; Howard, Gazmararian,   Parker, 2005; IOM, 2004). For example, patients with low health literacy and illness have less knowledge of illness management than those with higher health literacy (Kalichman et al., 2000; Schillinger et al., 2002; Williams, et al., 1998a, b).

The Institute of Medicine (IOM, p. 6) reported 90 million US adults "have difficulty locating, matching, and integrating information in written texts with accuracy and consistency." The IOM (p. 8) also reported adults with low health literacy skills have "less knowledge of disease management and of health-promoting behaviors, report poorer health status, and are less likely to use preventive services."

Currently, there is not a commonly accepted definition of health literacy. Conceptually, health literacy often is defined from a clinical perspective, where health literacy is considered a property of an individual to be assessed in order to mitigate the negative health impact of an individual with low health literacy skills. The interest lies primarily with diagnosing health literacy levels so clinical accommodations can be made to treat a patient.

The Ad Hoc Committee on Health Literacy of the American Medical Association in 1999 defined health literacy as the "constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment," and included everyday health functions such as the "ability to read and comprehend prescription bottles, appointment slips, and other essential health related materials" (American Medical Association, 1999). The latter definition captures key elements of health care, but seems to exclude factors external to clinical care settings (IOM, 2004). It is sometimes referred to as a 'deficit' model of health literacy (Smith, 2010).

Health literacy also is defined from a broader public health and socio-cultural perspective, where it is perceived as a complex attribute with social interactions and complications. This approach tends to view health literacy as an intermediate outcome that interacts with forces from culture and society, educational, and health systems. The IOM definition, adopted by some other groups including the National Library of Medicine, is:

...the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Ratzan & Parker, 2000; Selden et al, 2000; HHS, 2000).

This definition has been modified at times:

The degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions (Berkman, Davis, & McCormack, 2010; Berkman, Sheridan, Donohue, Halpern, Viera, et al., 2011; McCormack, Bann, Squires, et al., 2010).

In addition, the World Health Organization (WHO) defined health literacy as:

...the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health (Nutbeam, 1998).

The latter perspectives recognize the importance of individuals' motivations and abilities to obtain, understand, and use information to make informed health decisions and interact successfully with the health care system, rather than simply possessing a set of literacy skills. Health literacy includes both understanding of health information and the ability to use information to make appropriate health decisions. Nutbeam (2008) adds the definition adopted by WHO envisions health literacy more as a multidimensional process that can empower individuals to take control of their health.

HHS' Office of Disease Prevention and Health Promotion proposes health literacy levels are influenced by communication skills and knowledge of health topics among lay persons and professionals, as well as culture (e.g., language, norms), demands of the healthcare and public health systems, and demands of the situation/context. Health literacy also impacts individuals' abilities to: navigate the healthcare system, including filling out complex forms and locating providers and services, sharing personal information with providers, engaging in self-care and chronic-disease management, and understand mathematical concepts (numeracy skills) such as probability and risk. Numeracy skills can include competencies such as calculating cholesterol and blood sugar levels, measuring medications, and understanding nutrition labels.

In addition to basic literacy skills, health literacy often requires some knowledge about health. People with low health literacy often lack knowledge or are misinformed about human biology as well as the nature and causes of disease. Without the latter knowledge, it is difficult to understand complex health issues, such as the relationships among lifestyle factors such as diet and exercise with various health outcomes.

For a more comprehensive discussion of health literacy definitions and conceptual frameworks, see Sorensen et. al. (2012). A categorization of the diverse research topics within the health literacy literature is attached (Logan, 2012). The Agency for Healthcare Research and Quality published a second systematic review of health literacy literature in 2011 (Agency for Healthcare Research and Quality, 2011).

Suggested Measures

Health literacy primarily has been measured via three assessment tools: Rapid Estimate of Adult Literacy (REALM), Test of Functional Health Literacy in Adults (TOFHLA), and a subset of health items within the National Assessment of Adult Literacy Survey (NAALS). A missing consensus on a single measure of health literacy is unsurprising given the term's conceptual expansion. The REALM, TOFHLA, and several derivations are discussed here. In addition, the NAALS, Newest Vital Sign (NVS), eHealth Literary Scale (eHEALS), and a recently developed single index of health knowledge are provided.

REALM/ REALM-R

The Rapid Estimate of Adult Literacy in Medicine (REALM; Davis et al., 1991; Davis et al., 1993) consists of a 66-item word recognition and pronunciation test (e.g., cancer, caffeine, attack, kidney, hormones, herpes, seizure) that measures vocabulary abilities. The test administrator complies a score based on the success with which a participant correctly pronounces words. The time it takes for a respondent to complete the REALM ranges from 2 to 3 minutes Davis et al. (1998) to 5 to 6 minutes (Bass, Wilson, & Griffith, 2003).

REALM-R

The REALM-R is a revised, shorter version of the REALM that uses only eight words designed to rapidly screen patients for health literacy problems (Bass et al., 2003). The words in the REALM-R are: osteoporosis, allergic, jaundice, anemia, fatigue, directed, colitis, and constipation (α = 0.91). In the Bass et al. (2003) study, 157 patients at the University of Kentucky completed the instrument. The REALM-R correlated 0.64 with the WRAT-R (Wide Range Achievement Test-Revised; Jastak & Wilkinson, 1993).

  • Advantages

    • Extremely short (REALM-R)
    • Easy to administer
    • Correlated with WRAT-R
  • Disadvantages

    • Cannot assess participant understanding of words
    • Narrow focus on word recognition and pronunciation
    • REALM-R instrument has not been validated across samples or health areas

TOFHLA/ s-TOFHLA

The TOFLHA (Baker et al, 1999; Parker, et al, 1995) measures reading fluency and numeracy. It consists of reading comprehension section (a 50-item test using the modified Cloze procedure (Taylor, 1953)) to measure prose literacy and a "numeracy" section with 17 items assessing individuals' capacity to read and understand actual hospital documents and labeled prescription vials. For example, a prescription bottle has the label with the instructions: Take one tablet by mouth four times a day. The patient is asked: "If you take your first tablet at 7:00 am, when should you take the next one? And the next one after that?"

The abbreviated s-TOFHLA is a 36-item timed reading comprehension test that uses the modified Cloze procedure where every fifth to seventh word in a passage is omitted and four multiple-choice options are provided. The abbreviated s-TOFHLA is scored on a scale of 0-36, which then are categorized into three grades: inadequate, marginal, and adequate.

The s-TOFHLA has been shown to be reliable (Schillinger et al., 2002; Schillinger, et al., 2004).

  • Advantages

    • Relatively short
    • Easy to administer
    • Established reliability
    • Correlated with WRAT-R
  • Disadvantages

    • Cannot assess participant understanding of words
    • Narrow focus on word recognition and pronunciation
    • Instrument has not been validated across samples or health areas

NAALS

The 2003 National Assessment of Adult Literacy (NAAL, Kutner, Greenberg, Jin & Paulsen, 2006) measured responses from more than 19,000 respondents. The main NAAL included 152 items or tasks, 28 of which were health-related and constituted the health literacy assessment. Two of the 28 health-related tasks were repeated from the 1992 National Adult Literacy Survey (NALS) administered by the National Center for Education Statistics (NCES) (White, 2008).

Tasks used to measure health literacy were organized around three domains of health as well as health care information and services: clinical, prevention, and navigation of the health care system. The stimulus materials and the 28 health literacy tasks were designed to elicit respondents' skills to locate and understand health-related information and services and to represent three general literacy scales-prose, document, and quantitative-developed to report NAAL results. The Office of Disease Prevention and Health Promotion (ODPHP) within the U.S. Department of Health and Human Services suggested the materials as well as questions with input from other HHS agencies and stakeholders and experts, who used information derived from federal health materials and other health-related assessments. Of the 28 health literacy tasks, three represented the clinical domain, 14 represented the prevention domain, and 11 items represented the navigation of the health care system domain. Sample materials and questions can be found in Kutner, et al. (2006).

  • Advantages

    • Established reliability
    • Data collected from a very large sample
    • Summarized findings available
    • Data organized in a variety of ways
  • Disadvantages

    • Cannot easily administer to other samples
    • Variety of tasks and measures makes it difficult to assess reliability

Public health literacy knowledge scale:

Pleasant and Kuruvilla developed a public health literacy knowledge scale based on the Facts for Live, developed by major international public health organizations (e.g., UNICEF, WHO, UNESCO, etc.). They collected data as part of a larger survey coordinated by the World Health Organization in Mexico, China, Ghana, and India (α=.80; Pleasant & Kuruvilla, 2008):

  1. For a healthy pregnancy and birth, all pregnant women should visit a health worker before the baby is born (T)
  2. Births that are not assisted by a skilled birth attendant are as safe as births that are assisted by a skilled birth attendant (F)
  3. It is normal if children below the age of 1 year weigh the same over a 2-month period (F)
  4. Children who are vaccinated are protected from dangerous diseases (T)
  5. Overall, vaccination has more risks than benefits (F)
  6. Children learn a lot by playing (T)
  7. Most injuries and accidents cannot be prevented (F)
  8. If a child is breathing rapidly or has difficulty breathing, the child should be taken immediately to a health-care provider (T)
  9. Many diseases can be prevented by washing hands before touching food (T)
  10. Using condoms when having sex can prevent the spread of AIDS (T)
  11. Using mosquito nets helps prevent malaria (T)
  12. Exercise helps prevent heart disease (T)
  13. Coughs and colds only get better with medicine (F)
  14. It is the father's gene that decides whether the baby is a boy or a girl (T)
  15. Antibiotics kill viruses as well as bacteria (F)
  16. Cigarette smoking causes lung cancer (T)
  17. All bacteria are harmful to humans (F)
  • Advantages

    • Short
    • Easy to administer
    • Established reliability
  • Disadvantages

    • Cannot assess participant understanding of words
    • Narrow focus on knowledge of a few facts
    • Instrument has not been validated across samples or health areas

Rationale for selection

The REALM, TOHFLA, and their derivatives are provided because they are the most commonly used measures of health literacy and have generated the most validity and reliability data. The description and source for the NAALS represents a significant health literacy measurement investment by the US Department of Education. The Newest Vital Sign (NVS) is short, mirrors a typical health related task (assessing nutrition labels), and has a numeracy component. The eHEALS assesses individuals' confidence in their ability to access and evaluates online health information. The public health literacy knowledge index is relatively short and has good reliability.

Reliability

REALM. According to Davis et al. (1998), the REALM has high face validity and has been used in public health clinics across the country (Davis et al, 1993; Davis, et al., 1994; Doak, Doak, & Root, 1995; Murphy et al., 1993; Williams et al., 1995). In addition the REALM has high criterion validity, correlating .88 with the (Revised) WRAT-R (Jastak & Wilkinson, 1993), .96 with the Slosson Oral Reading Test-Revised (SORT-R, Slosson, 1990; Weiss & Coyne, 1997), and .97 with the Peabody Individual Achievement Test-Revised (PIATR; Markwardt, 1989). It also has high test-retest and reliability 0.97 (Davis et al, 1993).

TOHFLA: The TOFHLA also has good criterion validity with correlation coefficients of .74 with the reading section of the WRAT-3 and .84 with the REALM. Internal reliability using Cronbach's alpha is 0.98 (Davis et al, 1998).

NVS: The NVS showed reliability of .76 in an English context and .69 in Spanish. It correlates with the TOFHLA (English r=.64; Spanish r=.59).

eHEALS: The eHEALS has shown high internal consistency (.88-92 across samples), although it showed poor convergent validity in one study (van der Vaart, van Deursen, Drossaert, Tall, van Dijk, & van de Laar, 2011).

The public health literacy knowledge scale (Pleasant & Kuruvilla, 2008) is recent and concurrent validity with other, well-researched, indexes has not been assessed. The scale had good reliability (α=.80) in one study.

Examples of the use of various measures

REALM

Davis et al. (1994) found self-reported education levels comparatively did not accurately predict parents' reading ability. As an alternative, Davis et. al. (1994) suggested the REALM can easily be used in public health clinics to screen parents for reading ability. Fortenberry et al. (2001) found for the average respondent, REALM reading grade level of 9th grade or higher was associated with a 10% increase in the probability of having a gonorrhea test in the past year. Lindau et al. (2002) found that minority women were significantly more likely to have low literacy levels compared with white women (measured with REALM) and health literacy was the only factor independently associated with knowledge related to cervical cancer screening.

TOFHLA

Benson and Forman (2002) administered the TOFHLA to 93 seniors. They found 30% of the sample was unable to adequately comprehend written information. While TOFHLA scores were negatively associated with age, higher scores were correlated with more years of formal education and vice versa. There was no relationship between TOFHLA scores and gender. Kalichman et al. (2000) found persons of lower health literacy (TOFHLA) were significantly less likely to have an undetectable HIV viral load, were less likely to understand its meaning, were more likely to have misperceptions that anti-HIV treatments reduce risks for sexually transmitting HIV as well as believe anti-HIV treatments relax safer-sex practices.

In a study of n=402 patients with hypertension and 114 diabetes patients, Williams et al. (1998b) found hypertension patients (who scored higher on the TOHFLA) comparatively knew a blood pressure reading of 160/100 mm Hg was high. Also, diabetic patients who scored higher on the TOHFLA comparatively knew more about the symptoms of hypoglycemia.

s-TOFHLA

Scott, et al. (2002) found a self-reported lack of preventive services (such as influenza vaccination, pneumococcal vaccination, mammogram, Pap smear in the past two years) comparatively was higher among individuals with inadequate health literacy (measured with the s-TOFHLA). Schillinger et al. (2002) found associations among reduced glycemic control, higher rates of retinopathy, and patients with low health literacy and type 2 diabetes (s-TOFHLA). Tang et al. (2008) recently developed a Chinese version of s-TOFHLA. In their study of Chinese patients, Tang et. al. (2008) found health literacy scores were negatively correlated with a patient's diabetes management.

NAALS

Martin, Ruder, Escarce, et al. (2009) analyzed data from the 2003 NAAL to predict health literacy scores from various demographic variables, such as gender, age, race/ethnicity, education level, poverty status, marital status, language, etc. They found most variables predicted health literacy scores -- and lower educational attainment was the most robust predictor.

NVS

Patel, Steinberg, Goveas, et al. (2011) compared the completion time of the NVS with the s-TOFHLA among older African-American patients. Although both measures showed the sample to be "sufficiently literate" (51%-56%), the NVS took the patients considerably longer than expected to finish and was not appreciably shorter than the s-TOFHLA. VanGeest, Welch,   Weiner (2010) administered the NVS to 179 patients at a family care clinic. They found the screening did not generate shame or embarrassment to most patients. Also, nearly all patients said they would recommend similar a health literacy screening.

eHEALS

The eHealth literacy scale has been assessed across different populations, including Hispanic adolescents with varying results (Ghaddar, Valerio, Garcia,   Hansen, 2012; Knapp, Madden, Want, Sloyer,   Shenkman, 2011; Mitsutake, Shibata, Ishii, Okazaki,   Oka, 2011; van der Vaart, et al., 2011). In each case, the internal consistency of the scale remained high. The scale's predicted associations with other variables but was not demonstrated across all contexts.

Additional Commentary

While the summarized measures reflect current research literature trends, both the REALM and TOFHLA instruments have been critiqued by the IOM and the AHRQ because they are "assessments of reading ability, and as such are inadequate measures of health literacy." (HHS, 2009).

This raises the issues whether the methods used to measure health literacy reflect its conceptual expansion. Currently, most health literacy research use measures that assess health literacy as a set of competencies (e.g., word recognition, numeracy) in contrast with more dynamic social-cultural measures. Hence, health literacy research often is operationalized as a clinical risk factor (or a knowledge deficit) instead of a broader intermediate, socio-cultural outcome.

In addition, current assessment instruments do not differentiate health literacy measures from broader reading abilities, background knowledge of health-related domains, a lack of familiarity with language and types of health materials, and cultural differences. The current measures of health literacy do not assess oral communication or writing skills and none measure the health-literacy demands on individuals within different health contexts (IOM, 2004).

Recent Developments

Recent attention and efforts by a broad range of investigators focus on measurement and conceptual issues surrounding health literacy assessment. New and diverse approaches highlight the fluidity of current health literacy conceptualizations (Sorensen, 2012). The Journal of Health Communication devoted two special issues (one in 2010 and one in 2011) to health literacy research. The first issue reports research presented at the first Health Literacy Annual Research Conference (HARC), which was coordinated with the IOM Roundtable on Health Literacy and sponsored by AHRQ, NCMHD and several NIH institutes and centers. The introduction in this issue (Paasche-Orlow, Wilson,   McCormack, 2010) provides a description of the conference and subsequent articles. Berkman, Davis, & McCormack (2010) review the evolution of the "health literacy" concept at the time. Several articles present data from new health literacy measures and include pilot data from a skills-based instrument (McCormack et al., 2010), a talking touchscreen assessment tool (Yost, et al, 2010), and a measure that assesses the health literacy environment within some health plans (Gazmararian et al., 2010).

In the second issue, Pleasant, McKinney, & Rikard (2011, p. 11) propose a research agenda "focusing on development of a new, comprehensive approach to measuring health literacy." In the article, Pleasant et al. find there are about fifteen health literacy measures. They provide significant criticisms of these measures and their variants, including the REALM and TOHFLA tools.

A different approach suggested by Smith (2009) is based on Nutbeam's (2000) concept of health literacy as progressive levels of functioning (e.g., functioning in the health system) and the integration of personal life skills patterns and healthier behaviors within one's life and immediate environment. Smith (2009) introduces a Functional Health Literacy Measure (FHLM), which is comprised of two scales, the Functional Healthcare Literacy Scale (FHcL) and the Functional Selfcare Literacy Scale (FScL). Both are coded on 1-5 scales, where 1=inadequate functioning and 5=competent functioning. The FScL and FHcL are based on Wollesen and Peifer (2006) Life Skills Progression (LSP) instrument, which is widely used in social work assessment. The FHcL rates parents' ability to manage their children's health while the FScL rates parents' ability to mange their personal health. For example, the categories for tobacco on the FScL range from chain smokes (scored 1) to no tobacco use (scored 5). Data were collected in conjunction with in-home visitations across six program locations as part of a curriculum designed to promote functional health literacy and reflecting functioning in disadvantaged parents of very young children. While these measures have yet to be validated, they provide an alternative, macroscopic approach to health literacy measurement and conceptualization.

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Tang, Y.H., Pang, S.M.C., Chan, M.F., Yeung, G.S.P. & Yeung, V.T.F. (2008).

Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus.
Journal of Advanced Nursing, 62(1), 74–83.

Taylor, W.L. (1953).

"Cloze procedure": a new tool for measuring readability.
Journalism Quarterly, 30, 415–433.

U.S. Department of Health and Human Services.

Quick Guide to Health Literacy. Office of Disease Prevention and Health Promotion. Retrieved May 25, 2009
http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

U.S. Department of Health and Human Services. (2000).

Healthy People 2010.
Washington, DC: U.S. Government Printing Office. Originally developed for Ratzan SC, Parker RM. 2000. Introduction. In National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.

van der Vaart, R., van Deursen, A.J., Drossaert, C.H., Taal, E., van Dijk, J.A., & van de Laar, M.A. (2011).

Does the eHealth Literacy Scale (eHEALS) measure what is intends to measure? Validation of a Dutch version of the eHEALS in two adult populations.
Journal of Medical Internet Research, 13(4), e86.

VanGeest, J.B., Welch, V.L., & Weiner, S.J. (2010).

Patients' perceptions of screening for health literacy: Reactions to the Newest Vital Sign.
Journal of Health Communication, 15, 402-412.

Weiss, B. & Coyne, C. (1997).

Communicating with patients who cannot read.
New England Journal of Medicine, 337(4), 272-273.

Weiss, B.D., Mayes, M.Z., Martz, W., Castro, K.M., DeWalts, D.A., Pignone, M.P., Mockbee, J., & Hale, F.A. (2005).

Quick assessment of literacy in primary care: The Newest Vital Sign.
Annals of Family Medicine, 3(6), 514-522.

White, S. (2008).

Assessing the Nation's Health Literacy: Key Concepts and Findings of the National Assessment of Adult Literacy (NAAL).
Chicago, IL: American Medical Association Foundation.

Williams, M.V., Parker, R.M., Baker, D.W., Parikh, N.S., Pitkin, K., Coates, W.C., et al. (1995).

Inadequate functional health literacy among patients at two public hospitals.
Journal of the American Medical Association, 274, 1677-1682.

Williams, M.V., Baker, D.W., Honig, E.G., Lee, T.M., & Nowlan, A. (1998a).

Inadequate literacy is a barrier to asthma knowledge and self-care.
Chest, 114, 1008-1015.

Williams, M.V., Baker, D.W., Parker, R.M., Nurss, J.R. (1998b).

Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes.
Archives of Internal Medicine, 158, 166-172.

Wollesen, L. & Peifer, K. (2006).

Life Skills Progression: An outcome and intervention planning instrument for use with families at risk.
Baltimore, MD: Brookes.

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Acceptability of the talking touchscreen for health literacy assessment.
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Categories of Health Literacy Research - 7/23/12

This internal document (from the National Library of Medicine) categorizes a range of health literacy research. The document attempts to cover a variety of research areas but it is not exhaustive. The document is derived from some overviews of health literacy research, some of which are referenced below.

This document does not describe individual studies or health literacy's conceptual frameworks. A recommended introduction to health literacy's diverse conceptual frameworks is: Sorensen, K., Broucke S.V., Fullam, J., Doyle, G., Pelikan J., Slonska, A., Brand, H. HLS-EU Consortium Health Literacy Project European. (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12:80, doi:10:1186/1471-2458-12-80.

A recommended systematic review of health literacy research is: Agency for Healthcare Research and Quality. (2011). Health literacy interventions and outcomes: An updated systematic review. Rockville, MD. Agency for Healthcare Research and Quality, Evidence report/technology assessment number 199. http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf

Note: broad categories are in bold face, subcategories are in regular type face. The listed categories are in random order.

The identified broad categories within health literacy research are: population studies, social demographics, clinical outcomes, health behaviors, health care providers, health care delivery system, in home, health educational and prevention interventions, health educational and prevention interventions (K-12 and higher education), health policy, and health literacy research concepts, methods, and tools. These areas are addressed consecutively with relevant research subtopics.

Population studies - aggregate health literacy levels

Assessment of a population's health literacy capabilities/skills

Assessment in U.S. and other nations (UK, Korea, Australia, New Zealand)

Social demographics

Association of health literacy levels with: Health disparities, Medically underserved audiences, Race/Ethnicity, Geography [rural, urban areas], Age, Socio-economic status, Education, Income, Gender, Marital status, Health status, Health insurance status, Employment, Disability, Occupational status, Social support, Years in the U.S., Nationality, Citizen status, Homeless, Acculturation, Young adults living with parents, Car ownership, Food assistance, Psychosocial factors

Health literacy levels compared to other demographic covariates as a predictor of health outcomes (Is health literacy a more robust predictor of outcomes than other social demographic variables?)

Health literacy levels compared to other demographic and health behavior covariates/comorbidities as a predictor of health outcomes (e.g. alcohol use, smoking, depression, cognitive function, mental health, treatment status, years on medication, health beliefs, self-efficacy, number of over-the-counter drugs)

Likelihood of health literacy levels (predicted from other demographic measures)

Clinical outcomes

Associations among health literacy levels and clinical outcomes:

  • Diseases (chronic disease - such as diabetes, high blood pressure, arthritis, HIV/AIDS, hepatitis, respiration; acute disease - such as cancer, stroke, heart disease)
  • Conditions (depression, anxiety, stress, addiction, tobacco, alcohol, & legal/illegal drug use, obesity - BMI, mental health, physical, asthma, depressive symptomatology, distress over body changes, pain)
  • Clinical test scores (A1C, LDL/HDL, CD4 count, VRQol, mental & physical HRQoL, blood pressure, retinopathy, nephropathy)
  • Disease/condition prevalence and severity
  • Warfarin control
  • Acute and chronic disease recovery/management/prevention
  • Mortality (All cause, cardiovascular, cancer, age)
  • Risky health behaviors
  • Number of patient chronic conditions
  • Functional health status
  • Activity limitations
  • Other clinical outcome measures (e.g. IADL limitation, ADL impairment, BMI)

Health behaviors

Association between health literacy levels and broader health behaviors:

  • Adherence/compliance to clinical instructions (medication regimens, dose inhaler)
  • Adherence/compliance with health prevention guidelines [screening, annual check-ups, routine screening procedures (such as a dental checkup, vision checkup), colon, breast, prostate, and osteoporosis screening]
  • Patient choice of medical procedures (colonoscopy or sigmoidoscopy)
  • Patient completion of medical tests (mammograms, pap, HIV)
  • Patient completion of immunizations (flu shot)
  • Medication management test
  • Quality of caregiving
  • Health beliefs
  • Disease & health self-management
  • Self-efficacy
  • Cognitive skills
  • Self-reflection
  • Diet
  • Exercise (level of physical activity)
  • Weight management
  • Smoking
  • Alcohol use
  • Prescription drug abuse
  • Illegal drug use
  • Sexual debut
  • Health information seeking
  • Risk perception
  • Seat belt use
  • Patient engagement -- using PHRs, interest in health education, use of the Internet to obtain health information, interest in healthy activities, communicating with health care providers, and taking charge of one's health care

Health care providers

Development & implementation of health literacy guidelines in medical practice and in medical/nursing/pharmacy, allied health professional, dental education:

AMA, Joint Commission, AAMC (similar medical professional organizations)

Health literacy and enhancing health care provider skills/capacities at the point of care:

  • Provider cultural competency
  • Provider-patient interaction (interpersonal communication)
  • Compliance/adherence by patients to provider instructions
  • Reduction of medical errors
  • Reduction of unnecessary clinical procedures

Attitudes among health care professionals about informed and engaged patients, receiving patient health literacy information, and resulting clinical interventions

Patient trust

Patient health beliefs

Within the health care delivery system

User comprehension of clinical and health materials:

  • Patient understanding of medical terminology
  • Use of plain language
  • Comprehension of health messages
  • Tailoring health educational materials to specific audiences
  • Tailoring nutritional information
  • Pharmaceutical information on labels and inserts (patient understanding of dosage, frequency of use in OTC and prescription medications)
  • Patient understanding of vital signs
  • Patient understanding of medical tests and procedures
  • Patient understanding of clinical care forms
  • Patient understanding of informed consent
  • Patient understanding of billing, insurance forms, and other documents
  • Interior design, aesthetics, and enhancing patient understanding
  • Signage within hospitals and clinics and enhancing patient understanding
  • Health literacy and patient satisfaction
  • Efficacy of comparative media platforms to provide health information
  • User usability of health websites and other media platforms
  • Readability of health websites and other media platforms
  • Accessibility (IT, Language) of health websites and other media platforms

Utilization of the health care delivery system (how health literacy levels impact):

  • Days spent within a clinical facility
  • Hospitalization and re-hospitalization rates
  • Urgent care rates
  • Overnight stays in hospital
  • Frequency of patient visits to a physician
  • Frequency of patient use of emergency medical facilities
  • Frequency of patient use of preventive services and screening
  • Time from dialysis date to transplant to wait list
  • Enhancing discharge procedures/instructions
  • Health insurance status
  • Patient ability to select health plans
  • Medicaid costs
  • Use of health care institutional health education, interpretation, and translation services
  • Use of preventive services (influenza, HIV, mammograms)
  • Health care technology acceptance - use of EHRs, PHRs, information prescription
  • Cost reduction

Efficacy of patient health literacy screening efforts

Overall patient safety and medication safety

Efficacy of patient health education at point of care

Impact of health literacy accreditation standards -- established by the Joint Commission

Diffusion and adoption of health literacy practices by hospitals, clinics, and medical and dental practices (profiles of a health literacy-oriented medical/health organization)

In home

Life skills progression

  • Maternal, parental and caregiver capabilities, learning, self-reflection, adaptability

Enhancing health related skills and outcomes in maternal dyads

Quality of life

Health educational and prevention interventions

Health communication intervention campaigns and health literacy

Prevention interventions (clinical & community-based) and health literacy

Home visitation and health literacy

Health educational and prevention interventions (in K-12 and higher educational settings)

Comparison of health literacy with other 'literacies' – numeracy, financial, cultural

Interactions between health literacy and other educational initiatives and challenges:

  • Adult education
  • Adult literacy
  • Measures of reading comprehension developed within the educational literature
  • Health education in K-12, higher education (health education standards)
  • Health education in medical centers and clinics
  • English as a 2nd language
  • Limited language proficiency

Health policy

Health literacy levels and public understanding of health care reform

Health literacy levels and consumer understanding of medical economics

Health literacy levels and public support for diverse national health care insurance strategies

Health literacy levels and initiatives within governmental, private corporations, academic institutions & other NGO Leadership

Health literacy levels and their impact on health policy development

Health literacy research concepts, methods, tools

Health literacy research methods:

  • Development of instruments, testing approaches
  • Screening and research tools (NVS, REALM-S, S-TOFLA, SAHLSA, BHLS, SNS)
  • Construct development
  • Assessment of instruments and constructs

Health literacy theoretical framework development

Conceptual and methodological similarities with similar academic sub-disciplines (health communication, risk assessment, numeracy, public understanding of science, education, public health, consumer health informatics, mass communication)

Critical analysis

References

Agency for Healthcare Research and Quality. (2011).

Health literacy interventions and outcomes: An updated systematic review. Rockville, MD. Agency for Healthcare Research and Quality, Evidence report/technology assessment number 199. http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf

American Medical Association. (1999).

Health literacy: Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association.
Journal of the American Medical Association, 281(6), 552– 557.

Institute of Medicine. (2004).

Health Literacy: A Prescription to End Confusion.
Washington, DC: National Academies Press; 2004.

Pleasant, A., McKinney, J., & Rikard, R. V. (2011).

Health literacy measurement: A proposed research agenda.
Journal of Health Communication, 16(S3), 11–21.

Smith, S.A. (2009).

Promoting health literacy: Concept, measurement & intervention.
Dissertation Abstracts International, 70, 9.

Sorensen, K., Broucke S.V., Fullam, J., Doyle, G., Pelikan J., Slonska, A., Brand, H., HLS-EU Consortium Health Literacy Project European. (2012).

Health literacy and public health: A systematic review and integration of definitions and models.
BMC Public Health, 12:80, doi:10:1186/1471-2458-12-80.

U.S. Department of Health and Human Services.

Quick Guide to Health Literacy. Office of Disease Prevention and Health Promotion. Retrieved May 25, 2009 http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

Wollesen, L. & Peifer, K. (2006).

Life Skills Progression: An outcome and intervention planning instrument for use with families at risk.
Baltimore, MD: Brookes.

 

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