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REVIEW
MPharm Year 4 Research Project
Medicine Management
Student name: Quang T. Bui
Student ID: 4548337
A systematic review of health literacy measurementsQuang Thanh.Bui., Bhattacharya Debi. PHD, Paul Duell.
AbstractOjective: Health literacy has been an important factor ever since it was first conceptualised. However, despite its application, there is no “gold standard” test for measuring health literacy. We conduct a systematic review of the currently available tools and examine the different domains that they measure. We also take a look at the practicality of these tools to use in a community pharmacy setting.
Methods: We searched Ovid, Medline, Embase, CINAHL and PHARMLINE (1946-2013) for studies using either validated tools or validating a newly developed tool. Data was extracted and quality was assessed using a combination of Cochrane, CASP and Cosmin for their psychometric data. Data was aggregated and reported as trend.
Key findings: Of the 49 eligible studies with unclear to poor quality, 15 validated a newly developed tool and 34 used validated tools. The newly developed tools did not show enough clinical data to make any recommendation. Limited evidences suggested that the difference between TOFHLA and REALM was not significant, but there was clear discrepancy between numeracy skill and health literacy level. There was an association between completion time of a test and health literacy level measured, however evidence was not enough to make a conclusion. We would recommend for NVS to be used primarily based on available data; however due to the poor quality of the studies included, more research needed to be done.
Conclusion: Despite the quality of the papers, our study showed a clear discrepancy between numeracy and health literacy score, and the similarity between TOFHLA and REALM. More research would be required before reaching to a conclusion, but our data suggest that NVS should be used in community pharmacy.
Keywords: systematic review, health literacy,
numeracy, community pharmacy.
Introduction
The concept of health literacy was first recognised
in 19741, even though the main focus at that time
was to educate children to be “literate” in health as
they were in other subject like science or maths.
Subsequently, earlier efforts to define this have
been limited to the individual’s ability to
understand basic reading to function in a health
care setting2. With the recent focus on patient
education and share decision making, the term
health literacy has become of increasing
importance; thus the concept has been broadened
out. Ratzan argued that health literacy was not
simply health knowledge, but also needed to take
into account on other factors like age, mental
capacity and environment3. All of these will
account for an individual’s ability to process the
information and actually take an appropriate
decision. Because of the complexity of these
elements, Ratzan recognised the difficulty of
coming to an agreement for a definitive description.
A recent definition by the World Health
Organisation further expanded the concept, with
the rationale that health literacy was not limited to
a measure of writing and reading, but more
importantly, what it allowed us to do. This included
both cognitive function and social skills that
created the necessary motivation for making an
informed health decision. The new included
elements were categorised by Nutbeam into three
levels of health literacy: functional (acquiring of
information), interactive (development of skill
under educational environment) and critical
(development of cognitive function and skills to
make analyses and informed decisions) 4. A recent
definition has broadened the term
to include a group of individuals with regards to
public health literacy5.
The vast amount of definitions being used in
practice has led to a problem when considering a
measurement tool to be “standard”. A logic model,
developed by Berkman et al to analyse health
literacy, covers all three elements of the Nutbeam
definition; along with a simplistic behaviour model
called the Integrative Theory6..
The model took into account the common
influencing factors that could affect an individual’s
health literacy level, such as age, gender, ethnicity
and the relationship between the patient and
physician. A low level of health literacy could
affect an individual’s ability to access information
and evaluate emergency situation relating to him or
another’s health. This ability, coupled with
personal resources and the right level of support,
could define one’s health behaviour and his
adherence and lead to better outcomes: prevention
of diseases, lowering of risk factors, etc. Hence,
incorporating the same factors into a health literacy
measurement could potentially improve its level of
accuracy. His model, however, is not the definitive
guide to developing a measurement tool. The
direction of good outcome is not specified all the
time: while increase in adherence will lead to good
outcome, an increase in hospitalisation, however,
leads to bad outcome. Furthermore, several factors
are not included in this model. Higher cognitive
functions such as processing speed, inductive
reasoning or verbal ability have been shown to
impact an individual’s health literacy skill7.
Personal motivation, the extent to which an
individual actively seek out and engage with
information, also play an important part in defining
health literacy skill. A lack of motivation could
become a barrier and thus prevent the patient from
accepting diagnosis and reduce therapy
compliance8. A good tool therefore should cover all
these areas and be able to convert them to a rational
and meaningful scale.
Multiple tools are currently being used in practice
such as TOFHLA (Test of Functional Health
Literacy in Adult) or REALM (Rapid Estimate of
Adult Literacy in Medicine); each with separate
questions sets and covers different areas of the
definition. While various forms of TOFHLA
measures patient’s ability to perform health-related
task requiring reading and computational skills9,
REALM focuses on recognition and pronunciation
of medical words10. Similarly to TOFHLA, the
NVS (Newest Vital Sign) screening tool measures
the patient’s reading comprehension and basic
problem solving skills11. Most of these tools
focused on communicative or basic comprehension
elements and cover the static definitions of health
literacy, i.e. an individual’s progression in health
literacy over time is not reported. Each tool
measures different domains that affected an
individual’s health literacy level, as well as
covering different elements of Nutbeam’s
definition. To complicate the matter further, each
test also has a number of variations; S-TOHFLA
for example is a shorter version of TOHFLA and
can be used either with or without a time limit. This
small change can potentially produce significantly
different results when using correctly. Additionally,
the fact that these current tools only focus on
measuring an individual’s functional health literacy
skill raises the question of whether it is actually
useful to measure the other domains of Nutbeam’s
definition.
Because of these complications, despite their
frequent use, there has not been many reviews
conducted for comparison between these tools, and
most studies were done at a small scale. Either of
these tools is considered “standard” because of
their difference and applications. Therefore, further
research is required to evaluate the sensitivity and
validity of the current tools in use.
In this paper, we conduct a narrative review of the
current measurement tools, following Nutbeam’s
definition on the three elements of health literacy.
Thus, our focus was on determining the feasibility
of using the existing tools in a healthcare setting.
The sensitivity, validity and acceptability of each
tool will be taken into consideration when applying
to the healthcare environment. As each tool covers
different domains of the definition, a clear
description of domains representation by existing
tools will be reported. Furthermore, an assessment
on how each domain affect the final outcome of
health literacy will be conducted.
Methods
A standard systematic review method using the
Cochrane Guidance12 and York Handbook13 was
performed by two independent researchers in
autumn 2012 and spring 2013 and the results
compared and combined to obtain information
regarding the objectives outlined above.
Studies were identified through electronic searches
through the database of Ovid, Medline, Embase,
CINAHL and PHARMLINE (1946-2013). Search
strategies identified appropriate subject headings
plus text words: 19 keywords “measure”, “tool”,
“assess”, “critical”, “functional”, “communicate”,
“motivation”, “cognitive”, “Social skill”,
“numeracy”, “acceptable”, “feasible”, “valid”,
“perform”, “psychometric”, “score”, “sensitive”,
“specific” and “reliable” were combined (without
quotes) using truncations (*), wild cards ($),
hyphens and other relevant Boolean operators
and/or were combined with the search terms health
literacy or health competen*. From the resulting
list, studies were selected based on their titles and
abstracts.
Studies were included if they were 1) conducted in
a healthcare setting, with participants old enough to
have gone to school to be taught to read, 2)
measuring at least one of the domains of health
literacy defined by Nutbeam: functional,
communicative or critical, 3) along with studies
considering numeracy from a health literacy
perspective, and 4) including descriptive or
psychometric data comparing validated tools with
new tools. Exclusion criteria included studies
which only validated a foreign version of an
existing health measure developed in an English
speaking country, were conference abstracts or had
a sample size less than 50 participants.
An abstract screening tool was developed based on
the study inclusion and exclusion criteria to
identify the articles to be included in the systematic
review. Screening process was undertaken by two
independent researcher. Disagreements were
resolved by consensus and recorded for study
purpose.
Independent, duplicate data extraction of each
included study was performed by two researchers.
The data extraction form developed for this study
was piloted using a sample of studies and checked
for inter-rater reliability for the recording of
outcome data and quality assessment. Differences
were resolved through discussion or third party
referral if required. The following data was
extracted from the full papers:
Details of the authors, country of
publication/study, year of publication,
study population, setting and recruitment,
number of patients invited to the study,
number of patients that signed up and
participant dropout rates, exclusion
criteria. Demographic data such as sex and
age.
Details of the health literacy measure(s)
including the number and type of
questions asked, the scoring system, time
taken to complete and the different
classifications of health literacy within the
measurement scale and the domain
measured and results obtained.
Psychometric outcome data measures such
as content, criterion construct and face
validity, specificity, feasibility, sensitivity
and acceptability.
Independent, duplicate quality assessment was
conducted as part of the study by two researchers.
The main tool was decided to be the Cochrane
tool12 for reporting bias because of its reputation as
a validated tool. Although the “Sequence
generation” criterion was removed for not fitting
with the study, it was felt that this was a best fit for
the study. Additional assessment criterion was
included from the CASP co-hort study
questionnaire14. Studies measuring psychometric
data would be assessed by the Cosmin checklist15
for internal consistency, content validity and
criterion validity.
Results
Abstract screening
Based on the combination of keywords and search
terms, 453 publications were identified. From this
pool of samples, abstract screening process was
conducted independently and the final result, after
discussion, was 79 publications selected to data
extraction process. The agreement rate between
two researchers was high (93%), and the strength
of the agreement was good (Kappa= 0.799, SE =
0.035).
Figure 1:Flow diagram for selection of studies.
Data extraction
Out of the 79 publications selected, 18 were
excluded for being conference abstract, 6 as full
paper unavailable, 3 as translated version of an
English health literacy tool, 2 as fewer than 50
patients sample size, and 1 for being written in
another language. The final number of articles
chosen was 49 (62.0%) out of 79. Of the 49
articles, 15 (30.6%) were validation of a newly
Iden
tifica
tion Records identified through
database searching (n = 453)
Record screened (n=453)
Record excluded (n= 374)
Scre
enin
g
Full text article accessed (n=79)
Full text article excluded (n= 30)
Conference abstract n=18
Full text unavailable n=6
Translated version of an English health literacy tool n=4Studies included in
systematic review (n=49)In
clud
ed
developed tool. Figure 1 showed the flow diagram
of the studies selection process.
Analysis of study and methods
Over three quarters (79.1%) of the studies were
collected from convenient sample. The majority
(78.9%) of studies were conducted in the USA and
performed in English (82.7%). The target
population of most studies were mostly white,
African American, Latinos or Hispanic patients.
The sample size ranged from 50 to 6,819. Table 1
showed a summary of the studies involved in this
review, including participation rate and
demographic data.
Main exclusion criteria of most studies were visual
impairment (35.4%), cognitive impairment (18.8%)
and hearing impairment (14.6%).
Table 1: Summary of the studies included
Year of
publishi
ng
Authors Research Objectives (Approached/
Eligible)
Drop out
during
assessment
Time
required
Mean
age
Male
percentag
e
Female
percenta
ge
2011 Kirk K.J. et.al Performance of health literacy tests among older adults
with diabetes16
(563/593) 128 NA NA 38.1 61.8
2011 Kim M.T. et.al Development and validation of the high blood
pressure-focused health
literacy scale17
(440/NA) NA 10-15
minutes
70.9 30.5 69.5
2012 Ghaddar S.F.
et.al
Adolescent health literacy: The importance of credible
sources for online health information18
(305/NA) 25 NA 15.9 40.2 59.8
2011 Yin H.S. et.al Assessment of health literacy and numeracy among
Spanish-speaking parents of young children: Validation
of the Spanish parental health literacy activities test
(PHLAT Spanish)19
184/263) 8 NA 27.7 10.8 89.2
2011 Ferguson B.
et.al
Assessing literacy in clinical and community settings:
the patient perspective20
(150/NA) NA 40-45
minutes
NA 22 78
2011 Patel P.J. et.al Testing the utility of the newest vital sign (NVS) health
literacy assessment tool in older African - American
patients21
(62/NA) NA 17 minutes 73.2 NA NA
2011 McNaughton
C. et.al
Short, subjective measures of numeracy and general
health literacy in an adult emergency department22
(209/NA) 2 NA NA 55 45
2011 White III R.O.
et.al
Development and validation of a spanish diabetes-
specific numeracy measure: DNT-15 latino23
(150/163) 6 NA 47.8 38 62
2011 Robinson S. Assessing health literacy in heart failure patients24 (609/612) 3 7 66 58.8 41.2
et.al minutes/N
TL
2010 Golbeck A.
et.al
Correlating reading comprehension and health
numeracy among adults with low literacy25
(144/NA) NA NA NA 42 58
2010 Sakar U. et.al Validation of self-reported health literacy questions
among diverse english and spanish -speaking
populations26
(296/NA) NA NA 54.9 42.6 57.4
2010 Wu A.D. et.al Developing and evaluating a relevant and feasible
instrument for measuring health literacy of Canadian
high school students27
(275/NA) NA NA NA 48 52
2010 Clayman M.L.
et.al
Ask, understand, remember: a brief measure of patinet
communication self-efficacy within clinical
encounters28
(330/NA) NA NA 53.58 32.1 67.9
2009 Ozdemir H.
et.al
Health literacy among adults: a study from Turkey29 (456/579) NA NA 36.2 39.5 60.5
2009 Macek M.D.
et.al
Measuring conceptual health knowledge in the context
of oral health literacy: Preliminary results30
(100/NA) NA NA NA 45 55
2010 Kumar D. et.al Parental understanding of infant health information:
Health literacy, numeracy and the Parental Health
Literacy Activities Test PHLAT)31
(261/413) NA 21 minutes 25.6 11 89
2010 Lee.S-Y.D.
et.al
Short assement of health literacy- Spanish and English:
A comparable test of health literacy for spanish and
english speakers32
(403/NA) NA NA NA 44 56
2009 Rawson K.A.
et.al
The METER: A brief, self-administered measure of
health literacy33
(153/NA) NA 2 minutes 62.7 76.5 23.5
2009 Sabbahi D.A. Development and evaluation of an oral health literacy (100/NA) NA NA 39 27 73
et.al instrument for adults34
2009 Oettinger
M.D. et.al
Color-Coding improves parental understanding of body
mass index charting35
(165/285) 2 NA NA NA NA
2009 Lee T.W. et.al Testing health literacy skills in older Korean adults36 (410/NA) 11 20.1
minutes
73.3 39 61
2008 Ishikawa H.
et.al
Measuring functional, communicative, and critical
health literacy among diabetic patients37
(157/169) 19 NA 65 52.9 47.1
2008 Ishikawa H.
et.al
Developing a measure of communicative and critical
health literacy: A pilot study of Japanese office
workers38.
(229/419) 39 NA 43.2 100 0
2007 Gong D.A.
et.al
Development and testing of the test of functional health
literacy in dentistry (TOFHLiD)39
(102/NA) NA NA NA 12 88
2007 Lee J.Y. et.al Development of a word recognition instrument to test
health literacy in dentistry: the REALD-30 - a brief
communication40
(202/NA) NA NA 44.7 43.6 56.4
2007 Wagner C.
et.al
Functional health literacy and health-promoting
behaviour in a national sample of British adults41
(759/NA) 40 NA 47.2 42 58
2007 Donelle L.
et.al
Assessing health numeracy among community-
dwelling older adults42
(140/NA) NA 90 minutes NA 26.4 73.6
2007 Chisolm D.J.
et.al
Measuring Adolescent Functional Health Literacy: A
pilot validation of the Test of Functional Health
Literacy in Adults43
(50/NA) NA 45 minutes
total,
TOFHLA
12.9
minutes
14.7 48 52
2007 Baron-Epel O. Validation of a Hebrew health literacy test44 (119/138) NA NA NA 47.9 52.1
et.al
2006 Apter A.J.
et.al
Asthma numeracy skill and health literacy45 (73/NA) NA NA 47 15.1 84.9
2006 Lee S.Y. et.al Development of an easy-to-use Spanish health literacy
test46
(403/NA) NA NA 34.2 for
Spanish,
43.7 for
English
44 56
2006 Zun L.S. et.al English-language competency of self-declared English-
speaking Hispanic patients using written tests of health
literacy47
(105/354) NA NA NA 37.1 62.9
2005 Weiss B.D.
et.al
Quick assessment of literacy in primary care: The
newest vital sign48
(500/625) NA NA 41.3 for
English,
40.8 for
Spanish
NA NA
2005 Aguirre A.C.
et.al
Perfomance of the English and Spanish S-TOFHLA
among publicly insured Medicaid and Medicare
patients49
(2370/NA) NA NA Hispanic
English
31.7
13 87
Hispanic
Spanish
42.7
22 78
English
44.9
25 75
2004 Sanders L.M.
et.al
Number of children's books in the home: An indicator
of parent health literacy50
(163/NA) NA NA NA NA NA
1998 Baker D.W. Development of a brief test to measure functional (248/283) 7 NA 44 47 53
et.al health literacy51
2012 Apolinario D.
et.al
Short Assessment of Health Literacy for Portuguese-
speaking adults52
(226/360) NA NA 74.4 28.9 71.1
2011 Pendlimari R.
et.al
Assessment of Colon Cancer Literacy in screening
colonoscopy patients: a validation study53
(63/NA) 2 NA 64 46 54
2007 Diamond J.J.
et.al.
Development of a reliable and construct valid measure
of nutritional literacy in adults54
(341/NA) NA NA 46.4 22 78
2011 Fransen M.P
et.al.
Applicability of international available health literacy
measures in the Netherlands55
(289/NA) NA NA 59.7 66 34
2009 Huizinga
M.M. et.al.
Literacy,numeracy and portion-size estimation skills56 (169/248) 5 45 minutes 45.8 29 71
2009 Kathleen J.
et.al.
Billingual health literacy assessment using the Talking
Touchscreen/la pantalla parlanchina: Development and
pilot testing57
(231/NA) NA NA NA English 35,
Spanish
25.4)
English
65,
Spanish
74.6)
2011 Tsai T.I. et.al Methodology and validation of health literacy scale
development in Taiwan58
2009 Miller M.J.
et.al
Application of the cloze procedure to evaluate the
comprehension and demonstrate rewriting of pharmacy
educational materials59
(154/162) 1 NA NA 28.6 71.4
2010 Ohl M. et.al Do brief screening questions or provider perception
accurately identify persons with low health literacy in
the HIV primary care setting?60
(147/149) 2 NA NA 71 29
2008 Cavanaugh K.
et.al
Association of numeracy and diabetes control61 (398/615) NA NA NA 49 51
2010 Galesic M. Graph literacy: A cross-cultural comparison62 (987/NA) NA NA NA Germany Germany
et.al 50.3, US
48.4
49.7, US
51.6
2009 Jeppesen K.M.
et.al
Screnning questions to predicts limited health literacy:
A cross-sectional study of Patients with diabetes
mellitus63
(225/396) NA NA NA NA NA
2008 Hanchate A.D.
et.al
The demographic assessment for health literacy
(DAHL): A new tool for estimating association
between health literacy and outcomes in national
surverys64
Prudential Study
(2,824/NA)
NHIS-Elderly
Study (6,819/NA)
NA NA NA Prudential
Study 42,
NHIS-
Elderly
Study 38
Prudentia
l Study
58,
Elderly
Study 62
Testing instruments
Several instruments were used in these studies to
measure the three aforementioned domains of
Nutbeam’s definition of health literacy. Of the 25
known assessment tools used, 7 were used in more
than 1 study and were consisted of variation of
TOFHLA, REALM, NVS and WRAT numeracy
tests. Many studies aimed to validate a new
assessment tool, thus clinical data was limited.
The most commonly used health literacy measure
tools were S-TOFHLA (50%), REALM (32.5%)
and NVS (20%). The numeracy aspect of the
TOFHLA and its variance was often compared to
the WRAT numeracy test result.
The majority of the tests only measured functional
health literacy (82.5%), i.e. the subject’s ability to
acquire and process information. This included
both validated tests and newly developed tools for
validation. In 48 studies, only 1 attempted to
measure all 3 domains of Nutbeam’s definition of
health literacy37.
Data analysis
Out of 48 studies, only 8 (16.7%) measured both
variation of TOFHLA and REALM; all pointed to a
similarity in result and detection of inadequate
health literacy between the two tests. Correlation
between these tests was suggested to be
positive43,51, indicating that they both measured the
same functional domain of the patient’s health
literacy. Additionally, study by Ferguson20 claimed
that patients have no real preference between
TOFHLA and REALM.
There was little evidence comparing the result of
NVS and TOFHLA or REALM. One study by
Kirk16 compared the three tools reported a higher
detection of inadequate health literacy from NVS
than TOFHLA (49.8% compared to 28.8%).
However, Patel reported no real differences in
score between NVS and TOFHLA21. Thus, there
was no conclusive argument to be made for the
differences between NVS and TOFHLA/REALM.
Translated versions of NVS and REALM 29,55, on
the other hand, showed a clear discrepancy between
the score of these two instruments: with a
difference in inadequate literacy estimation of 30%
in both cases (higher estimation with REALM in
Turkish version and NVS in Dutch version).
8 studies in total (16.7%) employed a version of the
Wide Range Achievement Test (WRAT) or Cloze
to measure numeracy aspect of the patients along
with a health literacy assessment. In all 6 studies,
there were a clear discrepancy between a subject’s
health literacy skill and numeracy skill: the
majority of subjects displayed poor numeracy skill
(over 50% in all cases) despite a high level of
literacy skill. Miller estimated that only 8% of
patients recording poor numeracy score (Cloze in
this case) actually be tested positive for
marginal/inadequate health literacy by S-
TOFHLA59. Additionally, a study by Golbeck
suggested that only 60% of patients had the same
level of reading and numeracy (inadequate,
marginal or adequate), and 20% of patients were
reported to have one skill at a higher level than the
other25.
From 15 of the newly developed tools, 10 (66.7%)
were developed based on a current tool and
reported to have good validity and correlation with
either TOFHLA or REALM. However, each tool
was only used in one study, hence further research
would be required before they could be applied.
Completion rate and acceptability of the assessment
was reported each by 1 study, thus no conclusion
could be drawn. The time required to complete the
tests ranged from 2 to 90 minutes from 9 studies
(18.8%); as many employed multiple tests and only
total completion time was reported.
Quality assessment
The overall quality of articles included in this
review was poor, with all 48 studies assessed as
either of unclear or poor quality by our quality
assessment tool. The most reported flaws of the
studies were too few recruitment sites, missing
drop-out rate of the subjects and the employment of
multiple tests for elderly patients.
Discussion
The results of this review suggested that there was
no clear difference between the currently used tests
to determine a patient’s health literacy level. The
evidences were consistent between TOFHLA and
REALM; however data for comparison of such
tests with the NVS was limited and more research
would be required before any conclusion could be
drawn. Additionally, early evidences suggested a
high acceptability and no clear preference between
TOFHLA and REALM from patient, it could be
stated that the choice for community pharmacy
would come down to preference, time constraint
and the availability of the tests.
Conversely, the clear discrepancy in results
between numeracy and health literacy score
showed that while these tests all measured the same
functional domain of Nutbeam’s definition, the
extent to which each factors affected the outcome
was not the same. More research would be required
to determine whether numeracy tests should be
included: few studies had suggested that numeracy
skills also had an impact on the patient’s health 45,
65, although no firm conclusion could be drawn 6.
Different to the systematic review of Berkman6 and
Sorensen66, our study focused on the assessment
tools used to determine a patient’s health literacy
skill and their applicability to use in a community
health setting.
This study shares many limitations from other
systematic reviews. Although we conducted an
extensive literature search, the search was limited
to online journals only and evidently not all
published data had been included. Unpublished
studies and reports (‘grey literature’) were not
sought out.
Although we did not employ a standard data
extraction tool for this study, the process was
performed by two independent researchers and any
disagreements discussed until consensus was
reached. We were limited to the amount of
information included in the studies. Very few
studies reported patients' completion rate or reason
for patient drop-out; while this could be an
important factor to determine a potential flaw of the
instruments, no conclusion was drawn.
Additionally, the quality assessment tool was also
developed for the purpose of this review and
performed by two independent researchers.
Although every single aspect of the quality of each
paper was discussed, a general consensus was
formed between two researchers about the quality
of each study.
Another limitation that was unique to this review
was the overall quality of the included studies.
Most studies recruited patients as convenient
sample and from a few locations varying in settings
with little to no reason given for such choice of
location, thus negatively affecting their
generalisability. Some studies required the patients
to take multiple tests which could last up to 90
minutes42 and thus could lead to an increase in
drop-out rate.
Possible reason for the demographic of mostly
female, age 18-50 of the review was due to the
recruitment method of many studies: a convenient
sample pool recruited from health clinics. This
could be argued as a representative data of a
general health setting; however as no study so far
had explored the general population of a
community pharmacy, further research was
recommended.
The Test of Functional Health Literacy in Adult
(TOFHLA) and Rapid Estimate of Adult Literacy
in Medicine (REALM) were the most commonly
used and compared in this review. Both tests
measured a patient’s functional health literacy
level9.10, as suggested by their similarity in
detection rate. The Newest Vital Sign (NVS) tool,
however, showed mixed results from both
TOFHLA and REALM. This could be an
indication that the domains of health literacy
measured by NVS might be different from the
others. In the NVS test, patients were given
information about the nutritional value of a pint of
ice cream and asked a series of 6 questions in the
style of Yes/No48. The main difference between
NVS and the other two tests was that during the
testing period, the patient had access to that
information and was allowed to consult them as
they wished. This subsequently meant that instead
of having to remember the information, the main
focus of the test was how well the patient could
interpret the data and extract information from the
given fact. Thus, it could be suggested that NVS
measured not only the functional, but also the
communicative domain of health literacy; however
more evidence was required before any conclusive
comment could be drawn.
The contribution of each domain (functional,
communicative and critical) to an individual’s
overall health literacy level was not discussed so
often. In a study by Ishikawa et. al.37, a new scale
was developed to measure all three domains of the
patient’s health literacy. The study showed a
positive association between communicative and
critical health literacy, suggesting that both
domains involved more advanced skills than
functional health literacy. This was further
reinforced by the correlation between the number
of information sources consulted with
communicative and critical health literacy and not
functional health literacy, indicating that the
current tool might be sufficient to measure an
individual’s basic health literacy level in the
community pharmacies.
Miller59 showed a positive correlation between the
Cloze procedure and S-TOFHLA (which contained
a numeracy section modified from Cloze9).
However, he argued that the stronger correlation
between S-TOFHLA and REALM suggested that
both tests emphasized word recognition over actual
content comprehension. This suggestion was
further reinforced by the discrepancy between their
scores and WRAT score, specifically its numeracy
aspect. Additionally, a study by Golbeck25 showed
only 60% correlation between an individual’s level
of reading and numeracy skill using the current
tests. Although not enough research had been put
into studying the relationship between numeracy
skills and health literacy level, there had been
evidence in specific cases 45,48and we suggested that
a health literacy test including numeracy, such as
NVS should be preferred than other word
recognition tests.
The aspect of completion time was not recorded by
most studies; however an association between time
and health literacy score had been shown in a study
by Robinson24. Comparing between a standard 7
minutes S-TOFHLA test and a no-time-limit (NTL)
S-TOFHLA showed that on average, patients
attempted more questions, and an overall increase
in average score of 15 %. The study suggested that
the 7 minutes limit of S-TOFHLA might
underestimate the literacy level of patients;
however not enough evidence could be gathered to
make a conclusion. Thus, until more researches
were done, the practicality of carrying out health
literacy test in a community pharmacy required a
tool that was quick to use. Between the most
commonly used tools, NVS was shown to be the
quickest tool to used with only 6 questions and an
average completion of 2.9 minutes 48. Additionally,
some studies had pointed out the flaw of REALM
(tendency to both overestimate and underestimate
in the mid-range section) 51 and TOFHLA (many
items with weak correct alternatives, leading to an
easier answer choice for patient) 57. Therefore, we
suggested that based on the available evidences, the
NVS test should be used in the community
pharmacy setting until a better tool that measured
the three domains was developed. We also
suggested future studies to include the aspect of
completion time to further understand this issue.
Conclusion
The available evidences on health literacy
measurement tools did not allow us to draw any
definitive conclusion. However, current data
suggested that the difference between TOFHLA
and REALM was minimal and there was a clear
disparity between these tools and the numeracy
score of an individual. Despite the fact that there
was an association between completion time and
the health literacy score, not enough evidence was
given to assess its effect. Thus, until a better tool
measuring all three domains of health literacy was
developed, we suggested that NVS should be used
based on its short completion time and the
inclusion of a numeracy aspect.
However, because of the quality of the data, many
of these studies were not reproducible and further
research would be required before any conclusive
comment could be made.
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