Health literacy is a major determinant in patients’ abil-ity to achieve optimal health. The term literacy is usedto describe the ability to read and write, whereasfunctional health literacy involves the ability to obtain,understand, and process information vital to managinghealth. In today’s ever-changing health care environ-ment, it is essential that patients possess the healthliteracy skills necessary to make informed decisions.These skills often lead to longer life, reduced chronicdisease, and decreased health disparities.1 It is esti-mated that only 12% of the 228 million United Statesadults have the skills to adequately manage theirhealth care.2 Limitations in health literacy have beenassociated with more visits to providers, more fre-quent hospitalizations, increased morbidity, and higherhealth care costs.

Healthy People 2010 cited improvement ofhealth literacy as fundamental in reducing healthdisparities. Improvement begins with assessment.Numerous tools have been developed to assistwith assessment of health literacy. These tools fallinto 1 of 4 main categories: word recognition tests,reading comprehension tests, functional health lit-eracy tests, and informal methods.2,3

Word recognition tests are lists that patients areasked to read within a certain time frame. Thetests can generally be administered within 5 min-utes, but they measure only reading ability, notinterpretation or comprehension of the writtenmaterial. Examples of word recognition tests arethe Wide Range Achievement Test–Revised(WRAT-R), Rapid Estimate of Adult Literacy inMedicine–Short Form (REALM-SF), ShortAssessment of Health Literacy for Spanish Adults(SAHLSA-50), and the Medical TerminologyAchievement Reading Test (MART).2,3

Reading comprehension tests assess under-standing of information, but they are limited inmeasuring functional literacy, which is the ability toapply that information to one’s own situation. Theyare more time consuming to administer than word

recognition tests. The current tests are used morecommonly in educational rather than health caresettings.2,3

Functional health literacy tests assess patients’ability to comprehend and then act on the healthinformation they have received, thus demonstratingtheir level of functional health literacy. Examples ofthese tests include the Test of Functional Health

Literacy in Adults (TOFHLA) and the Newest VitalSign (NVS). The TOFHLA measures reading andfunctional application by having patients read andcomplete missing sections of selected passages ofinformation regarding an upper GI series, Medicaidapplication, and an informed consent document.Numeracy is assessed by reading and applying pre-scription labels and appointment slips. The originalTOFHLA takes 20 -30 minutes to administer andscore. A shortened version (S-TOFHLA) thatrequires 10-12 minutes for completion is now available.2,3

The NVS assesses functional health literacy byhaving patients read a nutritional label, then answer6 problem-solving questions. Administration andscoring can be accomplished in under 5 minutes.Both Spanish and English versions of the NVS, S-TOFHLA, and TOFHLA are available.2,3

Informal methods are the most common cate-gory of health literacy assessments. They involvethe observation of behavior patterns, such as sub-mitting incomplete forms, refusing to completeforms in the office, forgetting eyeglasses neces-

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Virginia Moore, WHNP-BC

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sary for reading information during visits, adminis-tering medication erratically, missing appointments,or failing to follow through with diagnostic tests orprocedures. Some providers employ the use ofopen-ended questions to gauge health literacy.Commonly used questions are “How confident areyou filling out medical forms by yourself?”, “Howconfident are you reading a prescription label?”, or“How confident are you answering specific medicalquestions?” Patients select 1 of 5 responses rang-ing from not at all confident to very confident.Interventions are based on the selectedresponses.2,3

Shame has been cited as the prevailing emotionassociated with limited health literacy. As a result,patients can be quite adept at hiding their limitations.Because of this, many providers have elected toforego screening and focus efforts on improvingcommunication with patients. Much attention hasbeen directed to the readability of written materials.

Readability tools can assist in developing materi-als that are appropriate for desired reading levels.The Flesch-Kincaid grade level and reading easetools are available for use with Microsoft Word.Other tools can be found at www.readabilityformulas.com. Additional suggestions for improvingreadability in written materials include a white back-ground to minimize distractions, pictures andgraphics for a better grasp of concepts, bulletpoints instead of paragraphs, and an emphasis ondesired behavior over medical facts.4

Strategies to ensure patient comprehension ofinformation include the teach-back method and theAsk Me 3. In the teach-back method, patients areasked to restate in their own words what was justexplained to them. Ask Me 3 teaches patients toask the following questions during any health careencounter: “What is my main problem?”, “Whatdo I need to do?”, and “Why is it important for meto do this?”5

Health literacy can affect patients’ ability to self-manage care and treatment plans. Several methodsare available to assess health literacy levels, as well asnumerous strategies to address limitations.Recognizing limitations and implementing appropriatestrategies will help to achieve optimal health.

References

1. National Institutes of Health. Health Literacy. http:/ / www.nih.gov/ clearcommunication/ healthliteracy.htm. Accessed November 21, 2011.

2. Egbert N, Nanna KM. Health literacy: Challenges and strategies.http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Health-Literacy-Challenges.aspx. Accessed January 10, 2012.

3. Glassman P. Health literacy. http:/ / nnlm.gov/ outreach/ consumer/ hlthlit.html. Accessed November 21, 2011.

4. Rajda C, George NM. The effect of education and literacy levels onhealth outcomes of the elderly. J Nurs Pract. 2009;5(2):115-119.

5. National Patient Safety Foundation. Ask Me 3. http://www.npsf.org/askme3. Accessed November 21, 2011.

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244 The Journal for Nurse Practitioners - JNP Volume 8, Issue 3, March 2012

Virginia Moore, MSN, WHNP-BC, is an instructor in nursing atthe Vanderbilt University School of Nursing in Nashville, TN,and can be reached at ginny.moore@vanderbilt.edu.