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Assessing Health Literacy in Clinical Practice


Incorporating Health Literacy Assessment Into Clinical Practice

As already discussed, NAAL data indicate that about one third of the American adult population has limited health literacy. Yet clinicians routinely overestimate the ability of their patients to understand medical information, as few clinicians would state that one third of their patients have limited health literacy. Clinicians thus need better awareness of the extent of limited health literacy among their patients.

The tools described in the previous section -- the prevalence calculator and the various assessment instruments -- are all available for use in clinical practice and research. The key questions about them are: (a) should clinicians be assessing health literacy, and if so, (b) how and when should they do it, and (c) which instruments are best?

Should Clinicians Perform Health Literacy Assessments?

Some health literacy experts have argued against performing health literacy assessments in practice because of concerns about offending patients. They argue that it would be preferable to simply use easy-to-use terms and explanation with all patients.

The concern about offending patients may stem from a study in which patients with limited health literacy expressed shame about their limited literacy and reported hiding this limitation from others. Two thirds of patients interviewed in the study had never told their spouse and more than half had never told their children about their limitation; 1 in 5 had never told anyone. [82] Other reports have also discussed the concern that people with limited health literacy harbor shame or embarrassment and do not want their limitation exposed. [83]

While it is true that patients with limited literacy are often ashamed of their limitation, there is little evidence to support the notion that patients would not discuss this limitation with a healthcare provider. Indeed, clinicians ask and patients answer questions about many issues -- sex and drug use being 2 obvious examples -- that are considerably more "invasive" than questions about education and reading skills.

A recent randomized controlled trial evaluated whether patients are willing to undergo a literacy assessment during the course of routine medical care and whether such assessments had an adverse effect on patient satisfaction. [69] Twenty public and private medical practices in Miami were randomized to an intervention group in which the NVS assessment was performed as part of routine nursing check-in procedures, or to a control group of practices in which no health literacy assessments were performed. Patient satisfaction was evaluated in both groups.

Results showed that more than 98% (284 of 289) of patients in the intervention group practices agreed to undergo an NVS assessment; nearly half of these patients had likely or possible limited health literacy based on NVS scores. When satisfaction of patients in the intervention and control group practices was compared, no difference was found. Thus, current research indicates that patients do not object to health literacy assessments during routine medical care, and such testing does not decrease patient satisfaction with care.

How Should Health Literacy Assessments Be Performed?

While the Miami study suggests that health literacy assessments can be incorporated into routine clinical practice, even the most rapidly administered assessment instruments, the NVS and the REALM, require 2 to 3 minutes per patient. In a busy office practice seeing 25 or more patients per day, addition of a health literacy assessment could add considerable time to the office routine. For this reason, many consider it impractical to assess every new patient seen in every practice.

However, given that clinicians so frequently underestimate the number of patients with limited literacy in their practices, many health literacy experts advocate that clinicians should perform health literacy assessments on a sample of their practice's patients -- perhaps 100 to 200 consecutive patients -- to learn the prevalence of limited health literacy among the patients. By conducting this exercise even once, most clinicians will be surprised to learn how many of their patients have limited health literacy.

Anecdotal reports indicate that after performing such an assessment and learning the true prevalence of limited health literacy in a particular practice, clinicians are "won over" to the need to change and simplify their mode of communication with patients. Guides and courses are available to assist clinicians with this change. [60,84,85]

Which Instrument Is Best?

It is difficult to know which assessment method is best because there has been little head-to-head comparison in clinical practice of the various approaches. Furthermore, when head-to-head comparisons have been performed and different instruments find different results, it is not clear which instrument is yielding the correct results.

For example, in a head-to-head comparison of the NVS vs the REALM and S-TOFHLA, the NVS was found to have very high sensitivity for detecting limited health literacy. [86] Its specificity varied, however, depending on whether the REALM or S-TOFHLA was used as the comparison standard, likely because the instruments all measure and emphasize somewhat different aspects of health literacy -- word recognition for the REALM, reading comprehension and numeracy for the S-TOFHLA, and document literacy and numeracy for the NVS.

In the end, it may not be as important which instrument is used as it is for clinicians to be aware of the prevalence of limited health literacy in their practice. Assessing the health literacy skills of a sample of patients using any of the established instruments will provide the answer. When clinicians learn how frequently they deal with patients who have limited health literacy, they can and should adjust their communication style to meet the needs of all of their patients.

Related Online Resources

American College of Physicians Health Literacy Resources

American Medical Association Foundation Health Literacy Initiative


Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide

National Institute for Literacy

National Patient Safety Foundation (Partnership for Clear Health Communication)

Reach Out and Read

Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff

Educational Programs and Institutes

Harvard School of Public Health: Health Literacy Studies

Health Literacy Center
University of New England, Biddeford, Maine

Clear Language Group

Health Literacy and the Older Adult (self-learning module)
University of Arizona Reynolds Program in Applied Geriatrics

Clinical Pearls

Based on the learning objectives of this activity, the key takeaways from this activity are:

  • About 1 in every 3 American adults has limited health literacy and, therefore, has difficulty understanding information provided to them by healthcare providers.

  • People with limited health literacy are more likely to make medication errors, and they have less health knowledge, worse health status, more hospitalizations, and higher healthcare costs than people with adequate literacy.

  • Although there are demographic risk factors for limited health literacy, such as membership in a racial/ethnic minority group, limited education, advanced age, poverty, and others, these factors cannot alone identify patients who have limited health literacy.

  • By using rapid screening tools, such as those discussed in this article, to assess a sample of patients in your practice, you can learn the extent of limited health literacy among your patients.

  • Effective communication techniques, such as those shown in Table 2, can be used to improve communication with all patients but are especially important when a practice's patients have a high rate of limited health literacy.

Supported by an independent educational grant from Pfizer



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