Journal of General Internal Medicine

, Volume 21, Issue 8, pp 874–877 | Cite as

Brief Report: screening items to identify patients with limited health literacy skills

  • Lorraine S. WallaceEmail author
  • Edwin S. Rogers
  • Steven E. Roskos
  • David B. Holiday
  • Barry D. Weiss
Original Articles


BACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians.

OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills.

METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard.

RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question. “How confident are you filling out medical forms by yourself?” was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P <.01) and also a greater AUROC than questions based on demographic characteristics.

CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Key words

literacy health literacy screening 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    National Center for Education Statistics. National Assessment of Adult Literacy A First Look at the Literacy of America’s Adults in the 21st Century. NCES Publication No. 2006470, December 2005.Google Scholar
  2. 2.
    Paasche-Orlow MK, Parker RM, Gazmararian JA, et al. The prevalence of limited health literacy. J Gen Intern Med. 2005;20:175–84.PubMedCrossRefGoogle Scholar
  3. 3.
    Weiss BD. Epidemiology of low health literacy. In: Schwartzberg JG, VanGest JB, Wang CC, eds. Understanding Health Literacy. Chicago, IL: American Medical Association; 2005:17–39.Google Scholar
  4. 4.
    Institute of Medicine. Health literacy: a prescription to end confusion. In: Neilsen-Bohlman L, Panzer AM, Kindig DA, eds. Washington, DC: National Academy Press; 2004:59–107.Google Scholar
  5. 5.
    Bass PF, Wilson JF, Griffith CH, et al. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Lindau ST, Tomori C, Lyons T, et al. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol. 2002;186:938–43.PubMedCrossRefGoogle Scholar
  7. 7.
    Brez SM, Taylor M. Assessing literacy for patient teaching: perspectives of adults with low literacy skills. J Adv Nurs. 1997;25:1040–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–34.PubMedCrossRefGoogle Scholar
  9. 9.
    Parikh NS, Parker RM, Nurss JR, et al. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health. 1994;84:119–21.PubMedCrossRefGoogle Scholar
  11. 11.
    Weiss BD, Coyne CA. Communicating with patients who cannot read. N Engl J Med. 1997;337:272–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Weiss BD. Health Literacy: A Manual for Clinicians. Chicago, IL: American Medical Association Foundation; 2003.Google Scholar
  13. 13.
    Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391–5.PubMedGoogle Scholar
  14. 14.
    Parker RM, Baker DW, Williams MV, et al. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.PubMedCrossRefGoogle 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;3:514–22.PubMedCrossRefGoogle Scholar
  16. 16.
    Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.PubMedGoogle Scholar
  17. 17.
    Centers for Disease Control and Prevention. Behavioral risk factor surveillance system. Available at: Accessed May 23, 2005.Google Scholar
  18. 18.
    Browner WS, Newman TB, Cummings SR, et al. Estimating sample size and power: the nitty-gritty. In: Hulley SB, Cummings SR, Browner WS, Grady D, Hearst N, Newman TB, eds. Designing Clinical Research. 2nd edn. Philadelphia: Lippincott Williams & Wilkins; 2001;65–85.Google Scholar
  19. 19.
    Bennett IM, Robbins S, Al Shamali N, et al. Screening for low literacy among adult caregivers of pediatric patients. Fam Med. 2003;35:585–90.PubMedGoogle Scholar
  20. 20.
    Sanders LM, Zacur G, Haecker T, et al. Number of children’s books in the home: an indicator of parent health literacy. Ambulatory Pediatr. 2004;4:424–8.CrossRefGoogle Scholar
  21. 21.
    Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Counc. 1999;38:33–42.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Lorraine S. Wallace
    • 1
    Email author
  • Edwin S. Rogers
    • 1
  • Steven E. Roskos
    • 1
  • David B. Holiday
    • 2
  • Barry D. Weiss
    • 3
  1. 1.Department of Family MedicineUniversity of Tennessee Graduate School of MedicineKnoxville
  2. 2.Research Triangle InstituteAtlantaUSA
  3. 3.Department of Family and Community MedicineUniversity of ArizonaTucsonUSA

Personalised recommendations