Article, Emergency Medicine

Health literacy of adults presenting to an urban ED

Original Contribution

health literacy of adults presenting to an urban ED?,??,?

Travis Olives MD, MPH, MEd, Roma Patel MPH, Sagar Patel, Julie Hottinger, James R. Miner MD?

Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minn 55415

Received 19 October 2009; revised 30 March 2010; accepted 31 March 2010


Objective: The aim of the study was to assess the prevalence of limited health literacy in an urban emergency department (ED) and its association with Sociodemographic variables.

Methods: This was a cross-sectional study of patients presenting to the ED of an urban county hospital. For 3 months, we screened a convenience sample of patients presenting to the ED. Participants completed a brief demographic survey and a validated assessment of health literacy, the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multinomial logistic regression model was used to analyze data.

Results: Of the 15 930 patients presenting to the ED, 5601 met inclusion criteria. Of eligible patients, 65% (3639) agreed to complete demographic surveys and 26% (960) of them agreed to complete the S-TOFHLA. The most common exclusions were inability to contact the patient and age less than 18 years. Participating patients were younger than those who declined (mean age, 36.8 compared to 40.8 [t = 7.49; P b .001]). Sex and ethnicity were not significantly different across groups. Of all participants, 15.5% possessed limited health literacy. Inadequate health literacy was independently associated with increasing age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.05-1.10), non- English primary language (OR, 6.97; 95% CI, 2.76-17.6), male sex (OR, 1.82; 95% CI, 1.03-3.21), nonwhite ethnicity (OR, 2.66; 95% CI, 1.40-5.04), and years of education in the United States (OR, 0.63; 95% CI, 0.42-0.92). Marginal health literacy was associated with increasing age (OR, 1.03; 95%

CI, 1.00-1.05); male sex (OR, 1.84; 95% CI, 1.04-3.24); ethnicity (OR, 2.08; 95% CI, 1.12-3.85); and

a housing status of homelessness (OR, 9.66; 95% CI, 2.33-40.0), living with friends (OR, 4.59; 95% CI, 1.18-17.9), or renting (OR, 4.16; 95% CI, 1.21-14.3). Moderate to high correlation among housing variables was observed.

Conclusions: Of patients enrolled in the study, 15.5% have limited health literacy. Age, male sex, non- English first language, nonwhite ethnicity, limited education, and unstable housing were associated with limited health literacy.

(C) 2011

? None of the authors have financial or other interests in the medications used in this study.

?? This work was presented at the SAEM Annual Meeting in New

Orleans, La, May 2009.

? Authors declare no conflict of interest or outside funding sources.

* Corresponding author. Tel.: +1 612 873 8791; fax: +1 612 904 4241.

E-mail address: [email protected] (J.R. Miner).



Literacy underpins all aspects of written and oral discourse and is critical to social interactions [1]. Illiteracy is implicated in difficulty with tasks as simple as the

0735-6757/$ – see front matter (C) 2011 doi:10.1016/j.ajem.2010.03.031

completion of oral language tasks and changes the manner in which the spoken word is processed [2]. An important part of literacy is the application of distinct linguistic registers to specific situations [3]. Up to 23% of American adults possess the lowest of literacy skills as measured by standardized testing instruments, suggesting the ability to perform only simple, routine tasks with written information [4]. The capacity to read and write therefore affects an individual in most aspects of daily life; health literacy is no exception.

Health literacy is a specific subset of literacy defined as “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [5]. It is estimated that 90 million Americans have limited health literacy [5]. Most medical information is written at a 10th grade level or higher and may therefore be inaccessible to many patients [6]. These individuals are likely to have difficulty understanding common medical terms and may risk poor control of their medical conditions due to limited understanding of appropriate treatment strategies [7]. Advanced age and lower educational and socioeconomic status have been shown to be independently associated with limited health literacy [8,9], and older patients may be disproportionately affected by limited health literacy due to simultaneous chronic disease [6]. Limited health literacy has also been associated with poor health outcomes, increased emergency department (ED) use, Prolonged hospitalizations, and increased health care costs [10].

The burden of limited health literacy has been demon- strated to reach deeply into the pockets of health care systems and to affect individual patients broadly. A 2005 survey of more than 3000 Medicare enrollees found that the adjusted difference in mean ED visit cost between patients with inadequate and adequate health literacy was $108 [11]. Limited health literacy has been associated with a poorer quality of life and more asthma-associated ED use among asthmatics, and children of parents with limited health literacy have been shown to have more frequent ED visits, hospitalizations, and missed school days [12-15]. In addition, reduced preventative health services use has been documented among patients with limited health literacy [16]. Limited health literacy is therefore a significant threat to effective patient care in the ED and warrants what previous authors have termed universal precautions–plain language, multimedia communicative techniques, and teach-back methods–in the ED to minimize miscommunications and optimize Treatment outcomes [17]. Additional research is needed to better define both the scope of the problem and methods to effectively investigate health literacy in the fast-

paced and often emotionally charged ED.


The ED patients often must understand their illness, decide on treatment options, and follow relevant instructions in the context of injury or disease before their discharge [8].

To understand the impact of limited health literacy on the treatment of ED patients, the treating physician must assess a patient’s health literacy with reference to the reading level of health materials provided in the ED, as well as the complexity of verbal instructions given to the patient. Patient-directed materials in the ED have been shown to range from 8th to 13th grade level [18,19] suggesting both the immediate importance of adequate health literacy and the need for further ED-specific research to maximize appropri- ate communication strategies.

Research has infrequently measured health literacy levels among ED patients. Existing estimates of the prevalence of limited health literacy ranges from 20% to greater than 50% by study and demographic assessed [8,20]. A recent multicenter study of urban ED patients reported a prevalence of limited health literacy of approximately 25% [9]. A higher prevalence of limited health numeracy, an important component of health literacy previously described as encompassing computation, estimation, and logic, has been demonstrated among ED patients when compared to the general population, suggesting the need to focus on the literacy level of ED patients [21]. Among those studies conducted in EDs, limited health literacy has been found to be independently associated with higher rates of retinopathy and worse Glycemic control among diabetics [22]. low health literacy is associated with poor understanding among HIV patients of their own health and treatment, suggesting poor understanding of the risks they pose in transmitting HIV to others [23,24]. Further investigation of the prevalence of limited health literacy in the ED is warranted to better characterize the extent of the problem and its effects on the care of ED patients.

Goals of this investigation

The goal of this investigation was to determine the prevalence of limited health literacy among patients present- ing to an urban county ED and to describe the association of sociodemographic characteristics with health literacy levels.


Study design and setting

This was a cross-sectional study conducted in the ED of an urban level I trauma center with approximately 106 000 annual visits. The Hennepin County Medical Center Human Subjects Research Committee approved the study before implementation. We prospectively screened patients pre- senting to the ED in convenience samples distributed over 24 h/d between June 10 and August 31, 2008. Consenting participants completed a brief demographic survey and a validated written assessment of health literacy, the Short Test of Functional Health Literacy in Adults (S-TOFHLA, Peppercorn Books 2003) [25].


All adult (age N 18) patients in the ED were eligible for this study. We excluded patients with high acuity complaints per the treating clinician (including sexual assault), prisoners and those in police custody, speakers of languages other than English and Spanish, patients presenting with altered mental status, and patients determined to be vulnerable adults. Because research associates had limited access to patients’ electronic medical records, determination of what constituted altered mental status or vulnerable adult was determined by the treating clinician. Among those participants who were subsequently noted to have completed the study more than once, we excluded those whose presentations to the ED were separated by less than 2 weeks.

Data collection

Patients were approached by trained and clearly identifi- able research associates (RAs), who assessed patient eligibility and delivered the survey instrument in a standard- ized fashion. Training of RAs included several group orientation sessions, directed instruction in the completion of S-TOFHLA forms, and instructional shifts for applied learning. After informed consent was obtained, each participant was read a standard set of instructions and answers to remaining questions were offered. Patients who requested further instruction in the completion of the S- TOFHLA were offered an example cloze statement but were not directed in the completion of specific questions on the assessment tool. Neither family members nor others accom- panying patients were allowed to assist in the completion of assessments, and those patients who reported inability to read the assessment tool did not complete them. Patient enrollment was monitored centrally by a single RA who maintained an electronic log of all patients over that screening period. Completed paper surveys were entered into an Excel spreadsheet maintained and electronically backed up on site.

Methods of measurement

Participants completed the S-TOFHLA, which consists of 36 modified cloze items, choosing from a list the word that best completes each sentence. Correct completion of 0 to 16 of the cloze items suggests inadequate health literacy (unable to read even the simplest health materials), correct completion of 17 to 22 items suggests marginal health literacy (difficulty comprehending more complex materials), and correct completion of 23 or more suggests adequate health literacy (successfully able to complete most tasks required in a health care setting). The primary outcome for this study was limited health literacy, defined by “inadequate” or “marginal” performance on the S-TOFHLA.

Sociodemographic variables were assessed through participant responses to a brief survey administered by

research associates. Participants did have the option to decline individual questions.

Primary data analysis

Data were analyzed using Stata 8.1 (Stata Corp, College Station, Tex). Multinomial logistic regression was performed to directly compare marginal and inadequate literacy levels to

Table 1 Participant demographics

Living with chronic disease, n (%) Regular primary care, n (%)

372 (38.8)

554 (57.8)

Total (N = 960)

Mean age (SD), y 36.7 (13.7)

Sex, n (%)


471 (49.1)


Ethnicity, n (%)

488 (50.9)


397 (41.4)


10 (1.0)


379 (39.5)

Native American

57 (5.9)


44 (4.6)


28 (2.9)


7 (0.7)


38 (4.0)

Self-reported overall health, n (%)


169 (17.6)


458 (47.7)


253 (26.4)


72 (7.5)

Don’t know

8 (0.8)

First language other than English, n (%) 77 (8.0)

Mean length of US education, n (%), y

b9 92 (9.6)

9 to b12 108 (11.3)

12 to b16 607 (63.2)

>=16 153 (15.9)

Insurance, n (%)


284 (29.6)


209 (21.8)

Medicare/Medicaid/Safety Net

317 (33.0)


133 (13.9)


Employment status, n (%)

17 (1.8)


467 (48.7)


465 (48.4)


27 (2.8)


Housing status, n (%)

1 (0.1)

Property owner

141 (14.7)


58 (6.0)

Halfway house/transitional housing

44 (4.6)

With friends or relatives

158 (16.5)


523 (54.5)

Nursing home

7 (0.7)


29 (3.0)

adequate health literacy levels, as defined by the S-TOFHLA. We included variables hypothesized to be associated with limited health literacy levels in our samples. These variables included age, sex, primary language, ethnicity, Access to a primary care provider, years of education in the United States, self-reported health, employment, housing, insurance, and chronic disease status. All results presented in the text are odds ratios (ORs) with 95% confidence intervals (CIs).

In our regression analysis, age was treated as a continuous variable. Educational attainment included all years of education completed in the United States, including primary, secondary, collegiate, and graduate education, and was categorized as less than 9 years, 9 to less than 12 years, 12 to less than 16 years, and 16 years or more. Respondents were asked to characterize their ethnic background as white, Asian, black, Hispanic, multiethnic, or “other.” As with all aspects of the survey, participants had the option to refuse this question. For analysis, ethnicity was analyzed as white (referent) and nonwhite. Health insurance status was treated as a categorical variable including “private” (employment or individual, referent group) insurance, Medicare/Medicaid/Safety Net coverage (including county and state programs) “no insur- ance,” and “other” insurance. Housing was treated as a categorical variable, with “property owner” as the referent group and “renting,” “living with friends or relatives,” “nursing home,” “halfway house/transitional housing,” and “homeless” treated as comparison groups. Employment was also treated as a categorical variable, with “currently employed” as the referent category and “unemployed” and

Table 2 Results of multinomial logistic regression–odds of inadequate or marginal health literacy

Inadequate health literacy Marginal health literacy

OR P 95% CI OR P 95% CI

“retired” as comparison groups. Self-reported health status was treated as an ordinal variable consisting of “excellent” (referent), “good,” “fair,” and “poor.” Sex, non-English first language, and survey items assessing status regarding living with chronic disease and access to regular primary care were treated as binary variables. Private insurance, home owner- ship, and report of current employment were used as referent groups in our regression model. The covariance matrix derived from our regression model was used to determine intervariable correlation.


Of the 15 930 patients presenting to the ED, 5601 met inclusion criteria. The most common causes of exclusion were inability to contact patient either due to ongoing care or inability to locate the patient (32%, eg, patient left against medical advice) and age less than 18 years (18%). Of the eligible patients, 1962 (35%) refused to be surveyed. The remaining 3639 patients (65%) completed demographic surveys; of them, 960 (26%) agreed to complete S- TOFHLAs. No single cause for the low participation rate among eligible patients was evident. Among those meeting inclusion criteria, participating patients were younger than those who declined (mean age, 36.8 compared to 40.8 [t = 7.49; P b .001]). Sex and ethnicity were not significantly different between participants and nonparticipants. Overall, 15.5% (n = 149) of patients enrolled had inadequate (8.54%)

Increasing age







Male sex







Nonwhite ethnicity







Self-reported health–compared to “excellent”







Non-English primary language







Length of US education, y







Insurance–compared to private insurance

Medicare/Medicaid/Safety Net





















Employment–compared to “employed”















Housing–compared to home ownership








Living with friends







Transitional housing







Nursing home a











Living with chronic disease







Regular primary care







a n = 0 nursing home residents in marginal health literacy group.

Inadequate, n = 82

Marginal, n = 67

Adequate, n = 811

Mean age (SD), y

45.7 (15.7)

38.6 (14.7)



Sex, n (%)




24 (35.8)






43 (64.2)



Ethnicity, n (%)




16 (4.0)






51 (9.1)



Native language, n (%)




60 (89.6)






7 (10.5)



Mean length of US

8.92 (5.5)

11.5 (3.5)



education (SD), y

Regular primary care,



37 (55.2)



n (%)

or marginal (6.98%) health literacy. Table 1 describes the baseline demographic characteristics of study participants enrolled in the study.

Table 3 Participant health literacy levels by key demographic characteristics

All a priori variables were included in the regression model. The model was run with insignificant variables

excluded to assess parsimony; however, the complete regression model is reported to control for confounding. In our regression model (Table 2), each additional year of age was associated with increased odds of inadequate (OR, 1.08; P b .001; CI, 1.05-1.10) and marginal (OR, 1.03;

P = .031; CI, 1.00-1.05) health literacy levels (compared to adequate health literacy). Non-English primary language was strongly associated with increased odds of inadequate health literacy (OR, 6.97; P b .001; CI, 2.76-17.6) but was not associated with increased odds of marginal health literacy. Male sex was associated with increased odds of both inadequate (OR, 1.82; P = .04; CI, 1.03-3.21) and marginal (OR, 1.84; P = .035; CI, 1.04-3.24) health literacy, and nonwhite ethnicity also predicted both inadequate (OR, 2.66; P = .003; CI, 1.40-5.04) and marginal (OR, 2.08; P = .02; CI, 1.12-3.85) health literacy. Years of education completed in the United States was inversely associated with inadequate health literacy (OR, 0.63; P = .02; CI, 0.42-0.92). Housing statuses of “renting” (OR, 4.16; P = .02; CI, 1.21-14.3), “living with friends” (OR, 4.59; P = .03; CI, 1.18-17.9), and “homeless” (OR,

9.66; P = .002; CI, 2.33-40.0) were associated with increased odds of marginal health literacy (Table 3). Figs. 1 and 2 display the results of our regression analysis.

Fig. 1 Logistic regression results: odds of inadequate health literacy.

Fig. 2 Logistic regression results: odds of marginal health literacy.

Moderate to strong multicollinearity of housing variables (0.34-0.85) was noted when intervariable correlation was analyzed. The US educational attainment and primary language were strongly correlated, as were insurance status variables. All other variables had Correlation coefficients less than 0.4. With serial removal of nonsignificant variables from our regression model, US educational attainment became a significant predictor of marginal health literacy; transitional housing, age, and sex narrowly lost predictive significance.


Despite a rigorous approach, a relatively small proportion of eligible patients presenting to the ED (26%) consented to participate in this study. Differences between respondents and nonrespondents are likely not completely elucidated by this study. Low participation rates may be due to both the rapid pace and emotionally trying environment of the ED. In addition, patients may perceive completion of an arduous study instrument–especially one that stands to point out a personal shortcoming such as limited literacy–as an

unnecessary addition to an already difficult situation. This concern was commonly reported by our research associates. We excluded the participation of intoxicated or acutely ill patients, both of whom may have different rates of limited health literacy than our results would indicate. We also excluded non-English/non-Spanish speakers, as we neither had resources to interview this portion of our patient population nor is the S-TOFHLA, to our knowledge, validated for this population. In diverse patient populations, such systematic exclusions may bias our findings. Impor- tantly, sociodemographic data were collected by self-report and therefore may be incomplete or inaccurate based on individual reporting. Patients were surveyed at only one site, and these results may not be representative of nonurban or private hospitals, of which the patient populations may differ considerably from our own. There was considerable correlation across our housing status variables, suggesting some misclassification; this may point out the difficulty of objectively measuring housing and homelessness in a population whose housing status may be quite fluid. Although this study did not directly adjust for SES, several of our variables including housing status are reflections of, or

at least closely correlated with, SES. Finally, our regression model accounted for multiple independent variables, and as such, the associations reported in this study should be verified in future investigations.


In this study of patients presenting to an urban ED, 15.5% of those surveyed possessed limited health literacy skills as measured by performance on a validated health literacy assessment tool. This population would have difficulty interpreting materials found in a health care setting. Increasing age, non-English native language, male sex, nonwhite ethnicity, and housing status were independently associated with increased odds of limited health literacy. Increasing years of US education appeared to carry a protective effect against limited health literacy, as it was associated with decreased odds of inadequate health literacy, though it did fall short of significance with respect to its inverse association with marginal health literacy. In contrast, self-reported health, insurance status, employment status, living with chronic disease, and regular primary care were not independently associated with limited health literacy. These results differ from a recent study of health literacy in the ED, which demonstrated slightly higher rates of limited health literacy and found only advanced age, lower education, and lower income levels to be associated with limited health literacy [8]. Another study performed on inpatients and outpatients, although with a smaller sample size than the present study, found only SES to be associated with limited health literacy [26]. Although the regression model used in the present study did not directly assess SES, it did include in the model several variables known to be tightly associated with SES (housing status, years of education, and ethnicity) and may therefore be interpreted to suggest a similar relationship between SES on health literacy levels.

Limited health literacy presents a difficult problem and may impede physicians’ capacity to adequately treat ED patients. This is evident when follow-up or medication instructions are central to a patient’s treatment, as is the case for the diseases treated in the ED. As patients are encouraged to become partners in their own health care, health literacy becomes a pivotal issue in the management of care and has important implications for the viability of the partner paradigm. In our study, more than 1 in 7 patients surveyed had limited health literacy skills. The problem of limited health literacy should be understood in the context of both the source and the receiver. The source, as previously discussed, includes prescription drug labels, health education brochures, and consent and discharge forms, whereas the receiver is the patient interpreting these materials. Patient education materials in the ED produced by hospitals and third parties range from the 8th to 13th grade levels [18,19]. Assessing the health literacy status of the receiver and providing source information at an

appropriate level is critical to ensuring the continuity and success of care in the ED. Further investigation is necessary to describe the implementation of validated health literacy assessment tools in the ED, specifically tools of which the use and brevity are both maximized. This study sets the stage for follow-up investigation into the association of limited health literacy with health outcomes, health care costs, length of stay, frequency, and nature of ED use. Applications of this research include the development of recommendations to minimize the effects of limited health literacy on ED outcomes through focused interventions such as the simplification of discharge instructions and alternative methods of discharge teaching than written information [27]. In particular, best practices including the teach-to-goal method of communi- cation, visual aids, self-management programs, and the use of lay health educators are suggested to manage limited health literacy in the ED [28]. Trials using mobile devices as a delivery model for providing diabetes information to patients with limited health literacy are currently underway and may provide an additional new direction for research [29]. Patients presenting to the ED with increased age, non-English native language, male sex, nonwhite ethnicity, nonproperty owners, or less years of US education should alert providers to be cognizant of their ability to understand information in the ED.


In our urban county ED, 15.5% of patients have limited health literacy precluding them from understanding written discharge instructions. Increasing age, non-English first language, male sex, limited US education, nonwhite ethnicity, and housing status were independently associated with limited health literacy. Although the assessment of health literacy levels in the ED is clearly an important goal for emergency physicians seeking to optimize the treatment of their patients, the implementation of an assessment tool that may inadvertently point out patient shortcomings during an already difficult experience presents a unique challenge to researchers. The development of a shorter assessment tool that can be implemented with minimal inconvenience to ED patients should be undertaken to expand this area of research. Further research should be done to better describe the association between health literacy levels and objective measured health outcomes in this population.


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