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, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006;54(5):770–6. CrossRef
- Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475–82. CrossRef
- Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503–9. CrossRef
- Rothman R, Malone R, Bryant B, Dewalt D, Pignone M. Health literacy and diabetic control. JAMA. 2002;288(21):2687–8. CrossRef
- Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175–84. CrossRef
- Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8):1278–83. CrossRef
- Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791–8. CrossRef
- Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008–15. CrossRef
- Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, Glass J. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78(9):1912–20. CrossRef
- Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166–72. CrossRef
- Sudore RL, Yaffe K, Satterfield S, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med. 2006;21(8):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. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42. CrossRef
- Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–22. CrossRef
- Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6):391–5.
- Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588–94.
- Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23(5):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. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21(8):874–7. CrossRef
- Sudore RL, Landefeld CS, Williams BA, Barnes DE, Lindquist K, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med. 2006;21(8):867–73. CrossRef
- Sudore RL, Landefeld CS, Perez-Stable EJ, Bibbins-Domingo K, Williams BA, Schillinger D. Unraveling the relationship between literacy, language proficiency, and patient-physician communication. Patient Educ Couns. 2009;75(3):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. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care. 2009;32(4):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. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29–36.
- Weinberger M, Kirkman MS, Samsa GP, et al. 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. 1995;10(2):59–66. CrossRef
- Osborn CY, Cavanaugh K, Wallston KA, White RO, Rothman RL. Diabetes numeracy: an overlooked factor in understanding racial disparities in glycemic control. Diabetes Care. 2009;32(9):1614–9. CrossRef
- Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148(3):839–43.
- Wolf MS, Davis TC, Shrank W, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67(3):293–300. CrossRef
- Paasche-Orlow MK, Wolf MS. Evidence does not support clinical screening of literacy. J Gen Intern Med. 2008;23(1):100–2. CrossRef
- Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996;27(1):33–9. CrossRef
- Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW. Patients' shame and attitudes toward discussing the results of literacy screening. J Health Commun. 2007;12(8):721–32. CrossRef
- Sarkar U, Piette JD, Gonzales R, et al. Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Patient Educ Couns. 2008;70(1):102–10. CrossRef
- Sarkar U, Karter A, Adler N, Liu J, Moffet H, Schillinger D. 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. 2008;23(s2):338.
- Sarkar U, Karter AJ, Liu JY, et al. 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. 2010;15(1):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