Psychometric Evaluation of Three Translated Measures of Functional Health Literacy among Jordanians

Assessment of functional health literacy (FHL) is not integrated into clinical settings in Jordan possibly because relevant psychometric studies are lacking. The aim of this secondary analysis of data on family caregivers (N = 115) was to evaluate the internal consistency reliability and construct validity of three measures of FHL among Jordanians: the Short Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), and the Single Item Literacy Screener (SILS). Cronbach's alpha was excellent for the S-TOFHLA (.92), but suboptimal for the REALM-R (.67). In bivariate analysis, FHL measured by the S-TOFHLA and the REALM-R, but not the SILS, was positively associated with educational attainment (p < .05) and negatively related to self-reported anxiety (p < .05). Among Jordanians, psychometric rigor was fully demonstrated for the S-TOFHLA and partially for the REALM-R, but not for the SILS.

Focused Education Increases Hepatocellular Cancer Screening in Patients with Cirrhosis Regardless of Functional Health Literacy

BACKGROUND

Health education interventions are successful in modifying lifestyle. Functional health literacy (FHL) can determine patient adherence to clinic visits and procedures and may adversely impact the success of these interventions.

AIMS

We sought to evaluate the hypothesis that a health education intervention would improve compliance with hepatocellular cancer (HCC) screening and that poor FHL would reduce such compliance.

METHODS

We assessed FHL using a short version test of functional health literacy in adults (STOFHLA). Cirrhotic patients free of HCC were prospectively enrolled from clinics and provided an educational intervention consisting of focused physician-led discussion regarding cirrhosis and HCC, along with written material on these topics for the subject to review at home. Patients were subsequently followed for 6 months (prospective time period), and the same cohort's clinic/HCC screening behavior between 6 and 12 months prior to the educational intervention (retrospective time period) was compared.

RESULTS

In total, 104 cirrhotic patients (age 60.01 ± 8.58 years, 80% men, MELD 12.70 ± 5.76) were included. Of these, 89 (85.57%) of patients had educational level 12th grade and higher. There were 76% (n = 79) with adequate, while 24% (n = 25) had inadequate/marginal FHL on S-TOHFLA. The number of HCC-related imaging increased from 59 (56.7%) to 86 (82.6%, p < 0.0001) post-education in the prospective compared to prior time period which was similar regardless of FHL.

CONCLUSIONS

While the educational intervention was successful in improving compliance with HCC screenings, FHL status did not impact the power of this intervention. Hence, the combination of specific verbal information, along with targeted written material, improved compliance with clinic visits and liver imaging for HCC.

Association of Health Literacy and Nutritional Status Assessment with Glycemic Control in Adults with Type 2 Diabetes Mellitus

While the role of medical and nutrition factors on glycemic control among adults with type 2 diabetes mellitus (T2DM) has been well-established, the association between health literacy (H.L.) and glycemic control is inconsistent. This study aims to determine the association of H.L. and nutritional status assessments with glycemic control in adults with type 2 diabetes mellitus. A total of 280 T2DM respondents (mean (SD) age = 49.7 (10.3) years, Glycated hemoglobin (HbA1c) = 9.9 (2.6) %, and Body Mass Index = 32.7 (15.1) kg/m²) were included in this study. A short-form Test of Functional Health Literacy in Adults (S-TOFHLA) assessed the H.L. levels. Nutritional status assessments included client history, glycemic control, anthropometric, and biochemical data. The mean (S.D.) H.L. score was 45.7 (24.6), with 56% of the respondents had inadequate H.L. Inadequate H.L. was more common among those females; housewives, low education, received oral antidiabetic therapy, and shorter diabetes duration. Respondents with inadequate H.L. were significantly older and had higher HbA1c than those with marginal and adequate H.L. Meanwhile, respondents with inadequate and marginal H.L. levels had significantly higher total cholesterol, LDL-cholesterol, and systolic blood pressure than the respondents with adequate H.L. Low H.L. scores, self-employment status, received dual antidiabetic therapy (insulin with oral agents), received insulin alone, and had higher fasting blood glucose explained about 21% of the total variation in HbA1c (adjusted R² = 0.21; p < 0.001). Respondents with inadequate H.L. had poor glycemic control. The H.L. scores, together with nutritional status assessments, were the factors that predicted poor glycemic control among adults with T2DM.

Measuring functional health literacy in Hungary: Validation of S-TOFHLA and Chew screening questions

OBJECTIVES

The first efforts to measure health literacy have recently started in Hungary, thus there remains a need for tools that can be effectively used in the clinical setting. The goal of the present study was two-fold: to validate tools for measuring functional health literacy in Hungary using the Short Test of Functional Health Literacy (S-TOFHLA) and the Chew screening measure, and to provide an overview of the health literacy level of the Hungarian population.

METHODS

The original English versions of both instruments were translated following the principles of cultural adaptation and standardized translation methods. The measures were administered to a random sample (N = 302) that was close to representative of the Hungarian population regarding age, gender and educational background. The Newest Vital Sign functional health literacy test and numerous socio-demographic variables (such as age, gender, education and income) were also administered to test convergent validity.

RESULTS

The Hungarian version of the S-TOFHLA and the Chew questions showed adequate internal consistency. Lower functional health literacy scores showed the expected association with known predictors of health literacy: higher age, male gender and lower education. Especially people above 65 years of age and individuals with a low level of educational attainment or being chronically ill are vulnerable to have marginal health literacy.

CONCLUSION

The Hungarian version of the S-TOFHLA is a valid and reliable measure of health literacy. Moreover, the Hungarian version of the Chew screening questions provides a valid self-reported assessment, which is particularly useful to rapidly detect patients with inadequate health literacy in hospitals. It is expected that these health literacy measurements will be used for not only scientific purposes, but also serve as tools for developing public health policy, especially health education and campaigns reducing potential health disparities in Hungary.

Health Literacy: Current Status and Challenges in the Work of Family Doctors in Bosnia and Herzegovina

Health literacy (HL) has become an important area of research. The aim of this study was to evaluate the HL of primary healthcare patients in the Republic of Srpska (RS), Bosnia and Herzegovina (B&H) and to identify socioeconomic and health factors associated with HL. This cross-sectional study among 768 patients was conducted in two healthcare centres between March and May 2017, using the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Analysis was done using descriptive and inferential statistics (a chi-squared test and logistic regression). Inadequate and marginal HL was found in 34,6% of respondents. Socioeconomic and self-reported health factors were significantly related to HL. An age of 55 years and over (OR 1.02), living in a rural environment (OR 2.25), being divorced (OR 3.32), being insufficiently physically active (OR 1.29), having poor income (OR 1.96), having more than three chronic diseases (OR 1.94), and poor health (OR 1.59) were significantly corelated with inadequate and marginal HL. The results of our study indicate that a low level of HL is related to the elderly, having a divorce, having a rural residence, poor income, having more than three chronic diseases, poor health, and insufficient physical activity. Further evaluation, monitoring, and activities to improve HL are of great importance for patients’ health outcomes.

Health literacy in Mainland China: Validation of a functional health literacy test in simplified Chinese

Health literacy tests in the Chinese-speaking parts of the world have been mainly developed in traditional Chinese to be used in Hong Kong or Taiwan. So far no validated tool in simplified Chinese to assess functional health literacy in Mainland China has been developed. The aim of the study was to validate the simplified Chinese version of the Short Test of Functional Health Literacy in Adults (S-TOFHLA). The traditional Chinese version was translated into simplified Chinese and 150 interviews in an outpatient department of a public hospital in Mainland China were conducted. Predictive validity was assessed by known predictors for health literacy and convergent validity by three health literacy screening questions. The Cronbach's α for the reading comprehension part was 0.94 and 0.90 for the numeracy items. Participants with lower education and men had significantly lower levels of health literacy. The reading comprehension part was significantly correlated with two of the health literacy screening questions. Our results indicate that the simplified Chinese version of the S-TOFHLA is a reliable measure of health literacy to be used in Mainland China.

Validation of Turkish health literacy measures

This study aimed to validate a Turkish version of the Short Test of Functional Health Literacy (S-TOFHLA) (Baker et al, Development of a brief test to measure functional health literacy. Patient Educ Counsel 1999; 38: :33-42) and a Turkish version of the Chew self-report scale (Chew et al., Brief questions to identify patients with inadequate health literacy. Family Med, 2004; 36: :588-94) for measuring functional health literacy. The original English version of the S-TOFHLA and the Chew items were translated by applying standardized translation methods and cultural adaptations, and both were administered to a sample of diabetes patients (N = 302) in two diabetes clinics in one of the major cities in Turkey. Self-administered paper-pencil questionnaires were distributed to eligible outpatients who had a clinic appointment. In addition to the S-TOFHLA measurement and the Chew screening questions, gender, age, educational attainment, income, marital status and diabetes knowledge were obtained. The Turkish version of S-TOFHLA showed high internal consistency. Both S-TOFHLA and the Chew screening scale correlated significantly with known predictors of health literacy: age, education and income. The Chew scale was also related weakly but significantly with general diabetes knowledge. It is expected that the Turkish versions of S-TOFHLA and the Chew scale will be used in Turkey as well as in other countries with large Turkish communities.

Uncovering health literacy: Developing a remotely administered questionnaire for determining health literacy levels in health disparate populations

INTRODUCTION

Low health literacy contributes to health disparities. We sought to develop and evaluate a remotely administered tool to measure health literacy in health disparate populations. The basic research design involved asking the remotely administered questions in conjunction with an existing and valid measure of health literacy, the S-TOFHLA, to a non-representative convenience sample of individuals drawn from lower income communities. The measures of the remotely administered questions were then correlated with the results of the S-TOFHLA to determine if there was a connection between the two measures. We found a statistically significant correlation between a single question in the remotely administered survey and the validated S-TOFHLA measure. This research supports previous work that points to the importance of just a single remotely administered question in terms of correspondence with the S-TOFHLA.

OBJECTIVE

Develop a questionnaire that can be remotely administered to check for Health Literacy.

METHODS

Correlation analysis is conducted between various questions and S-TOFHLA scores to determine criterion validity.

RESULTS

A single question, "How confident are you in filling out medical forms by yourself?" outperforms other measures in correlating with the S-TOFHLA scores.

CONCLUSIONS

Further assessment of the confidence question both in isolation and in conjunction with other literacy identifiers should be conducted. Also, this question should be tested against other measures of health literacy beyond the S-TOFHLA.

The S-TOFHLA as a measure of functional literacy in patients with mild Alzheimer's disease or mild cognitive impairment

In developing countries, education levels vary dramatically, and the number of years of schooling does not always correlate with the true level of educational competency. This study was designed to verify the accuracy of the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) in individuals with mild cognitive impairment (MCI) and mild Alzheimer's disease (AD), when compared with healthy controls (HCs), in order to assess its utility as a measure of functional literacy. One hundred forty-eight subjects were divided into three groups: HC (n = 61), MCI patients (n = 42), and AD patients (n = 45). The S-TOFHLA does not seem to be suitable as an instrument to measure functional literacy for patients with advanced cognitive impairment, but proved to be appropriate in both the HC group and MCI patients in numeracy and prove to be useful as an adjuvant to estimate IQ, reading ability, and premorbid IQ, as an indicator of cognitive reserve.

The association of health literacy with adherence and outcomes in moderate-severe asthma

BACKGROUND

Low health literacy is associated with poor outcomes in asthma and other diseases, but the mechanisms governing this relationship are not well defined.

OBJECTIVE

We sought to assess whether literacy is related to subsequent asthma self-management, measured as adherence to inhaled steroids, and asthma outcomes.

METHODS

In a prospective longitudinal cohort study, numeric (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults) were assessed at baseline in adults with moderate or severe asthma for their impact on subsequent electronically monitored adherence and asthma outcomes (asthma control, asthma-related quality of life, and FEV1) over 26 weeks, using mixed-effects linear regression models.

RESULTS

A total of 284 adults participated: age, 48 ± 14 years, 71% females, 70% African American, 6% Latino, mean FEV1 66% ± 19%, 86 (30%) with hospitalizations, and 148 (52%) with emergency department visits for asthma in the prior year. Mean Asthma Numeracy Questionnaire score was 2.3 ± 1.2 (range, 0-4); mean Short Test of Functional Health Literacy in Adults score was 31 ± 8 (range, 0-36). In unadjusted analyses, numeric and print literacy were associated with better adherence (P = .01 and P = .08, respectively), asthma control (P = .005 and P < .001, respectively), and quality of life (P < .001 and P < .001, respectively). After controlling for age, sex, and race/ethnicity, the associations diminished and only quality of life (numeric P = .03, print P = .006) and asthma control (print P = .005) remained significantly associated with literacy. Race/ethnicity, income, and educational attainment were correlated (P < .001).

CONCLUSION

While the relationship between literacy and health is complex, interventions that account for and address the literacy needs of patients may improve asthma outcomes.

Formal education, health literacy and Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) is a widely used screening test for cognitive impairment, but is heavily biased by education. Educational level has frequently been ranked using years of schooling, which may not be a good indirect measure of educational level because there is great heterogeneity in standards of schooling among populations and across regions of the same country. S-TOFHLA is a measure of health literacy with some results indicating that it is a good measure for literacy level.

Objective

To evaluate the correlations between years of schooling and scores on the S-TOFHLA and the MMSE.

Methods

Healthy subjects without cognitive impairment were submitted to the S-TOFHLA and the MMSE. Correlations and regression analysis were performed to determine possible associations among variables.

Results

Both years of schooling and S-TOFHLA scores were strongly correlated with MMSE scores, but the strongest association was reached by the S-TOFHLA (r=0.702, p<0.01), where the S-TOFHLA was the best predictor of MMSE scores (R²=0.494, p<0.001).

Conclusions

A stronger association between S-TOFHLA scores and MMSE performance was found than between years of education and MMSE scores. This finding justifies further studies incorporating years of schooling together with S-TOFHLA score, to evaluate cognitive performance.

S-TOFHLA in mild Alzheimer's disease and Mild Cognitive Impairment patients as a measure of functional literacy: Preliminary study

The greatest difficulty in diagnosing cognitive loss in our population is the diversity of its education which has a broad spectrum ranging from illiteracy, functional illiteracy and different degrees of literacy, even in those with the same level of schooling.