Nikki Lurie at RAND and A.I.R. (the contractor that conducted the NAAL) are developing a geographic health literacy estimator using NAAL health literacy data. I believe they will have a working model for one state this summer, and plan to expand it further pending additional funding.
 
Cindy Brach
Center Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
301-427-1444
fax: 301-427-1430
Cindy.Brach at ahrq.hhs.gov

________________________________

From: healthliteracy-bounces at nifl.gov on behalf of Seubert, Douglas
Sent: Fri 6/6/2008 2:57 PM
To: healthliteracy at nifl.gov; Jsorensen at afmc.org; mcggayer at sbcglobal.net
Subject: [HealthLiteracy 2061] Re: Health Literacy Assessment Survey


 

If you really want to do a thorough survey to assess the health literacy of a county population, there are probably many areas you'd need to cover in your questionnaire.

The example of the Low Literacy Prevalence Calculator I mentioned in my previous post is a good starting point. It looks at these key areas:

Percent over 65 years of age
Percent enrolled in Medicaid or other public assistance program
Percentage that are White
Percentage that are Black (African American)
Percentage that are Hispanic
Percentage that mainly speak a language other than English

So, you would want to collect demographic data on age, gender, race (would asking about a person's primary language be part of race?). Considering those enrolled in Medicaid or other public assistance programs is only one aspect concerning income and poverty status. What the calculator does is look at some of the BIG factors impacting literacy. (see my closing comments below for more on this).

An example of a comprehensive health survey that covers many of these key areas -- and has lots of sample questions -- is the California Health Interview Survey conducted by the UCLA Center for Health Policy Research in 2007.  The results were just released in March 2008. You can view the entire report here: http://www.chis.ucla.edu/pdf/CHIS2007_adult_q.pdf

For a "health literacy" survey, you might want to consider questions from these areas:

SECTION A - DEMOGRAPHIC INFORMATION, PART I
Age
Gender
Ethnicity
Race
Marital Status

SECTION G - DEMOGRAPHIC INFORMATION, PART II
Country of Birth
Language Spoken at Home
Additional Language Use
Citizenship and Immigration
Child and Teen Selection
Paid Child Care, Cost
Educational Attainment

SECTION K - EMPLOYMENT, INCOME, POVERTY STATUS, FOOD SECURITY
Hours Worked
Income Last Month
Annual Household Income
Number of persons supported
Poverty level test
Food Availability in Household
Hunger

SECTION L - PUBLIC PROGRAM PARTICIPATION
TANF/CalWORKS
Food Stamps
Supplemental Security Income
WIC
Assets
Alimony/Child Support
Social security/Pension Payments

SECTION M - HOUSING, PARKS, TRANSPORTATION
Housing


OK, that's a lot of ground to cover! Most of this data is probably already collected in your state and is available by county. Since we know some of the BIG factors that impact literacy, we can conclude that they also effect health literacy. Both, however, crossover into every part of our culture. Asking someone's race, education level and employment status may not tell you anything about their health literacy level. For that you almost need to use one of the health literacy assessment tools like REALM or TOFHLA. I suppose you could include some demographic questions and then as a few questions specific to health literacy.

But as stated many times by many experts, health literacy fluctuates. Stress, hearing bad news from a doctor, anxiety, exhaustion, and any number of uncontrollable factors can effect understanding. How do you collect that type of information in a survey?

Also, keep in mind these studies:

Evidence does not support clinical screening of literacy --- According to a recent article in the Journal of General Internal Medicine, clinical screening for literacy is not recommended: "Limited health literacy is a significant risk factor for adverse health outcomes. Despite controversy, many health care professionals have called for routine clinical screening of patients' literacy skills. Whereas brief literacy screening tools exist that with further evaluation could potentially be used to detect limited literacy in clinical settings, no screening program for limited literacy has been shown to be effective. Yet there is a noted potential for harm, in the form of shame and alienation, which might be induced through clinical screening. There is fair evidence to suggest that possible harm outweighs any current benefits; therefore, clinical screening for literacy should not be recommended at this time." http://www.ncbi.nlm.nih.gov/pubmed/17992564?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


Patients' shame and attitudes toward discussing the results of literacy screening --- Health care providers must recognize the potential shame patients might experience as a result of literacy screening. http://www.ncbi.nlm.nih.gov/pubmed/18030638?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


AND MOST INTERESTING OF ALL --- Brief report: screening items to identify patients with limited health literacy skills: According to this study, one screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited and limited/marginal health literacy skills.  http://www.ncbi.nlm.nih.gov/pubmed/16881950?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&dbfrom=pubmed

According to this study, researchers were able to accurately predict which patients had low health literacy skills by asking one question. The results were just as accurate had they used REALM or TOFHLA. So maybe your survey only needs one question????

The idea of a survey for a large population seems like a lot of effort and expense, especially since NAAL already did that for you. We know the BIG factors that impact literacy, and they carry over into health literacy (race, language spoken, education level, employment status) and you should already have access to this information for your county.

A survey won't measure those uncontrollable things that effect us all day to day. Who among us hasn't experienced a time when we didn't understand what someone was telling us (for any of the various reasons I already mentioned). If you give me the TOHFLA test I'd do really well. Or if I took the NAAL survey (http://nces.ed.gov/NAAL/sample_results.asp) right now I'd score in the proficient range. Under stress I wouldn't do as well. 

So, think about using the data already available to you. Create a demographic profile of your county population. List out the BIG factors. Estimate how many people might have low literacy. Use more of your time and energy for educating health care organizations and social services in your community about the need to communicate clearly. Consider the "universal design" concept. Everyone benefits from clear, simple communication.

Doug Seubert
Quality Improvement & Care Management
Family Health Center/Community Heath Access

Marshfield Clinic
1000 N Oak Avenue
Marshfield, WI 54449
www.marshfieldclinic.org/quality

(715) 387-5096 (1-800-782-8581 ext. 75096)
seubert.douglas at marshfieldclinic.org


------Original Message------
From:   "Matt Gayer" <mcggayer at sbcglobal.net>
Date:   Thu Jun 05, 2008 -- 09:12:38 PM
To:     healthliteracy at nifl.gov
Subject:        [HealthLiteracy 2053]  Health Literacy Assessment Survey

Hello All-
    I am health literacy intern this summer at a county health department in Missouri.  My first goal is to assess the current health literacy rate of the county so we can identify strengths and weaknesses, then prepare an implementation plan tailored to best fit the community.  In order to assess current health literacy, I proposed that a survey of some sort would probably be necessary in order to formulate our initial research.  I have been able to thus far find any examples of such a survey/questionnaire, and was wondering if anyone had used/created one or knew from where I could find one.  I very much appreciate any help with this as I prepare to begin the first steps in our new health literacy program.  Thank you.

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