Development of an Easy-to-Use Spanish Health Literacy Assessment Tool

1. Development of an Easy-to-Use Spanish Health Literacy Assessment Tool Shoou-Yih D. Lee, PhD 1 Deborah E. Bender, PhD 1 Rafael Ruiz, ScM 1 Young Ik Cho, PhD 2 1 University of North Carolina at Chapel Hill 2 University of Illinois at Chicago

2. Problems of Low Health Literacy • Health literacy means “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” • Inadequate health literacy may reduce health status, and possibly threaten health care quality and increase the use of unnecessary high-cost services. • Inadequate health literacy may cost $30 billion to $73 billion in 1998 U.S. dollars, or about 3.2 to 7.6 percent of personal health care expenditures

3. Health Literacy Among Latinos • Latinos are the fastest growing ethnic group in the U.S. In 2003, they surpassed African Americans to become the nation’s largest minority group. Their share of the U.S. population is expected to rise to more than 21% in the mid-2000s. • The growth of the Latino population has created new demands on our health care system. • Low health literacy may be a particularly salient problem among Latinos. What is the extent of the problem? What is its health impact?... NOT MUCH IS KNOWN!

4. Assessment ofSpanishHealth Literacy • One existing instrument: Spanish Test of Functional Health Literacy in Adults (S-TOFHLA)- a comprehension test, containing sections on reading comprehension and a numeracy.- lengthy, cumbersome to administer and score • Rapid Estimate of Adult Literacy in Medicine (REALM)- a word recognition test (if examinees have trouble pronouncing words, which is a beginning-level reading skills, they are likely to have difficulty with comprehension, which is a higher order skill)- short, easy to use- construction of a Spanish version failed because of regular phoneme-grapheme correspondence in the Spanish language- lack of a correspondence between the reading and comprehension abilities in Spanish-speaking Latinos

5. Rapid Estimate of Adult Literacy in Medicine (REALM) ASK THE RESPONDENT TO READ ALOUD THE FOLLOWING WORDS, STARTING FROM LIST 1 AND THEN LIST 2 AND LIST 3. Here are three lists of words. Please read them aloud to me. (GIVE EACH LIST TO RESPONDENT. CHECK WORDS HE/SHE CAN READ/PRONOUNCE CORRECTLY.) List 1List 2List 3 fat ________ fatigue ________ allergic ________ flu ________ pelvic ________ menstrual ________ pill ________ jaundice ________ testicle ________ dose ________ infection ________ colitis________

6. Short Assessment of Health Literacy for Spanish Adults (SAHLSA) • A modification of REALM by incorporating questions that test the examinee’s understanding of the meanings of the words. • The test is analogous to multiple-choice questions. It consists of a stem (in the form of a question or command) and choices (in the form of an answer to the question or command)- Stem: question or command- Key: correct choice- Distractor: incorrect but plausible choice

7. SAHLSA I’m going to show you cards with 3 words on them. First I would like you to read the word on the top out loud. Then I will read the two words on the bottom to you and I would like you to tell me which on of the two words is more similar to the word on the top. If you do not know the answer, please say, “don’t know.” Do not guess. fat _________ ___orange ___butter ___don’t know flu _________ ___well ___sick ___don’t know pill _________ ___tablet ___cookie ___don’t know dose _________ ___sleep ___amount ___don’t know eye _________ ___listen ___see ___don’t know stress _________ ___worry ___happy ___don’t know pap smear _________ ___test ___vaccine ___don’t know nerves _________ ___bored ___anxiety ___don’t know germs ____________bacteria ___mood ___don’t know meals ____________dinner ___walk ___don’t know disease ____________diabetes ___exercise ___don’t know cancer ____________tumor ___fracture ___don’t know

8. Procedures for the Development of SAHLSA • Instrument development: the Delphi process- Translation of the 66 medical terms in REALM- Selection of the appropriate key and distractor for each of the 66 medical terms in English- Translation and back translation of the selected keys and distractors • Validation of the instrument- Pilot-testing with 10 English-speaking and 10 Spanish-speaking patients at the UNC Ambulatory Care Center- Interviewing 202 English-speaking and 201 Spanish-speaking patients to test the instrument’s validity and reliability

9. Results

12. Results (cont.) • Item response analysis and OLS were used to reduce the number of items while increasing the discriminatory power of SAHLSA • Reduced to 37 items • Correlated with TOFHLA at r=0.72 • Significantly correlated with health status at r=0.17 (correlation between TOFHLA and health status is r=0.15) • Correlated with education at r=0.53 (correlation between TOFHLA and education is r=0.52 in Spanish speakers and r=0.40 in English speakers) • Test-retest reliability is r=0.80

13. Discussion • Healthy People 2010 Objectives: Draft for the Public Comment notes that health literacy is"increasingly vital to help people critically evaluate health information" • Rapid growth of Hispanic residents in the nation makes the development of a reliable and easy-to-use health literacy assessment tool in Spanish an important task • Results suggest SAHLSA is valid and reliable • Further improvement will make SAHLSA an easy-to-use screening tool in clinical and community settings