The shame associated with limited literacy often prevents patients from receiving appropriate medical care, as they tend to hide their reading problem. Also, healthcare providers often do not consider low health literacy in their patient care.18,47 As previously mentioned, certain groups are at higher risk for limited health literacy, but even people with adequate literacy levels who are unfamiliar with the healthcare context may have difficulty navigating the healthcare system and often go undetected.
The following are common signs that may suggest a person has limited health literacy skills1,17,48:
- Reads slowly
- Has difficulty telling a coherent story
- Fills out forms incorrectly or incompletely
- Uses excuses such as, “I forgot my glasses,” “I'll read this later,” or “I don't have time to read this now. Can I take it home?”
- Brings along a friend or family member for assistance
- Fails to show up for appointments or is late for refills
- Does not ask questions for clarification
- Has difficulty following instructions
- Nods in agreement or expresses understanding but does not truly understand information
A medication review may be very useful in identifying patients with limited health literacy skills. If the refill history is accessible, one might find that they often forget to refill their medications on time or never pick them up. They may not be able to verbalize a list of their medications despite having a short list. If the medication bottles are available, the patient can be asked to state the name, use, and dosing instructions for each of their medications. Patients with limited health literacy may not be able to respond accurately. They may say, “I take them just like it says on the bottle,” or they have to look at the pill color and shape before they can respond.
If patients have a medication reconciliation list from their last visit, they may hand over the list to the health professional and say, “This is everything that I am taking.” However, when probing a little further, they likely do not know the contents of that list, and it may not be exactly what they are taking. When asked to read a medication label that says, “Take one tablet by mouth once daily at bedtime,” they may recognize the pill and say it reads, “Take one every day,” because they have memorized the instructions that may or may not match the container label. When picking up refills, patients with limited health literacy may ask the pharmacist for the old bottles because they depend on their personal markings such as an X on the cap.49
Because of the high prevalence of inadequate health literacy, many experts recommend that health professionals practice “universal precautions” by trying to communicate as clearly as possible with all patients and family members.50 Others suggest that professionals should screen patients' health literacy and then tailor communications accordingly. It is not clear which approach is best.
Sidebar: Clinical Controversy
Should patients be tested for limited health literacy and then receive appropriately tailored health information? Although several instruments have been developed to screen and assess literacy levels, some advocate for the use of “universal precautions” so that all patients will receive clear communication in language that is plain and easy to understand.
A number of instruments have been developed to assess health literacy in both English and Spanish. These instruments can identify patients with “low,” “marginal,” “inadequate,” or “below basic” skills, all of which mean that the patient has limited health literacy. An article by Mancuso provides a comprehensive review of health literacy assessment tools.51
Two of the most widely used measures of health literacy are the rapid estimate of adult literacy in medicine (REALM)52 and the test of functional health literacy in adults (TOFHLA).53 These tests are mainly used in research, but they can be used in practice. Additionally, a survey revealed that patients do not mind having their literacy assessed in the clinical setting.54 More than 98% of patients agreed to a literacy assessment in a routine health visit, including 46% of patients with limited literacy skills.
The REALM is a word-recognition test and estimates health literacy based on patients' ability to pronounce a list of medical terms. The TOFHLA consists of a reading comprehension section to measure prose literacy and a numeracy section. Passages with health information have words that have been deleted, and the patient is to choose the correct word from a list of four options. The Newest Vital Sign (NVS) assesses health literacy by having patients review a nutrition label and answer six questions about the label.55
While there are continued calls for comprehensive measures of health literacy, there is just as much interest in developing short versions of instruments for rapid assessment of literacy skills. Thus, in addition to shorter versions of the REALM (shortened-REALM)56 and TOFHLA,57 one-item measures have been developed and evaluated for rapid screening of health literacy skills.58,60–62
Table 3–4 provides a list of these commonly used assessment tools.5,55–62
TABLE 3-4 Common Methods to Assess Health Literacy |Favorite Table|Download (.pdf)
TABLE 3-4 Common Methods to Assess Health Literacy
|One-Item Measures58,60–62||Length (minutes)||Interpretation/Scoring|
“How confident are you filling out medical forms by yourself?”
(0–extremely, 1–quite a bit, 2–somewhat, 3–a little bit, 4–not at all)
|≤1||Positive answers are “somewhat,” “a little bit,” or “not at all”|
|“How often do you have someone help you read hospital material?” (0–none of the time, 1–a little of the time, 2–some of the time, 3–most of the time, 4–all of the time)||≤1||positive answers are “some of the time,” “most of the time,” “all of the time”|
|Assessment Tool||Description||No. of items||Length (minutes)||Interpretation/Scoring|
|National Assessment of Adult Literacy [NAAL]5||Main purpose was to measure general literacy but included items specifically to assess health literacy||28||[Not for practice; survey done every 10 years]|
|Shortened rapid estimate of adult literacy in medicine [Shortened-REALM]56,a||Word recognition list. Patients read list of 66 common medical words and are scored on correct pronunciation||66||2–3|
|Short test of functional health literacy in adults [S-TOFHLA]57||Patients must fill in words that have been deleted systematically from a sample text of common health instructions; words are selected from a list of multiple-choice options||36||7|
|Short Assessment of health literacy for Spanish adults –50 [SAHLSA-50]59,a||Based on REALM and reading a list of common medical words in Spanish (includes two association words; key and distracter)||50||3–6||0–37 Inadequate|
|Newest Vital Sign [NVS]55||Patients review a nutrition label and answer 6 questions about the label||6||3||0–1 indicates >50% likelihood of marginal or inadequate literacy 2–3 indicates possibility of limited literacy 4–6 adequate literacy|