Assessing Adult Health Literacy in Urban Healthcare Settings

Objective: To determine if health literacy is lower among those using the emergency department as compared to those using community health clinics. A comparison was done of the health literacy level of patients at a level-I adult and pediatric emergency department and 3 community health clinics. The second purpose of the study was to identify and assess predictors of low or adequate health literacy in order to better accommodate the communication needs of these patients. Methods: The study used a convenience, cross-sectional design. The settings for the study were varied. The emergency department was a level-I inner-city pediatric and adult trauma center with 45,000 annual visits. The 3 outpatient clinics were all members of a 44-clinic network of private, community health centers that serve 175,000 underserved patients annually. Overall, 536 patients were approached to complete an in-person survey that included a 15-item written questionnaire and the Short Test of Functional Health Literacy in Adults (S-TOFHLA), a English- and Spanish-validated health literacy measure. Based on language spoken with healthcare providers, patients were given either the Spanish or English S-TOFHLA. Results: The refusal rate was 25.7%, with 536 patients approached and 398 completing the survey. Three of the four sites had a refusal rate of 8% per site. The fourth site had a higher refusal rate at 38%. Overall, 20% of subjects had marginal or inadequate functional health literacy. There was a significant difference at p=18.42, df=3, p=0.001 among sites. Three of the sites had >= 78% of the participants scoring at the adequate level. The fourth site, however, only had 66% who scored at the adequate level, with 34% of the scores in the inadequate functioning level as compared with 14% for the emergency department and its adjacent clinic and 3% for the clinic located at the city's edge. Using logistical regression, there was an association between literacy level and education (t=2.653, sig 0.008) and age (t=-6.451, sig 0.001). Conclusion: Less-than-adequate functional health literacy was seen at 20% of all sites. The location of healthcare access was not as predictive of low functional health literacy as were demographic indicators, such as age and education levels.