Literature Review Chapter: Newest Vital Sign and Realm Screen Tools

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Newest Vital Sign and REALM screen tools in health literacy

In a clinical setting, the quality and robust nature of a number of diagnostic tools are central to both accurate results and a medical professional's ability to assess the medical situation. For example, there are numerous tools designed to assess health literacy within the clinical setting. Two of these tools, REALM (Rapid Estimate of Adult Literacy in Medicine) and the NVS (Newest Vital Sign Screening) tool, have very different approaches to the same problem set. Under this rubric, the seminal question becomes one of preference, ease of use, accuracy of results, and whether one too or another will influence usage and robustness of data. Since these types of tools are primarily used by registered nurses, it stands to reason that the nursing population's preference sets the tone and timbre of clinical acceptance (Arozulla, Yarnold, Benett, Soltysilk, et al., 2007).

Health literacy is defined as "the ability to read and comprehend prescription bottles, appointment slips, and other essential health related materials required to successfully function as a patient" (Health Litarcy: Report of the Council on Scientific Affairs, 1999, 552). This is typically something most medical professionals take for granted when dealing with the average adult population. It implies not only a basis for knowledge, but the ability to actively participate in the co-responsibility of their own healthcare by having the basic reading, writing, comprehension, and cognitive questioning skills. The facts, though, show a different paradigm: about 20% are completely unable to understand health related information, and another 20% able to read the materials, but not really understand what it means to their own healthcare situation (Berger, 2000).

In addition, and possibly more concerning within the paradigm of 20th century medicine, studies not that as many as 90 million Americans cannot fully understand health information (Powers, Trinh, and Hayden, 2010). Lack of understanding sometimes also means lack of acting on instructions, taking medications as required, and the ability to interact with medical professionals with cogent questions or concerns (Weiss, et al., 2005). Physicians, however, are not trained in pedagogy. Combined with the psychological "white coat syndrome," they often do not notice that patients are not understanding their explanation or directions. If we combine this with the average reading level of adults in America, we find that about three-fourths of medical materials were written above the average comprehension level (Davis and Wolf, 2004)

The REALM -- The REALM is one of the most widely used tools for studying literacy. Even though developed in the, it has remained an important asset desgiend to help clinicians identify patients who might be at the greatest risk for understanding healthcare related materials (Davis, Long and Jackson, 1993). REALM is constructed for ease of use as well as a quick assessment tool: 1) it is a word-pronounciation review with common patient direction and educational materials, 2) The newer, shortened list from 125 words and phrases to 66, focuses on issues that are highly discriminatory (Bass, Wilson and Griffith, 2003). The items are ordered by difficulty; one-syllable to multi-syllable words. The client reads as many as possible, but when they see a word they do not know they are asked to look at the rest of the words and pronounce as fluently as possible. A standard dictionary pronouciation is the scoring standard, and the number of words read correctly is translated into one of four literacy levels. The test typically takes less than 5 minutes to administer and score. Early research with REALM also shows a fairly high correlation with standard reading achievment assessments with coefficients from the .80-.95 range (Ibrahim, Reid, Shaw, Rowlands, et al., 2008).

The NVS -- Specifically in response to research showing that the two most misunderstood pieces of medical information were nutrition labels and prescription instructions, the NVS bi-lingual (English and Spanish) tool was developed. Additional research showed that despite decades of using REALM, inter-hospital programs, and even national literacy development, about 20% of the population were still unable to adequately understand basic medical terms. This population had a high incidence of needing help reading hosptial material, filing out medical forms, and understanding written medical information (Chew, Bradley, and Boyko, 2004).

The NVS is based on how well a patient can comprehend the use of nutrition label information from an ice cream container, administered and scored in less than 3 minutes typically. Clients are given the label and asked six questions concerning the information on the label. Based on the correct responses, health literacy levels are assessed, 0-6 (zero lowest, 6 highest). Scores at or above 6 are considered adequate literacy (Mpofu and Oakland, 2010, 686).

Bias- Almost all tests are biased in some way. Linguist, cultural, educational, and even generational differences become accentuated when testing a rather amorphous concenpt like health literacy through traditional oral means. However, using other testing models, research found that both the REALM and NVS score in approximately the 75th percentile in predicting poor literacy outcomes, and even into the 95th and above percentile within certain demographic areas (Mpofu, 685).

The REALM test, for instance, seems to have a bias in favor of caucasian middle class and above participants, primarily due to word choice based on cultural bias. The choices of words, too, may be problematical; in some studies 40% of the questions were deemed unanswerable within the confines of a typical diverse American popuylation. The juxtaposition between measurement and prediction is also somewhat a problem in that numerous students show a 55% or better comprehension rate but an inability to remember and use many of the terms (Dowse, Lecoko and Ehlers, 2005).

Demographically and psychographically, the NVS seems to be more appropriate because it attempts to limit cultural bias. Almost everyone has seen or heard of an ice cream label, and using the two major population group languages in the United States allows for a larger grouping within population. Research in comparing the two tests for validity did not show significant differences in white populations, but did within minority and undereducated African-Americans (Shea, beers, McDonal, et al., 2005). In some geographic areas, the African-American population is large, and cultural research shows that they are more likely to prefer aggressive and sometimes complicated treatments in a variety of situations. Health literacy issues then become a vital concern due to the need for more complicated procedures and pharmacology (Volandes, Paasche-Orlow, Gillick, Cook, et al., 2008). Screening time, however, is almost equal, as is reading and interpreting of scores (Johnson and Weiss, 2008).

There will be significant socio-demographic differences between the two tests, depending again, on the populations assessed. In addition to diversity issues, some patients want to please the nurse or doctor so much that when asked if they "understand" something they are rife to admit they do not. For these patients, either test is appropriate because they must identify and articulate specific answers (VanGeest, Welct, and Weiner, 2010)

Implications -- Understandably, the level of literacy often correlates to patient outcome. If a patient is unable to understand directions, they will remain unable to act responsibly in assisting in their recuperation. Missed or wrong prescription dosages can actually harm or cause adverse medical outcomes. Ideal practices and standard care methodologies call for the increasing attention towards medical literacy. As part of recording vital signs and prepping the patient for the docto's visit, then, the nurse should assist by running a simple literacy lest to determine what, if any, alternative measure are necessary for this client. Appropriate and timely intervention and support promotes high quality care, optimal outcomes for patients, and certainly lower medica costs over the long-term (Nielsen-Bohlman, Panzer, and Kindig, 2004).

In certain disciplines the need for health literacy is accentuated. Dentistry requires very specific care instructions (Richman, Lee, Rozier, Gary, Gon, et al., 2007), post-operative or pre-test issues, and family medicine are also of concern to the medical population. If parents do not understand care instructions for their child, they are unable to assist in that child's well-being. Similarly, a number of misinterpretations are in evidence within sports medicine, school innoculations, and even post-birth situations, all which could have rather disastrous effects (Shah, Bremmeyer, Katazryna, and Ruth, 2010).

Conclusions- Based on the data, there is a clear preference for the NVS as a tool accessible and understandable to most population groups (Chew, Griffin, Partin, Noorbaloochi, et al., 2008). There is a weak, but consistent, relationship between fluency in healthcare literacy and patient satisfaction with their medical care (Shea, Guerra, Ravelnell, McDonal,, 2007). What has not yet been established, however, are two major questions: 1) What is the overall relationship longitudinally between literacy scores and prognosis or overall health, and 2) What are the national implications of health literacy on an increasingly diverse population?

Works Cited

Health Litarcy: Report of the Council on Scientific Affairs. (1999). Journal of the American Medical Association, 28(1), 552-7.0

Arozulla, Y., Benett, S., Soltysilk, T., et al. (2007). Development and Validation of a Short-Form, Rapid Estimate of Adult Literacy in Medicine. Medical Care,… [END OF PREVIEW]

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