[MUSIC] Now we're going to talk about findings from the TOFHLA assessments. So what do we know about general medical populations in their scores on the TOFHLA questionnaires? We know something about inner city patients to public hospitals, a study that was done by Williams and colleagues. And they found that 35% of English-speaking, but almost two-thirds, 62% of Spanish-speaking patients, had inadequate or marginal functional health literacy. And this occurred even when the TOFHLA was assessed in Spanish for Spanish-speaking patients. So this notion of inadequacy is reflected in basic scores on the lower end of the continuum. In another study, Baker and colleagues found that more than two-thirds, 66%, of adults 60 years of age have inadequate or marginal literacy, with the highest rates of these deficits being found with older patients, patients older than 75. So deficits around functional health literacy is pretty significant and widespread. Appears to be especially high among the elderly and especially high for non-native English speakers, at least in the context of Spanish speakers in large populations found in two large public hospitals. We also know from those dimensional elements that 41% of this population taking the TOFHLA test did not comprehend basic medication instructions. A little bit more than a quarter, 26%, did not understand the appointments slips. That means that they couldn't answer adequately those questions about, where do I go and when do I go there? 60% did not appropriately respond to the close items around informed consent for a medical procedure, and following the instructions for that procedure. And almost half, 49%, could not determine their eligibility for care when given a segment around Medicaid or Medicare eligibility. So again, we see that deficits, broadly, are considerable. In contrast to the TOFHLA, there are two other ways in which health literacy can be assessed. Another approach to assessing health literacy is the rapid estimate of literacy in medicine, referred to as the REALM. It's quite different than the TOFHLA because it doesn't test dimensionality, it's not testing your ability to comprehend instructions or to make numerical adjustments and calculations for administration of medication, nor is it exploring your ability to navigate a document. It's rather straightforward and simple decoding task, decoding means a reading task. The test administrator hands a patient or a respondent a list of words, they're organized in three columns. The first column are one-syllable words, those should be the easiest words for respondent to read if they have literacy restrictions. The second column is two-syllable words, and the third column is three-syllable words. So they're 22 words per column and the administrator notes the respondents' ability to pronounce the words, so they may read the words. If they have difficulty in the pronunciation they're told to just move on, and then there's a count of the number of words that the individual is able to fluently read. After three mistakes the administrator will say, that's fine, we can stop now. We don't want respondents to struggle with words that that they clearly can't decode, and because the lists are in increasing difficulty it's easy to see when it's appropriate to stop the test. There is also a short form of the REALM which is based on only eight words. These are the most difficult of the 66 words, and studies have shown that asking patients to read these eight words can very rapidly give you a sense of reading ability. There is a third way in which literacy is assessed, and it's called a subjective assessment of literacy. Chew and colleagues had found that asking three questions predicts literacy quite well in regard to full assessment by the TOFHLA or full assessment by the REALM. The three questions, as displayed on the slide, are, how confident are you filling out forms by yourself? Not only is that a good question that appears to be the best question, it has the strongest relationship to the other much longer measures, but it's one of three. The second question is, how often do you have someone help you read hospital materials? And third, how often do you have problems learning about your medical condition because of difficulty reading hospital materials? So all three of those items are quite good, the authors use them in combination. But as I mentioned earlier, they also say, if you only want to ask one question, ask the first one, because your result is going to be quite similar to those longer assessments and you don't gain all that much by having all three questions asked. So the bottom line on assessment and considerations of measures has to do with respondent burden. The time to complete the full TOFHLA assessment averages about 23 minutes, so that's a lot of time for an assessment in a clinical setting. The short TOFHLA does much better, it includes selected items from each of those three domains and the time to administer is about 12 minutes. As suggested earlier, the full TOFHLA and the short TOFHLA are highly correlated, so you're not losing all that much by going with the short measure, although a consideration in the broader measure is that the face validity of all of the domains are acknowledged and valued by many researchers. The difference between the full REALM and the Eight-item REALM also suggests that you may decrease respondent burden. The full REALM is between 4 and 6 minutes while the Eighth-item REALM is usually less than 2 minutes, and the correlation between the two are quite high. So that would suggest that you can go for the simpler shorter item and still get a very good assessment of decoding or reading ability. The subjective literacy question, even asking all three will probably be less than two minutes. Asking one of those three questions, the strongest question as suggested by the author of that scale, is likely to take less than one minute. All the measures and modified versions, as I mentioned, are highly correlated with one another and they're all correlated with the subjective literacy measure whether you use the one key item or all three items. Why is it interesting and important to consider the assessment of literacy using any one of the measures that we talked about? The reason is that the American Medical Association thinks that literacy is so important as to recommend universal precautions in the delivery of medical care in regard to literacy. And what that means is that clinicians should assume patients have literacy deficits unless they know otherwise. The way in which they might know otherwise is to do a fast screen or a literacy assessment. This is important, because a number of studies have demonstrated that physician recognition of low literacy among patients is quite poor, they're not generally aware of it. A study by Bass and colleagues found that fewer than 25% of patients who have been found to have low literacy skills in one study and in a second study only 10% of low literate patients were recognized as having any literacy deficits by their physician. Well, why not? Why is it that the physicians are not accurate in recognizing patients with literacy deficits? We know from a study by Parikh and colleagues that shame and humiliation is common among individuals with literacy deficits and disclosure of the deficits are not. Some two-thirds of patients with low literacy, as measured by the TOFHLA, did not admit to difficulties reading. Of those who admitted difficulty, 40% said that they felt shame associated with that deficit. And the majority of the poor readers, some two-thirds, had said that they never told a spouse or their children about their problems reading. And 19% said they never told anyone about their reading problem. For patients who have literacy deficits tests like the TOFHLA and the REALM are stressful, they're stressful because they're likely to encounter challenges and to feel failure. The subjective literacy assessments are not stressful in that regard, and there's evidence that respondents have no difficulty in answering those questions and appeared to, in fact, appreciate being asked those questions. [MUSIC]
