Validation of Self-Reported Health Literacy Questions Among Diverse English and Spanish-Speaking Populations
Limited health literacy (HL) contributes to poor health outcomes and disparities, and direct measurement is often time-intensive. Self-reported HL questions have not been validated among Spanish-speaking and diverse English-speaking populations.
To evaluate three self-reported questions:1 “How confident are you filling out medical forms?”;2 “How often do you have problems learning about your medical condition because of difficulty understanding written information?”; and3 “How often do you have someone help you read hospital materials?” Answers were based on a 5-point Likert scale.
This was a validation study nested within a trial of diabetes self-management support in the San Francisco Department of Public Health.
English and Spanish-speaking adults with type 2 diabetes receiving primary care.
Using the Test of Functional Health Literacy in Adults (s-TOFHLA) in English and Spanish as the reference, we classified HL as inadequate, marginal, or adequate. We calculated the C-index and test characteristics of the three questions and summative scale compared to the s-TOFHLA and assessed variations in performance by language, race/ethnicity, age, and education.
Of 296 participants, 48% were Spanish-speaking; 9% were White, non-Hispanic; 47% had inadequate HL and 12% had marginal HL. Overall, 57% reported being confident with forms “somewhat” or less. The “confident with forms” question performed best for detecting inadequate (C-index = 0.82, (0.77-0.87)) and inadequate plus marginal HL (C index = 0.81, (0.76-0.86); p < 0.01 for differences from other questions), and performed comparably to the summative scale. The “confident with forms” question and scale also performed best across language, race/ethnicity, educational attainment, and age.
A single self-reported HL question about confidence with forms and a summative scale of three questions discriminated between Spanish and English speakers with adequate HL and those with inadequate and/or inadequate plus marginal HL. The “confident with forms” question or the summative scale may be useful for estimating HL in clinical research involving Spanish-speaking and English-speaking, chronically-ill, diverse populations.
- U.S. Department of Health and Human Services. (Government Printing Office. Originally developed for Ratzan SC, Parker RM. 2000. Introduction. In National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services). Healthy People 2010. 2000.
- Sudore, RL, Mehta, KM, Simonsick, EM (2006) Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 54: pp. 770-6 CrossRef
- Schillinger, D, Grumbach, K, Piette, J (2002) Association of health literacy with diabetes outcomes. JAMA 288: pp. 475-82 CrossRef
- Baker, DW, Wolf, MS, Feinglass, J, Thompson, JA, Gazmararian, JA, Huang, J (2007) Health literacy and mortality among elderly persons. Arch Intern Med 167: pp. 1503-9 CrossRef
- Rothman, R, Malone, R, Bryant, B, Dewalt, D, Pignone, M (2002) Health literacy and diabetic control. JAMA 288: pp. 2687-8 CrossRef
- Paasche-Orlow, MK, Parker, RM, Gazmararian, JA, Nielsen-Bohlman, LT, Rudd, RR (2005) The prevalence of limited health literacy. J Gen Intern Med 20: pp. 175-84 CrossRef
- Baker, DW, Gazmararian, JA, Williams, MV (2002) Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health 92: pp. 1278-83 CrossRef
- Baker, DW, Parker, RM, Williams, MV, Clark, WS (1998) Health literacy and the risk of hospital admission. J Gen Intern Med 13: pp. 791-8 CrossRef
- Williams, MV, Baker, DW, Honig, EG, Lee, TM, Nowlan, A (1998) Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 114: pp. 1008-15 CrossRef
- Davis, TC, Arnold, C, Berkel, HJ, Nandy, I, Jackson, RH, Glass, J (1996) Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer 78: pp. 1912-20 CrossRef
- Williams, MV, Baker, DW, Parker, RM, Nurss, JR (1998) Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 158: pp. 166-72 CrossRef
- Sudore, RL, Yaffe, K, Satterfield, S (2006) Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med 21: pp. 806-12 CrossRef
- Institute of Medicine. (National Academy Press, Institute of Medicine Committee on Quality of Health Care in America). Crossing the quality chasm: A new health system for the 21st century. 2001
- Baker, DW, Williams, MV, Parker, RM, Gazmararian, JA, Nurss, J (1999) Development of a brief test to measure functional health literacy. Patient Educ Couns. 38: pp. 33-42 CrossRef
- Weiss, BD, Mays, MZ, Martz, W (2005) Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 3: pp. 514-22 CrossRef
- Davis, TC, Long, SW, Jackson, RH (1993) Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 25: pp. 391-5
- Chew, LD, Bradley, KA, Boyko, EJ (2004) Brief questions to identify patients with inadequate health literacy. Fam Med. 36: pp. 588-94
- Chew, LD, Griffin, JM, Partin, MR (2008) Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 23: pp. 561-6 CrossRef
- Powers BJ, Trinh JV, Bosworth HB. Can this patient read and understand written health information? JAMA;304(1):76-84.
- Wallace, LS, Rogers, ES, Roskos, SE, Holiday, DB, Weiss, BD (2006) Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 21: pp. 874-7 CrossRef
- Sudore, RL, Landefeld, CS, Williams, BA, Barnes, DE, Lindquist, K, Schillinger, D (2006) Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med. 21: pp. 867-73 CrossRef
- Sudore, RL, Landefeld, CS, Perez-Stable, EJ, Bibbins-Domingo, K, Williams, BA, Schillinger, D (2009) Unraveling the relationship between literacy, language proficiency, and patient-physician communication. Patient Educ Couns. 75: pp. 398-402 CrossRef
- Lee SY, Stucky BD, Lee JY, Rozier RG, Bender DE. Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers. Health Serv Res;45(4):1105-20.
- Schillinger D, Hammer H, Wang F, et al. Seeing in 3-D: Examining the Reach of Diabetes Self-Management Support Strategies in a Public Health Care System. Health Educ Behav. 2007.
- Schillinger, D, Handley, M, Wang, F, Hammer, H (2009) Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care. 32: pp. 559-66 CrossRef
- Institute of Medicine. (National Academy Press, Institute of Medicine Committee on Health Literacy). Health Literacy: A Prescription to End Confusion. 2004.
- Hanley, JA, McNeil, BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 143: pp. 29-36
- Weinberger, M, Kirkman, MS, Samsa, GP (1995) A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Intern Med. 10: pp. 59-66 CrossRef
- Osborn, CY, Cavanaugh, K, Wallston, KA, White, RO, Rothman, RL (2009) Diabetes numeracy: an overlooked factor in understanding racial disparities in glycemic control. Diabetes Care. 32: pp. 1614-9 CrossRef
- Hanley, JA, McNeil, BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 148: pp. 839-43
- Wolf, MS, Davis, TC, Shrank, W (2007) To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 67: pp. 293-300 CrossRef
- Paasche-Orlow, MK, Wolf, MS (2008) Evidence does not support clinical screening of literacy. J Gen Intern Med. 23: pp. 100-2 CrossRef
- Parikh, NS, Parker, RM, Nurss, JR, Baker, DW, Williams, MV (1996) Shame and health literacy: the unspoken connection. Patient Educ Couns. 27: pp. 33-9 CrossRef
- Wolf, MS, Williams, MV, Parker, RM, Parikh, NS, Nowlan, AW, Baker, DW (2007) Patients' shame and attitudes toward discussing the results of literacy screening. J Health Commun. 12: pp. 721-32 CrossRef
- Sarkar, U, Piette, JD, Gonzales, R (2008) Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Patient Educ Couns. 70: pp. 102-10 CrossRef
- Sarkar, U, Karter, A, Adler, N, Liu, J, Moffet, H, Schillinger, D (2008) Limited health literacy is associated with increased risk of hypoglycemia among insured, type 2 diabetes patients: the Diabetes Study of Northern California (DISTANCE) Society for General Internal Medicine. Pittsburgh, PA. J Gen Intern Med 23: pp. 338
- Sarkar, U, Karter, AJ, Liu, JY (2010) The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system—results from the Diabetes Study of Northern California (DISTANCE). J Health Commun 15: pp. 183-196 CrossRef
- Validation of Self-Reported Health Literacy Questions Among Diverse English and Spanish-Speaking Populations
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Journal of General Internal Medicine
Volume 26, Issue 3 , pp 265-271
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- health literacy
- limited English proficiency
- Hispanic American
- validation studies
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- Author Affiliations
- 1. San Francisco Center for Vulnerable Populations, San Francisco General Hospital, University of California, San Francisco, CA, USA
- 2. Department of Medicine, Division of General Internal Medicine, University of California, Box 1364, 1001 Potrero, Bldg 10, 3rd floor, San Francisco, CA, 94143-1364, USA
- 3. San Francisco VA Medical Center, San Francisco, CA, USA
- 4. Division of Geriatrics, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA