Assessing Health Literacy
Kristin Greer
The Christ College of Nursing and Health Sciences
NUR150
March 28, 2011

Assessing Health Literacy
When a registered nurse gets a new client, the nursing process begins with assessing the client. Initial assessment establishes a complete database for problem identification and care planning (Taylor, 2008). There are many issues that can come about if the initial assessment doesn’t consider all aspects of a client’s health including health literacy. United States Department of Health and Human Services defined the term health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Cornett, 2009, p.2). Health literacy is a key concept for a nurse to understand to perform adequate client assessments to enhance client outcome. The client has the right to understand health literacy in order to obtain, use, and interpret their given medical instructions for the follow-up of their treatments. Baker argues that it is unfortunate that patients with limited health literacy are often considered noncompliant, when the real problem is a low level of health literacy (as cited in Cornett, 2009, p. 1). During care the nurse needs to obtain methods to assess the client’s health literacy level to address any low health literacy issues.
Methods to assess a patient’s health literacy can be very simple but also can be technically calculated. Many methods are being constructed and tried through evidence-based practice including: Rapid Estimate of Adult Literacy (REALM, REALM- revised, short- REALM), Test of Functional Health Literacy in Adults (TOFHLA, short- TOFHLA, brief- TOFHLA), Medical Achievement Reading Test (MART), Newest Vital Sign (NVS), and Short Assessment of Health Literacy for Spanish-Speaking (SAHLSA). The two most commonly used in research are the REALM and TOFHLA, each with two reduced versions that are quicker and easier to use (Mancuso 2009). Healthcare facilities are more willing to incorporate effective methods to assess health literacy that are easy to use, quick, and inexpensive.
The REALM version is a 125 word recognition test developed to identify clients with low health literacy and to provide a reading grade for those with limited literacy skills in about 3-5 minutes. Some positive aspects of this method are the excellent reliability with acceptable validity. The shortened version, Short-REALM, is the same grade concept but is a 66 word recognition test taking about 1- 2 minutes. This method is takes less time, has excellent reliability with acceptable validity. The brief version, REALM- R, is again the same design but with only 8 words taking 1-2 minutes with scores less than or equal to 6 being at risk for low health literacy. The validity of REALM-R is questionable. The REALM and its reduced versions are all quick and easy to use and calculate the scores. Also, using health-related words for the word recognition is an acceptable method in a health-care facility. Some drawbacks for REALM include the following: all versions don’t measure the client’s understanding of the words but only measure sight-reading ability, versions are only available in English, and more research needs to be done in regards to reliability and validity (Mancuso, 2009).
TOFHLA is the “golden standard” to test health literacy through a client’s ability to read passages and phrases containing numbers using real materials from the health-care setting. The test consists of two timed parts of numeracy and reading comprehension at 4th, 10th, and 19th grade level involving the client to choose and fill in the most acceptable word from choices to place in a phrase. TOFHLA is a 50 item reading comprehension and 17 item numerical evaluations taking about 22 minutes and scored by the sum of both parts ranging 0-100. Both Spanish and English versions had excellent reliability with good validity. With an original time of 22 minutes the brief version of the TOFHLA, was designed with 40 total items with a time of only 5-7 minutes. The shortest TOFHLA version is only 36 reading comprehension questions taking 7 minutes and scored only 0-36, with good validity. The short TOFHLA only measures reading comprehension and technically not health literacy. Advantages of TOFHLA it has quick and easy administration with strong reliability and an available Spanish version (Mancuso, 2009).
The Medical Achievement Reading Test (MART) in a word recognition test consisting of 42 words based on the Wide Range Achievement Test (WRAT) which determines a clients reading grade level. MART was designed to resolve the excuses a client might give for not being able to read such as using medical terms, small print, and a glossy cover. The advantages of MART are the following: strong reliability, quick use and scoring for more precise grade levels in about 3-5 minutes. A drawback like the REALM-R is that it only assesses sight recognition and not understanding of the medical terms. The MART being based on the WRAT which has strong validity gave researchers a reason for an incomplete evaluation of MART. Their assumption doesn’t guarantee validity so further testing on MART needs to be done (Mancuso, 2009).
The Newest Vital Sign (NVS) is a screening test that uses a six-question assessment using an ice cream label. Scores are calculated from answering questions correctly in regards to the label. NVS works efficiently by the easy use and quick 3-5 minutes administration available in English and Spanish. A problem with NVS is the lack of precision by screening for only a likelihood of low health literacy which possibly overestimates the number of clients titled with limited health literacy (Mancuso, 2009). This aspect may be a positive precaution to ensure a patient’s learning and understanding occurs.
Lastly, the Short Assessment of Health Literacy for Spanish-speaking adults (SAHLSA) is also a word recognition test by the client reading aloud a list of 50 medical terms and associating the term with another term with a similar meaning. An indication of low health literacy is simply done by receiving a score less than 37. Positive features of SAHLSA are quick and easy administration and available score in 3-6 minutes with strong reliability for Spanish-speaking clients. Limitations include questionable validity, no numeracy section, and not applicable to other Latino idiomatic expressions (Mancuso, 2009).
Concerns for these assessment tools are the different screening questions that need to be sensitive to the client’s time restraints and embarrassment. Questions should address if the client receives help obtaining, using, and/ or interpreting medical instructions. Instances would include filling out forms, reading medication labels, and insurance forms (Cornett, 2009). The Single-Item Literacy Screener (SILS) uses a question to identify clients with health illiteracy (Lewis, Dirksen, Heitkemper, Bucher, Camera, 2010). The question is, “How often do you need to have someone help you when you read instructions, pamphlets, or written documents from the physician or pharmacy?” which allows the patients an opportunity to express their needs but there is no guarantee they will be truthful. The questions need to be unbiased and non-judgmental in order to enhance the honesty and trust between the client and the healthcare provider, which may possibly lead to the nurse verbalizing the questions. Also, a nurse may use the client’s preferential style of learning by reading, discussing, observing and listening. Using the client’s preferred method of learning is a possible method to assess and address a client’s health literacy needs.
A nurse should be able to use their initial assessment to pick up certain clues that may indicate low health literacy. Some clues include excuses for incomplete forms and medical history, odd behavior during instruction, and incorrect information when using the teach-back method. The “teach-back” method is a useful tool for patients to confirm their understanding with their own words while the nurse assesses the need to clarify anything further (Cornett, 2009). “Teach-back” method is a good indicator on how a nurse’s teaching methods are working for the client and if the nurse needs to try an alternate route for the benefit of the client, such as printed communication.
The Joint Commission created guidelines to assess client health literacy but does not require specific testing. The reason for not requiring tests for health literacy is to reduce the client’ embarrassment and shame that would likely occur if the test was required (Cornett, 2009). The ultimate purpose for health literacy is for the client to feel empowered in order to promote and maintain good health (Speros, 2005). Options that are currently being evaluated in evidence-based research for methods to assess health literacy in a client include: REALM, TOFHLA, MART, NVS, and SAHLSA. The strongest method or “golden standard” and most heavily researched is the TOFHLA method because of the reading comprehension plus numerical parts. Without any current regulated form to test health literacy it is upon the nurse’s best judgment to assess the client’s needs. Again, there is a need to address the issue of client health literacy and the nursing assessment to interconnect through the proper assessment methods. Whether a nurse’s assessment is having the patient reading words (REALM, TOFHLA, MART, SAHLSA) or asking direct questions about a given label (NVS), the best method remains unknown. Evidence- based practice will continue to evaluate the effectiveness of the many health literacy methods and encourage the use of a method that offers the best results. A registered nurse may only begin care with their initial assessment of new client, yet it is this important step that can lead to a positive or negative medical outcome for the client.
References
Cornett, S. (2009). Assessing and addressing health literacy. The Online Journal of Issues in Nursing, 14(3), 1. Retrieved from EBSCOhost.
Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2010). Medical surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis: Mosby.
Mancuso, J. (2009). Assessment and measurement of health literacy: an integrative review of the literature. Nursing & Health Sciences, 11(1), 77-89. Retrieved from EBSCOhost.
Speros, C. (2005). Health literacy: concept analysis. Journal of Advanced Nursing. 50(6), 633-640.
Taylor, C. R., Lillis C., & LeMone, P., Lynn P. (2008). Assessing. Fundamentals of nursing: The art and science of nursing care (6th ed.). 243-258. Philadelphia: Lippincott, Williams, & Wilkins.