Testing the utility of the newest vital sign (NVS) health literacy assessment tool in older African-American patients

Objective

To evaluate utility of the newest vital sign (NVS) which can be completed in 3 min compared to the short version test of functional literacy in adults (S-TOFHLA) that takes 7 min for health literacy in the older African American patients.

Methods

We enrolled 62 older (age > 65 years) African American patients and administered the NVS and the S-TOFHLA. A score of less than 4 for the NVS and less than 16 for the S-TOFHLA was indicative of limited health literacy.

Results

Mean age of our patients was 73.2 + 7.9 years with an average education level of twelfth grade. Using S-TOFHLA 51% of the subjects were deemed to be sufficiently literate, with a score of 23.0 + 8.6 compared to 56% on the NVS with a score of 3.0 + 1.9. The average time for completing the NVS was 11 min in our patient population.

Conclusion

Based on our data, while health literacy level can be assessed with the NVS its practicality as a quick screening tool in the elderly population appears limited.

Practice implications

Knowing the level of patient's health literacy may help physicians deliver health information in the format that patients can understand.     

Association between health literacy and child and adolescent obesity

Objective

We tested the association between child and parental health literacy (HL) and odds of child and adolescent obesity.

Methods

We conducted an anonymous cross-sectional survey of a convenience sample of English-speaking child-parent dyads. Newest Vital Sign (NVS) measured HL. We used multivariable logistic regression to test adjusted association between child and parental NVS and obesity. Analyses were stratified for school-aged children (aged 7–11) vs. adolescents (aged 12–19).

Results

We surveyed 239 child-parent dyads. Median child age was 11 [inter-quartile range 9–13]; 123 (51%) were male; 84% Medicaid recipients; 27% obese. For children, the odds of obesity [adjusted odds ratio (95% confidence interval)] decreased with higher parent NVS [0.75 (0.56,1.00)] and increased with parent obesity [2.53 (1.08,5.94)]. For adolescents, odds of obesity were higher for adolescents with the lowest category of NVS [5.00 (1.26, 19.8)] and older parental age [1.07 (1.01,1.14)] and lower for Medicaid recipients [0.21 (0.06,0.78)] and higher parental education [0.38 (0.22,0.63)].

Conclusion

Obesity in school-aged children is associated with parental factors (obesity, parental HL); obesity in adolescents is strongly associated with the adolescent's HL.

Practice implications

Strategies to prevent and treat obesity should consider limited HL of parents for child obesity and of adolescents for adolescent obesity.     

Development and validation of the high blood pressure-focused health literacy scale

Objective

While the role of health literacy in chronic disease management is well documented, few intervention studies have been reported. A major barrier to designing and implementing such interventions is the lack of valid health literacy tools. This study developed and tested a novel health literacy scale for individuals with high blood pressure (HBP).

Methods

A two-step design process was used: In the construction phase, focus group studies and a literature review were conducted to generate a pool of items. The testing phase involved a psychometric evaluation and pilot-testing of the scale on hypertensive Korean Americans (n = 386). The end product was a HBP-health literacy scale (HBP-HLS) with two essential domains, print literacy and functional health literacy.

Results

Psychometric testing indicated that the scale was reliable (Kuder–Richardson-20 coefficient = 0.98), valid (content validity index ≥0.8), and significantly correlated with theoretically selected variables (education, r = 0.67, p < 0.01; HBP knowledge, r = 0.33, p < 0.01).

Conclusion

The HBP-HLS demonstrated its utility for evaluating HBP management interventions in the community setting.

Practice implications

Utilizing the HBP-HLS should be considered as a potential tool for improving health literacy and evaluating intervention studies in the context of HBP management.     

Cross-cultural adaptation and validation of the health literacy assessment tool METER in the Portuguese adult population

Objective

We aimed to culturally adapt and validate METER in the Portuguese population, and to define cut-off values for adequate health literacy.

Methods

We used the standard procedure for the adaptation of the words and surveyed health professionals to select the non-words. The instrument was administered to a total sample of 249 participants and retested in a sub-sample of 45 after three months. Cut-offs were defined using the modified Angoff procedure. Construct validity was assessed through association with educational attainment and health-related occupation.

Results

Exploratory factor analysis revealed two dimensions of the instrument, one for words and another for non-words. METER showed a high degree of internal consistency, and acceptable test–retest reliability. Adequate health literacy was defined as scoring at least 35/40 in words and 18/30 in non-words. Physicians scored higher than any other group, followed by health researchers, researchers from other areas and by people with progressively lower levels of education (p < 0.001).

Conclusion

We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and reliable.

Practice implications

The Portuguese version of METER can be used to assess health literacy in Portuguese adults and to explore associations with health outcomes.     

Validation of the Dutch functional,communicative and critical health literacy scales

Objective

While most existing health literacy (HL) measures focus primarily on reading comprehension, the functional, communicative and critical HL scales from Ishikawa et al. [19] aim to measure a broader HL spectrum. The objective of this study was to evaluate the validity of the Dutch translation of this instrument.

Methods

Two survey studies (n = 79 and n = 209) and one cognitive interview study (n = 18) were performed among samples of breast cancer patients and patients with rheumatic diseases.

Results

Analyses showed the scales measured three distinct factors and convergent validity was satisfactory for communicative and critical HL. Nevertheless, the comprehension of the items and the suitability of the response options raised some problems.

Conclusion

The HL scales seem promising to measure a broad definition of HL. By revising some of the items and response options as proposed in this article, the scale will become more understandable for people with low HL skills, which might increase the content validity and the distributional properties of the scale.

Practice implications

The scale should be revised and revalidated. An improved version should be used in practice to gain insight into HL levels of patients. This will help to develop suitable education programs for people with low HL skills.     

Tools to measure health literacy among Chinese speakers: A systematic review

ObjectiveHealth literacy measurement can identify healthcare consumers’ needs and help inform healthcare service delivery. The objective of this review is to identify and evaluate tools to measure health literacy among Chinese speakers.MethodsA systematic literature search was undertaken in nine databases, both English and Chinese, on articles published from the databases’ inception to May 2018, addressing health literacy among Chinese speakers.ResultsTen health literacy instruments in the Chinese language were reported in 17 studies, of which ten were published in English and seven in Chinese. Of the 17 studies, six reported on a new instrument, while the remainder reported on derivative instruments. All, except for one, are self-administered. These studies applied various implicit or explicit conceptual or operational health literacy definitions. The psychometric strength varied across the instruments.ConclusionsA number of instruments are available for assessing health literacy among Chinese speakers. Careful selection is recommended, given the variation in components and psychometric properties assessed.Practice implicationsThis review can be used by healthcare providers and researchers to select effective health literacy tools to examine patients’ ability to understand and apply health information so that services can be more appropriately tailored to Chinese speaking patients.     

Validation of an Australian parenting health literacy skills instrument: The parenting plus skills index

ObjectiveExisting instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills.MethodsThe PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20−44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500).ResultsFollowing the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments.ConclusionsThe PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting.Practice implicationsThe PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions.     

Time to sign: The relationship between health literacy and signature time

Objective

To evaluate the relationship between amount of time taken to sign one's name and health literacy.

Methods

A prospective, one time assessment was conducted on a convenience sample of 98 patients recruited in an inner-city outpatient internal medicine clinic. The amount of time required to sign (i.e. initiation to completion of writing) was measured by stopwatch. Health literacy was measured with the REALM.

Results

The sample averaged 54.1 (SD 16.2) years of age. Twenty-seven percent had less than high school education and 33% had a terminal general equivalency diploma or high school degree. The time required to sign ranged from 0.91 to 21.3 s. Sixty-two percent of the sample had health literacy challenges. Signature time was longest for those with inadequate health literacy (mean 10.0 s), compared with marginal (7.3 s) and adequate (4.7 s, p ≤ 0.001). Signature time remained significant in a logistic regression model after controlling for education and age (AOR = 0.785, CI = 0.661–0.932).

Conclusion

Individuals with signatures completed in six seconds or less were highly likely to display adequate health literacy.

Practice implications

Signature time may offer a practical and quick approach to health literacy screening in the health care setting.     

Test-retest reliability of the Newest Vital Sign health literacy instrument: In-person and remote administration

Objective

To determine the reliability of the Newest Vital Sign (NVS) administered via telephone by examining test-retest properties of the measure.

The right pick: Does a self-assessment measurement tool correctly identify health care consumers with inadequate health literacy?

ObjectivesThe aim of this study was to investigate whether a self-report measurement instrument (the Brief Health Literacy Screen, BHLS) correctly identifies healthcare consumers with inadequate health literacy. The yardstick for assessing the tool was the Newest Vital Sign (NVS).MethodsThe study used baseline data from the Västerbotten Intervention Programme - VIsualiZation of Asymptomatic Atherosclerotic disease for Optimum Cardiovascular Prevention (VIPVIZA), a randomized controlled trial that is nested within the Västerbotten Intervention Program (VIP) in Sweden. Our analyses were computed on a subsample of 460 persons who underwent the measure of both health literacy scales. ROC analysis was used for the crucial computations.ResultsThe potential of the BHLS to identify healthcare consumers with inadequate health literacy remained unsatisfying for the complete sample, but reached an acceptable level for women and persons with only basic education.ConclusionsThe relationship is somewhat weaker than in comparable research in various other European countries. The differences might partly have been caused by the use of self-perception questions. Self-delusions, invariably a part of self-perception, may have affected the respective measure.Practice implicationsCaution is advised when patients’ health literacy is assessed by only a few questions for self-report.     

Abilities,skills and knowledge in measures of health literacy

Objective

Health literacy has been recognized as an important factor in patients’ health status and outcomes, but the relative contribution of demographic variables, cognitive abilities, academic skills, and health knowledge to performance on tests of health literacy has not been as extensively explored. The purpose of this paper is to propose a model of health literacy as a composite of cognitive abilities, academic skills, and health knowledge (ASK model) and test its relation to measures of health literacy in a model that first takes demographic variables into account.

Methods

A battery of cognitive, academic achievement, health knowledge and health literacy measures was administered to 359 Spanish- and English-speaking community-dwelling volunteers. The relations of health literacy tests to the model were evaluated using regression models.

Results

Each health literacy test was related to elements of the model but variability existed across measures.

Conclusion

Analyses partially support the ASK model defining health literacy as a composite of abilities, skills, and knowledge, although the relations of commonly used health literacy measures to each element of the model varied widely.

Practice implications

Results suggest that clinicians and researchers should be aware of the abilities and skills assessed by health literacy measures when choosing a measure.     

Developing performance-based measures of health literacy: A narrative case study and checklist of considerations

Research in health literacy is fundamentally impacted by our ability to adequately assess the construct. Although various measures of health literacy have been developed, there are few reflective discussions of the challenges and learnings from the instrument development process. This is somewhat surprising given that health literacy is a multi-dimensional and contested concept (with inherent measurement challenges), and that there are important practical considerations owing to the fact that people completing health literacy assessments may have lower general literacy (i.e. ability to read and write) and English-language skills. This paper discusses our learnings from developing a performance-based measure of parenting health literacy skills (the Parenting Plus Skills Index). The performance-based instrument is characterised by its grounding in health literacy as asset, with items spanning Nutbeam’s functional, communicative and critical health literacy skills, and was designed chiefly to capture improvements resulting from health literacy skills training. This paper elucidates critical junctures in the development process, particularly regarding the conceptualisation and operationalisation of the construct. We also outline our approach to addressing practical measurement issues (e.g. administration time; item difficulty). In summarising these, we offer a 13-item checklist to inform the development of health literacy instruments for other health contexts or health conditions.     

Measurement properties and comparative performance of health literacy screening questions in a predominantly low income African American population with diabetes

Objective

To examine the measurement properties of the 16 screening questions (16-SQ) of inadequate health literacy (HL) and their briefer version (3-SQ), and identify the best screen for inadequate HL in non-white populations.

Methods

Sample included 378 individuals with type-2 diabetes. We computed sensitivity, specificity, positive and negative likelihood ratios, and C-indices, using the s-TOFHLA as a reference measure. We also conducted exploratory factor analysis, and used structural equation modeling (SEM) for confirmatory purposes.

Results

Mean age was 56.1 years, 69% were female, and 83% were African–American. 10% had limited HL (s-TOHFLA scores <23). Six questions (6-SQ) were identified and included in the final item-reduced factor analysis, which showed good fit in confirmatory SEM (chi-square = 9.5; P = 0.305; RMSEA = 0.023). Weighted summative score of the 6-SQ and the item “difficulty understanding written information” performed better than the 3-SQ in identifying patients with inadequate HL (C-indices 0.67 versus 0.75).

Conclusion

The weighted summative score of the 6-SQ and the item “difficulty understanding written information” performed better than the other items or combinations of these items in identifying individuals with inadequate HL.

Practice implications

The proposed weighting of scores could be applied in studies using these screening questions for better classification of inadequate HL.     

Development and validation of the General Health Numeracy Test (GHNT)

Objective

Because existing numeracy measures may not optimally assess ‘health numeracy’, we developed and validated the General Health Numeracy Test (GHNT).

Methods

An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity.

Results

On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39 K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20 = 0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p < .001). Furthermore, both versions were associated with participants’ understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses.

Conclusions

The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy.

Practice implications

Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.     

Health literacy and patient empowerment in health communication: The importance of separating conjoined twins

Objective

Patient empowerment and health literacy have both been studied empirically, but they have hardly ever been explicitly linked.

Methods

Pertinent literature from the development of both concepts was studied, drawing not only on health care literature, but also on management research.

Results

This article argues that it is important to recognize that the concepts are distinct, both conceptually and empirically. At the same time, the impacts of health literacy and patient empowerment are deeply intertwined. High literacy does not necessarily entail empowerment and vice versa, and mismatches of the two can have deleterious consequences. High levels of health literacy without a corresponding high degree of patient empowerment creates an unnecessary dependence of patients on health professionals, while a high degree of empowerment without a corresponding degree of health literacy poses the risk of dangerous health choices.

Conclusion

We discuss the importance of carefully conceptualizing both approaches, the implications for their measurement and the design of health interventions.

Practice implications

Communication programs must include the empowerment that motivates consumers to engage and the literacy that enables them to make informed and reasoned choices.     

Functional health literacy in Switzerland—Validation of a German,Italian, and French health literacy test

Objective

This study aimed to translate and validate German, Italian, and French versions of the Short-Test of Functional Health Literacy (S-TOFHLA), to be used in Switzerland and its neighboring countries.

Methods

The original English version of the S-TOFHLA was translated by applying standardized translation methods and cultural adaptations. 659 interviews were conducted with Swiss residents in their preferred language (249 German, 273 Italian, and 137 French). To assess the validity of the measures, known predictors for health literacy (age, education, and presence of a chronic condition) were tested.

Results

For all three language versions, results show that younger participants, participants with a higher education and participants with chronic medical conditions had significantly higher levels of health literacy. Furthermore, the three health literacy scales categorized participants into three health literacy levels with most people possessing either inadequate or adequate levels. The highest levels of health literacy were found in the Swiss-German sample (93%), followed by the Swiss-French (83%) and Swiss-Italian (67%) samples.

Conclusion

The German, Italian, and French versions of the S-TOFHLA provide valid measures of functional health literacy.

Practice implications

The translated versions can be used in the three different language regions of Switzerland as well as in neighboring countries following ‘country specific’ adjustments and validations.     

The psychometric testing of the functional,communicative, and critical health literacy tool

ObjectiveThe purpose of this study is to assess the validity and reliability of the English version of the FCCHL tool in urban and rural, socioeconomically vulnerable or unstable, chronic comorbid adults in the United States.MethodsA cross-sectional study measuring both validity and reliability.ResultsA total of 276 participants were recruited. Internal consistency was measured using Cronbach’s alpha of α = 0.87. External reliability was measured by test-retest methodology. Construct validity was measured using Confirmatory Factor Analysis that showed good fit. Criterion validity was measured by comparing the mean scores of the FCCHL tool sub-scales. Concurrent validity was measured by comparison of means of the FCCHL tool and education level compared to the NVS and s-TOFHLA.ConclusionThe results demonstrated that the FCCHL tools is measuring three different concepts. Overall, the FCCHL tool was seen to have good validity and reliability in the identified population.Practice ImplicationsThe FCCHL tool is a 14-item, self-report health literacy tool measuring more than functional health literacy. The tool can be used in practice to improve not only functional health literacy, but also communicative and critical which is highly applicable.     

Preference for and understanding of graphs presenting health risk information. The role of age,health literacy,numeracy and graph literacy

ObjectiveTo investigate 1) younger (< 65) and older (> 65) adults’ preference for and understanding of graph formats presenting risk information, and 2) the contribution of age, health literacy, numeracy and graph literacy in understanding information.Materials and methodsTo assess preferences, participants (n = 219 < 65 and n = 227>65) were exposed to a storyboard presenting six types of graphs. Understanding (verbatim and gist knowledge) was assessed in an experiment using a 6 (graphs: clock, bar, sparkplug, table, pie vs pictograph) by 2 (age: younger [<65] vs older [>65]) between-subjects design.ResultsMost participants preferred clock, pie or bar chart. Pie was not well understood by both younger and older people, and clock not by older people. Bar was fairly well understood in both groups. Table yielded high knowledge scores, particularly in the older group. Lower age, higher numeracy and higher graph literacy contributed to higher verbatim knowledge scores. Higher health literacy and graph literacy were associated with higher gist knowledge.Discussion and conclusionAlthough not the preferred format, tables are best understood by older adults.Practice implicationsGraph literacy skills are essential for both verbatim and gist understanding, and are important to take into account when developing risk information.     

Airway diseases and health literacy (HL) measurement tools: A systematic review to inform respiratory research and practice

Objective

To identify and evaluate asthma/COPD measurement tools that assess any of the five health literacy (HL) domains: (1) access, (2) understand, (3) evaluate, (4) communicate, and (5) use, as well as numeracy.

Optimizing usability and signal capture: a proactive risk assessment for the implementation of a wireless vital sign monitoring system

Wearable vital sign monitors are a promising step towards optimal patient surveillance, providing continuous data to allow for early detection and treatment of patient deterioration. However, as wearable monitors become more widely adopted in healthcare, there is a corresponding need to carefully design the implementation of these tools to promote their integration into clinical workflows and defend against potential misuse and patient harm. Prior to the roll-out of these monitors, our multidisciplinary team of clinicians, clinical engineers, information technologists and research investigators conducted a modified Healthcare Failure Mode and Effect Analysis (HFMEA), a proactive evaluation of potential problems which could be encountered in the use of a wireless vital signs monitoring system. This evaluation was accomplished by focussing on the identification of procedures and actions that would be required during the devices’ regular usage, as well as the implementation of the system as a comprehensive process. Using this method, the team identified challenges that would arise throughout the lifecycle of the device and developed recommendations to address them. This proactive risk assessment can guide the implementation of wearable patient monitors, optimising the use of innovative health information technology.