Health Literacy in Older Adults With and Without
Low Vision
MeSH TERMS
 comprehension
 health literacy
 macular degeneration
 reading
 vision, low
Mary Warren, PhD, OTR/L, SCLV, FAOTA, is
Associate Professor and Program Director, Graduate
Certificate in Low Vision Rehabilitation, Department of
Occupational Therapy, University of Alabama at
Birmingham; warrenm@uab.edu
Dawn K. DeCarlo, OD, MS, MSPH, is Associate
Professor, Department of Ophthalmology, University of
Alabama at Birmingham.
Laura E. Dreer, PhD, is Associate Professor and
Director of Psychological and Neuropsychological Clinical
Research Services, Department of Ophthalmology,
University of Alabama at Birmingham.
The American Journal of Occupational Therapy
Mary Warren, Dawn K. DeCarlo, Laura E. Dreer
OBJECTIVE. In this study, we investigated whether older adults with low vision (LV) from age-related
macular degeneration (AMD) demonstrated lower functional health literacy than older adults without LV.
METHOD. Fifty adults with AMD were matched with adults without LV on age, gender, education, and
income. We measured visual acuity, contrast sensitivity, and reading speed and administered the Test of
Functional Health Literacy in Adults (TOFHLA) using two test time conditions, standard and unlimited,
to measure health literacy levels.
RESULTS. The group with LV had considerably lower TOFHLA scores for both time conditions (p < .001)
and took notably longer to complete the test (p < .001). Poorer acuity correlated with lower TOFHLA scores
in the group with LV.
CONCLUSION. Older adults with LV may take longer to read and understand health information, which has
important implications for providing health education to support self-management. Modifying components of
the reading task may facilitate reading performance and understanding of health education materials.
Warren, M., DeCarlo, D. K., & Dreer, L. E. (2016). Health literacy in older adults with and without low vision. American
Journal of Occupational Therapy, 70, 7003270010. http://dx.doi.org/10.5014/ajot.2016.017400
T wo-thirds of older adults live with chronic health conditions that limit
participation in everyday activities (Vogeli et al., 2007). Chronic health
conditions generally have no cure and are often medically complex. Patients
learn to self-manage a condition by modifying lifestyle and health behaviors to
minimize its effect on daily life (Richardson et al., 2014). Health care providers
support patient self-management efforts through education and instruction
(Richardson et al., 2014). Occupational therapy practitioners are increasingly
providing interventions to improve the self-management skills of older adults
with chronic conditions (Foster, Bedekar, & Tickle-Degnen, 2014; Richardson
et al., 2014).
Successful self-management requires a knowledgeable patient who is able to
understand and adhere to medical regimens and navigate the complex health care
system to obtain services. Proficiency in functional health literacy is considered
an important component of self-management (Rudd, 2007). Functional health
literacy is the ability of a person to acquire health knowledge by locating and
using information in documents, deciphering numbers, and completing cal-
culations. Low functional health literacy levels are associated with poorer self-
management and health status and increased hospitalization among older adults
(Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011).
As a skill dependent on reading, functional health literacy may be influenced
by intrinsic variables (e.g., age, innate intelligence, primary language, cognitive
decline) and extrinsic variables that reflect environmental influences (e.g., ed-
ucational attainment, profession, socioeconomic status, culture; Martin et al.,
2009). A person must also have sufficient vision to accurately decipher print on
instructions, labels, and devices. Thus, low vision (LV), a permanent level of
7003270010p1
vision loss sufficient to limit completion of daily activi-
ties, may also affect functional health literacy.
LV is a common chronic condition in older adults;
age-related macular degeneration (AMD) is the most
prevalent cause of LV among older Americans (Eye Diseases
Prevalence Research Group, 2004). People with AMD of-
ten experience impaired reading performance, including
lower reading speed and accuracy, but not necessarily re-
duced comprehension (Legge, 2007). Although many older
adults with AMD and other age-related eye diseases can
read documents using magnifiers, researchers of health lit-
eracy studies have systematically excluded participants with
LV (Paasche-Orlow, Parker, Gazmararian, Nielsen-Bohlman,
& Rudd, 2005). Consequently, little is known about health
literacy levels of older adults with visual impairment, even
though nearly one-third of these adults live alone without
in-home or family support (Sloan, Ostermann, Brown, &
Lee, 2005) and are often responsible for self-managing
their chronic conditions.
In this study, we investigated whether community-
dwelling older adults with LV resulting from AMD dem-
onstrated lower functional health literacy levels than older
adults without LV using the Test of Functional Health
Literacy in Adults (TOFHLA; Nurss, Parker, & Baker,
1995). We further examined associations in the group with
LV among TOFHLA scores and variables including visual
acuity, contrast sensitivity, and reading speed.
Method
The universitys institutional review board approved the
study; participants provided written informed consent.
Inclusion criteria for all participants included (1) mini-
mum age of 65 yr, (2) community dwelling, (3) high
school diploma or equivalence, (4) English speaking, (5)
no medical condition that might affect cognition or
reading, (6) no major uncorrected hearing loss, (7) self-
report of reading at least 20 min daily, (8) minimal risk
for cognitive impairment defined as less than four errors
on the Short Portable Mental Status Questionnaire
(Pfeiffer, 1975), and (9) minimal risk for depression
defined as less than five errors on the Geriatric De-
pression ScaleShort Form (Yesavage & Sheikh, 1986).
Participants with LV were required to have a documented
AMD diagnosis without another major eye disease or
condition that would affect reading and a distance visual
acuity between 20/60 and 20/400 in the better eye.
Participants without LV were required to have 20/30 or
better habitual distance acuity and no known eye disease.
Visual acuity was measured with the Early Treatment
Diabetic Retinopathy Study (ETDRS; Ferris, Kassoff,
7003270010p2
Bresnick, & Bailey, 1982) acuity chart while participants
were wearing their habitual correction.
Participants
One hundred two participants were recruited; 2 people
were ineligible, resulting in 50 adults with LV and 50
adults without LV. Participants with LV were recruited
from the University of Alabama at Birmingham Center for
Low Vision Rehabilitation. We recruited participants
without LV from the same metropolitan area using flyers
and referrals to obtain a sample closely matching the group
with LV on age, gender, education, and income.
Instruments
The first author (Warren) administered five assessments to
the participants during one 60- to 90-min session in a
private, distraction-free environment, typically in the
participants home. Rest breaks were offered between and
during assessments to minimize fatigue. Participants in
both groups used rest breaks, but the number of breaks
provided was not recorded.
The 12-point-font, long version of the TOFHLA
was chosen to measure the functional health literacy of
the participants because it has been used extensively in re-
search on functional health literacy in older adults (Mancuso,
2009). The TOFHLA uses real-life examples to measure
comprehension of printed health information. The test
has two sections: numeracy and reading comprehension.
Summed section scores produce a composite score ranging
from 0 to 100 points. The point score categorizes the health
literacy level as inadequate (059), marginal (6074), and
adequate (75100). The 17-item numeracy test is admin-
istered first and given orally with props such as prescription
medicine bottles. It is used to assess understanding of
dosage, timing, and expiration of medications; medical test
results; scheduling of medical appointments; and eligibility
for financial aid. Responses are scored according to spe-
cific guidelines. The raw score (017 points) is converted to
a weighted score ranging from 0 to 50.
The reading comprehension section has three short
passages written at sequentially higher reading grade levels:
preparation instructions for an X-ray (4.3 grade reading
level), a Medicaid document excerpt (10.4 grade reading
level), and a surgical consent (19.5 grade reading level). The
passages are read silently. Each sentence has 1 word missing;
the participant selects the best word from a choice of 4 words.
The section has 50 missing words to produce a raw score
between 0 and 50 points.
Standard administration time is 10 min for numer-
acy and 12 min for reading comprehension; unanswered
May/June 2016, Volume 70, Number 3
questions are scored as errors. Scoring unanswered ques-
tions as errors meant that participants with LV might score
lower because of a slower reading speed. To capture the
effect of slow reading, we modified the timing procedure
so that participants were allowed to complete each section.
Two scores were recorded: the standard time score
recorded for the last test item completed when the
specified time limit elapsedand an unlimited time
scorerecorded when all items were answered. Two
completion times were also recorded: time required to
complete the section under the standard timing con-
dition (standard time) and time required to complete
all test items (unlimited time). Rest breaks were not
included in the recorded time; the examiner stopped
the timer and resumed timing after the break.
The MNREAD Acuity Chart (Regents of the
University of Minnesota, 1994) was used to determine
maximum reading speed. The chart simulates a real-
world reading experience and has been used extensively
in LV reading research (Legge, 2007). The chart con-
tains 19 sentences composed of 10 standard-length
common third-grade words. The sentences descend
in order from 1.3 logMar (20/400 Snellen acuity at
40 cm) to 0.13 logMar (20/6 Snellen acuity at 40 cm).
The sentences are read aloud and timed. Participants
wore their habitual reading correction and held the test
chart at their preferred distance. Participants with LV
used their personal magnifier if needed; all participants
were offered use of a 50-watt halogen reading lamp to
complete the test. Maximum reading speed was calculated
as the mean of the three fastest recorded reading speeds
following procedures described by Patel, Chen, Da Cruz,
Rubin, and Tufail (2011) and was converted into words
per minute with a standardized conversion chart.
The Mars Letter Contrast Sensitivity Test (Arditi,
2005) is a clinical test that measures peak contrast sen-
sitivity between 100% and 1% contrast. The test has 48
letters, each with a value of 0.04 log contrast sensitivity,
arranged in rows. The total contrast sensitivity score
represents the value of the last correctly identified letter
minus 0.04 for each incorrectly read letter before the
last two consecutive errors. Participant contrast sensi-
tivity scores were categorized as normal, moderate, se-
vere, or profoundly impaired on the basis of norms
established for people age >60 yr.
The Leisure Activity Score Questionnaire (Bull, 1982)
is an orally administered structured self-report question-
naire that identifies older adult participation in leisure
activities. The person rates participation in 12 common
leisure activities (e.g., TV and radio, card games, reading,
rides and walks, crafts, gardening, theater and movies,
The American Journal of Occupational Therapy
church activities, volunteer work, singing and playing
musical instruments) and 4 leisure activities of the per-
sons choosing. The test yields a score between 0 and 16
points to provide an index of activity involvement.
Statistical Analyses
Statistical analyses were completed with IBM SPSS
Statistics (Version 19; IBM Corporation, Armonk, NY).
Chi-square analyses and t tests were conducted to test
equivalency between groups on variables associated with
reading performance. The t tests were conducted to test
the differences between groups on TOFHLA scores for
the two timing conditions. A Wilcoxon signed-rank
test was used to test differences in health literacy levels.
Pearson correlations were calculated to test associations
among vision-related variables and TOFHLA scores
for the two timing conditions in the group with LV. A
(two-tailed) significance level of .05 was used.
Results
Participants were age 6594 yr, with an average age of
81 yr (standard deviation [SD] 5 5.87); all but 2 par-
ticipants were White. The two groups were equivalent in
age; gender; marital status; living arrangement; income;
education; occupation; years in retirement; and number of
comorbidities, prescribed medications, and leisure activi-
ties (Table 1). Most participants lived in their own homes,
had some college or a college degree, had worked in
skilled or professional occupations, and reported an
average income greater than $40,000 per year. They
regularly participated in an average of nine leisure ac-
tivities (SD 5 2.4), reported an average of three co-
morbidities (SD 5 1.2), and took an average of seven
prescribed medications (SD 5 3.5). All participants
demonstrated minimal risk for cognitive impairment or
depression per inclusion criteria.
The groups differed considerably on vision and reading-
related variables. Compared with the group without LV,
participants with LV had poorer acuity, t(49) 5 21.9, p
.001; poorer contrast sensitivity function, t(49) 5 15.3,
p .001; and lower reading speeds, t(49) 5 7.75, p .001.
Two-thirds of the participants with LV (n 5 33) used an
optical device to read test materials, and 30% (n 5 15) of
the participants with LV used extra task lighting; the par-
ticipants without LV relied on typical lighting.
Table 2 shows the difference in TOFHLA scores
between the groups. The group with LV had considerably
lower composite scores and reading comprehension scores
than the group without LV under both timing condi-
tions. Participants with LV scored an average of 15 points
7003270010p3
Table 1. Participant Demographics and Equivalency Analyses 2.2, p 5 .03. Although both groups showed significantly
With Low Vision Without Low Vision higher scores with unlimited time, the group with LV
Characteristic (n 5 50), n (%) (n 5 50), n (%) p benefited more from the extra time, increasing an average
Gender 1.00 of 13 points compared with 1.5 points for the group
Male 15 (30) 15 (30) without LV. Unlimited test time also considerably im-
Female 35 (70) 35 (70)
proved health literacy levels in the group with LV, with
Marital status .62
Married 20 (40) 18 (36)
the percentage of participants classified as possessing ad-
Widowed 26 (52) 25 (50) equate health literacy increasing from 60% to 98% (z 5
Single 4 (8) 7 (14) 24.13, p 5 .001).
Living arrangement .07 For the group with LV, associations were found
Own home 37 (74) 31 (62) among TOFHLA scores and acuity (r 5 2.55, p 5 .001)
Residential facility 9 (18) 18 (36)
and reading speed (r 5 .61, p 5 .001) on the standard
With family 4 (8) 1 (2)
Education 1.00
time condition. Lower acuity and lower reading speed
High school 15 (30) 15 (30) were associated with lower test scores. In the unlimited
Some college 13 (26) 13 (26) time condition, only acuity remained significantly cor-
College degree 22 (44) 22 (44) related with test scores (r 5 .45, p 5 .01), showing that
Occupation .58 poorer acuity was associated with lower test scores.
Professional 22 (44) 17 (34)
Skilled 13 (26) 16 (32)
Nonskilled 15 (30) 17 (34)
Discussion
Average income .16
$20,000$39,999 23 (46) 21 (42) In this study, we provided an initial exploration of the
$40,000$50,000 10 (20) 18 (36) relationship between LV and functional health literacy by
>$50,000 17 (34) 11 (22) investigating whether community-dwelling older adults
Retirement years .63
with AMD demonstrated lower functional health literacy
0 (active retirementa) 12 (24) 12 (24)
115 yr 11 (22) 15 (30)
than older adults without LV. Participants with LV were
>15 yr 27 (54) 23 (46) more impaired on all vision-related variables and had
Comorbidities considerably slower reading speeds than the adults without
Arthritis 33 (66) 34 (68) .83 LV. The influence of slow reading speed on test perfor-
Cardiovascular 31 (62) 31 (62) 1.00 mance was apparent in the considerable improvement in
High blood pressure 29 (58) 33 (66) .41
scores when participants with LV were given unlimited
Hearing 12 (24) 19 (38) .13
Diabetes 9 (18) 7 (14) .78
time to complete the TOFHLA. This finding suggests that
Lung 8 (16) 6 (12) .40 the participants with LV might have differed from the
Kidney and digestive 12 (24) 9 (18) .46 participants without LV not in ability to comprehend
a
Active retirement 5 working on a limited basis in profession (e.g., lawyer, health materials but rather in the amount of time required
business owner). to achieve an adequate comprehension level.
According to Legge (2007), older adults with LV may
lower on the composite test under the standard time experience greater difficulty comprehending print mate-
condition. The mean difference in scores between the rials because they are forced to allocate more attention
groups was reduced to only about 3 points with unlimited to decoding difficult-to-see words, straining attentional
time but remained statistically significant, t(99) 5 2.89, reserves already diminished by aging. To compensate,
p 5 .005. Participants with LV had considerably lower readers with LV might deliberately slow reading speed to
scores on the reading comprehension section for both reduce the demands on attention and improve compre-
timing conditions, but scores for the numeracy section hension (Legge, 2007). However, even with unlimited time
were considerably lower only on the standard timing to complete the test, there was a statistically significant
condition, t(99) 5 2.14, p 5 .036. mean difference of 3.4 points in scores between the groups.
Participants with LV took considerably more time to The correlation between visual acuity and TOFHLA scores
complete the test than the group without LV, averaging for the unlimited time condition suggests that poorer
4 min longer on the standard time condition and 11 min acuity may have contributed to the lower scores in the
longer on the untimed condition (Table 3). Unlimited group with LV.
test time improved scores for both groups: group with The paragraph format of the TOFHLA reading com-
LV, t(49) 5 6.45, p .001; group without LV, t(49) 5 prehension section may also have contributed to more errors

7003270010p4 May/June 2016, Volume 70, Number 3

Table 2. Differences in TOFHLA Scores for Standard and Unlimited Time Conditions
TOFHLA Score With Low Vision (n 5 50), M (SD) Without Low Vision (n 5 50), M (SD) t p 95% CI
Composite
Standard time 77.9 (16.3) 93.2 (7.2) 6.12a <.001 [10.3, 20.2]
Unlimited time 91.3 (6.5) 94.7 (5.2) 2.89 <.005 [1.1, 5.8]
Reading comprehension
Standard time 32.9 (12.3) 46.4 (4.9) 7.19a <.001 [9.7, 17.2]
Unlimited time 45.2 (4.0) 47.8 (2.8) 3.69a <.001 [1.2, 3.9]
Numeracy
Standard time 44.1 (8.0) 46.8 (3.9) 2.14a .036 [0.2, 5.2]
Unlimited time 45.5 (6.0) 46.9 (3.8) 1.27 .207 [20.7, 3.3]
Note. CI 5 confidence interval; M 5 mean; SD 5 standard deviation; TOFHLA 5 Test of Functional Health Literacy in Adults.
a
Denotes Levenes correction for unequal variances.

in the group with LV. According to Legge (2007), paragraph-
style formats require more attentional effort from readers with
LV, which may increase fatigue. Although all participants
were offered and took rest breaks, it is possible that partici-
pants with LV experienced greater fatigue, causing them to
commit more errors on the reading comprehension section.
Study Limitations and Future Research
Studying only people with AMD limited generalization of
the findings to the greater population with LV. Future
researchers should include other age-related eye diseases to
obtain a more representative description of the effect of LV
on functional health literacy levels. On the basis of the
study findings, one can also question the efficacy of using
timed tests such as the TOFHLA to measure health lit-
eracy in adults with LV; future researchers should explore
test designs that accommodate readers with LV.
Implications for Occupational
Therapy Practice
A consistent complaint voiced by people with LV is the
heavy reliance by health care providers on using visually
inaccessible print materials to deliver health information,
including instructions on medications and medical regi-
mens as well as appointments, referrals, and other paperwork
required to receive services (Harrison, Mackert, & Watkins,
2010; Sharts-Hopko, Smeltzer, Ott, Zimmerman, &
Duffin, 2010; Williams, 2002). Difficulty reading print
can limit the persons ability to participate fully in self-
management of his or her health conditions; some
people with LV believe that it suggests to health care
providers a cognitive inability to manage their health,
and thus they are excluded from patientprovider conver-
sations (Sharts-Hopko et al., 2010). Of the LV participants
in this study, 70% had been to college and read on a daily
basis, but they still had lower TOFHLA scores than their
peers without LV. However, when slow reading speed was
accommodated for with unlimited test time, 98% of the
participants with LV achieved adequate health literacy on the
basis of TOFHLA scores.
The American Occupational Therapy Association
(2011) published a societal statement on health literacy,
committing occupational therapy practitioners to ensure
that all health-related information and education . . .
match that persons literacy abilities (p. S78). Resources
are readily available to assist occupational therapy prac-
titioners to create accessible print materials for clients
with LV. The American Printing House for the Blind

Table 3. Differences in TOFHLA Completion Time for Standard and Unlimited Time Conditions
TOFHLA Score Low Vision (n 5 50), M (SD) Without Low Vision (n 5 50), M (SD) t p 95% CI
Composite
Standard time 19.1 (2.6) 15.0 (3.4) 6.78a <.001 [2.6, 5.3]
Unlimited time 26.8 (10.4) 15.7 (4.7) 6.89a <.001 [7.9, 14.4]
Reading comprehension
Standard time 11.5 (1.3) 9.2 (4.9) 6.03a <.001 [1.5, 3.0]
Unlimited time 18.5 (7.9) 9.9 (3.6) 7.02a <.001 [6.2, 11.2]
Numeracy
Standard time 7.5 (1.7) 5.7 (1.5) 5.49 <.001 [1.1, 2.4]
Unlimited time 8.3 (3.5) 5.8 (1.5) 4.73a <.001 [1.5, 3.6]
Note. Test of Functional Health Literacy in Adults (TOFHLA) time is reported in minutes. CI 5 confidence interval; M 5 mean; SD 5 standard deviation.
a
Denotes Levenes correction for unequal variances.

The American Journal of Occupational Therapy 7003270010p5

(Kitchel, n.d.) and Lighthouse International (Arditi, n.d.)
offer guidelines for improving print visibility for readers
with LV. Other organizations, such as Pfizer (n.d.), pro-
vide guidelines for simplifying language and sentence
structure to lower reading grade levels and to improve the
readability of health education materials.
Occupational therapy practitioners working in any
practice setting can assist older clients with LV to un-
derstand important health materials by addressing print
visibility and formatting along with the context of the
reading task. Specific recommendations include to
Combine low literacy and LV guidelines to create opti-
mally accessible formats for printed health materials;
Encourage the client to take rest breaks and as much
time as needed to read and understand printed health
materials;
Create an environment conducive to reading and un-
derstanding health information (e.g., remove auditory
distractions, provide additional nonglare task lighting,
and encourage the client to use magnifying devices);
Consider providing recorded instructions to replace or
augment print materials; and
If a client struggles with reading using these mod-
ifications, seek the expertise of a specialist in LV
rehabilitation. s
Acknowledgment
We thank John E. Crews and Scott Snyder for their in-
valuable assistance with this study.
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