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Health Literacy

In Brief: Identifying Medicare Beneficiaries with Poor Health Literacy Skills: Is a Short Screening Index Feasible?

Research Report

Joyce Dubow, M.U.P., AARP Public Policy Institute

June 2005


This In Brief summarizes the AARP Public Policy Institute Issue Paper, #2005-01, Identifying Medicare Beneficiaries with Poor Health Literacy Skills: Is a Short Screening Index Feasible?, by Judith Hibbard, Jessica Greene, and Martin Tusler of the University of Oregon.

Health literacy is a major, albeit under-recognized health policy issue. Having adequate literacy skills allows individuals to successfully navigate the health care system. Without such skills, people are unable to actively participate in their health care. In addition, those with inadequate skills have less knowledge about their medical conditions, worse health status, less understanding and use of preventive services, and a higher rate of hospitalization than those with marginal or adequate health literacy skills. As the Medicare program continues to evolve and offers beneficiaries more choices of benefits, health plans, physicians, hospitals, and treatment options, proficiency in literacy is essential.

The findings from a previous study showed that at least half of Medicare beneficiaries had difficulty understanding comparative information to help them make Medicare coverage choices. Although health literacy was not specifically measured in that investigation, it is likely that those unable to understand the information had inadequate or marginal literacy skills. That earlier study found that a three-variable index predicted with 70% accuracy whether Medicare beneficiaries had sufficient skill to understand and use information to make Medicare choices. The three variables in the index were: respondent age, self-rated health status, and education. This study assesses the potential of this same index to identify those with low health literacy quickly and easily.

This study uses a cross-sectional design and a convenience sample of 293 Medicare beneficiaries age 65 and older who were recruited and paid for their participation. Recruitment and data collection took place primarily at Eugene/Springfield, Oregon senior community centers; therefore, homebound and institutionalized beneficiaries were, de facto, excluded. Thus, the sample is skewed toward higher-performing individuals.

The Test of Functional Health Literacy (S-TOFHLA) is used to assess health literacy.

The S-TOHFLA produces a numeric score that is grouped into three health literacy skill levels: inadequate, marginal, and adequate.

The prevalence of inadequate and marginal literacy levels is low in this sample. Nevertheless, the screening index achieves a relatively high level of both sensitivity and specificity for predicting health literacy levels. Seventy-one percent of respondents are correctly classified by the screening index as either a true positive (low health literacy) or a true negative (adequate health literacy). However, this dichotomized health literacy score, which produces only two levels of scoring (adequate or marginal or less) is cruder than the suggested approach in the S-TOHFLA, which identifies three literacy levels (inadequate, marginal, and adequate).

This study represents a first step toward the development of a screening tool that could be applied easily in a clinical setting or a Medicare counseling center to identify people who will need extra assistance in following instructions, using information, and making choices. The findings indicate that the approach is feasible, and the results suggest that additional research with larger, more diverse populations is warranted.

Written by Joyce Dubow, AARP Public Policy Institute
May 2005
©2005 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

Pub ID: INB97