Medical Student Research Fellowship for Summer 2011
Mentor: Celette Sugg Skinner, PhD
Department: Clinical Sciences
Room number: E5.506
Mail Code: 9066
Phone number: 214-648-9559
Project title: Validation of screening questions for health literacy in a large population of English and Spanish-speaking adults
Human subjects IRB approved project number (where applicable): pending
Animal subjects IRB approved project number (where applicable): N/A
Project Type (patient-based research, animal-based research, or basic research; this characterization is only to permit a general classification for grouping similar types of projects) Patient-based research
Brief Description of Project:
Background: Health literacy, defined as “the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions,” is an important component of health care (IOM). Low health literacy has been associated with adverse health outcomes, including underuse of preventive services and poor overall health status (Powers 2010, DeWalt 2004). The adverse health effects of low health literacy may be more pronounced in the Spanish-speaking Latino population, the fastest growing ethnic group in the United States (Lee 2010). The 2009 U.S. Census Bureau Current Population Survey showed that the proportion of Hispanics aged 25 years and older who had less than a fifth grade education was about 15 times greater than that of non-Hispanic whites. Such a low literacy level, coupled with the language barrier, may increase vulnerability of Hispanic populations to other health barriers and limit their access to needed health care (Lee 2006).
Ability to identify patients with potential literacy problems in a health care setting is crucial for meeting their needs. Without accurate assessment, efforts to understand and ameliorate health problems associated with limited health literacy among Spanish and English speaking individuals are unlikely to succeed (Baker 2006). Our participants are people—volunteers we rely on and without whom we could conduct research (Ridpath 2010). As investigators, we need to ensure they understand information they are receiving. We need to understand what written health materials need to be simplified and what health concepts need to be taught more effectively in schools and in health care settings, so our research can be more effective.
Generally, researchers and health care providers have used standardized tests to measure reading capacities and numeracy skills. Even though most of the instruments are available in Spanish, the tests were originally designed for English-speaking populations; therefore, simple forward and backward translation does not always suffice. Communication involves a range of skills and socio-lingual characteristics that should be taken into account when designing any successful instrument. For these reasons, most of the currently available instruments listed below are inappropriate for assessing Spanish speakers’ health literacy. The reading capacity test approach includes the following tests, which are cumbersome to administer.
Purpose: We would like to validate a single-item question to screen for health literacy in Spanish- and English-speaking populations. Using Chew’s most recent study and Garcia’s (2008) pilot study as models, we will test 3 health literacy screening questions against 2 validated health literacy measures in Spanish and English. We will test the following 3 health literacy screening questions: (1) How often do you have someone help you read hospital materials? (2) How confident are you filling out medical forms by yourself? (3) How often do you have problems learning about your medical condition because of difficulty understanding written information. The Test of Functional Health Literacy in Adults (TOFHLA), created in 1995, was the first available tool for measuring functional health literacy in English and Spanish. The TOFHLA measures patients’ ability to perform health-related tasks that require reading and computational skills. It consists of a reading comprehension section, containing 50 items that measure a patient’s ability to read and fill in the missing word on selected passages about upper GI series, a Medicaid application, and a procedure consent form. It also contains 17 numeracy items that assess a patient’s ability to understand numbers such as those on prescription bottle labels and blood glucose results. There is a short form of the TOFHLA called Short TOFHLA (S-TOFHLA) that requires up to 12 minutes to administer. The short form is composed of 4 numeracy items and 36 reading comprehension items. The S-TOFHLA is also available in Spanish. The Rapid Estimate of Adult Literacy in Medicine (REALM), created in 2002, is a widely used screening test that measures reading and pronunciation ability in English. The REALM is a medical word recognition and pronunciation test comprising 66 commonly used medical terms, arranged in order of complexity by the number of syllables and pronunciation difficulty, starting with simple one-syllable words and ending with multi-syllable words. The examinee is instructed to read aloud from the list of medical words and his/her literacy level is rated by the number of words that are correctly pronounced (Lee 2006). An effort to translate the REALM in Spanish was unsuccessful due to the phonetic structure of the Spanish language. Unlike English, Spanish has a regular phoneme-grapheme correspondence, meaning that one sound is usually represented by one letter. As a result, it is easy to pronounce words in Spanish if you can recognize the letters. A poor reader can usually score high on a word recognition test, violating the design and purpose of the REALM test (Lee 2006).
The Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) was developed in 2006 to test the comprehension of commonly used medical terms. The test, only available in Spanish, requires examinees to read aloud a list of medical terms (like the REALM) and associate each term to another word similar in meaning to demonstrate comprehension. It consists of 50 questions and takes 20 minutes to administer. In 2010, Lee and his team developed a comparable test for both English and Spanish speakers. This test, the Short Assessment of Health Literacy- Spanish and English (SAHL-S&E), has the same format as the SAHLSA but contains only 18 items, making it much easier to administer in 2 to 3 minutes.
We will validate and compare the health literacy screening questions against the STOFHLA in Spanish and the SAHL-S and the TOFHLA and REALM in English.
Method: We will conduct in-person interviews among a random sample from our Community Health Registry to complete 3 health literacy screening questions and 2 validated health literacy measures questions with 325 Spanish and 325 English-speaking participants.
The student would be working closely with the project manager to recruit participants, conduct interviews and analysis.
Previous Research Activities or Publications with Medical Students:
Elisabeth Brown was a Medical Student Research Fellow in Summer 2010 and was co-mentored by Dr. Celette Sugg Skinner and Dr. Heidi Hamann. Ms. Brown worked primarily on a project focused on BRCA1/2 testing uptake and surgery/surveillance among women seen for genetic counseling at Parkland Hospital. As part of this project, Ms. Brown conducted medical record abstractions and participated in regular project meetings. To supplement her experience, she also shadowed genetic counselors and a breast surgeon in their Parkland clinic, and observed a breast surgery. Ms. Brown presented the findings from her research at the Medical Student research poster session in January 2011. She is also assisting with a publication write-up for the study.