Hi, I'm Debra Roter and a professor in the Department of Health, Behavior in Society. Today I'm going to talk with you about literacy assessment and educational materials for populations with limited health literacy. The overall objectives for today's talk is to provide definitions of functional literacy and functional health literacy, to describe various approaches to the assessment of health literacy, to consider the implications and the consequences of literacy deficits on medical risks and health outcomes, to become familiar with adult education principals and perspectives as applied to this issue of materials development for populations with literacy deficits, and finally, to appreciate the power of plain language and a good story as a vehicle of health education and behavior change, and as an especially effective strategy for reaching people with marginal literacy skills. The first section will focus on the differences and similarities between literacy and health literacy. When we consider the differences and similarities between literacy and health literacy, we can think very broadly about the philosophic differences reflected in the statement of end goals and definitions. But it's also important to recognize that assessment and operationalization in both general literacy and health literacy are similar, they share a common skill base. Often but not always, general functional literacy assessments and health literacy assessments differ in topical focus. What I mean by that is, in measures of general literacy, there may be questions that are about reading food labels, for instance. A content of topic that overlaps with health literacy assessments. Definitional and philosophic differences as I noted, exists between measures and conceptualization of functional health literacy and broad functional literacy. The important elements of the definition for functional health literacy is the degree to which individuals have the capacity to obtain process and understand basic health information and services needed to make appropriate health decisions, and it is the second part of that definition, which really is a statement of the end goal. Functional health literacy is designed and appreciated as a mechanism of assisting patients in making health decisions. This notion of appropriate health decisions is also an interesting element of the definition. These definitions were used by healthy people 2010 and in the Institute of Medicine report on health literacy, as well as the Task Force of the American Medical Association on health literacy. So it's widely adopted and widely used. The notion of appropriateness of health decisions then is largely taken within a medical care context. Some of the controversy is who determines the appropriateness of a health decision? Is that a medical provider or a medical institution or is it an individual patient? Most people would argue that a health decision is one that an individual feels as appropriate for themselves. But there are health decisions that health care providers believe, there is little controversy around the appropriateness or the non-appropriateness of the decision. If we take a shift to think about what the definitions of functional literacy are, they're not dealing with decisions, or decision-making at all. The definition of functional literacy is the ability to read, write, and speak in English, and compute and solve problems at a level of proficiency necessary to function on the job in society, to achieve one's goals, and develop one's knowledge and potential. A very broad perspective of the means to an end. Your ability to read, write, speak, compute, and solve problems to an end. The ability to function on the job and in society but not only that, the ability to achieve one's goals and to develop one's knowledge and one's potential. There are a number of measures that have been widely used for health literacy. Perhaps the best known of these measures is the Test of Functional Health Literacy in Adults, often referred to by its acronym TOFHLA. There are both long and short measures of the TOFHLA, which I'll describe in a few minutes. A second popular measure of health literacy is the Rapid Assessment of Adult Literacy in Medicine called the REALM. There is also a longer and shorter version of the REALM. Third approach to Subjective Assessment of Literacy. The subjective assessment simply asks people about their comfort in using health information, and I'll give you some illustration of that. I'll begin to talk a little bit more about the specifics of the Test of Functional Health Literacy in Adults. The popularity of this measure is largely based on its face validity, and you'll see what I mean in that context in a few minutes. It's used among English and non English-speaking patient populations. This is important in a distinction from measures of general literacy, at least those measures used by the National Adult Literacy Survey, which is limited to English speakers. So in developing the health literacy in adults measure, interest was to broadly characterize how well patients, overall, will be able to access health information too, as you remember, used to make appropriate health decisions. Because it's applied to all patients, there's much more of an appreciation for how non English-speakers may be struggling with using an accessing health information. So there are three aspects of the TOFHLA. There's a measure of numeracy and unlike general literacy, it's not only ability to do mathematical calculations. In the TOFHLA, the measures of numeracy are specifically applied to a patient's ability to do calculations in regard to things like medication, administration, and dosing. There's also a measure of document literacy. The idea is to be able to present challenge to patients that can reflect their ability to understand and navigate appointment and referral slips. So if they see a document, like an appointment slip, will they be able to figure out where they have to go and when? That is navigation and fact-finding within a document format. Finally, the TOFHLA uses an investigation of comprehension of prose. It's not just "Can a patient read a presentation or a statement, something like consent forms or procedures for preparation?" But do they really understand? Can they comprehend that? The approach taken in the TOFHLA is the use of what's called closed format questions, and I'll illustrate that in the next few slides. The TOFHLA prose measure, the cloze format, is a way of assessing comprehension by asking patients to fill in a word given in a list of alternatives, which would assess their comprehension of not just the words that are opposed, but the meaning of the entire sentence. So on the slide, I have an illustration of a passage. For instance, your doctor has sent you to have a blank X-ray. The alternatives are; a stomach X-ray, a diabetes X-ray, a stitches X-ray, or germs X-ray. So the question there is whether a respondent can choose the correct answer, which is a stomach X-ray. They have to understand that you cannot X-ray diabetes, you cannot X-ray a stitch or you cannot X-ray germs. Another example is the last one on the slide, the day before an X-ray, these are procedures, for supper, only have a blank snack of fruit, and the alternatives are; a little snack of fruit, a broth snack of fruit, an attack snack of fruit, or a nausea snack of fruit. The second part of this sentence is blank and jelly with coffee or tea, and the alternatives are; toes, throat, toast, or thigh. Clearly the correct answer is toast and jelly with coffee and tea. The document measure of TOFHLA is designed to assess how well a respondent can navigate a document presentation. In the slide, there is a facsimile of an appointment slip that might be given to a patient by a doctor for a referral. It provides information regarding the name of the clinic, the location in the hospital, the day, the date, hour of the appointment. The challenge is, however, that the way in which the information is presented may be confusing to an individual that has literacy deficits. The way the test works is that the respondent is given this appointment slip and asked to respond, when is your next appointment? Hoping that they can find the day and where should you go? Hoping that the patient would understand and report the location and the clinic name. Finally, there's a TOFHLA numeracy measure. Here as I had intimated earlier, is assessment of calculation that a patient may need to make to appropriately take medication or follow instructions associated with the medication. The slide shows a medication label that names the doctor who has prescribed the medication, the name of the medication, the dosage, and an instruction which reads, take the medication on an empty stomach one hour before or two or three hours after a meal, unless otherwise directed by your doctor. The questions are;if you eat lunch at 12 noon, and you want to take this medication before lunch, what time should you take it? So the calculation is based on the instruction to take it on an empty stomach, one hour before, or two or three hours after eating. Then the follow-up question is, if you forgot to take it before lunch, what time should you take it? Again, that is an indication of whether the patient can make these very basic calculations. This is a good time to take a break, and when we resume, we'll discuss some of the TOFHLA findings.
