Data collection for health literacy research is labor intensive because the most widely used measures of health literacy are administered in-person by trained research staff. This limits our ability to perform large epidemiological studies on the consequences of inadequate health literacy. It also restricts our ability to assess the effectiveness of health system interventions by level of health literacy, because this critical variable is not being recorded in clinical databases. These important forms of research would be facilitated by the availability of a brief, verbally-administered measure of health literacy. Three short questions (""""""""How confident are you filling out medical forms by yourself?,"""""""" """"""""How often do you have someone help you read hospital materials?,"""""""" and """"""""How often do you have problems learning about your medical condition because of difficulty understanding written information?"""""""") effectively identified patients with inadequate health literacy in 5 previous studies. However, these items have not yet been tested outside of the ambulatory care setting or when administered by clinical personnel. Rigorous psychometric analyses have not yet been performed, nor has their association with clinical outcomes been examined.
The Specific Aims of this proposal are to: 1) Establish the feasibility of incorporating brief health literacy questions into an electronic health record (EHR) upon hospital admission for use as a research tool, 2) Perform a psychometric evaluation of the brief health literacy questions, and 3) Examine the independent association of the brief health literacy questions with important clinical outcomes including blood pressure control and heart failure readmissions.
For Aim 1, we will incorporate the items into the admission nursing history at Vanderbilt University Hospital (VUH), train nurses in their administration, examine uptake of the health literacy measure by auditing nursing documentation of the items in the EHR, and observe encounters for fidelity of scale administration.
For Aim 2, we will define a large retrospective cohort of hospitalized patients and enroll a smaller prospective cohort. We will assess internal consistency reliability and test-retest reliability, use structural equation modeling to perform confirmatory factor analysis, and examine construct validity by comparing responses on the health literacy questions to patient demographics and another health literacy measure.
For Aim 3, we will define a retrospective cohort of patients who are admitted to VUH with a pre-existing diagnosis of hypertension, and a second cohort admitted for acute decompensated heart failure. We will examine the association of the brief health literacy items with blood pressure at the time of hospital admission and at outpatient follow-up in the hypertension cohort, and Emergency Department visits and hospital readmission within 60 days of discharge in the heart failure cohort. By examining the health literacy items alone and in combination, and controlling for age, race, and education, we will determine which item(s) are best suited as a brief measure of health literacy.
The Institute of Medicine report on health literacy called for additional research to better understand the consequences of inadequate health literacy, as well as system-based interventions to address health literacy, which should analyze intervention effectiveness by level of health literacy. However, progress in these areas is being limited by the absence of a valid and brief measure of health literacy that can be incorporated into large surveys or into the electronic health record for use as a research tool. This research seeks to validate 3 candidate health literacy questions which could be used widely for such research.
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