Assessing and addressing low health literacy among surgical outpatients

AORN Journal,  Sept, 2007  by Cindy L. Monachos

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TOOLS FOR ASSESSING HEALTH LITERACY

Education will increase patients' understanding of their health care regimens and increase the quality of care they receive. (15) To educate patients, health care providers need to begin by testing patients' levels of health literacy. Assessment tools and process improvements are needed in every aspect of a patient's treatment regimen, and some tools have been developed to assist health care providers in assessing literacy levels.

Two broad categories of standardized literacy assessment tools can be used to test patients' health literacy skills. One group of tests relies on word recognition, and the other, which uses the cloze technique, relies on reading comprehension. The doze technique measures reading comprehension by removing certain words from a paragraph and having the reader fill in the blanks. Three of the more common tests used in evaluating health literacy are the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS). (16)

THE REALM. The REALM is a word recognition and pronunciation test comprising 66 medical terms arranged in order of pronunciation difficulty. Starting with simple, one-syllable words (eg, pill, eye) and ending with multi-syllable words (eg, antibiotics, potassium), the patient reads down the list, pronouncing aloud as many words as possible. Simultaneously, the examiner scores the number of words that are pronounced correctly, using the standard dictionary pronunciation as the scoring standard. (16)

One point is awarded for every word pronounced correctly for a total of 66 possible points. The points correspond to four categories of grade-equivalent reading levels. Based on their score, patients are assigned a grade-equivalent reading level that indicates their level of health literacy skills. (Table 1). (16) The REALM test is the most commonly used health literacy test available today because it takes only five minutes for a patient to complete the test and have it graded. (16)

THE TOFHLA. The TOFHLA, which uses the cloze technique, is a timed reading comprehension test that is available in both English and Spanish. The standard test takes about 22 minutes to administer; a short form of the test also is available that takes about seven minutes to administer. The patient is asked to read a passage in which every fifth to seventh word has been omitted, and he or she must select a word from four possible choices to fill in the blank. The standard TOFHLA is scored on a scale from zero to 100, and the short form, or S-TOFHLA, is scored with 36 possible points. Depending on the number of test points a patient receives, he or she is rated as having adequate, marginal, or inadequate comprehension (Table 2). (16)

THE NVS. The NVS is a statistically proven, quick screening tool capable of reliably testing patients for low health literacy. Patients extract information from an ice cream nutritional label and are then required to answer six questions interpreting the information from the label. Patients are awarded one point for each correct answer, and the number of points indicates the level of literacy. A score of greater than four indicates adequate literacy ability, and a score of less than four indicates limited literacy. Health professionals need to take necessary precautions when dealing with patients who score less than two because this score indicates that the patient has a greater than 50% chance of having marginal or inadequate literacy skills (Table 3). (17)