Health Literacy Time to sign: The relationship between health literacy and signature time Lisa K. Sharp a, *, Peter J. Ureste a , Leianne A. Torres a , Lauren Bailey b , Howard S. Gordon a,c,d , Ben S. Gerber a,c,d a Section of Health Promotion Research, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, USA b University of Illinois at Chicago, School of Public Health, Chicago, USA c Jesse Brown VAMC, Center for Management of Complex Chronic Care, Chicago, USA d General Internal Medicine, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, USA 1. Introduction Our understanding of literacy has evolved over the centuries. During the seventeenth and eighteenth century in Europe, literacy was defined by one’s ability to provide a signature. Individuals who were illiterate relied upon an ‘‘X’’ as their signature. By the beginning of the twentieth century, literacy was equated with educational attainment. However, as awareness grew that educational attainment does not translate directly into level of reading ability, the concept of functional literacy emerged [1,2]. In addition to the ability to read and write text, functional literacy often includes the ability to apply the content of the text to relevant activities. As such, functional literacy may include information processing, working memory, problem-solving skills, and numeracy or quantitative ability [3,4]. Health literacy is a relatively new concept that emanated from the United States in response to a growing recognition that literacy and health outcomes were closely associated. As is the case with functional literacy, no single definition of health literacy is accepted by all [2,3,5–7]. The concept refers to a range of literacy capacities that impact health, health-related behaviors, and clinical decision-making. Hence, individuals may have functional literacy that allows them to perform their job in a low-level public sector position, but may have inadequate functional health literacy to partner with a physician and self-manage a complex chronic disease. In sum, health literacy is a context-specific form of functional literacy. The World Health Organization defines health literacy as ‘‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’’ [3]. A commonly cited definition of health literacy in research from the United States comes from the 2004 Institute of Medicine report, Health Literacy: Prescription to End Confusion, ‘‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’’ [8]. Regardless of definitions, most agree that low Patient Education and Counseling 90 (2013) 18–22 A R T I C L E I N F O Article history: Received 14 September 2012 Received in revised form 5 October 2012 Accepted 19 October 2012 Keywords: Health literacy Screening Primary care A B S T R A C T Objective: To evaluate the relationship between amount of time taken to sign one’s name and health literacy. Methods: A prospective, one time assessment was conducted on a convenience sample of 98 patients recruited in an inner-city outpatient internal medicine clinic. The amount of time required to sign (i.e. initiation to completion of writing) was measured by stopwatch. Health literacy was measured with the REALM. Results: The sample averaged 54.1 (SD 16.2) years of age. Twenty-seven percent had less than high school education and 33% had a terminal general equivalency diploma or high school degree. The time required to sign ranged from 0.91 to 21.3 s. Sixty-two percent of the sample had health literacy challenges. Signature time was longest for those with inadequate health literacy (mean 10.0 s), compared with marginal (7.3 s) and adequate (4.7 s, p  0.001). Signature time remained significant in a logistic regression model after controlling for education and age (AOR = 0.785, CI = 0.661–0.932). Conclusion: Individuals with signatures completed in six seconds or less were highly likely to display adequate health literacy. Practice implications: Signature time may offer a practical and quick approach to health literacy screening in the health care setting. ß 2012 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Section of Health Promotion and Research, University of Illinois at Chicago, 1747 W. Roosevelt Road (MC275), Chicago, IL 60608, USA. Tel.: +1 312 355 3569; fax: +1 312 413 8950. E-mail address: sharpl@uic.edu (L.K. Sharp). Contents lists available at SciVerse ScienceDirect Patient Education and Counseling jo ur n al h o mep ag e: w ww .elsevier .co m /loc ate/p ated u co u 0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2012.10.012