Utilizing Health Literacy To Improve Patient Outcomes

Patient Education and Counseling 90 (2013) 247–253


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All Aspects of Health Literacy Scale (AAHLS): Developing a tool to measure functional, communicative and critical health literacy in primary healthcare settings

Deborah Chinn a,*, Catherine McCarthy b

a Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK b Tower Hamlets Community Health Services, London, UK


Article history:

Received 18 August 2011

Received in revised form 3 October 2012

Accepted 12 October 2012


Health literacy

Patient–healthcare practitioner


Scale development


Primary healthcare


Objective: Our aim was to develop and pilot a tool to measure health literacy in primary health care

settings, encompassing functional, communicative and critical health literacy.

Methods: Following consultation with providers and users of primary health care we developed a

fourteen-item self-report scale, which was piloted on 146 participants. The reliability, content and

construct validity of the scale was investigated as well as relationships between scores on the scales and

participant characteristics.

Results: The overall scale had adequate reliability (Cronbach’s alpha = 0.74), though reliability of the

subscales was less consistent. Principal component analysis indicated that scale items loaded on four

factors, corresponding to skills in using written health information; communicating with health care

providers; health information management and appraisal assertion of individual autonomy with regards

to health. Overall scores and different subscale scores were associated with ethnic minority status,

educational level, and self-rated health status, though the picture was complex.

Conclusion: Health literacy is a complex and evolving construct. Nevertheless, we succeeded in

developing a brief measure relating to different health literacy competencies, beyond functional literacy


Practice implications: Assessment using the AAHLS can provide important information for health care

practitioners about the health literacy needs and capabilities of service users.

� 2012 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

The concept of health literacy originated within the US public health arena and is broadly defined as ‘the capacity of an individual to obtain, interpret and understand basic health information and

services in ways that are health-enhancing’ [1]. Health literacy is now understood as a social determinant of health impacting on health outcomes for patients with a range of conditions [2–4]. There is a growing recognition that inadequate health literacy contributes to health inequalities as it is more prevalent among lower socioeconomic groups, ethnic minorities, the elderly and those with long-term conditions or disabilities [1]. Health workers are urged to assess the health literacy of service users [5] in order to identify service users who might need additional support. However, they are confronted with contrasting conceptualisations

* Corresponding author at: King’s College London, Florence Nightingale School of

Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London

SE1 8WA, UK. Tel.: +44 20 7848 3636.

E-mail address: deborah.chinn@kcl.ac.uk (D. Chinn).

0738-3991/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2012.10.019

of this term and little guidance about the sort of assessment that would be most appropriate, especially in socially deprived and ethnically diverse areas.

Recent reviews of existing measures of health literacy suggest a degree of dissatisfaction among communities of researchers and healthcare providers regarding the theoretical underpinnings of current measures, their reliability and validity, and suitability to real life healthcare settings [6–8]. Measuring health literacy is likely to be a particular challenge as it is an emerging and evolving construct [9]. Initially researchers defined health literacy quite narrowly and closely related to reading, writing and numeracy skills as ‘being able to apply literacy skills to health related materials such as prescriptions, appointment cards, medicine labels, and

directions for home health care’ [10]. The Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Set of Brief Screening Questions (SBSQ) were developed to assess these skills, either through direct testing of reading abilities [10–12] or self-report [13,14].

Subsequent reconceptualisations of the health literacy con- struct have argued that individuals need a wider range ofhttp://dx.doi.org/10.1016/j.pec.2012.10.019mailto:deborah.chinn@kcl.ac.ukhttp://www.sciencedirect.com/science/journal/07383991http://dx.doi.org/10.1016/j.pec.2012.10.019

D. Chinn, C. McCarthy / Patient Education and Counseling 90 (2013) 247–253248

cognitive and social skills for dealing with and acting on health information in all its presentations, beyond basic reading and writing skills [15–17]. There has been increasing interest in developing definitions of health literacy based on service users’ own understandings of the term [18–20] and in understanding health literacy in its social and institutional context. Papen suggests that competencies in health literacy should be seen as distributed within the individual health service user’s immediate social circle [21]. Others argue that focusing only on the health literacy skills demonstrated by the service user misses the contribution of health care providers in supporting or undermining the achievement of health literacy [22–24].

Other dimensions of health literacy measures that have come under scrutiny are their applicability, feasibility and acceptability. Some measures take up to half an hour to administer (approxi- mately 22 min in the case of the TOFHLA), and require that administrators have special training and skills which need frequent refreshing and updating [25]. Putting service users in the position where they are struggling to read out loud can evoke feelings of shame and embarrassment [26]. There is also the issue of the cultural and gender specificity of health literacy skills which are being assessed [27,28]. Stimulus materials developed in the US, for example the nutritional label for a tub of icecream [12], may be unfamiliar to service users in other countries. More generally, different health systems may demand different key health literacy skills, whether it is being able to fill in health insurance forms in the US [14] or understanding the public health context of schistosomiasis in China [29]. Health literacy measures need to reflect local health priorities and belief systems, and in the UK, the experiences of patients who do not speak English as a first language [30,31].

1.1. Study aims

With all this in mind, as primary healthcare based clinicians and researchers our goal was to create a measure of health literacy which would be appropriate to use in primary care settings in Tower Hamlets. This is an inner London borough characterised by a mixture of vibrant social and cultural activity, social deprivation and ethnic diversity [32]. We wanted to develop a tool which was quick and easy to use in primary care contexts, took account of local knowledge and expertise and addressed a range of health literacy skills, using Nutbeam’s health promotion orientated model [15]. Nutbeam describes three levels of health literacy: basic/functional literacy, which corresponds to basic reading and writing skills and basic knowledge of health conditions and health systems; communi- cative/interactive literacy, communicative and social skills which can be used to extract information and derive meaning from different forms of communication and to apply new information to changing circumstances; and critical literacy, the advanced cognitive and social skills, which can be applied to critically analyse information, and to use this information to exert greater control over life events and situations relating to individual and community level wellbeing goals.

We also intended the measure would be able to achieve different goals: to act as a screening tool to provide population- level information for commissioners and managers of local primary health and public health services; to alert health practitioners to individual health literacy needs and competencies and to evaluate the impact of local patient education initiatives which were at least partly designed to improve aspects of health literacy, such as expert patient self-management programmes [33], and ESOL (English as a Second or Other Language) classes focusing on health [34].

2. Methods

2.1. Project design

Our first step in designing the new measure was to undertake a review of published research on health literacy definitions and concepts, and on its measurement. Next, we drew up a list of potential items and then presented them in the course of a local consultation exercise consisting of 10 interviews with health service managers and commissioners, and seven focus groups with health workers and local service users. We received some very useful feedback in these sessions. We were repeatedly advised to simplify the language and administration of the measure (we subsequently reduced response options from a 5-point to a 3-point scale featuring the prompts ‘‘rarely’’, ‘‘sometimes’’ and ‘‘often’’) and were offered ideas for new original items. We ran a small pre- pilot involving healthcare assistants undertaking health checks with new patients in GP surgeries, to test the ease of use of the scale and its face validity with health care staff and patients. Finally we undertook the pilot study in three community and five primary healthcare settings in Tower Hamlets.

2.2. Creation of the measure

The measure items were constructed to reflect the dimensions of health literacy in Nutbeam’s [15] definition encompassing functional, communicative and critical health literacy. For functional health literacy items, we reviewed standardised self- report measures devised by Chew et al. [13,14] as well as questionnaires previously used with healthcare users in Tower Hamlets in a social marketing campaign [32]. Items were selected to assess patients’ ability to read health information; writing ability, and access to support networks (see questions FQ1–FQ4 in Table 2). We did not retain all the items or the original wording of the US research, as participants in our consultation exercise found the sentence construction too complex, or felt that the questions related to the US health system. Bearing in mind recent reconceptualisations of health literacy as a set of ‘‘distributed competencies’’, an aggregate score for items 1 and 2 was calculated to look at relationship between limited functional health literacy and access to support.

A review of existing measures and a wider exploration of the literature on patient communication skills suggested that Nut- beam’s category of communicative health literacy could be separated into two components: information gathering and processing skills, and interactive skills needed for successful consultations with health providers. We adapted items from Ishikawa et al.’s self-report items relating to information gathering aspects of communicative health literacy [35] into a single item to assess patients’ willingness to access and use multiple sources of information about their health (‘Are you someone who likes to find out lots of different information about your health?’). Three further items (questions Com Q1–Com Q3 in Table 2) were developed from research identifying key patient communication skills, such as asking questions or requesting clarification, which have been found to improve satisfaction and outcomes from health con- sultations [36–39].

The definition of critical health literacy is also diffuse and requires clearer conceptualisation [40]. Existing research has focused on information appraisal [35,41,42], but Nutbeam’s definition suggests that this aspect of health literacy also involves taking a critical and reflexive stance vis-a-vis health information, considering issues of the relevance and reliability, and integrating knowledge of the social determinants of health and skills in community-level action [43]. To construct our seven critical health literacy items, we drew from existing research not only within the

Table 1 Socio-demographic and health information.

N = 146

Age (years) Mean age: 38 years (SD = 15.37)

Range: 15–82 years

Gender Females: 114 (78%)

Males: 32 (22%)

Ethnicity Asian: 81 (56%)

Black: 5 (3.%)

Mixed race: 2 (1%)

White: 51 (35%)

Other: 7 (5%)

Highest level of qualification No qualifications: 55 (39%)

GCSE/O levels/secondary school certificate:

22 (16%)

A levels: 7 (5%)

Undergraduate degree: 31 (22%)

Postgraduate degree: 25 (18%)

General health rating Poor: 16 (11%)

Fair/ok: 40 (28%)

Good: 68 (47%)

Very good/excellent: 21 (15%)

Long term health condition Yes: 40 (28%)

No: 100 (69%)

Don’t know: 5 (3%)

Time since last visit to GP Within last week: 34 (23%)

Within last month: 43 (30%)

Within last 6 months: 48 (33%)

Within last year: 12 (8%)

More than one year: 8 (6%)

D. Chinn, C. McCarthy / Patient Education and Counseling 90 (2013) 247–253 249

health literacy field, but also relating to media literacy [44], social capital [45] and psychological empowerment [46]. Critical health literacy items Cr2–Cr4 (see Table 2) reflect skills in the information appraisal aspect of health literacy, and ability to evaluate the relevance and validity of different kinds of health information (questions Cr2 and Cr3 were adapted from Ishikawa et al. [35] and question Cr4 was suggested by one of the participants in a consultation focus group). The remaining questions in this section (Emp1–Emp3) address capabilities for empowerment at the level of community and social engagement. We faced a challenge in devising items to assess understandings of and ability to act on social determinants of health, identified by the WHO as a key aspect of health literacy [47]. We reviewed studies, which have used structured measures and questionnaires to assess the priority that individuals place on social determinants rather than individual lifestyle choices and behaviours [5] and included one question relating to respondents’ judgement of the relative importance of these factors [48,49]

2.3. Data collection

A total of 146 participants were recruited for the pilot study. The majority were approached by a member of the research team in the waiting room of their local GP practice. Additionally, a number of participants (27%) were recruited via local health education programmes held in community facilities. We suggested that participants had the material read to them by one of the research team as we did not wish to exclude those with reading difficulties, or others tending to babies or young children who literally had their hands full. We also gave participants the option to read the material by themselves, as we did not have access to a private room in our study settings and were aware that some individuals would not be comfortable with verbally answering questions about health issues in a public setting. Sixty one (42%) of the participants chose to read the measure by themselves. Administration of the scale took approximately 7 min on average. Given the ethnic mix of Tower Hamlets, we anticipated that a number of participants would not be fluent in English. The largest ethnic minority in Tower Hamlets, comprising about 33% of the population is Bangladeshi, overwhelmingly from the Sylhet region of Bangladesh [32] and speakers of Sylheti, a dialect of Bengali. We therefore had the items translated into Sylheti by a bilingual health worker, and then checked by two others for accuracy. As Sylheti is a purely oral language and does not have a written form this version was recorded on a CD and used as a reference by a bilingual research assistant attached to the project who used this method to administer the items to 35 individuals (46% of the Asian sample).

Socio-demographic data were collected via a self-report questionnaire included age, gender, ethnicity, years in education, highest level of qualification, ESOL level (for those in participating health education programmes) as well as some general health markers, including health status, presence/absence of a long term health condition and use of local primary care services.

3. Results

3.1. Socio-demographic and health factors

Socio-demographic and health information are displayed in Table 1. As a non-randomised sampling method was used, the study does not claim to be representative of the general population of Tower Hamlets. Tower Hamlets has a young, ethnically diverse population. Over 50% of the population belongs to an ethnic group other than white British; as pointed out above, about a third of the total population are of Bangladeshi origin. In the study sample, 65% of the population identified as belonging to an ethnic group other

than White British, of whom 56% identified as Asian. In the current study, Asian participants were purposively recruited to reflect the high level of unmet healthcare needs in this population [50]. Tower Hamlets has a slightly higher male to female ratio but the sample did not reflect this, with significantly higher numbers of women probably because most recruitment took place in GP surgeries which are more frequently attended by women, either on their own behalf or with their children [51]. Moreover, the health education programmes involved in the research included female only ESOL classes. Tower Hamlets has a particularly young population, with the third largest percentage of 20–34 year olds (37%) of all local authorities in the country. Fifty nine percent of the population are 15–44 year olds compared with 42% of this age group in the country as a whole. The average age of participants in the current study was 38 years old.

Forty percent of the sample said they had no formal educational qualifications. This can be compared with local borough-wide statistics, which describe 40% of the population are at or below NVQ Level 1 [52] which corresponds to 5 good passes at GCSE or high school certificate.

Twenty eight percent of the sample reported that they had a health problem, which affected their everyday life. The sample appeared to be relatively frequent attenders of primary health care settings, with nearly half reporting that their previous visit had been within the last month.

3.2. Scores on AAHLS items

Scores on the different items are displayed in Table 2. We did not establish a cut-off for ‘‘adequate’’ health literacy skills in the different areas. However, we noted that relating to functional health literacy 22% reported that they ‘‘often’’ needed help to read health information and a further 24% ‘‘sometimes’’ needed help. Of these a third said they could ‘‘often’’ access help, and 27% reported they could ‘‘sometimes’’ get help. We noted higher scores on the

Table 2 Item scores, cross-tabulations and factor loadings.

AAHLS item Item score

(mean and SD)

Chi-square tests: value and significance Principal component analysis





Age Health rating Gender Factor loadings

Factor 1 Factor 2 Factor 3 Factor 4

Functional health literacy

FQ1 How often do you need someone to help you when you are given information to read by your doctor, nurse or pharmacist?

2.33� 0.81 34.91 <0.00**


<0.00** 8.47



0.04* 4.17


0.87 0.308 0.04 0.14

FQ2 When you need help, can you easily get hold of someone to assist you?

1.74�1.21 22.31 <0.00**









�0.71 0.08 �0.06 0.31

FQ3 Aggregate of Q1 and Q2 0.75 0.27 0.09 0.18 FQ4 Do you need help to fill in official documents? 2.23� 0.873 33.81

<0.00** 62.15

<0.00** 13.790.0.03* 32.45

<0.00** 1.69


0.76 0.19 0.00 0.27

Communicative health literacy

Com Q1 When you talk to a doctor or nurse, do you give them all the information they need to help you?

2.71� 0.592 18.11 <0.00**









0.28 0.69 0.6 0.09

Com Q2 When you talk to a doctor or nurse, do you ask the questions you need to ask?

2.57� 0.636 16.80 <0.00**


0.00** 4.10






0.22 0.68 0.06 0.20

Com Q3 When you talk to a doctor or nurse, do you make sure they explain anything that you do not understand?

2.71� 0.542 4.03 1.34









�.10 0.53 0.14 0.36

Critical health literacy

Cr 1 Are you someone who likes to find out lots of different information about your health?

2.26� 0.767 2.74 0.26









0.04 0.30 0.67 �0.01

Cr 2 How often do you think carefully about whether health information makes sense in your particular situation?

2.21� 0.659 5.30 0.07




<0.00** 7.52




0.31 0.03 0.67 0.05

Cr 3 How often do you try to work out whether information about your health can be trusted?

2.17� 0.736 8.75 0.01*




<0.00** 4.78




�0.21 �0.07 0.81 0.04

Cr 4 Are you the sort of person who might question your doctor or nurse’s advice based on your own research?

2.06� 0.784 0.86 0.65


<0.00** 17.10

<0.00** 13.02

0.04* 0.03


0.14 0.07 0.33 0.66

Emp 1 Do you think that there plenty of ways to have a say in what the government does about health?

1.56� 0.719 1.01 0.64









0.03 0.20 �0.19 0.67

Emp 2a Within the last 12 months have you taken action to do something about a health issue?

1.43� 0.828 0.08 0.78








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