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.     

The association of health literacy with illness and medication beliefs among older adults with asthma

Objective

Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs.

Methods

Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n = 420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models.

Results

Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2–2.82; OR: 2.22, 95% CI: 1.29–3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (β = 0.92, p = .05), despite recognizing their necessity (β = −1.36, p = .01).

Conclusions

Older asthmatics with low HL endorse erroneous asthma beliefs.

Practice implications

Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.     

Processes of knowing in the translation of a health communication intervention for dialysis patients awaiting kidney transplantation

ObjectiveTo strengthen patients’ health literacy and their role as active knowledge actors, we developed a health communication intervention including a film-viewing and counselling session for patients awaiting kidney transplantation. We aimed to explore processes of knowing in the translation of the intervention.MethodsWe applied an ethnographic research approach, observing nine intervention sessions with patients and dialysis nurses. Afterwards, the patients and the nurses were interviewed in-depth. Data were analysed using Engebretsen’s modified version of Lonergans’ four-step model of knowing.ResultsThe following knowing processes were identified: i) Knowing as meaning-making; ii) Knowing as acquiring confidence; and iii) Accessing professionals’ and peer experts’ knowledge. Divergent considerations were taken by the different knowledge actors, which had a direct influence on the knowing processes and knowledge translation.ConclusionsThe findings support active interactions between patients and healthcare providers in processes of knowing. These include self-conscious approaches and critical questioning in both parties.Practice implicationsFor transplant professionals, this study demonstrates knowing processes in a real-life context. It also spotlights professional skills and attitudes regarding the importance of self-conscious questioning and a critical interrogating position (for both patients and providers).     

A user-study measuring the effects of lexical simplification and coherence enhancement on perceived and actual text difficulty

PurposeLow patient health literacy has been associated with cost increases in medicine because it contributes to inadequate care. Providing explanatory text is a convenient approach to distribute medical information and increase health literacy. Unfortunately, writing text that is easily understood is challenging. This work tests two text features for their impact on understanding: lexical simplification and coherence enhancement.MethodsA user study was conducted to test the features’ effect on perceived and actual text difficulty. Individual sentences were used to test perceived difficulty. Using a 5-point Likert scale, participants compared eight pairs of original and simplified sentences. Abstracts were used to test actual difficulty. For each abstract, four versions were created: original, lexically simplified, coherence enhanced, and lexically simplified and coherence enhanced. Using a mixed design, one group of participants worked with the original and lexically simplified documents (no coherence enhancement) while a second group worked with the coherence enhanced versions. Actual difficulty was measured using a Cloze measure and multiple-choice questions.ResultsUsing Amazon's Mechanical Turk, 200 people participated of which 187 qualified based on our data qualification tests. A paired-samples t-test for the sentence ratings showed a significant reduction in difficulty after lexical simplification (p < .001). Results for actual difficulty are based on the abstracts and associated tasks. A two-way ANOVA for the Cloze test showed no effect of coherence enhancement but a main effect for lexical simplification, with the simplification leading to worse scores (p = .004). A follow-up ANOVA showed this effect exists only for function words when coherence was not enhanced (p = .008). In contrast, a two-way ANOVA for answering multiple-choice questions showed a significant beneficial effect of coherence enhancement (p = .003) but no effect of lexical simplification.ConclusionsLexical simplification reduced the perceived difficulty of texts. Coherence enhancement reduced the actual difficulty of text when measured using multiple-choice questions. However, the Cloze measure results showed that lexical simplification can negatively impact the flow of the text.     

Health literacy in patients referred for transplant: do patients have the capacity to understand?

Adequate levels of health literacy are needed for transplant recipients to be able to understand and comply with medical recommendations. However, little is known about health literacy among transplant candidates. Therefore, the purpose of this study was to examine the levels of health literacy and cognitive functioning among patients being evaluated for various types of transplantation. There were 398 patients who completed a required psychological evaluation prior to being listed for transplant. This included a screen for cognitive impairment and limited reading and math ability. The prevalence of limited reading ability was 27.5%, limited math ability was 42.8%, and 30.7% had probable cognitive impairment. Rates of limited reading and math ability and cognitive impairment varied for each type of end‐stage disease. Limited reading ability was related to poorer cognitive functioning. Those with a higher likelihood of limited reading ability included blacks and males. Those more likely to have cognitive impairment included blacks and patients who are older. Results from this study suggest that patients should be regularly screened for health literacy and cognitive impairment. Once patients with difficulties are identified, recommendations can be provided to these patients at a level that they are able to understand.     

Low Health Literacy and Evaluation of Online Health Information: A Systematic Review of the Literature

Background

Recent years have witnessed a dramatic increase in consumer online health information seeking. The quality of online health information, however, remains questionable. The issue of information evaluation has become a hot topic, leading to the development of guidelines and checklists to design high-quality online health information. However, little attention has been devoted to how consumers, in particular people with low health literacy, evaluate online health information.

Objective

The main aim of this study was to review existing evidence on the association between low health literacy and (1) people’s ability to evaluate online health information, (2) perceived quality of online health information, (3) trust in online health information, and (4) use of evaluation criteria for online health information.

Methods

Five academic databases (MEDLINE, PsycINFO, Web of Science, CINAHL, and Communication and Mass-media Complete) were systematically searched. We included peer-reviewed publications investigating differences in the evaluation of online information between people with different health literacy levels.

Results

After abstract and full-text screening, 38 articles were included in the review. Only four studies investigated the specific role of low health literacy in the evaluation of online health information. The other studies examined the association between educational level or other skills-based proxies for health literacy, such as general literacy, and outcomes. Results indicate that low health literacy (and related skills) are negatively related to the ability to evaluate online health information and trust in online health information. Evidence on the association with perceived quality of online health information and use of evaluation criteria is inconclusive.

Conclusions

The findings indicate that low health literacy (and related skills) play a role in the evaluation of online health information. This topic is therefore worth more scholarly attention. Based on the results of this review, future research in this field should (1) specifically focus on health literacy, (2) devote more attention to the identification of the different criteria people use to evaluate online health information, (3) develop shared definitions and measures for the most commonly used outcomes in the field of evaluation of online health information, and (4) assess the relationship between the different evaluative dimensions and the role played by health literacy in shaping their interplay.     

Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information

Objective

To develop a reliable and valid instrument to assess the understandability and actionability of print and audiovisual materials.

Methods

We compiled items from existing instruments/guides that the expert panel assessed for face/content validity. We completed four rounds of reliability testing, and produced evidence of construct validity with consumers and readability assessments.

Results

The experts deemed the PEMAT items face/content valid. Four rounds of reliability testing and refinement were conducted using raters untrained on the PEMAT. Agreement improved across rounds. The final PEMAT showed moderate agreement per Kappa (Average K = 0.57) and strong agreement per Gwet's AC1 (Average = 0.74). Internal consistency was strong (α = 0.71; Average Item-Total Correlation = 0.62). For construct validation with consumers (n = 47), we found significant differences between actionable and poorly-actionable materials in comprehension scores (76% vs. 63%, p < 0.05) and ratings (8.9 vs. 7.7, p < 0.05). For understandability, there was a significant difference for only one of two topics on consumer numeric scores. For actionability, there were significant positive correlations between PEMAT scores and consumer-testing results, but no relationship for understandability. There were, however, strong, negative correlations between grade-level and both consumer-testing results and PEMAT scores.

Conclusions

The PEMAT demonstrated strong internal consistency, reliability, and evidence of construct validity.

Practice implications

The PEMAT can help professionals judge the quality of materials (available at: http://www.ahrq.gov/pemat).     

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.     

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.