Journal of General Internal Medicine

, Volume 23, Issue 5, pp 561–566 | Cite as

Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

  • Lisa D. Chew
  • Joan M. Griffin
  • Melissa R. Partin
  • Siamak Noorbaloochi
  • Joseph P. Grill
  • Annamay Snyder
  • Katharine A. Bradley
  • Sean M. Nugent
  • Alisha D. Baines
  • Michelle VanRyn
Original Article

Abstract

Objectives

Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population.

Methods

We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of “inadequate or marginal” health literacy based on the S-TOFHLA and 2) inadequate and the combination of “inadequate or marginal” health literacy based on the REALM.

Measurements and Main Results

Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, “How confident are you filling out medical forms by yourself?” had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69–0.79) and 0.84 (95% CI: 0.79–0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting “inadequate or marginal” health literacy than for detecting inadequate health literacy for each of the 3 questions.

Conclusion

A single question may be useful for detecting patients with inadequate health literacy in a VA population.

KEY WORDS

health literacy screening validation questions 

References

  1. 1.
    Institute of Medicine. Health Literacy: a Prescription to End Confusion. Washington DC: National Academic Press; 2004.Google Scholar
  2. 2.
    Kirsch IJA, Jenkins L, Kolstad A. Adult Literacy in America: a First Look at the Findings of the National Adult Literacy Survey. Washington DC: National Center for Education Statistics, U. S. Dept of Education; 1993.Google Scholar
  3. 3.
    Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health literacy: report of the Council on Scientific Affairs. JAMA. 1999;281(6)552–7.CrossRefGoogle Scholar
  4. 4.
    Davis TC, Arnold C, Berkel HJ,et al. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78(9)1912–20.PubMedCrossRefGoogle Scholar
  5. 5.
    Williams MV, Baker DW, Parker RM,et al. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2)166–72.PubMedCrossRefGoogle Scholar
  6. 6.
    Williams MV, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4)1008–15.PubMedCrossRefGoogle Scholar
  7. 7.
    Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12)791–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8)1278–83.PubMedCrossRefGoogle Scholar
  9. 9.
    Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4)475–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Bass PF 3rd, Wilson JF, Griffith CH, et al. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77(10)1039–41.PubMedCrossRefGoogle Scholar
  11. 11.
    Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5(6)329–34.PubMedCrossRefGoogle Scholar
  12. 12.
    Parikh NS, Parker RM, Nurss J, et al. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27(1)33–9.PubMedCrossRefGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6)391–5.PubMedGoogle Scholar
  15. 15.
    Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6)514–22.PubMedCrossRefGoogle Scholar
  16. 16.
    Brandes WL, ed.. In: Literacy, Health and the Law: An Exploration of the Law and the Plight of Marginal Readers Within the Health Care System: Advocating for Patients and Providers. Philadelphia: Health Promotion council of Southeastern Pennsylvania, Inc; 1996.Google Scholar
  17. 17.
    Davis TC, Michielutte , Askov EN, et al. Practical assessment of adult literacy in health care. Health Educ Behav. 1998;25(5)613–24.PubMedCrossRefGoogle Scholar
  18. 18.
    Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004;36(8)588–94.PubMedGoogle Scholar
  19. 19.
    Wallace LS, Cassada DC, Rogers ES, et al. Can screening items identify surgery patients at risk of limited health literacy. J Surg Res. 2007;140(2)208–13.PubMedCrossRefGoogle Scholar
  20. 20.
    Morris NS, MacLean CD, Chew LD, et al. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7:21.PubMedCrossRefGoogle Scholar
  21. 21.
    Wallace LS, Rogers ES, Roskos SE, et al. Brief report: Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21(8)874–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Baker DW, Gazmararian JA, Sudano J, et al. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci. 2000;55(6)S368–74.PubMedGoogle Scholar
  23. 23.
    Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry. 2001;16(2)216–22.PubMedCrossRefGoogle Scholar
  24. 24.
    Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44(8)763–70.PubMedCrossRefGoogle Scholar
  25. 25.
    Jaeschke, Guyatt GH, Sackett DL. Users’ Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. JAMA. 1994;271(9)703–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Delong E, Delong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating curves: a nonparametric approach. Biometrics. 1988;44:837–45.PubMedCrossRefGoogle Scholar
  27. 27.
    The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, Kansas: AAPOR; 2006.Google Scholar
  28. 28.
    Baker DW. The meaning and the measure of health literacy. J Gen Intern Med. 2006;21(8)878–83.PubMedCrossRefGoogle Scholar
  29. 29.
    McGee S. Simplifying likelihood ratios. J Gen Intern Med. 2002;17(8)646–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21)1677–82. Dec 6.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Lisa D. Chew
    • 1
  • Joan M. Griffin
    • 2
    • 3
  • Melissa R. Partin
    • 2
    • 3
  • Siamak Noorbaloochi
    • 2
    • 3
  • Joseph P. Grill
    • 2
  • Annamay Snyder
    • 2
  • Katharine A. Bradley
    • 4
    • 5
  • Sean M. Nugent
    • 2
  • Alisha D. Baines
    • 2
  • Michelle VanRyn
    • 6
  1. 1.Department of Medicine, Division of General Internal MedicineUniversity of Washington, Harborview Medical CenterSeattleUSA
  2. 2.Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Medical CenterMinneapolisUSA
  3. 3.Department of Medicine, Division of General Internal MedicineUniversity of MinnesotaMinneapolisUSA
  4. 4.Health Services Research & Development, Primary and Specialty Medical Care, and Center of Excellence in Substance Abuse Treatment and EducationVA Puget Sound Health Care SystemSeattleUSA
  5. 5.Department of Medicine and Health ServicesUniversity of WashingtonSeattleUSA
  6. 6.Department of Family Medicine and Community HealthUniversity of MinnesotaMinneapolisUSA

Personalised recommendations