Annals of Family Medicine -- Comments for Jeppesen et al., 7 (1) 24-31

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Original Research:
Kelly Marvin Jeppesen, James D. Coyle, and William F. Miser
Screening Questions to Predict Limited Health Literacy: A Cross-Sectional Study of Patients With Diabetes Mellitus
Ann Fam Med 2009; 7: 24-31 [Abstract] [Full text] [PDF]

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Electronic letters published:

Do We Need to be Screening for Health Literacy?: Paul D. Smith, Kelly Kwiatkowksi, MA (13 February 2009)

Do We Need to be Screening for Health Literacy? 13 February 2009

Paul D. Smith,
Madison, WI
Associate Professor, University of Wisconsin, Department of Family Medicine,
Kelly Kwiatkowksi, MA
Send response to journal:
Re: Do We Need to be Screening for Health Literacy?

When I first became interested in health literacy I was of the mind, as it appears Jeppesen, Coyle, and Miser are, that clinicians needed a better health literacy assessment tool. The literature indicates that several other researchers believe the same(1-5). As these authors and others suggest, there really is no easy way for clinicians to identify patients who have limited health literacy. This is not only unfortunate, it is risky given that only a reported 12% of American adults are proficient in health literacy(6) and we know from many previous studies that limited literacy is associated with poorer health outcomes, increased number of hospitalizations, medication errors, and higher medical costs.
Having done this work for over five years, I believe the more important question to answer is “Should we be screening for limited health literacy?” The low frequency of proficient health literacy in the United States demands that we address the issues of improving effective communication of health information for everyone. I believe this is a better use of effort and resources over finding the “best” screening tool for limited health literacy in clinical settings in certain patient populations. It has already been suggested that the health care system should adopt “universal precautions” regarding health literacy and institute improvements in how health information is communicated in verbal and written format for all patients.(7) After a series of town hall meetings across the country, the Health Literacy Workgroup at the U.S. Department of Health and Human Services is drafting a call to action. Based on the presentations and comments at the town halls, the report likely will consider both sides of the problem: 1. Improving the presentation of complex health information so that is understandable to most people and 2. improving the health related skills and knowledge of all Americans.(8)
What this means for health literacy research and health literacy assessment tools is that research should be focused on clinician-patient communication—identifying what is being discussed at the point of care, how it is conveyed, whether it’s understood, etc. It also means that a health literacy assessment tool that is generally accepted as the gold standard for researching health outcomes and for measuring population- based health literacy should be developed. Health literacy has been reported to be one of the strongest demographic factors associated with health outcomes(9) which suggests that health literacy assessment should become one of the standard demographic factors evaluated for every study about health outcomes whether for individual patients or a particular population.
Healthcare researchers should learn and use the evidence-based methods for conveying health information from the field of adult education and then test those methods in the context of providing medical care or population-based health education. If health literacy researchers put clinician-patient communication at the heart of the research agenda, developed a gold-standard assessment and adopted the methods of adult literacy experts, it would do a whole lot more towards understanding the consequences of limited health literacy and finding effective solutions to address it.
References
1. Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22. Erratum in: Ann Fam Med. 2006 Jan-Feb;4(1):83.
2. Morris NS, MacLean CD, Chew LD, Littenberg B. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006 Mar 24;7:21.
3. Diamond JJ. Development of a reliable and construct valid measure of nutritional literacy in adults. Nutr J. 2007 Feb 14;6:5.
4. Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF Jr. Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD). J Public Health Dent. 2007 Spring;67(2):105-12.
5. Shea JA, Beers BB, McDonald VJ, Quistberg DA, Ravenell KL, Asch DA. Assessing health literacy in African American and Caucasian adults: disparities in rapid estimate of adult literacy in medicine (REALM) scores. Fam Med. 2004 Sep;36(8):575-81.
6. Kutner M, Greenberg E, Jin Y, Paulsen C. 2006. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education. Washington, DC: National Center for Education Statistics.
7. Paasche-Orlow M, Schillinger D, Greene S, Wagner E. How Health Care Systems Can Begin to Address the Challenge of Limited Literacy. J Gen Intern Med 2006; 21:884–887.
8. National Call to Action to Improve Health Literacy, personal communication 2/12/09, Baur C., Director, Division of Health Communication and Marketing, National Center for Health Marketing, Centers for Disease Control and Prevention.
9. Sudore R, Yaffe K, Satterfield S, et al. Limited Literacy and Mortality in the Elderly. J Gen Intern Med 2006; 21:806-812.
Competing interests: None declared