Short Assessment of Health Literacy-Spanish and English: A Comparable Test of Health Literacy for 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 et al. 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 (Gazmararian et al. 2003; Parker, Ratzan, and Lurie 2003; Davis et al. 2006; Cho et al. 2008;), poor disease/self-management knowledge (Gazmararian et al. 2003), underuse of preventive services and routine physician and dental visits (Lindau et al. 2002; Scott et al. 2002; Baker et al. 2004; Lindau, Basu, and Leitsch 2006; Rogers, Wallace, and Weiss 2006; Jones, Lee, and Rozier 2007;), increased hospitalizations and medical costs (Baker et al. 2002; Howard, Gazmararian, and 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 et al. 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, have been developed to assess health literacy in the United States (Davis et al. 1993; Murphy et al. 1993; Parker et al. 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 et al. 1995).1 Where a Spanish version is available, for example, 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, and 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 et al. 2006). The SAHLSA is focused on testing an individual's reading ability in the health context. The test contains 50 test items and has good psychometric qualities. It has been adopted in research and clinical practice in the United States (Keselman et al. 2007) and is being validated for use in Latin American countries (Huaman-Calderon, Quiliano-Terreros, and 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 and English (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 used to validate the instrument, results of the validation, and recommendations for the use of the instrument.