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Read critically! Health literacy studies rely on reading tests

The headline caught my eye: Health Literacy Not a Predictor of a Healthy Heart.  The story
says authors of a new study on health literacy in patients with health failure were surprised
to find that highly educated patients who score well on the Test of Functional Health Literacy
in Adults (TOFHLA) did not do any better at managing their care than their less educated, less
health literate counterparts.  In the interview, one author speculates that less educated people
have more symptoms and so are more familiar with treatments.  Hmmm, it is well established
that education does not predict literacy or health literacy level, so are we talking about education
or health literacy?  And how is it that less education equates to more symptoms?  There are
likely a number of other explanations.  So I found the article [1] in the Nov/Dec issue of the

According to the study, better readers did a better job of day-to-day “self-care maintenance
to improve their physical condition, for example, monitoring their weight and sodium intake and
exercising. But less skilled readers did better at “self-care management” to respond to symptoms,
for example consulting a doctor or reducing fluid intake.  

Interpret with caution
First we must interpret all results of this study with caution because there were only 49 subjects;
and they self-selected to participate by responding to a printed information sheet and completing
three self-administered questionnaires. So it is not surprising that only 12% (6 people) scored
“inadequate” on the TOFHLA – Test of Functional Health Literacy in Adults[2]. And for them, a
critical reader must wonder how reliable their answers can be. So we say, the findings are not
generalizable, they do not apply to any other group.

How do you measure health literacy?
But the core issue here is the question that has plagued health literacy research from the beginning.
What we measure and how we measure it matters because it determines what we find out about what
is worth doing and who should do it [3]. 

The authors state erroneously that the TOFHLA is a valid measure of health literacy.  In fact, the
TOFHLA is a reading comprehension test. It is validated against the REALM (Rapid Estimate of Adult
Literacy in Medicine), a medical-word recognition test which is validated against the WRAT, a
school-based reading test.  The Agency for Healthcare Research and Quality stated in a 2004
Technology Bulletin that all these are reading tests, and not measures of health literacy [4].

Measuring reading tells you about reading
And here’s the problem with that; since the tests only measure reading, they say nothing about
ability to use information – to apply it in context for personal benefit.  It is a giant leap from
understanding information to acting on it. And understanding has no affect on outcomes, only
the action matters.  

The meaning of “functional literacy” has evolved
Reading and numeracy, traditionally called “functional” literacy skills are used to understand
information and gain knowledge. Literacy scholars acknowledge that these basic skills are now
insufficient to function in the modern world, especially in the high tech healthcare arena. 
The meaning of ‘functional literacy” has evolved to include two additional categories of literacy
skills needed to use information to function in society. Interactive and reflective skills are used
to personalize information and apply it in context [5].  Strong skills in these areas can compensate
for weak basic skills. Read more.

Missing ingredients for health literacy
While this study offers little direction for promoting health literacy, it adds weight to increasing
evidence that reading skill is certainly helpful, but not necessary, and clearly insufficient for
managing health and healthcare. (Read more). Interactive and reflective skills are needed to make the leap
from understanding information to engaging in right action for coping, recovering and promoting
health.  These are the missing ingredients in health literacy.  ss

1. Yehle, KS, PLake KS, Murawski,MM et al.(2011). Journal of Cardiovascular Nursing 26 (60, 446-451.

2. Baker, D.W., Williams, M.V., Parker, R.M., Gazmararian, J.A. & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education and Counseling, 38, 33-42.

3. Schorr, L. (1997). Common purpose: Strengthening families and neighborhoods to rebuild America. New York, NY: Anchor Books.

4. Berkman, N.D., DeWalt, D.A., Pignone, M.P., Sheridan, S.L., Lohr, K.N., Lux L., et al. (2004). Literacy and health outcomes. Evidence Report/Technology Assessment No. 87 (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality.

5. Lonsdale, M., & McCurry, D. (2004). Literacy in the new millennium. Adelaide, Australia: National Center for Vocational Education Research
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