TY - JOUR
AU1 - Tkacz, Victoria, L.
AU2 - Metzger,, Anne
AU3 - Pruchnicki, Maria, C.
AB - The U.S. National Literacy Act of 1991 defines literacy as “an individual’s ability to read, write, and speak English and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals and to develop one’s knowledge and potential.”1 Health literacy goes beyond this definition to include the ability to use these skills to read and understand health-related information, such as medication labels and insurance forms.2 These skills are vital for patients to receive the highest quality of care; however, 90 million people (nearly half of all Americans) have limited health literacy skills.3 This number is based on the 2003 National Assessment of Adult Literacy (NAAL), which for the first time included a component designed to specifically test adults’ ability to read and understand health-related information. The U.S. Department of Health and Human Services uses the NAAL to evaluate progress toward the Healthy People 2010 goal “to improve the health literacy of persons with inadequate or marginal literacy skills.”4 Raising awareness about this issue is important, since the NAAL showed no change in the average overall literacy score between the most recent assessment in 2003 and the prior assessment conducted a decade earlier.5 Improving health literacy is key to addressing health disparities and is a major focus area identified in both the Healthy People 2000 and Healthy People 2010 initiatives.6,7 Disparities are observed differences in health conditions, access to health care, and disease outcomes that can be linked to patient characteristics such as age, sex, race or ethnicity, education, geographic location, and socioeconomic status. In their review of health disparities, Mullins et al.7 identified sex- and race-related health disparities in the areas of cardiovascular disease, diabetes mellitus, and cancer and identified issues such as barriers to communication (written and oral), cultural sensitivity, and appropriate use of health services. These authors suggested that improvements should focus on community-based health interventions developed with input from ethnically diverse or aware health care providers, language interpreters, and the patients who use these services. In general, patients with low health literacy have poorer health status and higher medical resource utilization, as demonstrated by increased hospitalizations, less preventive care (e.g., mammograms, immunizations), and increased risk of premature death.7,8 The causes of low health literacy are likely to be multifactorial and may include delays in seeking or obtaining health care, increased severity of illness at diagnosis, overuse or underuse of medical services, and overuse or underuse of medications. In addition to an increased susceptibility to medication errors, which can result in adverse effects, the need for additional treatments, or therapeutic failures, patients with low health literacy skills may lack the knowledge and skills necessary to adhere to their prescribed drug regimen.8 Medication knowledge (including the literacy component) and adherence have both been associated with fewer emergency department visits in older patients with congestive heart failure.9 A study focusing on glaucoma control found that the level of medication adherence was positively related to health literacy; however, race, sex, age, severity of disease, and level of education were not correlated.10 Similar results were shown in patients with human immunodeficiency virus, for whom health illiteracy but not race significantly predicted nonadherence.11 In patients with type 2 diabetes mellitus, inadequate health literacy was found to be the independent variable associated with poor glycemic control and higher rates of retinopathy.12 Pharmacists must recognize the lack of health literacy as a national crisis in the United States. As front-line community and health-system providers, they will be increasingly challenged to address health literacy issues in both dispensing medications and providing medication and disease management services.7 Currently, there is a paucity of data describing pharmacists’ knowledge and abilities in this area, and more research is needed. A single, small study described the frequency and type of pharmacist interactions in the realm of health literacy in the community setting.13 Forty-four pharmacies in the Atlanta, Georgia, area were selected based on location of the pharmacy and patient demographics and contacted to participate in a telephone survey. Many of the pharmacies were located in urban areas, including several near a large inner-city hospital, with a patient population with an average education level of less than 12th grade based on census information; a number of pharmacies were also selected from middle-class communities. Thirty pharmacists responded to questions such as “Does your pharmacy do anything to try to identify patients with low health literacy?” and “When a patient with low health literacy is identified, what measures do you take to optimize their health care?” Of these, only 2 (7%) reported that they attempted to identify literacy-related needs among their patients, and neither respondent was asked or described how he or she did so. Interestingly, many of the pharmacists surveyed expressed surprise at the mention of literacy, and 3 (10%) specifically noted that they were not concerned about low literacy because their patient populations included few Medicaid recipients and were mostly middle class. Although patient characteristics may be used to describe at-risk populations, all health practitioners need to be conscious that the literacy level of individual patients cannot be determined just by looking at them or knowing only their socioeconomic status. Patients rely on their pharmacist to provide them with the information necessary to safely and effectively use their medications. A study of homeless women found that regardless of health literacy level, 75% preferred to receive both written and oral drug information and nearly 80% listed physicians and pharmacists as their first and second choice, respectively, for oral drug information.14 Pharmacy-printed leaflets and drug company inserts were the most desired written resources. Unfortunately, medication information in these formats is often incomplete, not standardized, and not commonly written for patients with low health literacy.15 For example, Roskos et al.16 found that most consumer medication information for seven intranasal corticosteroid inhalers is written at a level slightly higher than the recommended fifth- or sixth-grade level, printed in a font size of 9 versus the recommended 12 point or larger, and inadequately illustrated for patient education. Pharmacists adding spoken directions and providing more intensive oral counseling may improve the effectiveness of written materials in patients with very low literacy.13,17 Therefore, being able to identify low-literacy patients and having the skills necessary to work appropriately with them are of utmost importance. Formal assessments of health literacy There are currently three published tests of health literacy available for use with patients: the Rapid Estimate of Adult Literacy in Medicine (REALM),18 the Test of Functional Health Literacy in Adults (TOFHLA),19 and the Newest Vital Sign (NVS).20 Table 1 summarizes key characteristics of the three formal evaluations and describes the formats and sample questions. All three assessments were designed to be administered in the clinic by a health care professional and require the patient to perform various reading tasks and respond with oral answers. The optimal time to administer the assessments is when gathering demographic information, medical history, and vital signs from the patient, as understanding the patient’s literacy level can help guide patient interactions and education for initial and future visits. Years of schooling completed and patient age are the strongest (though limited) predictors of health literacy, and research suggests that patients over 60 years and those completing 8 or fewer years of school are very likely (>80%) to have inadequate health literacy; younger patients who have a high school education are least likely to have inadequate health literacy (≤20%).21 As much weaker associations exist for patients older than 45 years and those who have completed 9–12 years of schooling (20–50% with inadequate health literacy), assessments may be most informative in these groups as functional literacy issues will be difficult to identify without formal testing. Screening or systematic use of formal literacy assessments can also help guide overall educational programming in individual practice settings by determining the prevalence of patients with inadequate health literacy. For instance, relying mainly on written educational materials in a clinic with a large illiterate population would be unlikely to be successful. REALM The REALM was the first health literacy assessment to be developed and remains the most commonly used test of health literacy in medical settings.22 The evaluation asks the patient to pronounce 66 medical terms that are ordered in increasing difficulty and number of syllables. The words on the patient handout are listed in three widely spaced columns with enlarged text. A patient’s raw reading score is the total number of words pronounced correctly, making 66 the maximum achievable score.18 This raw score is then converted into one of four reading grade levels (Table 1). Although initially reported to take only a few minutes to administer, a shortened version known as the REALM—Revised (REALM-R) was developed in response to the REALM’s longer actual completion time of five to six minutes in a busy clinical setting.23 This shortened version uses the same ideology as the long version but asks the patient to pronounce only 8 medical terms (osteoporosis, allergic, jaundice, anemia, fatigue, directed, colitis, and constipation). The REALM-R averages a response time of less than two minutes; a score of ≤6 corresponds with a risk of poor health literacy.24 Although the pilot study of the REALM-R was promising, additional data establishing its validity and reliability are needed.23 Possible limitations to the use of both the REALM and REALM-R are that they are not available in languages other than English and use pronunciation skills as a surrogate for patient understanding. TOFHLA The TOFHLA is the test of health literacy used mostly commonly in health care research.20 The evaluation consists of two parts, testing both reading comprehension and numeracy. The first part focuses on reading comprehension using the Cloze procedure25: every fifth to seventh word in the passage is deleted and the reader must then pick from four choices the word that best completes the sentence grammatically and contextually. The second part tests a patient’s numeracy skills using actual hospital forms and prescription vials. These items are presented to the patient who is then orally asked questions about the information. The two parts are weighted equally at 50 points each, for a total score of 100. The original TOFHLA contains three prose passages in part one and 17 numeracy items in part two; the short TOFHLA (S-TOFHLA) was developed to make the test less cumbersome to administer and contains only two prose passages and 4 numeracy items.21 This decreased the time to completion from 22 minutes (for the original) to 12 minutes, which remains a limitation for its use in clinical practice. However, the TOFHLA does have the advantages of measuring both reading and numeracy skills and being available in English and Spanish, the most-often spoken language of foreign-born U.S. residents after English.26 NVS The most recently developed formal test of health literacy is the NVS.20 This evaluation requires the patient to look at an ice cream nutrition label and answer six questions by referring to the label (Figures 11 and 22). This scenario tests both reading comprehension and numeracy skills. The questions allow the patient to demonstrate skills that are often necessary to self-manage chronic diseases, such as the ability to locate relevant information and to use abstract reasoning skills. The label serves a dual purpose, as it can be used for education and promotes a healthy lifestyle by referencing nutrition information. The entire assessment takes under three minutes to complete and is available in English and Spanish. The scores are correlated to the TOFHLA, meaning a score of 4–6 on the NVS indicates adequate health literacy as measured by the TOFHLA. A limitation of the NVS is that the evaluation tends to overestimate the percentage of patients with limited literacy.20 However, some would argue that overestimating is better than underestimating. In addition, the NVS is the newest to the field and has therefore not been used or critiqued as widely as the other evaluations. Usefulness in clinical practice The usefulness of these assessments of health literacy in routine clinical practice has yet to be established, and to our knowledge nothing has been published regarding their performance in community pharmacy settings. An obvious limitation to each assessment is that they all require oral interaction to complete and score the instrument, which may not easily accommodate patients with language or communication barriers. The REALM and REALM-R scores depend on the correct pronunciation of terms to determine the raw reading score; patients with heavy accents or mispronunciation may indeed understand the term in question while those with the “right” pronunciation may not. The use of interpreters or telecommunication devices (e.g., teletypewriter) is possible for the other assessments but increases the time requirement and may limit when and where they can be administered. Furthermore, issues of cultural competence or appropriateness for immigrants, minorities, and patient populations with neurologic (e.g., poststroke) conditions need to be addressed.8 As a result, future studies are needed to determine the role of these assessments in day-to-day pharmacy practice. However, the advent of Medicare Part D and the continued expansion of clinical pharmacy services into community pharmacy settings should provide these opportunities. For example, pharmacists should be encouraged to include a health literacy assessment as a routine component of services such as comprehensive medication reviews, medication therapy management, and expanded disease or medication education sessions. Studies on the selection and implementation of patient-specific assessments and accommodations for patients with disabilities or special needs should be conducted to optimize their use. Other indicators of limited health literacy Since health literacy assessments are not routinely used in pharmacy settings, particularly those where the main emphasis is on dispensing a prescription product, the argument is often made that practitioners should simply assume that all patients would benefit from assistance in navigating the health care system. This would include tasks such as completing medical and insurance forms, scheduling and following directions for health care appointments, complying with medical instructions, and reading and following prescription directions.27 Despite the arguable merit of this approach, there are behavioral signals that all practitioners should be aware of to alert them if a patient is struggling due to health illiteracy. A comprehensive list of patient behaviors that may indicate limited health literacy is included in Appendix A. Among the most revealing of these patient cues is the refusal to read information in front of a pharmacist, health care practitioner, or others. This refusal to read is often the direct result of a fear of failure and shame at not being able to read. One way to test if a patient is willing to read in front of a practitioner is to hand a leaflet upside down to the patient. A patient who does not know how to read will often not orient the leaflet right-side up.30 Another cue is when patients do not fill out medical forms while at the clinic or pharmacy. Many times, patients will take the forms home with them and bring them back completed at a later time, or they may hand the form back with only a few parts of the form completed. It is important to note that these behaviors are cues only and more indicative of the overall literacy level of a patient or written fluency in English (for English-language learners) rather than measures of health literacy per se. While patients must have general literacy skills to understand and use health information, even patients with adequate reading and writing skills may not have the ability to perform the clinical, preventive, and navigation tasks required in the contemporary health care system.31 Likewise, patients with language barriers may not understand oral instructions regarding written materials or forms, or those with good oral communication skills may have difficulty with written information. This is especially true if English is a second or nonnative language. Thus, further interaction or evaluation of both reading and writing and nonreading and nonwriting patients is warranted. A cue specific to the practice of pharmacy is the request by a patient for old prescription bottles to be returned, especially if the bottles have rubber bands, numbers, or symbols on them. Often the patient uses these markings to remember how many tablets to take or when to take the medication. Patients with low health literacy can become extremely distraught when these old bottles are not returned with their newly refilled prescriptions because it disrupts their established coping systems.28 Literacy interventions for pharmacists Once a patient has been identified as someone who may need additional assistance due to health illiteracy, pharmacists should be aware of appropriate means to educate that patient. This includes the use of both education aids and oral counseling methods to achieve the best outcomes. Appropriate educational aids Patient handouts should be written so that patients can use the information in their daily life. Therefore, the most useful handouts focus on the patients’ experience with the disease rather than the pathophysiology of the disease; the emphasis should be on the desired behavior rather than the medical information.32 For instance, a handout for a patient with type 1 diabetes mellitus should focus on how to monitor blood glucose and give an insulin injection rather than the mechanism of action of the insulin. The most useful educational aids combine both pictures and text. Pictures can be essential to helping patients with low literacy understand their health regimen; however, the pictures must be easy to understand. Pictures should be designed according to the following criteria: apply realistic colors, draw images to scale, use appropriate magnification, and maintain an uncluttered background. Abstract pictures, those that convey motion, and those that demonstrate multiple steps can be more difficult to understand, so these and all pictures should be accompanied by written or oral instructions to avoid misinterpretation.33 In a review of the literature, Katz et al.34 found that the combination of pictures with explanatory text significantly enhanced patients’ comprehension of medication labels and patient information sheets versus text-only versions; this is similar to the findings of Dowse and Ehlers.35 Pictograms were reported to be particularly effective in conveying complex information, including timing of doses and special instructions (e.g., take on an empty stomach, complete the antibiotic regimen). The 2004 National Quality Forum report “Improving Use of Prescription Medications: A National Action Plan” recommends that providers simplify written educational materials and use standardized symbols and pictures on drug labels and prescription inserts.36 Thus, pharmacists should be trained to evaluate and modify written medication information used in their practice sites, as needed. The text of all health education materials should be written at the fifth- or sixth-grade reading level.37 The use of medical terminology can significantly increase this reading level; therefore, authors should attempt to replace medical terms with simple explanatory phrases whenever possible.38 There are a few commonly used indicators of readability available: the Flesh-Kincaid Readability Test (FK), the Fry Readability Formula (Fry), and the Simplified Measure of Gobbledygook (SMOG).37,39,–42 Detailed descriptions and advantages and disadvantages of each are included in Table 2. The reading-level indicator available in Microsoft Word is the FK. This indicator typically reads a grade and a half below the other readability formulas and is not highly recommended for measuring the grade level of health care educational aids for this reason.39 The computer software program recognizes each period as the end of a sentence, so abbreviations, numbers with decimals, and bullets can inappropriately lower the reading level.39 The Fry and SMOG both provide more reliable measures of grade level, particularly for health-related material. The Fry is recommended because of its ease of use.39 In addition, the Fry is available in an electronic format called the Health Literacy Advisor (version 1, Health Literacy Innovations, LLC, Bethesda, MD). The SMOG is also readily available to test the readability of health literature, as it is available free of charge on the Internet.42 However, the SMOG is based on strict criteria for readability and calculates the reading grade level based on 100% comprehension of every word, which can lead to an overestimation of the reading level. The National Cancer Institute recommends using the SMOG to analyze health education materials.39 The aforementioned tools are useful for determining the reading level of materials written in English, but currently there is not a single, user-friendly tool for assessing the readability of materials written in other languages. The most favorable approach to developing non-English-language materials is to start with the appropriate English materials and work with well-trained medical translators to convert the materials to other languages.40 The FK, Fry, and SMOG are limited in their usefulness because they measure only the surface characteristics of the text. Once materials have been developed at the appropriate reading level, they should be field-tested with patients to assess coherence and the quality of the text in terms of patient comprehension and learning. Counseling methods for low literacy patients The key to successfully counseling a health illiterate patient is to create an environment that reduces feelings of shame and embarrassment, both of which are significant barriers to optimal communication. One study found that two thirds of health illiterate patients had never told their spouse, one half had never told their children, and 19% had never told anyone about their trouble with reading.29 The primary method to reduce feelings of shame in a practice setting is to avoid asking the patient to read and write; this will require systems to be in place to help patients complete forms and provide additional instructions.40 If the patient is comfortable, relatives should be encouraged to participate in the counseling sessions. Various resources and models exist to help providers communicate clearly with patients. For example, the Indian Health Service counseling model teaches pharmacists to ask patients three prime questions: (1) What did the doctor tell you the medication is for? (2) How did the doctor tell you to take it? and (3) What did the doctor tell you to expect? After asking these questions, the pharmacist should make sure to verify patients’ understanding. To avoid creating barriers associated with poor literacy, the responsibility should be focused on the pharmacist, not the patient. For example, the pharmacist may say, “Just to make sure that I didn’t leave anything out, please tell me how you are going to take your medication.”43 Patients should be encouraged to take an active role in their health care. However, many patients are unsure what questions to ask their provider and have complex communication issues. The Ask Me 3 program from the Partnership for Clear Health Communication (PCHC) encourages providers to make their patients aware of three key questions to ask any health provider.44 These are (1) What is my main problem? (2) What do I need to do? and (3) Why is it important for me to do this? According to PCHC’ website, two different studies have supported the use of the Ask Me 3 program: one at the University of Texas Health Science Center at San Antonio and another conducted by the American Academy of Family Physicians.45 In both studies, more than half of the patients felt that their communication with their physician improved as a result of asking these three questions. To our knowledge, neither study has been published in the medical literature. Similarly, pharmacists and other health care providers must improve their success in facilitating patient–provider communication, particularly in the areas of soliciting information and using effective education methods. In their review of health literacy research focusing on the impact of poor health literacy on patient–physician communication, Williams and colleagues46 described six simple steps that health care providers should take to enhance understanding among patients with low health literacy (Appendix B). Conclusion Pharmacists have a responsibility to make sure that all patients are able to make the best use of their medications. Formal assessments and cues from patient behaviors are tools that pharmacists can use to help identify patients with low health literacy skills and optimize patient care. Using educational aids written at an appropriate grade level with only vital health information and using effective oral communication that verifies patient understanding with an opportunity to ask questions are strategies to improve health outcomes in all patients. Appendix A—Patient behaviors indicating limited health literacy13,27,–30 Asks for old prescription bottles to be returned, especially if bottles have markings or symbols Refers to medications by color and shape rather than by name Opens the medication bottle to identify the medication rather than reading the prescription label Offers excuses when asked to read something (e.g., forgot glasses, will read it later, will show it to a family member) Cannot describe how to take his or her medications Does not know the purpose of each drug Takes drug incorrectly (e.g., early or late refill, nonadherence to regimen) Brings along someone who can read for him or her Frequently misses appointments Has poor adherence to recommended lifestyle changes (e.g., diet, exercise, sleep hygiene) Postpones decision-making (e.g., “May I take the instructions home?” or “I’ll read through this when I get home”) Watches others or mimics behavior Pretends to read offered materials Does not fill out forms while at the pharmacy or health care facility Has no questions about information received Asks staff for help to complete tasks Appendix B—Six steps to enhance understanding among patients with low health literacya Slow down and take time to assess patients’ health literacy skills. Use “living room” language instead of medical terminology. Show or draw pictures to enhance understanding and subsequent recall. Limit information given at each interaction and repeat instructions. Use a “teach back” or “show me” approach to confirm understanding. This approach involves having clinicians take responsibility for adequate teaching by asking patients to demonstrate what they have been told to ensure that education has been adequate. Be respectful, caring, and sensitive, thereby empowering patients to participate in their own health care. a Reprinted from reference 46, with permission. Table 1. Formal Assessments of Health Literacya Assessment Time To Complete Measure(s) Parts Scoring Language(s) aREALM = Rapid Estimate of Adult Literacy in Medicine, NVS = Newest Vital Sign, TOFHLA = Test of Functional Health Literacy in Adults. REALM18 3–5 min Reading 66 medical terms to pronounce 0–18, ≤3rd-grade level; 19–44, 4th–6th-grade level; 45–60, 7th- or 8th-grade level; 61–66, ≥9th-grade level English REALM—Revised23 1–2 min Reading 8 medical terms to pronounce ≤6, risk of poor health literacy English NVS20 3 min Reading and numeracy 6 questions relating to a nutrition label 0–1, probably inadequate; 2–3, possibly inadequate; 4–6, adequate English and Spanish TOFHLA21 22 min Reading and numeracy 3 prose passages and 17 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Short TOFHLA21 12 min Reading and numeracy 2 prose passages and 4 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Assessment Time To Complete Measure(s) Parts Scoring Language(s) aREALM = Rapid Estimate of Adult Literacy in Medicine, NVS = Newest Vital Sign, TOFHLA = Test of Functional Health Literacy in Adults. REALM18 3–5 min Reading 66 medical terms to pronounce 0–18, ≤3rd-grade level; 19–44, 4th–6th-grade level; 45–60, 7th- or 8th-grade level; 61–66, ≥9th-grade level English REALM—Revised23 1–2 min Reading 8 medical terms to pronounce ≤6, risk of poor health literacy English NVS20 3 min Reading and numeracy 6 questions relating to a nutrition label 0–1, probably inadequate; 2–3, possibly inadequate; 4–6, adequate English and Spanish TOFHLA21 22 min Reading and numeracy 3 prose passages and 17 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Short TOFHLA21 12 min Reading and numeracy 2 prose passages and 4 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Table 1. Formal Assessments of Health Literacya Assessment Time To Complete Measure(s) Parts Scoring Language(s) aREALM = Rapid Estimate of Adult Literacy in Medicine, NVS = Newest Vital Sign, TOFHLA = Test of Functional Health Literacy in Adults. REALM18 3–5 min Reading 66 medical terms to pronounce 0–18, ≤3rd-grade level; 19–44, 4th–6th-grade level; 45–60, 7th- or 8th-grade level; 61–66, ≥9th-grade level English REALM—Revised23 1–2 min Reading 8 medical terms to pronounce ≤6, risk of poor health literacy English NVS20 3 min Reading and numeracy 6 questions relating to a nutrition label 0–1, probably inadequate; 2–3, possibly inadequate; 4–6, adequate English and Spanish TOFHLA21 22 min Reading and numeracy 3 prose passages and 17 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Short TOFHLA21 12 min Reading and numeracy 2 prose passages and 4 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Assessment Time To Complete Measure(s) Parts Scoring Language(s) aREALM = Rapid Estimate of Adult Literacy in Medicine, NVS = Newest Vital Sign, TOFHLA = Test of Functional Health Literacy in Adults. REALM18 3–5 min Reading 66 medical terms to pronounce 0–18, ≤3rd-grade level; 19–44, 4th–6th-grade level; 45–60, 7th- or 8th-grade level; 61–66, ≥9th-grade level English REALM—Revised23 1–2 min Reading 8 medical terms to pronounce ≤6, risk of poor health literacy English NVS20 3 min Reading and numeracy 6 questions relating to a nutrition label 0–1, probably inadequate; 2–3, possibly inadequate; 4–6, adequate English and Spanish TOFHLA21 22 min Reading and numeracy 3 prose passages and 17 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Short TOFHLA21 12 min Reading and numeracy 2 prose passages and 4 numeracy items 0–59, inadequate; 60–74, marginal; 75–100, adequate English and Spanish Table 2. Indicators of Readability37,39,–42 Indicator Method Advantage(s) Disadvantage(s) Flesh-Kincaid Readability Formula Counts the number of syllables per word and words per sentence Available in Microsoft Word Reads a grade and a half below other formal tools Fry Readability Formula Takes the average number of sentences and average number of syllables per 100-word passages and plots on the Fry Readability Graph Can be calculated manually, validated in Spanish Time-consuming if done manually Simplified Measure of Gobbledygook Based on average sentence length and number of words with 3 or more syllables in 30 sentences Available free on the Internet, recommended by the National Cancer Institute Calculates reading grade level based on 100% comprehension, overestimates reading grade level Indicator Method Advantage(s) Disadvantage(s) Flesh-Kincaid Readability Formula Counts the number of syllables per word and words per sentence Available in Microsoft Word Reads a grade and a half below other formal tools Fry Readability Formula Takes the average number of sentences and average number of syllables per 100-word passages and plots on the Fry Readability Graph Can be calculated manually, validated in Spanish Time-consuming if done manually Simplified Measure of Gobbledygook Based on average sentence length and number of words with 3 or more syllables in 30 sentences Available free on the Internet, recommended by the National Cancer Institute Calculates reading grade level based on 100% comprehension, overestimates reading grade level Table 2. Indicators of Readability37,39,–42 Indicator Method Advantage(s) Disadvantage(s) Flesh-Kincaid Readability Formula Counts the number of syllables per word and words per sentence Available in Microsoft Word Reads a grade and a half below other formal tools Fry Readability Formula Takes the average number of sentences and average number of syllables per 100-word passages and plots on the Fry Readability Graph Can be calculated manually, validated in Spanish Time-consuming if done manually Simplified Measure of Gobbledygook Based on average sentence length and number of words with 3 or more syllables in 30 sentences Available free on the Internet, recommended by the National Cancer Institute Calculates reading grade level based on 100% comprehension, overestimates reading grade level Indicator Method Advantage(s) Disadvantage(s) Flesh-Kincaid Readability Formula Counts the number of syllables per word and words per sentence Available in Microsoft Word Reads a grade and a half below other formal tools Fry Readability Formula Takes the average number of sentences and average number of syllables per 100-word passages and plots on the Fry Readability Graph Can be calculated manually, validated in Spanish Time-consuming if done manually Simplified Measure of Gobbledygook Based on average sentence length and number of words with 3 or more syllables in 30 sentences Available free on the Internet, recommended by the National Cancer Institute Calculates reading grade level based on 100% comprehension, overestimates reading grade level Figure 1. Open in new tabDownload slide Nutrition label used by the Newest Vital Sign to assess health literacy. Figure 1. Open in new tabDownload slide Nutrition label used by the Newest Vital Sign to assess health literacy. Figure 2. Open in new tabDownload slide Questions and answers score sheet for the Newest Vital Sign assessment of health literacy. Figure 2. Open in new tabDownload slide Questions and answers score sheet for the Newest Vital Sign assessment of health literacy. References 1 Kirsh IS, Jungeblut A, Jenkins L et al. Adult literacy in America: a first look at the findings of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics; 1993 . 2 Youmans SL, Schillinger D. Functional health literacy and medication use: the pharmacist’s role. Ann Pharmacother . 2003 ; 37 : 1726 –9. Crossref Search ADS PubMed 3 Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Washington, DC: National Academy Press; 2004 . 4 U.S. Department of Health and Human Services. Healthy People 2010. www.healthypeople.gov/ (accessed 2007 Aug 17). 5 National Center for Education Statistics. NAAL factsheets. Health literacy component. http://nces.ed.gov/naal/fct_hlthliteracy.asp (accessed 2007 Aug 3). 6 Sentell TL, Halpin HA. Importance of adult literacy in understanding health disparities. J Gen Intern Med . 2006 ; 28 : 862 –6. 7 Mullins CD, Blatt L, Gbarayor CM et al. Health disparities: a barrier to high-quality care. Am J Health-Syst Pharm . 2005 ; 62 : 1873 –82. Crossref Search ADS PubMed 8 Weiss BD, Hart G, Pust R. The relationship between literacy and health. J Health Care Poor Underserved . 1991 ; 1 : 351 –63. Crossref Search ADS PubMed 9 Hope CJ, Wu J, Tu W et al. Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure. Am J Health-Syst Pharm . 2004 ; 61 : 2043 –9. Crossref Search ADS PubMed 10 Muir KW, Santiago-Turla C, Stinnett SS et al. Health literacy and adherence to glaucoma therapy. Am J Ophthalmol . 2006 ; 142 : 223 –6. Crossref Search ADS PubMed 11 Osborn CY, Passhce-Orlow MK, Davis TC et al. Health literacy an overlooked factor in understanding HIV health disparities. Am J Prev Med . 2007 ; 33 : 374 –8. Crossref Search ADS PubMed 12 Schillinger D, Grumbach K, Piette J et al. Association of health literacy with diabetes outcomes. JAMA . 2002 ; 288 : 475 –82. Crossref Search ADS PubMed 13 Praska JL, Kripalani S, Seright AL et al. Identifying and assisting low-literacy patients with medication use: a survey of community pharmacies. Ann Pharmacother . 2005 ; 39 : 1441 –5. Crossref Search ADS PubMed 14 Sleath BL, Jackson E, Thomas KC et al. Literacy and perceived barriers to medication taking among homeless mothers and their children. Am J Health-Syst Pharm . 2006 ; 63 : 246 –51. 15 Shrank WH, Avorn J. Educating patients about their medications: the potential and limitations of written drug information. Health Aff . 2007 ; 26 : 731 –40. Crossref Search ADS 16 Roskos SE, Wallace LS, Weiss BD. Readability of consumer medication information for intranasal corticosteroid inhalers. Am J Health-Syst Pharm . 2008 ; 65 : 65 –8. Crossref Search ADS PubMed 17 Houts PS, Doak CC, Doak LG et al. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006 ; 61 : 173 –90. [Erratum, Patient Educ Couns. 2006; 64:393–4.] Crossref Search ADS PubMed 18 Davis TC, Long SW, Jackson RH et al. Rapid Estimate of Adult Literacy in Medicine: a shortened screening instrument. Fam Med . 1993 ; 25 : 391 –5. PubMed 19 Parker RM, Baker DW, Williams M et al. The Test of Functional Health Literacy in Adults: a new instrument for measuring patient’s literacy skills. J Gen Intern Med . 1995 ; 10 : 537 –41. Crossref Search ADS PubMed 20 Weiss BD, Mays MZ, Martz W et al. Quick assessment of literacy in primacy care: the Newest Vital Sign. Ann Fam Med . 2005 ; 3 : 514 –22. Crossref Search ADS PubMed 21 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. Crossref Search ADS PubMed 22 Wolf MS, Davis TC, Tilson HH et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health-Syst Pharm . 2006 ; 63 : 1048 –55. Crossref Search ADS PubMed 23 Bass PF, Wilson JF, Griffith CH. A shortened instrument for literacy screening. J Gen Intern Med . 2003 ; 18 : 1036 –8. Crossref Search ADS PubMed 24 Case Management Society of America. Chapter 3: health literacy. Case management adherence guidelines. www.cmsa.org/portals/0/pdf/CMAG2.pdf (accessed 2007 Aug 3). 25 Taylor WS. Cloze procedure: a new test for measuring readability. Journalism Q . 1953 ; 30 : 415 –33. 26 U.S. Census Bureau. Census 2000 special tabulations. Profile of selected housing characteristics for the foreign-born population: 2000. www.census.gov/population/www/socdemo/foreign/STP-159-2000tl.html (accessed 2007 Dec 4). 27 Safeer RS, Kenan J. Health literacy: the gap between physicians and patients. Am Fam Physician . 2005 ; 72 : 463 –8. PubMed 28 Hardin LR. Counseling patients with low health literacy. Am J Health-Syst Pharm . 2005 ; 62 : 364 –5. Crossref Search ADS PubMed 29 Parikh NS, Parker RM, Nurss JR et al. Shame and health literacy: the unspoken connection. Patient Educ Couns . 1996 ; 27 : 33 –9. Crossref Search ADS PubMed 30 Lone JM, Thakkar B, Dolinsky D et al. Counseling patients with low health literacy: an educational intervention for pharmacy students. J Manag Care Pharm . 2001 ; 1 : 37 –46. 31 White S, Kolstad A. National Assessment of Adult Literacy (NAAL) health literacy component. http://novel.nifl.gov/nifl/webcasts/20040803/webcast08-03.html (accessed 2007 Dec 4). 32 Center for Health Care Strategies. Preparing patient education materials. www.chcs.org (accessed 2007 Jul 23). 33 Dowse R, Ehlers MS. Pictograms in pharmacy. Int J Pharm Pract . 1998 ; 6 : 109 –18. Crossref Search ADS 34 Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. Am J Health-Syst Pharm . 2006 ; 63 : 2391 –7. Crossref Search ADS PubMed 35 Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns . 2005 ; 58 : 63 –70. Crossref Search ADS PubMed 36 National Quality Forum. Improving use of prescription medications: a national action plan. www.qualityforum.org/txMedUseBEACH09-28-05.pdf (accessed 2007 Dec 4). 37 Center for Health Care Strategies. Tools to evaluate patient education materials. www.chcs.org (accessed 2007 Jul 23). 38 Sand-Jeckin K. The impact of medical terminology on readability of patient education materials. J Community Health Nurs . 2007 ; 24 : 119 –29. Crossref Search ADS PubMed 39 Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav . 2006 ; 33 : 352 –73. Crossref Search ADS PubMed 40 Rosales A. Health literacy among diverse groups. Session presented at Health Literacy for Diverse Audiences workshop. Columbus, OH; 2007 May 8. 41 Health Literacy Innovations, LLC. The Health Literacy Advisor online demo. www.healthliteracyinnovations.com/demo/slideshow (accessed 2008 Mar 10). 42 McLaughlin GH. SMOG readability calculator. www.harrymclaughlin.com/SMOG.htm (accessed 2003 Jul 23). 43 McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effective precepting. Am J Pharm Educ . 2006 ; 70 : 58 . Crossref Search ADS PubMed 44 National Patient Safety Foundation. Ask Me 3. www.npsf.org/askme3 (accessed 2008 Feb 20). 45 Partnership for Clear Health Communication. Pfizer Clear Health Communication Initiative. www.clearhealthcommunication.org/ (accessed 2007 Sep 5). 46 Williams MV, Davis T, Parker RM et al. The role of health literacy in patient–physician communication. Fam Med . 2002 ; 34 : 383 –9. PubMed Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Health literacy in pharmacy
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp070520
DA - 2008-05-15
UR - https://www.deepdyve.com/lp/oxford-university-press/health-literacy-in-pharmacy-LpEx67dZPr
SP - 974
VL - 65
IS - 10
DP - DeepDyve
ER -