0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Socioeconomics and Health Services |

Functional Health Literacy in Patients With Glaucoma in Urban Settings FREE

Mark S. Juzych, MD, MHSA; Sandeep Randhawa, MD; Aman Shukairy, MD; Padmini Kaushal, MD; Anju Gupta, MD; Nadia Shalauta, ScD, MS
[+] Author Affiliations

Author Affiliations: Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan (Drs Juzych, Randhawa, Shukairy, Kaushal, and Gupta); and Michigan Public Health Institute, Okemos (Dr Shalauta).


Section Editor: Lee Paul P., MD

More Author Information
Arch Ophthalmol. 2008;126(5):718-724. doi:10.1001/archopht.126.5.718.
Text Size: A A A
Published online

Objective  To assess the relationship between health literacy and compliance, disease awareness, and disease progression in patients with glaucoma.

Methods  A cross-sectional observational study of 204 English-speaking patients treated for glaucoma for at least 1 year at Kresge Eye Institute was conducted. Health literacy was assessed using the standardized Test of Functional Health Literacy in Adults (TOFHLA). An oral questionnaire assessed patients' demographic information and glaucoma understanding. A retrospective medical record review was conducted to record parameters indicating glaucoma severity.

Results  One hundred two participants (50%) were categorized as having poor functional health literacy (mean [SD] TOFHLA score, 18.4 [7.5]) and 102 participants (50%) had adequate health literacy (mean [SD] TOFHLA score, 42.8 [5.1]). The poor health literacy group showed significant differences in income, education, medication compliance, glaucoma understanding, and missed appointments compared with the adequate health literacy group (P < .001). Patients with poor health literacy showed a greater visual field loss on initial presentation (mean deviation [SD], − 10.58 [9.3] dB) compared with the adequate health literacy group (mean deviation [SD], − 7.79 [6.9] dB; P = .02) and significantly worse visual field parameters when comparing pattern SDs on the recent and the initial visual fields (pattern SD change [SD], 0.19 [2.5] dB in the poor health literacy group vs − 0.7 [2.2] dB in the adequate health literacy group; P = .02).

Conclusions  Patients with poor health literacy had poorer compliance, worse disease understanding, and greater disease progression compared with the adequate health literacy group, highlighting the need to promote health literacy in patients with glaucoma.

Figures in this Article

Health literacy, as a discrete form of literacy, is increasingly important in health care. The US Department of Health and Human Services defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate healthdecisions.”1 The American Medical Association's Council on Scientific Affairs more specifically defines functional health literacy as “the ability to apply reading and numeracy skills in a healthcare setting.”2 These skills include the ability to (1) read consent forms, medicine labels and inserts, and other written health care information, (2) understand written and oral information given by physicians, nurses, pharmacists, and insurers, and (3) act on necessary procedures and directions, such as medication and appointment schedules.

Recent research has examined the effect of patients' literacy skills on health and health care. Numerous studies have demonstrated that health materials, such as discharge instructions,36 consent forms,711 and medical education brochures,1214 are often written at levels that exceed patients' reading skills. In addition, patients with low health literacy and chronic diseases have less knowledge of their disease and its treatment and fewer correct self-management skills than literate patients.15,16 These factors likely contribute to higher hospitalization rates among patients with poor functional health literacy compared with those with adequate health literacy.17 While many patients with poor literacy are unaware of their deficiency,18 others feel shame and are unwilling to disclose their reading problem to health care professionals.19,20 Poor health literacy has been found to be common among patients with long-term medical conditions, such as type 2 diabetes, asthma, AIDS, and hypertension.15,16,2124

Although the extent to which health literacy is associated with or causally related to outcomes is unclear, there are reasons to believe that poor health literacy may contribute to poor outcomes. Patients with poor health literacy have greater difficulty naming and describing their indications,25 more frequently hold health beliefs that interfere with adherence,23 and are more likely to have a poor understanding of their condition and its management.15,16,21

We investigated the association between health literacy and glaucoma awareness and outcomes among patients in an urban eye clinic. Vision experts estimate that half of those affected with glaucoma may be unaware they have it, because symptoms may not occur during the early stages of the disease.26 Assessing the association of health literacy and glaucoma awareness and outcomes may have important clinical implications for the care of individual patients as well as strategic implications for the reduction of racial, ethnic, and socioeconomic disparities in glaucoma care.

SETTING AND STUDY PARTICIPANTS

The study protocol was approved by the institutional review board of Wayne State University, Detroit, Michigan. The study population consisted of 231 patients from the clinics at the Kresge Eye Institute at Wayne State University treated between September 2004 and January 2006. Patients were considered eligible for the study if they were older than 18 years, spoke English, and had a diagnosis of glaucoma for at least 1 year before enrollment. Patients who had a concomitant retinal pathology (which could affect retinal nerve fiber layer [RNFL] thickness on optical coherence tomography [OCT] or their Humphrey visual field [Carl Zeiss Meditec, Jena, Germany]) and/or a documented psychiatric disorder (which may interfere with accurate health literacy measurement) were excluded.27 Psychiatric disorders were excluded by medical record review. We also excluded patients who had a best-corrected visual acuity of less than 20/50 in the better eye (unable to read 14-point type of the literacy test). Written consent was obtained from patients before enrollment. To facilitate comprehension of the study and consent process, the research assistants read the consent form to all patients (patients with significant hearing disabilities who had difficulty comprehending the consent were excluded). Patients were then administered the reading comprehension section of the English version of the Test of Functional Health Literacy in Adults (TOFHLA), a reliable and validated instrument used to assess health literacy level.2729 The validity for this test has been ensured by using actual hospital medical texts.29

Research assistants also orally administered a questionnaire regarding demographic information (age, sex, marital status, race/ethnicity, education, employment, health insurance, and income), health insight and education (self-reported general health status, number of medications taken per day, glaucoma education, as well as awareness/insight), social support, and compliance (to identify problems and patterns with the use of eye drops and factors contributing to noncompliance). The demographic section of the questionnaire was adapted from the Michigan Diabetes Research and Training Center,30 with specific modifications and additions to address glaucoma understanding and compliance with therapy in patients. Additionally, a retrospective medical record review was conducted to record parameters indicating glaucoma severity. The investigator conducting the retrospective medical record review was masked to the responses from the demographic questionnaire and the results of theTOFHLA.

MEASURES

A cross-sectional observational study of English-speaking patients treated for glaucoma was conducted. Sample size was estimated a priori to achieve a power of 80%. Health literacy was assessed by the standardized TOFHLA. The TOFHLA is a tool designed to evaluate functional health literacy in adults under the assumption that more than classroom reading ability is necessary to understand and negotiate the health care system adequately. We used the reading comprehension section of the TOFHLA, comprising 50 items covering preparation for an upper gastrointestinal tract radiographic procedure (passage A), Medicaid's “Rights and Responsibilities” passage (passage B), and informed consent (passage C), which was to be completed in 12 minutes. The reading comprehension scale uses the Cloze procedure,31 a technique that uses reading passages with every fifth to seventh word missing; the patient must select the appropriate missing word from a list of 4 possible answers. According to the Gunning-Fog index (an index to grade readability), the reading levels for the reading comprehension sections were grade 4.3 for passage A, grade 10.4 for passage B, and grade 19.5 for passage C. The TOFHLA reading comprehension section is scored on a scale of 1 to 50. We categorized patients as having poor health literacy if the TOFHLA score was 0 to 30, and as having adequate health literacy if the score was 31 to 50. Adequate health literacy indicates an ability to successfully complete most tasks required to function in the health care setting, though comprehending more difficult information (materials written at higher than a 10th-grade reading level) may still be difficult. Patients with poor functional health literacy have a decreased ability to read and comprehend prescription bottles, appointment slips, and other essential health-related materials and cannot understand medical instructions required to successfully function as a patient. They also have difficulty processing oral communication and conceptualizing risk. Because socioeconomic factors, glaucoma awareness, and compliance may affect the patients' glaucoma control, we assessed these domains as part of the survey questionnaire.

During the medical record review, the patients' visual field parameters (pattern SD [PSD] and mean deviation [MD], Humphrey Swedish Interactive Threshold Algorithm [SITA]–Fast) on initial presentation and at the most recent visit as well as their average RNFL thickness on OCT (numeric value and color category, Stratus, Carl Zeiss Meditec) at the most recent visit were noted. The visual field data were included for the participants in whom it was reliable and the same testing strategy (Humphrey SITA-Fast) had been used for the initial and the most recent visual field analyses. These parameters were used as indicators of glaucoma severity. The OCT data were included for all the participants in which they were available, though we could not use the data in a longitudinal fashion because the technology had become available just shortly before the commencement of this study. The recent visual field and OCT measurements had been done within 3 months of the interview and test date. Additionally, the frequency of missed appointments per year was derived from the medical records and used as a surrogate marker for patient compliance.

STATISTICAL ANALYSIS

Categorical variables were compared using an unadjusted χ2 test and continuous variables were compared with the t test or analysis of variance. The 2 health literacy groups (poor and adequate) were compared to determine whether there is a significant difference in demographic characteristics (race, sex, education, income, and insurance coverage) and compliance (assessed by the number of missed appointments per year and self-reported frequency of missed eye drops) between the 2 groups. The physicians' subjective interpretation of the patients' reading level was also compared with their literacy category (ascertained from theTOFHLA score) without the physician knowing the patients' TOFHLA scores. The 2 groups were statistically compared for insight and awareness of different aspects of glaucoma care and knowledge (graded as good or poor).

We conducted statistical analyses to evaluate any differences in glaucoma parameters between the 2 literacy groups. During the study design phase, it had been randomly decided to use the right eye for analyses (a priori). Specific parameters including PSD and MD (on initial presentation, most recent visit, and the difference between them) were compared between the 2 literacy groups. The average RNFL thickness (categorized by OCT color) was also compared between the 2 literacy groups.

For all analyses, P < .05 was used to determine final statistical significance. All statistical analyses were performed with Statview software, version 5.0 (SAS Institute Inc, Cary, North Carolina).

Based on an initial medical record screening, 231 patients were asked to participate in the study. Of these, 16 were excluded (concomitant retinal pathology [n = 10], diagnosed psychiatric condition [n = 3], and hearing disability [n = 3]). Eleven patients refused to participate (main reasons for refusal: “not wanting to answer any personal questions” or “not wanting to take any tests”). Thus, we enrolled 204 patients in our study.

The demographic characteristics and the mean TOFHLA scores of the study participants are summarized in Table 1 and the relationship between TOFHLA scores and level of education is shown in the Figure. One hundred two participants (50%) had poor functional health literacy (TOFHLA score, 0-30), and 102 participants (50%) had adequate literacy (TOFHLA score, 31-50). Patients with poor health literacy were more likely than patients with adequate health literacy to be African American, to have received only some high school education or less, to have an annual income of less than $20 000, and to have only Medicaid insurance coverage (as opposed to commercial insurance, as in the adequate group). Fifty-six percent of African American participants had poor health literacy compared with only 16% of white participants (P = .002). There is a significant difference in the participants' level of education (P < .001), income (P < .001), type of insurance (P < .001), and marital status (P = .05) between the 2 literacy groups. Six participants, all of whom belonged to the adequate literacy group, declined to disclose their income (Table 1). The physicians' qualitative assessment of the participants' reading level correlated with the measured literacy level (P < .001).

Place holder to copy figure label and caption
Figure.

Histogram demonstrating the mean Test of Functional Health Literacy in Adults (TOFHLA) scores (with standard error of mean) for different levels of education.

Graphic Jump Location
Table Graphic Jump LocationTable 1. Demographic Characteristics of Patients With Glaucoma by Health Literacy Level

In multivariate analyses of the demographic variables (Table 2), race/ethnicity, education, and household income were all significantly associated with health literacy. Being of white race, having an education of some college or more, and having a household income of $20 000 or greater was associated with a lower likelihood of having poor health literacy.

Table Graphic Jump LocationTable 2. Adjusted Odds Ratios (ORs) for Having Poor vs Adequate Health Literacy

As presented in Table 3, the mean (SD) number of missed appointments per year in the poor literacy group (1.9 [0.9]) was significantly higher than that in the adequate literacy group (0.5 [0.5]; P < .001). The self-reported frequency of missed eye drops in the poor health literacy group was found to be significantly higher than that in the adequate health literacy group (65 participants in the poor literacy group reported having missed taking eye drops ≥ 2 times/mo compared with only 34 participants in the adequate health literacy group, P < .001).

Table Graphic Jump LocationTable 3. Comparison of Self-Reported Glaucoma Education and Compliance Between Health Literacy Groups

Patients in the adequate literacy group had a better conception of their health in general. Sixty-five participants from the adequate health literacy group thought that they had good health compared with only 37 participants from the poor health literacy group (P < .001). More patients in the adequate health literacy group felt that they had received glaucoma education compared with the poor health literacy group (P = .01). Patients with adequate health literacy felt they had a better understanding of their overall glaucoma care, medications, treatment, prevention of its consequences, and the benefits of lowering eye pressure (P < .001) compared with participants with poor health literacy (Table 4).

Table Graphic Jump LocationTable 4. Comparison of Perceived Glaucoma Insight and Understanding Between Health Literacy Groups

The comparison of the visual field parameters between the 2 groups (right eye, a priori) is presented in Table 5. Patients with poor health literacy showed a greater MD (SD) (greater visual field loss) on initial presentation (− 10.58 [9.3] dB) compared with the adequate health literacy group (− 7.79 [6.9] dB, P = .02). The recent visual field also showed a significantly worse MD in the poor health literacy group (− 11.49 [9.8] dB) than in the adequate health literacy group (− 7.45 [7.7] dB, P = .004) (Table 5). Participants with poor health literacy showed significantly worse visual field parameters when comparing their visual field on initial presentation with their most recent visual field (recent visual field PSD – initial visual field PSD = 0.19 [2.5] dB in the poor healthy literacy group compared with − 0.7 [2.19] dB in the adequate group, P = .02; recent visual field MD – initial visual field MD = − 1.75 [6.8] dB in the poor health literacy group compared with 0.28 [3.9] dB in the adequate health literacy group, P = .02) (Table 5).

Table Graphic Jump LocationTable 5. Comparison of Glaucoma Parameters in the Right Eye (A Priori) Between Healthy Literacy Groups

There was no statistically significant difference in average RNFL thickness on OCT between the 2 groups, though a higher number of participants in the poor health literacy group had a compromised RNFL (65% in the red color category on OCT) compared with the adequate group (49% in the red color category on OCT; P = .09) (Table 5).

This study examines functional health literacy in an urban population of patients with glaucoma. We found that among patients with glaucoma, half of the respondents had poor health literacy. This figure is somewhat consistent with statistics on general reading ability from the 1993 National Adult Literacy Survey, which reported that 44% of adults were at a low reading level.18 Our study demonstrates that poor health literacy in patients with glaucoma in urban settings is related to socioeconomic factors, compliance, and understanding of glaucoma. It also highlights that patients with poor health literacy and poor compliance with glaucoma treatment had worse visual field results on follow-up examinations. Muir et al32 have also found a positive correlation between low health literacy and adherence to glaucoma medications using a different tool: the Rapid Assessment of Health Literacy in Medicine. Missing appointments has been correlated with lower adherence rates to prescribed regimens in other studies as well.3335 Results from part 3 of the Advanced Glaucoma Intervention Study are similar to some of our results, especially with respect to socioeconomic differences and severity of glaucoma on visual fields between white and black patients. The Advanced Glaucoma Intervention Study enrolled 332 black and 249 white patients. Relatively fewer black patients (51%) than white patients (78%) had completed high school. Although the 2 groups had similar intraocular pressures on enrollment, visual field defects on average were found to be substantially more severe in black than in white participants.36

In the current health care environment, in which scientific advances and market forces place greater technical and self-management demands on patients, poor health literacy may be a particularly important barrier to chronic disease care. According to the National Adult Literacy Survey, 75% of Americans with a long-term illness had limited literacy.18

From the public health perspective, health literacy may represent an important variable explaining the prevalence of poor health outcomes among patients with glaucoma as well as some of the socioeconomic and ethnic disparities in glaucoma outcomes. Glaucomatous visual loss is often preventable with current drug regimens and surgical techniques, provided that intervention occurs in the early stages. Because of its higher prevalence in African American and Latino populations, poor health literacy may contribute to higher rates of advanced glaucoma in these populations. Although African American individuals are a high-risk group and more likely to develop glaucoma, they may be less aware of the disease and less likely to initiate glaucoma treatment.37,38 Also, glaucoma in African American individuals is more advanced at the stage of discovery and more commonly leads to blindness in this group.3944

Ontiveros et al45 showed that African American individuals are less likely than white individuals to have a primary care physician and to undergo glaucoma screening, though all the respondents were eligible for Medicare and had access to a university medical center within a short driving distance. There is evidence suggesting that African American individuals may be undertreated for glaucoma owing to the underuse of medical facilities and that they may seek medical care for glaucoma later in the course of the disease.46

Our study has a number of limitations. First, its cross-sectional design did not allow us to ascertain whether poor health literacy was causally associated with worse glaucoma outcomes. It is possible that health literacy is simply a marker for other factors that represent unmeasured confounders, such as one's health-seeking behavior or psychological makeup. Our study does not elucidate mechanisms through which poor health literacy may result in worse glaucoma outcomes. Glaucoma care requires that a host of concepts and skills be conveyed by a team of health care providers and successfully carried out by the patient. Patients must recognize the signs and symptoms and often must perform self-administration of multiple eye drops. Therefore, glaucoma outcomes may be especially sensitive to problems in communication, empowerment, and self-treatment. It is possible that patients with poor health literacy are less likely to recognize signs and symptoms of glaucoma and present to care later and are less compliant and therefore are more likely to have worse glaucoma outcomes. Also, although psychiatric disorders had been excluded by medical record review (since this could have affected the ability to remember or recall things), a Mini-Mental Status Examination was not specifically conducted.

Results from this study have important implications for all levels of the health care delivery system—patient, physician, and organization. Health literacy is not only important for self-treatment of chronic conditions; it also affects the spectrum of health care, from prevention and screening to history taking and explanation of diagnosis and treatment. Because symptoms only appear in the advanced stages of glaucoma, patients are often unaware of their disease, with only 50% of cases known to the health care system in developed countries.47 Our study confirms the findings of the Baltimore Eye Survey that this lack of awareness is higher in patients with lower educational levels.48 Because early detection of glaucoma is the key to preventing its progression, the need to enhance health literacy of glaucoma awareness, particularly among high-risk groups, is crucial. Awareness of the possible outcomes of glaucoma as well as the importance of compliance with treatment need to be stressed. The perceptions that patients have of their illness can also have a significant effect on management, as the belief that glaucoma is treatable is likely to result in better compliance to a drug regimen.45 Health literacy has been shown to be an important factor affecting disease course, especially in chronic diseases that require an appropriate insight and knowledge and self-treatment (medication adherence and compliance) as outpatients. This should be taken into account while designing studies that evaluate disease progression.

It is crucial to promote literacy and awareness and to better understand the attitudes that patients with poor health literacy have toward glaucoma, so that monitoring and treatment of glaucoma can be more effective. Programs dedicated to increasing glaucoma awareness and treatment availability in the high-risk poor health literacy population may ultimately result in prevention of visual loss.

Our study demonstrated that physicians can readily identify patients with poor health literacy skills. Because physician communication is very important in treatment compliance, physicians must be aware of their patients' health literacy skills.

The patient who walks through the examination room door may have gained access to a medical facility, but access to effective health care will remain elusive if communication barriers have not been fully addressed. Future research should focus on effective health-education techniques and the causal pathway of how poor health literacy influences health and chronic disease outcome.

Closing the gap in health literacy is 1 essential component in reducing disparities in glaucoma care. Screening patients for poor literacy is a first step. However, the real challenge is in shaping effective public health communication that is culturally and linguistically appropriate for patients and promotes compliance with medications and follow-up treatment with their physicians. In addition, there is a need to improve physician communication, which should consider the needs and competencies of patients with poor health literacy.4951

Correspondence: Mark S. Juzych, MD, MHSA, Department of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine, 4717 St Antoine St, Detroit, MI 48201 (mjuzych@med.wayne.edu).

Submitted for Publication: May 11, 2007; final revision received October 1, 2007; accepted October 22, 2007.

Financial Disclosure: None reported.

Funding Support: This study was supported by the Penta Glaucoma Fund, which had a role in the design and conduct of the study.

Additional Contribution: Chaesik Kim, BSEE, served as a statistical consultant.

Seiden  CRZorn  MRatzan  S  et al.  Health Literacy, January 1990 Through 1999[NLM Publication No. CBM 2000-1].  Bethesda, MD National Library of Medicine2000;
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, Health literacy: report of the Council on Scientific Affairs. JAMA 1999;281 (6) 552- 557
PubMed Link to Article
Powers  RD Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med 1988;17 (2) 124- 126
PubMed Link to Article
Jolly  BTScott  JLFeied  CFSanford  SM Functional illiteracy among emergency department patients: a preliminary study. Ann Emerg Med 1993;22 (3) 573- 578
PubMed Link to Article
Spandorfer  JMKarras  DJHughes  LACaputo  C Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med 1995;25 (1) 71- 74
PubMed Link to Article
Williams  DMCounselman  FLCaggiano  CD Emergency department discharge instructions and patient literacy: a problem of disparity. Am J Emerg Med 1996;14 (1) 19- 22
PubMed Link to Article
Morrow  GR How readable are subject consent forms? JAMA 1980;244 (1) 56- 58
PubMed Link to Article
Grundner  TM On the readability of surgical consent forms. N Engl J Med 1980;302 (16) 900- 902
PubMed Link to Article
Baker  MTTaub  HA Readability of informed consent forms for research in a Veterans Administration medical center. JAMA 1983;250 (19) 2646- 2648
PubMed Link to Article
LoVerde  MEProchazka  AVByyny  RL Research consent forms: continued unreadability and increasing length. J Gen Intern Med 1989;4 (5) 410- 412
PubMed Link to Article
Grossman  SAPiantadosi  SCovahey  C Are informed consent forms that describe clinical oncology research protocols readable by most patients and their families? J Clin Oncol 1994;12 (10) 2211- 2215
PubMed
Meade  CDDiekmann  JThornhill  DG Readability of American Cancer Society patient education literature. Oncol Nurs Forum 1992;19 (1) 51- 55
PubMed
Petterson  TDornan  TLAlbert  TLee  P Are information leaflets given to elderly people with diabetes easy to read? Diabet Med 1994;11 (1) 111- 113
PubMed Link to Article
Doak  CCDoak  LGRoot  JH Teaching Patients With Low Literacy Skills. 2nd ed. Philadelphia, PA JB Lippincott Co1996;
Williams  MVBaker  DWParker  RMNurss  JR Relationship of functional health literacy to patients' knowledge of their chronic disease. Arch Intern Med 1998;158 (2) 166- 172
PubMed Link to Article
Williams  MVBaker  DWHonig  EGLee  TMNowlan  A Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114 (4) 1008- 1015
PubMed Link to Article
Baker  DWParker  RMWilliams  MVClark  WS Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13 (12) 791- 798
PubMed Link to Article
Kirsch  IJungeblut  AJenkins  LKolstad  A Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey.  Washington, DC National Center for Education Statistics, US Dept of Education1993;
PubMed
Baker  DWParker  RMWilliams  MV  et al.  The health care experience of patients with low literacy. Arch Fam Med 1996;5 (6) 329- 334
PubMed Link to Article
Parikh  NSParker  RMNurss  JRBaker  DWWilliams  MV Shame and health literacy: the unspoken connection. Patient Educ Couns 1996;27 (1) 33- 39
PubMed Link to Article
Kalichman  SCRompa  D Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr 2000;25 (4) 337- 344
PubMed Link to Article
Kalichman  SCBenotsch  ESuarez  TCatz  SMiller  JRompa  D Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med 2000;18 (4) 325- 331
PubMed Link to Article
Kalichman  SCRamachandran  BCatz  S Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med 1999;14 (5) 267- 273
PubMed Link to Article
Schillinger  DGrumbach  KPiette  J  et al.  Association of health literacy with diabetes outcomes. JAMA 2002;288 (4) 475- 482
PubMed Link to Article
Williams  MVParker  RMBaker  DWCoates  WNurss  J The impact of inadequate functional health literacy on patients' understanding of diagnosis, prescribed medications, and compliance [abstract]. Acad Emerg Med 1995;2 (5) 386
Link to Article
American Health Association Foundation, The Facts on Glaucoma: National Glaucoma Research. http://www.ahaf.org/glaucoma/about/glabout.htm. Accessed February 2, 2007
Parker  RMBaker  DWWilliams  MVNurss  JR The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10 (10) 537- 541
PubMed Link to Article
Baker  DWWilliams  MVParker  RMGazmararian  JANurss  J Development of a brief test to measure functional health literacy. Patient Educ Couns 1999;38 (1) 33- 42
PubMed Link to Article
Nurss  JParker  RWilliams  MBaker  D TOFHLA: Test of Functional Health Literacy in Adults.  Snow Camp, NC Peppercorn Books & Press2001;
The Michigan Diabetes Research and Training Center Survey Instruments,http://www.med.umich.edu/mdrtc/profs/survey.html#dkt. Accessed February 2, 2007
Taylor  WL Cloze procedure: a new tool for measuring readability. Journal Q 1953;30415- 433
Muir  KWSantiago-Turla  CStinnett  S Health literacy and adherence to glaucoma therapy. Am J Ophthalmol 2006;142 (2) 223- 226
PubMed Link to Article
Bowen  PGRich  RSchlotfeldt  RM Effects of organized instruction for patients with the diagnosis of diabetes mellitus. Nurs Res 1961;10151- 159
Link to Article
Gordis  LMarkowitz  MLillienfeld  AM Studies in the epidemiology and preventability of rheumatic fever, IV: a quantitative determination of compliance in children on oral penicillin prophylaxis. Pediatrics 1969;43 (2) 173- 182
PubMed
Karter  AJParker  MMMoffet  HH  et al.  Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients. Med Care 2004;42 (2) 110- 115
PubMed Link to Article
The AGIS Investigators, The advanced glaucoma intervention study (AGIS), 3: baseline characteristics of black and white patients. Ophthalmology 1998;105 (7) 1137- 1145
PubMed Link to Article
Gasch  ATWang  PPasquale  LR Determinants of glaucoma awareness in a general eye clinic. Ophthalmology 2000;107 (2) 303- 308
PubMed Link to Article
Glynn  RJGurwitz  JHBohn  RL  et al.  Old age and race as determinants of initiation of glaucoma therapy. Am J Epidemiol 1993;138 (6) 395- 406
PubMed
Tielsch  JMSommer  AKatz  J  et al.  Racial variations in the prevalence of primary open-angle glaucoma. JAMA 1991;266 (3) 369- 374
PubMed Link to Article
Sommer  ATielsch  JMKatz  J  et al.  Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med 1991;325 (20) 1412- 1417
PubMed Link to Article
Glaucoma Laser Trial Research Group, The Glaucoma Laser Trial (GLT), 5: subgroup differences at enrollment. Ophthalmic Surg 1993;24 (4) 232- 241
PubMed
Grant  WBurke  JF  Jr Why do some people go blind from glaucoma? Ophthalmology 1982 Sep;89 (9) 991- 998
PubMed Link to Article
Wilson  RRichardson  TMHertzmark  EGrant  WM Race as a risk factor for progressive glaucomatous damage. Ann Ophthalmol 1985;17 (10) 653- 659
PubMed
Martin  MJSommer  AGold  EBDiamond  EL Race and primary open-angle glaucoma. Am J Ophthalmol 1985;99 (4) 383- 387
PubMed
Ontiveros  JABlack  SAJakobi  PLGoodwin  JS Ethnic variation in attitudes toward hypertension in adults ages 75 and older. Prev Med 1999;29 (6, pt 1) 443- 449
PubMed Link to Article
Hiller  RKahn  HA Blindness from glaucoma. Am J Ophthalmol 1975;80 (1) 62- 69
PubMed
Quigley  HABroman  AT Number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90 (3) 262- 267
PubMed Link to Article
Tielsch  JMSommer  AKatz  J  et al.  Socioeconomic status and visual impairment among urban Americans: Baltimore Eye Survey Research Group. Arch Ophthalmol 1991;109 (5) 637- 641
PubMed Link to Article
Schillinger  DPiette  JWang  F  et al.  Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163 (1) 83- 90
PubMed Link to Article
Doak  CCDoak  LGFriedell  GHMeade  CD Improving comprehension for cancer patients with low literacy skills: strategies for clinicians. CA Cancer J Clin 1998;48 (3) 151- 162
PubMed Link to Article
Schillinger  D Improving the quality of chronic disease management for populations with low functional health literacy: a call to action. Dis Manage 2001;4103- 109
Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Histogram demonstrating the mean Test of Functional Health Literacy in Adults (TOFHLA) scores (with standard error of mean) for different levels of education.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 5. Comparison of Glaucoma Parameters in the Right Eye (A Priori) Between Healthy Literacy Groups
Table Graphic Jump LocationTable 4. Comparison of Perceived Glaucoma Insight and Understanding Between Health Literacy Groups
Table Graphic Jump LocationTable 3. Comparison of Self-Reported Glaucoma Education and Compliance Between Health Literacy Groups
Table Graphic Jump LocationTable 2. Adjusted Odds Ratios (ORs) for Having Poor vs Adequate Health Literacy
Table Graphic Jump LocationTable 1. Demographic Characteristics of Patients With Glaucoma by Health Literacy Level

References

Seiden  CRZorn  MRatzan  S  et al.  Health Literacy, January 1990 Through 1999[NLM Publication No. CBM 2000-1].  Bethesda, MD National Library of Medicine2000;
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, Health literacy: report of the Council on Scientific Affairs. JAMA 1999;281 (6) 552- 557
PubMed Link to Article
Powers  RD Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med 1988;17 (2) 124- 126
PubMed Link to Article
Jolly  BTScott  JLFeied  CFSanford  SM Functional illiteracy among emergency department patients: a preliminary study. Ann Emerg Med 1993;22 (3) 573- 578
PubMed Link to Article
Spandorfer  JMKarras  DJHughes  LACaputo  C Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med 1995;25 (1) 71- 74
PubMed Link to Article
Williams  DMCounselman  FLCaggiano  CD Emergency department discharge instructions and patient literacy: a problem of disparity. Am J Emerg Med 1996;14 (1) 19- 22
PubMed Link to Article
Morrow  GR How readable are subject consent forms? JAMA 1980;244 (1) 56- 58
PubMed Link to Article
Grundner  TM On the readability of surgical consent forms. N Engl J Med 1980;302 (16) 900- 902
PubMed Link to Article
Baker  MTTaub  HA Readability of informed consent forms for research in a Veterans Administration medical center. JAMA 1983;250 (19) 2646- 2648
PubMed Link to Article
LoVerde  MEProchazka  AVByyny  RL Research consent forms: continued unreadability and increasing length. J Gen Intern Med 1989;4 (5) 410- 412
PubMed Link to Article
Grossman  SAPiantadosi  SCovahey  C Are informed consent forms that describe clinical oncology research protocols readable by most patients and their families? J Clin Oncol 1994;12 (10) 2211- 2215
PubMed
Meade  CDDiekmann  JThornhill  DG Readability of American Cancer Society patient education literature. Oncol Nurs Forum 1992;19 (1) 51- 55
PubMed
Petterson  TDornan  TLAlbert  TLee  P Are information leaflets given to elderly people with diabetes easy to read? Diabet Med 1994;11 (1) 111- 113
PubMed Link to Article
Doak  CCDoak  LGRoot  JH Teaching Patients With Low Literacy Skills. 2nd ed. Philadelphia, PA JB Lippincott Co1996;
Williams  MVBaker  DWParker  RMNurss  JR Relationship of functional health literacy to patients' knowledge of their chronic disease. Arch Intern Med 1998;158 (2) 166- 172
PubMed Link to Article
Williams  MVBaker  DWHonig  EGLee  TMNowlan  A Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114 (4) 1008- 1015
PubMed Link to Article
Baker  DWParker  RMWilliams  MVClark  WS Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13 (12) 791- 798
PubMed Link to Article
Kirsch  IJungeblut  AJenkins  LKolstad  A Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey.  Washington, DC National Center for Education Statistics, US Dept of Education1993;
PubMed
Baker  DWParker  RMWilliams  MV  et al.  The health care experience of patients with low literacy. Arch Fam Med 1996;5 (6) 329- 334
PubMed Link to Article
Parikh  NSParker  RMNurss  JRBaker  DWWilliams  MV Shame and health literacy: the unspoken connection. Patient Educ Couns 1996;27 (1) 33- 39
PubMed Link to Article
Kalichman  SCRompa  D Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr 2000;25 (4) 337- 344
PubMed Link to Article
Kalichman  SCBenotsch  ESuarez  TCatz  SMiller  JRompa  D Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med 2000;18 (4) 325- 331
PubMed Link to Article
Kalichman  SCRamachandran  BCatz  S Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med 1999;14 (5) 267- 273
PubMed Link to Article
Schillinger  DGrumbach  KPiette  J  et al.  Association of health literacy with diabetes outcomes. JAMA 2002;288 (4) 475- 482
PubMed Link to Article
Williams  MVParker  RMBaker  DWCoates  WNurss  J The impact of inadequate functional health literacy on patients' understanding of diagnosis, prescribed medications, and compliance [abstract]. Acad Emerg Med 1995;2 (5) 386
Link to Article
American Health Association Foundation, The Facts on Glaucoma: National Glaucoma Research. http://www.ahaf.org/glaucoma/about/glabout.htm. Accessed February 2, 2007
Parker  RMBaker  DWWilliams  MVNurss  JR The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10 (10) 537- 541
PubMed Link to Article
Baker  DWWilliams  MVParker  RMGazmararian  JANurss  J Development of a brief test to measure functional health literacy. Patient Educ Couns 1999;38 (1) 33- 42
PubMed Link to Article
Nurss  JParker  RWilliams  MBaker  D TOFHLA: Test of Functional Health Literacy in Adults.  Snow Camp, NC Peppercorn Books & Press2001;
The Michigan Diabetes Research and Training Center Survey Instruments,http://www.med.umich.edu/mdrtc/profs/survey.html#dkt. Accessed February 2, 2007
Taylor  WL Cloze procedure: a new tool for measuring readability. Journal Q 1953;30415- 433
Muir  KWSantiago-Turla  CStinnett  S Health literacy and adherence to glaucoma therapy. Am J Ophthalmol 2006;142 (2) 223- 226
PubMed Link to Article
Bowen  PGRich  RSchlotfeldt  RM Effects of organized instruction for patients with the diagnosis of diabetes mellitus. Nurs Res 1961;10151- 159
Link to Article
Gordis  LMarkowitz  MLillienfeld  AM Studies in the epidemiology and preventability of rheumatic fever, IV: a quantitative determination of compliance in children on oral penicillin prophylaxis. Pediatrics 1969;43 (2) 173- 182
PubMed
Karter  AJParker  MMMoffet  HH  et al.  Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients. Med Care 2004;42 (2) 110- 115
PubMed Link to Article
The AGIS Investigators, The advanced glaucoma intervention study (AGIS), 3: baseline characteristics of black and white patients. Ophthalmology 1998;105 (7) 1137- 1145
PubMed Link to Article
Gasch  ATWang  PPasquale  LR Determinants of glaucoma awareness in a general eye clinic. Ophthalmology 2000;107 (2) 303- 308
PubMed Link to Article
Glynn  RJGurwitz  JHBohn  RL  et al.  Old age and race as determinants of initiation of glaucoma therapy. Am J Epidemiol 1993;138 (6) 395- 406
PubMed
Tielsch  JMSommer  AKatz  J  et al.  Racial variations in the prevalence of primary open-angle glaucoma. JAMA 1991;266 (3) 369- 374
PubMed Link to Article
Sommer  ATielsch  JMKatz  J  et al.  Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med 1991;325 (20) 1412- 1417
PubMed Link to Article
Glaucoma Laser Trial Research Group, The Glaucoma Laser Trial (GLT), 5: subgroup differences at enrollment. Ophthalmic Surg 1993;24 (4) 232- 241
PubMed
Grant  WBurke  JF  Jr Why do some people go blind from glaucoma? Ophthalmology 1982 Sep;89 (9) 991- 998
PubMed Link to Article
Wilson  RRichardson  TMHertzmark  EGrant  WM Race as a risk factor for progressive glaucomatous damage. Ann Ophthalmol 1985;17 (10) 653- 659
PubMed
Martin  MJSommer  AGold  EBDiamond  EL Race and primary open-angle glaucoma. Am J Ophthalmol 1985;99 (4) 383- 387
PubMed
Ontiveros  JABlack  SAJakobi  PLGoodwin  JS Ethnic variation in attitudes toward hypertension in adults ages 75 and older. Prev Med 1999;29 (6, pt 1) 443- 449
PubMed Link to Article
Hiller  RKahn  HA Blindness from glaucoma. Am J Ophthalmol 1975;80 (1) 62- 69
PubMed
Quigley  HABroman  AT Number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90 (3) 262- 267
PubMed Link to Article
Tielsch  JMSommer  AKatz  J  et al.  Socioeconomic status and visual impairment among urban Americans: Baltimore Eye Survey Research Group. Arch Ophthalmol 1991;109 (5) 637- 641
PubMed Link to Article
Schillinger  DPiette  JWang  F  et al.  Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163 (1) 83- 90
PubMed Link to Article
Doak  CCDoak  LGFriedell  GHMeade  CD Improving comprehension for cancer patients with low literacy skills: strategies for clinicians. CA Cancer J Clin 1998;48 (3) 151- 162
PubMed Link to Article
Schillinger  D Improving the quality of chronic disease management for populations with low functional health literacy: a call to action. Dis Manage 2001;4103- 109
Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,504 Views
36 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Glaucoma

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Make the Diagnosis: Glaucoma