Low health literacy is a significant barrier to quality care, especially among elderly patients, but increased use of simple and effective health literacy assessment tests by nurses and clinicians can help improve communication and health outcomes.

Several screening tools are available to assess health literacy but they are underutilized, according to a presentation at the 36th Annual Congress of the Oncology Nursing Society (ONS) by Ellen C. Mullen, RN, ANP-BC, GNP-BC, nurse practitioner in the Lymphoma and Myeloma Center at The University of MD Anderson Cancer Center.

Further, nurses and other health professionals routinely underestimate the prevalence of limited health literacy -- the degree to which an individual can obtain, process and understand health information needed to make appropriate health decisions -- and overestimate patients' ability to understand medical information.

A 2003 survey by the National Assessment of Adult Literacy showed that 36 percent of American adults overall have limited health literacy. Nearly 60 percent of those over age 65 meet only basic or below-basic health literacy levels.

Previous studies have shown that low health literacy adversely impacts cancer incidence, mortality and quality of life. For example, missed or misunderstood cancer screening information can result in patients being diagnosed at a later, less treatable stage. Treatment decisions may not be fully comprehended and informed consent documents may be too complex, affecting medical decision making. Low health literacy has also been shown to increase hospitalization rates and ER visits, medication errors and health care costs.

According to Mullen, there are several readily available health literacy screening tools, including the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), the Wide Range Achievement Test (WRAT) and the Newest Vital Signs assessment. The tests take nurses roughly three minutes to perform.

"Health literacy is particularly pertinent for cancer patients and the elderly, who may have hearing or vision problems that further complicate communication," says Mullen. "Cancer patients are bombarded with big terminology and medical information that they may not understand, so they return asking the same questions. Nurses can address this issue if we take the time to assess patients' literacy levels at the first appointment."

Once literacy is assessed, nurses should tailor their communications -- oral and written -- to match the patient's level of understanding. For patients with low literacy, Mullen suggests:

Developing written materials below fifth grade reading levels;

Keeping content and format simple, with shorter words and sentences;

Using larger, boldface or underlined fonts, increasing space between lines and black ink;

Having a magnifying glass and good lighting available for older adults;

Ensuring patients have assistive devices, such as reading glasses and hearing aids; and

Involving a significant other or caregiver.

She also notes that nurses can refer patients to online resources for medical information and community programs that help improve health literacy levels.