Assess patients' health literacy before teaching

New assessment tools work well

Too often health care professionals give patients instructions and education without taking the additional step of making sure they understand.

"We talk about what they need to do — that's how we're all trained," says Susan A. Rogers, RN-BC, BSN, CCM, president of Rogers Professional Guidance in Overland Park, KS. Rogers spoke about assessing health literacy at the 18th annual conference of the Case Management Society of America (CMSA), held June 17-20, 2008, in Orlando, FL.

"We never take time to ask if individuals are hearing and understanding what we say to them," Rogers says.

"As we become more of a consumer-defined world, health care has made the change toward the consumer as the focal point," she adds. "When we were trained back in the day it was all about the doctor."

As part of this new patient-centered process, discharge planners and case managers need to assess each patient's health literacy in order to adapt the educational message.

"The whole premise is that you assess the patient with assessment tools that give you an understanding of where the patient is with their knowledge, as well as the patient's motivation with regard to medication adherence," Rogers explains.

One available tool is the Rapid Estimate of Adult Literacy Measure (REALM), which is a one-page sheet listing health words like "constipation," she says.

Discharge planners then ask patients to read the list, and this helps to identify people who have low reading skills and who might be able to read some words but are unsure of their meaning.1

Another test that could be given is the Test of Functional Health Literacy in Adults (TOFHLA), which measures reading comprehension and numeracy, using health-related materials like a typical appointment slip.2

According to Peppercorn Books, which publishes the TOFHLA (, the tool includes multiple choice questions such as the following:

* Your doctor has sent you to have a ________ X-ray.

a. stomach

b. diabetes

c. stitches

d. germs

The shortened version of the TOFHLA takes only seven minutes to complete, Rogers notes.

"The longer one is 50 items and takes about 22 minutes, but the seven-minute version will get you the information you need," she explains.

The theory behind assessing health literacy is that it's difficult for people to take care of their own health care if they don't understand what their health care providers are saying, Rogers says.

A third tool is the Newest Vital Sign, an English and Spanish health literacy screening tool developed by Pfizer and available through the web site:

The tool shows patients a sample food nutrition label and then asks them to answer questions about the label, including this question: "If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?"3

"I really like the Newest Vital Sign," Rogers says. "If they can't comprehend this kind of label, which they see every day, then it's a pretty good assessment that their health literacy is not where it needs to be to comprehend the more complex instructions, like preparing for an MRI."

Rogers has used the Newest Vital Sign with patients and has found it to be a good indication of whether a diabetic patient, for example, will understand his own nutritional and exercise needs and insulin dose changes with exercise and eating, she says.

"This gives you a good clue of what a patient will do in the real world," Rogers adds.

Assessing health literacy also requires paying close attention to a patient's learning style and motivation to follow medical instructions.

Rogers visualizes this as a table with knowledge and motivation as two categories and the assessment divided between low and high.

A person might score as being highly motivated, but has low knowledge. In this case, the discharge planner should simplify instructions and spend a little more time with the person.

Or someone might demonstrate the opposite of high knowledge and low motivation, and it would be the discharge planner's job to find out what the obstacles are to the patient's willingness to carry out instructions.

Another way to conceptualize health literacy is to categorize how people learn, Rogers suggests.

While there's some overlap, most people could be said to favor one of these three ways people learn: through seeing, through listening, and through experiencing.

"The listeners are the people who've heard mom say a million times to not touch the stove when it's turned on, and they believe the information and never touch the stove," Rogers explains.

"The people who learn through seeing are the ones who heard mom's message, but didn't quite believe it until they saw their brother touch the stove," Rogers adds. "And the experiencers are those who say they won't believe it until they try it and touch the stove for themselves."

It's helpful to know which of these three types of learners a patient is before a discharge planner provides written or video or other types of information.

For instance, the stakes might be higher with patients who learn through experiences.

Rogers recalls that her own grandmother was someone who would learn through experience.

"She was a diabetic, and when she came out of the doctor's office one time I asked her if she told the doctor about the sore on her foot," Rogers says. "She said, 'No, he's the doctor, and he knows what to ask and if he didn't ask me about my foot then it's not important.'"

Unfortunately, it was important because her grandmother later ended up having an amputation, and she died from gangrene, Rogers says.

The person who learns through experience often has the attitude of "You can tell me to watch for these symptoms, but if you're not going to pay attention to it, then I'm just going to do what I want, and we'll see what happens," she says.

"There are 90 million individuals who cost the health care system $58 billion annually," Rogers says. "So it's not a small problem that people are not adhering to treatment plans and medications."

The key is for discharge planners to spend more time with patients who might fit this bill and make certain they really understand how important it is to watch for symptoms and to adhere to their medication regimens, she adds.

"We have to sit down with these people and see if they're really getting what we're telling them," Rogers says.


1. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6):391-395.

2. Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33-42.

3. Weiss BD, Mays MZ, Martz W, et al. Annals Fam Med. 2005;3(6):514-522. n


For more information, contact:

• Susan A. Rogers, RN-BC, BSN, CCM, president, Rogers Professional Guidance, Overland Park, KS. Email: