Deborah E. Bender

Short Assessment of Health Literacy—Spanish and English: A Comparable Test of Health Literacy for Spanish and English Speakers

OBJECTIVE The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations. STUDY DESIGN The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument. DATA COLLECTION Validation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System. PRINCIPAL FINDINGS Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p<.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p<.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p<.05) and the English TOFHLA (r=0.68, p<.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy. CONCLUSIONS The new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.It is hardly news anymore that a significant proportion of adults in the United States have difficulty navigating the health care system and managing personal health issues because of inadequate health literacy or limited “capacity to obtain, process, and understand health information and services needed to make appropriate health decisions” (Seldon, Zorn, Ratzan, & Parker, 2000). Inadequate health literacy, as a growing body of research has shown, is a risk factor for patients’ difficulties in understand health information and following medical instructions (Cho, Lee, Arozullah, & Crittenden, 2008; Davis et al., 2006; Gazmararian, Williams, Peel, & Baker, 2003; Parker, Ratzan, & Lurie, 2003), poor disease/self-management knowledge (Gazmararian et al., 2003), underuse of preventive services and routine physician and dental visits (Baker et al., 2004; Jones, Lee, & Rozier, 2007; Lindau, Basu, & Leitsch, 2006; Lindau et al., 2002; Rogers, Wallace, & Weiss, 2006; Scott, Gazmararian, Williams, & Baker, 2002), increased hospitalizations and medical costs (Baker et al., 2002; Howard, Gazmararian, & Parker, 2005), and high mortality rates (Sudore et al., 2006). Identifying individuals with inadequate health literacy is difficult because information such as age, educational attainment (i.e., years of schooling), and self-reported literacy skills do not reliably reflect an individual’s health literacy level (Bass, Wilson, Griffith, & Barnett, 2002; Davis, Jackson, George, et al., 1993; Davis, Arnold, Berkel, et al., 1996; Nurss, el-Kebbi, Gallina, et al., 1997). Over the years, several instruments, including the Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Newest Vital Sign (NVS), have been developed to assess health literacy in the U.S. (Davis et al., 1993; Murphy, Davis, Long, Jackson, & Decker, 1993; Parker, Baker, Williams, & Nurss, 1995; Weiss et al., 2005). Most of the instruments, however, have a strong focus on the English-speaking populations and are inappropriate for assessing the health literacy level of Spanish-speakers. In the case of REALM, an attempt to develop a Spanish version failed because of the phonetic structure of the Spanish language (Nurss, Baker, David, Parker, & Williams, 1995).1 Where a Spanish version is available, e.g., TOFHLA-Spanish, the Spanish instrument is usually developed using a rudimentary translation-and-back-translation technique and is not validated psychometrically. A recent study comparing the psychometric properties of the English and Spanish versions of shortened TOFHLA raised a significant concern about their comparability (Aguirre, Ebrahim, & Shea, 2005). Our research team developed an easy-to-use health literacy test, the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for Spanish-speakers (Lee, Bender, Ruiz, & Cho, 2006). The SAHLSA contains 50 test items and has good psychometric qualities. It has been adopted in research and clinical practice in the U.S. (Keselman et al., 2007; Rosembla & Tse, 2006) and is being validated for use in Latin American countries (Huaman-Calderon, Quiliano-Terreros, & Vilchez-Roman, 2009). Since the publication of SAHLSA, many users have expressed the need for an English version to allow comparisons of health literacy level between Spanish and English speakers for research and clinical purposes. In this paper, we report our subsequent effort to develop a comparable test for Spanish and English-speakers, named Short Assessment of Health Literacy-Spanish & English or SAHL-S&E, based on the same methods used in developing SAHLSA. The test contains 18 items and is easy to administer. In taking the test, examinees are asked to read aloud each of the 18 medical terms and then associate each term to another word similar in meaning to demonstrate comprehension. The following sections describe the development of the SAHL-S&E, the methods employed to validate the instrument, results of the validation, and recommendations for use of the instrument.

Tell Me What you Mean by “Sí”: Perceptions of Quality of Prenatal Care among Immigrant Latina Women

Individual perceptions form the basis of many health research reports related to access, utilization, continuity, and quality. Many health care providers are not well equipped for designing studies or collecting data with immigrant populations. In this article, the authors examine issues in data collection on topics related to perceptions of quality of prenatal care among immigrant Latino populations. The conceptual model is Donabedian’s framework for quality. Two instruments—a qualitative interview with photographs representing components of quality and a questionnaire—were used for data collection. Examples of narrative responses given by women in response to the photo-narrative prompts are presented and compared to shorter survey responses. The authors emphasize the importance of designing research instruments that reflect the perceptions of the research subjects rather than simply those of the investigators.

Use of Preventive Maternal and Child Health Services by Latina Women A Review of Published Intervention Studies

Some health indicators for Latinos tend to be more positive than socioeconomic status would predict. Yet, Latina women and their young children use fewer preventive health services and have a higher incidence of preventable diseases than non-Hispanic whites. The Institute of Medicine recently called for intervention research among minority subgroups to end racial and ethnic disparities in health care. To help guide future intervention research, this article presents a critique and synthesis of the peer-reviewed literature on interventions that enroll Latina women into preventive reproductive health services (prenatal care, cervical cancer screening, and child immunizations). Results are presented according to three categories of interventions: improvements within formal health care settings, outreach through lay health advisors (promotoras) and media, and interventions combining these approaches. An agenda for intervention research is proposed for preventive-care use by this population.

Explaining the Birth Weight Paradox: Latina Immigrants' Perceptions of Resilience and Risk

In the US, prenatal care is positively associated with improved birth outcomes. However, among Mexican-born Latinos, rates of low birth weight are lower than those of US-born counterparts despite the fact that recently arrived Latino immigrants are less likely to have received adequate prenatal care. The “birth weight paradox,” identified through analysis of the HHANES, appears to hold constant across variations in age, marital status or educational attainment. The authors explore Latina immigrants perceptions of resilience factors related to these better birth outcomes through focused group interviews, photonarratives, and documentation of local kin networks. The womens responses are grouped into five resilience factors and one risk complex that have the potential to further explain the HHANES findings. Womens responses, the stories of their photographs, and kin networks are presented. Knowledge of these protective and risk factors can be useful to health professionals and Latino advocacy groups in the design of community-based interventions that protect health status and promote the practice of protective health behaviors within immigrant families and communities.

Rural origin as a risk factor for maternal and child health in periurban Bolivia.

Rapid migration in Latin America is settling rural women and their families next to those of urban origin in sprawling urban settings. Those born and reared in rural areas bring with them knowledge and skills learned and adapted to rural areas; those same skills may be maladaptive in urban areas. Hypothesized is that urban women of rural origin are more likely to have poorer health outcomes for themselves and their children than lifelong urban counterparts. Identification of specific risk factors affecting child and/or maternal health status in peri-urban barrios can assist health workers to target limited resources to those least likely to access available services.

Improving Access for Latino Immigrants: Evaluation of Language Training Adapted to the Needs of Health Professionals

The number of Latinos in North Carolina grew by almost 400% between 1990 and 2000. The rapid change in demographics in this state and other southeastern states has caught healthcare providers unprepared. Lack of ability to communicate with Latino patients may result in errors in diagnosis or reduced compliance with recommended treatments. The Culturally and Linguistically Appropriate Services (CLAS) Standards, published in 2001, mandate culturally and linguistically appropriate services for persons with limited English proficiency. This paper describes an innovative strategy to promote Spanish and culture-learning skills of healthcare providers and presents results of the evaluation conducted to determine its impact on access to quality care. The evaluation used a 360° case study design, at 1-year follow-up. Use of Spanish language health-related materials is key to the trainings success. The authors make recommendations for replication of the integrated language and culture-training model in other new settlement areas, especially those in the southeast of the United States.

Social Support and Dental Utilization among Children of Latina Immigrants

Latino children use fewer professional dental services and experience more dental decay than non-Hispanic White and non-Hispanic Black children. This study tested the association between four types of social support (information, influence, material aid, emotional aid) and dental use among children of Latina immigrants in North Carolina. Latina mothers age 15–44 years (N=174) were sampled from four counties using a multistage church-based sampling design. Each mother reported dental care use for her oldest child younger than 11 years of age. Instrumental aid (information) alone was not associated with dental care use, but receiving any of the other types of social support was associated with dental care use at the bivariate level (p<.01) and at the multivariate level (OR = 3.13; 95% CI = 1.67–5.87). Over half of the women (65.2%) received at least one of these forms of social support. Interventions expanding dental-related social support could help Latina immigrant mothers overcome barriers to dental care for their children.

Social Support Among Latina Immigrant Women: Bridge Persons as Mediators of Cervical Cancer Screening

New Latina immigrants face numerous linguistic, cultural, logistical, and material barriers to cervical cancer screenings. Promotoras (lay health advisors) are a proven strategy to promote utilization of care. Since the mid-1990s, interventions in North Carolina have aimed to connect Latina immigrants to a broader range of bridge persons. This study assessed the effect of bridge persons on utilization of cervical cancer screening by Latina immigrants in North Carolina. Women were recruited in Spanish-language churches in four counties (N = 223). Logistic regression results show that persons known through advocacy organizations appeared to increase probability of recent Pap screening by an average of 10.4 percentage points (p < 0.05).Promotoras remain more effective, increasing probability of screening by 12.9 percentage points (p < 0.05) but few women (14%) knew one. No association was found with other bridge person profiles. Interventions are needed to better engage all bridge persons in linking immigrants to preventive health services.

Immunization drop-outs and maternal behavior: evaluation of reasons given and strategies for maintaining gains made in the national vaccination campaign in Liberia.

Through annual National Vaccination Weeks, Liberia, one of thirteen African countries participating in the CCCD program, has achieved good rates of initial vaccination coverage against childhood diseases. However, rates of completion have been disappointing. Described is a community-based operations research methodology for a.) identifying reasons for non-completion of the vaccination series according to groups of mothers, front-line health workers and country level administrators, b.) for making recommendations for alternatives in the delivery system, and c.) for critiquing the focus group methodology as a tool for increasing commitment to program goals.

Perceptions of Quality of Reproductive Care Services in Bolivia: Use of Photo Prompts and Surveys as an Impetus for Change

Surveys are sometimes used to assess womens perceptions of the quality of reproductive health care, but less empowered women may feel uncomfortable expressing their views in this method. We demonstrate the use of a participatory approach, combining a standard survey with an innovative photonarrative method. Women in Cochabamba, Bolivia, were asked to participate in exit surveys (n = 108). A subsample did photonarratives (n = 20). The survey showed rural women had less access to care, but photonarratives revealed the cause—fear. Women asserted quality of care was high, but photonarratives contradicted survey results. Staff used photonarratives to select action items for quality improvement.