More Than Meets the Eye: Relationship Between Low Health Literacy and Poor Vision in Hospitalized Patients

Abstract

Patient-centered care includes involving patients and their families in self-management of chronic diseases. Identifying and addressing barriers to self-management, including those related to health literacy and vision limitations, may enhance one's ability to self-manage. A set of brief verbal screening questions (BVSQ) that does not rely on sufficient vision to assess health literacy was developed by Chew and colleagues in the outpatient setting. The authors aimed to evaluate the usefulness of this tool for hospitalized patients and to determine the prevalence of poor vision among inpatients. In a prospective study, the BVSQ and the Rapid Estimate of Adult Learning in Medicine–Revised (REALM-R; among participants with sufficient vision, ≥ 20/50 Snellen) were administered to general medicine inpatients. Of 893 participants, 79% were African American, and 57% were female; the mean age was 53 years. Among 668 participants who completed both tools, the proportion with low health literacy was 38% with the BVSQ versus 47% with the REALM-R (p = .0001). Almost one fourth of participants had insufficient vision; participants with insufficient vision were more likely to be identified as having low health literacy by the BVSQ, compared with those with sufficient vision (59% vs. 38%, p < .001).

Acknowledgments

A pilot award from the Center on the Demography and Economics of Aging (National Institute of Aging P30 AG012857) and a seed grant from the Center for Health Administration Studies Seed Grant supported this project. Dr. Press received funding from the National Cancer Institute (KM1CA156717). Ms. Shapiro received support from the Summer Research Program funded by the National Institutes on Aging Short-Term Aging-Related Research Program (T35AG029795). Dr. Meltzer received funding from the National Institutes on Aging Short-Term Aging-Related Research Program (T35AG029795), and from the Agency for Healthcare Quality and Research through the Hospital Medicine and Economics Center for Education and Research in Therapeutics (U18 HS016967-01), and from the National Institute of Aging through a Midcareer Career Development Award (1 K24 AG031326-01), from the National Cancer Institute (1 KM1 CA156717) and from the National Center for Advancing Translational Science (2UL1TR000430-06). Dr. Arora received funding from the National Institutes on Aging Short-Term Aging-Related Research Program (T35AG029795), and National Institutes on Aging (K23AG033763).

Valerie G. Press and Madeleine I. Shapiro are co-first-authors.

Notes

Note. BSVQ = Brief verbal screening questions; REALM-R = Rapid Estimate of Adult Learning in Medicine–Revised.

^a Data were missing for 1 participant in the sufficient vision group (completed both BVSQ and REALM-R); 375 of 667 participants in the sufficient vision group were female (56%), 292 of 667 participants were male (44%). Data were missing for one participant in the insufficient vision group (completed BVSQ only); 125 of 212 participants in the insufficient vision group (completed BVSQ only) were female (59%), 87 of 212 participants were male (41%).

^b Data were missing for nine participants in the sufficient vision group (completed both BVSQ and REALM-R). Race was dichotomized into White and non-White; 124 of 659 participants in the sufficient vision group (19%) were White, and all other responses were defined as non-White. African Americans made up the majority of the non-White category with 506 of 659 participants (77%), 6 of 659 participants (0.9%) were American Indian/Alaskan native, 2 of 659 participants (0.3%) were Asian/Pacific Islander, and 21 of 659 participants (3%) chose the “other” category. Data were missing for one participant in the insufficient vision group (completed BVSQ only). Race was dichotomized into White and non-White; 20 of 212 participants in the insufficient vision group (9%) were White, and all other responses were defined as non-White. African Americans made up the majority of the non-White category with 186 of 212 participants (88%), 3 of 212 participants (1%) were American Indian/Alaskan native, 0 of 212 participants (0%) were Asian/Pacific Islander, and 3 of 212 participants (1%) chose the “other” category.

^c Data were missing for 16 participants in the sufficient vision group (completed both BVSQ and REALM-R); education categories for this group include junior high school or less (17/652, 3%), some high school (90/652, 14%), high school graduate (188/652, 29%), some college/junior college (219/652, 34%), college graduate (87/652, 13%), and postgraduate (51/652, 8%). Data were missing for four participants in the insufficient vision group (completed BVSQ only); education categories for this group include junior high school or less (16/209, 8%), some high school (46/209, 22%), high school graduate (64/209, 31%), some college/junior college (54/209, 26%), college graduate (16/209, 8%), and postgraduate (13/209, 6%).

^d Data were missing for 102 participants in the sufficient vision group (completed both BVSQ and REALM-R); insurance categories for this group include Medicare (230/566, 41%), Medicaid (169/566, 30%), private (145/566, 26%), no payer (21/566, 4%), and grants (1/566, 0.2%). Data were missing for 112 participants in the insufficient vision group (completed BVSQ only); insurance categories for this group include Medicare (63/101, 62%), Medicaid (20/101, 20%), no payer (6/101, 6%), and private (12/101, 12%).

^e Data were missing for 411 participants in the sufficient vision group (completed both BVSQ and REALM-R); income categories for this group include $2,500 or less (26/257, 10%), $2,501 to $5,000 (10/257, 4%), $5,001 to $10,000 (26/257, 10%), $10,001 to $15,000 (31/257, 12%), $15,001 to $25,000 (26/257, 10%), $25,001 to $35,000 (33/257, 13%), $35,001 to $50,000 (29/257, 11%), $50,001 to $100,000 (52/257, 19%), $100,001 to $200,000 (18/257, 4%), and over $200,000 (6/257, 2%). Data were missing for 156 participants in the insufficient vision group (completed BVSQ only); income categories for this group include $2,500 or less (6/57, 11%), $2,501 to $5,000 (4/57, 7%), $5,001 to $10,000 (7/57, 12%), $10,001 to $15,000 (8/57, 14%), $15,001 to $25,000 (14/57, 25%), $25,001 to $35,000 (7/57, 12%), $35,001 to $50,000 (4/57, 7%), $50,001 to $100,000 (3/57, 5%), $100,001 to $200,000 (3/57, 5%), and over $200,000 (1/57, 2%).

Note. AUROC = area under the receiver operating characteristic curve; LR = likelihood ratio. Questions adapted from the Brief Questions to Identify Patients With Inadequate Health Literacy, by Chew, Bradley, and Boyko (2004).

^a Confident with forms = “How confident are you filling out medical forms by yourself?”.

^b Help read = “How often do you have someone help you read hospital materials?”.

^c Problems learning = “How often do you have problems learning about your medical condition because of difficulty understanding written information?”.