A health literacy model for limited English speaking populations: sources, context, process, and outcomes

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Mei-Po Yip
Acting Assistant Professor, Division of General Internal Medicine, School of Medicine, University of Washington; General Internal Medicine, Harborview Medical Center, Seattle, WA, USA

PP: 160 - 168

Abstract

Health literacy is critical to effective communication between individuals and their health care providers. However there is little consistency in conceptualization and measure of health literacy. The objective of this review is to examine existing health literacy models and measures to assess their application to limited English proficient population in the context of information and communication technology. Communication platforms change with the development of new technology and existing health literacy models and measures are insufficient to capture the complex interaction that occurred in these communication platforms. A new health literacy model composed of four domains: sources, context, process, and outcome were introduced.

Keywords

Limited English Proficiency, health literacy, Asian Americans

Article Text

Health literacy is fundamental to communication between individuals and their health care providers. With advances in information and communication technologies, the way in which health information is created and conveyed directly affects communication. A broader understanding is needed about when and where adults take action to locate, process, and act on health information. Reframing the concept of health literacy to better reflect the full array of literacy skills necessary to function in the current technological environment is particularly important for the growing number of residents in the United States (U.S.) who speak little English.

Health literacy, as understood in the U.S., assumes that English is the primary language used by the individual and the health care system. As a result, language barriers increase difficulties with health literacy. Individuals with limited English proficiency (LEP) may be at greater risk for health problems because of their limited capacity to access, interpret, and use health information presented in English. Drawing on a review of the current literature on health literacy, with a sub-focus on LEP Asian Americans who may particularly have more specific problems in health literacy, this article proposes a new model to address the sources, processes, and outcomes of health literacy for LEP populations in the context of health information technology.

Sources of health literacy and health outcomes

Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Institute of Medicine of the National Academies, 2004). It is typically recognized that health literacy is generative. Instead of remaining relatively stable over time, health literacy is dynamic, and the associated capacities evolve over the lifespan and are likely to be influenced by health-related, socioeconomic, psychosocial, and cultural factors (Baker, 2006; Derose & Baker, 2000; Zarcadoolas, Pleasant, & Greer, 2005). Core elements of health literacy that allow individuals to function in the health care system have moved beyond reading and numeracy to include a constellation of skills, such as critical thinking, problem solving, decision making, information seeking, and communication (Mancuso, 2009). The Institute of Medicine describes health literacy as the result of multiple, complex social and individual factors (Institute of Medicine of the National Academies, 2004). Individual factors may include education, culture, language, and communication skills. Social factors may consist of educational systems, health systems and the media.

Low health literacy impairs an individual's capacity to function in the contemporary health care environment, and particularly in the patient-physician encounter (Schillinger et al., 2003). Disparities in access to health information, services and technology due to low health literacy can result in less usage of preventive services, less knowledge of chronic disease management, higher rates of hospitalization, and poor self-rated health condition (Berkman et al., 2004). Low health literacy is common in the U.S., and little improvement in adult health literacy has been observed over time (Berkman et al., 2004; Kutner, Greenberg, Jin, & Paulsen, 2006; Rudd, 2007). In 2004, White adults had the highest rates of health literacy (Berkman et al., 2004), while an estimated 90 million Americans had limited health literacy (Institute of Medicine of the National Academies, 2004). The elderly, ethnic minorities, and persons with low levels of education tend to have low rates of health literacy (Kutner et al ., 2006). For example, thirty-one percents of Asian Americans and Pacific Islanders have limited health literacy (Andrulis & Brach, 2007)

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References

Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse populations. American Journal of Health Behavior, 31 (Suppl. 1), s122-133.

Baker, D. W. (2006). The meaning and the measure of health literacy. Journal of General Internal Medicine, 21 (8), 878-883.

Baker, D. W., Williams, M. V., Parker, R. M., Gazmararian, J. A., & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education and Counseling, 38 (1), 33-42.

Bass, P. F., 3rd, Wilson, J. F., & Griffith, C. H. (2003). A shortened instrument for literacy screening. Journal of General Internal Medicine, 18 (12), 1036-1038.

Batalova, J., & Fix, M. (2010). A profile of limited English proficient adult immigrants. Peabody Journal of Education, 85, 511-534.

Berkman, N. D., Davis, T. C., & McCormack, L. (2011). Health literacy: What is it? Journal of Health Communication, 15 (Suppl. 2), 9-19.

Berkman, N. D., Dewalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux, L., et al. (2004). Literacy and health outcomes. Evidence Report/Technology Assessment (Summary) (87), 1-8.

Britigan, D. H., Murnan, J., & Rojas-Guyler, L. (2009). A qualitative study examining Latino functional health literacy levels and sources of health information. Journal of Community Health, 34 (3), 222-230.

Cantor, D., Coa, K., Crystal-Mansour, S., Davis, T., Dipko, S., & Sigman, R. (2009). Health Information National Trends Survey (HINTS) 2007. Rockville, MD: National Cancer Institute.http://hints.cancer.gov/docs/HINTS2007FinalReport.pdf.

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. Family Medicine, 36 (8), 588-594.

Cruz-Correia, R., Fonseca, J., Lima, L., Araujo, L., Delgado, L., Castel-Branco, M. G., et al. (2007). Web-based or paper-based self-management tools for asthma - patients' opinions and quality of data in a randomized crossover study. Studies in Health Technology and Informatics, 127, 178-189.

Curran, J. (2002). Remarks presented at 5th Annual Pfizer Health Literacy Conference, September 19, 2002. Washington, D.C.

Davis, T., Kennen, E.M., Gazmararian, J.A., & Williams, M.V. (2005). Literacy testing in health care research. In J.G. Schwartzberg, J.B. Vangeest, & C.C. Wang (Eds.), Understanding Health Literacy: Implications for Medicine and Public Health (pp. 157-180). Chicago, IL: American Medical Association Press.

Derose, K. P., & Baker, D. W. (2000). Limited English proficiency and Latinos' use of physician services. Medical Care Research and Review, 57 (1), 76-91.

Dewalt, D. A., & Pignone, M. P. (2005). The role of literacy in health and health care. American Family Physician, 72 (3), 387-388.

Educational Testing Services. (2011). Test content for health activities literacy tests. Available at http://www.ets.org/literacy/about/content/health_activities_content. Accessed July 1, 2011.

Farmer, G. C., Papachristou, T., Gotz, C., Yu, F., & Tong, D. (2010). Does primary language influence the receipt of influenza and pneumococcal immunizations among community-dwelling older adults? Journal of Aging and Health, 22 (8), 1158-1183.

Ferguson, T. (1995). Consumer health informatics. The Healthcare Forum Journal, 3 8(1), 28-33.

Glasgow, R. E., Christiansen, S. M., Kurz, D., King, D. K., Woolley, T., Faber, A. J., et al. (2011). Engagement in a diabetes self-management website: usage patterns and generalizability of program use. Journal of Medical Internet Research, 13 (1), e9.

Global Reach. (2005). Global Internet Statistics: Sources and References. Retrieved September 15, 2005, from http://global-reach.biz/globstats/refs.php3.

Golbeck, A., Paschal, A., Jones, A., & Hsiao, T. (2010). Correlating reading comprehension and health numeracy among adults with low literacy. Patient Education and Counseling, 84 (1), 132-134.

Greenberg, D. (2001). A critical look at health literacy. Adult Basic Education, 11 (2), 67-79.

Greenhalgh, T., Hinder, S., Stramer, K., Bratan, T., & Russell, J. (2010). Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ, 341, c5814.

Guerra, C. E., Dominguez, F., & Shea, J. A. (2005). Literacy and knowledge, attitudes, and behavior about colorectal cancer screening. Journal of Health Communication, 10 (7), 651-663.

Hakuta, K., Butler, Y., & Witt, D. (2000). How long does it take English learners to attain proficiency? Policy Reports. Berkley, CA: University of California Linguistic Minority Research Institute.

Han, H. R., Kim, J., Kim, M. T., & Kim, K. B. (2011). Measuring health literacy among immigrants with a phonetic primary language: a case of Korean American women. Journal of Immigrant and Minority Health, 13 (2), 253-259.

Hanson-Divers, E. C. (1997). Developing a medical achievement reading test to evaluate patient literacy skills: a preliminary study. Journal of Health Care for the Poor and Underserved, 8 (1), 56-69.

Hill, L. H. (2004). Health literacy is a social justice issue that affects us all. Adult Learning, 15 (1), 4-6.

Holubar, S. D., Hassinger, J. P., Dozois, E. J., Wolff, B. G., Kehoe, M., & Cima, R. R. (2009). Impact of a multimedia e-learning module on colon cancer literacy: A community-based pilot study. Journal of Surgical Research, 156 (2), 305-311.

Institute of Medicine of the National Academies. (2004). Health literacy: a prescription to end confusion. Washington, DC. National Academies Press.

Jacobs, E. A., Karavolos, K., Rathouz, P. J., Ferris, T. G., & Powell, L. H. (2005). Limited English proficiency and breast and cervical cancer screening in a multiethnic population. American Journal of Public Health, 95 (8), 1410-1416.

Joseph, C. L., Peterson, E., Havstad, S., Johnson, C. C., Hoerauf, S., Stringer, S., et al. (2007). A web-based, tailored asthma management program for urban African-American high school students. American Journal of Respiratory and Critical Care Medicine, 175 (9), 888-895.

Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42 (2), 727-754.

Kim, E. H., Stolyar, A., Lober, W. B., Herbaugh, A. L., Shinstrom, S. E., Zierler, B. K., et al. (2009). Challenges to using an electronic personal health record by a low-income elderly population. Journal of Medical Internet Research, 11 (4), e44.

Kirchhoff, K., Turner, A. M., Axelrod, A., & Saavedra, F. (2011). Application of statistical machine translation to public health information: a feasibility study. Journal of the American Medical Informatics Association, 18 (4), 473-478.

Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy. Washington DC: National Center for Education Statistics. Available at http://www.nces.ed.gov/pubs2006/2006483.pdf.

Lee, S. Y., Bender, D. E., Ruiz, R. E., & Cho, Y. I. (2006). Development of an easy-to-use Spanish Health Literacy test. Health Services Research, 41 (4 Pt 1), 1392-1412.

Lee, S. Y., Tsai, T. I., Tsai, Y. W., & Kuo, K. N. (2010). Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC Public Health, 10, 614.

Makoul, G., Cameron, K. A., Baker, D. W., Francis, L., Scholtens, D., & Wolf, M. S. (2009). A multimedia patient education program on colorectal cancer screening increases knowledge and willingness to consider screening among Hispanic/Latino patients. Patient Education and Counseling, 76 (2), 220-226.

Mancuso, J. M. (2009). Assessment and measurement of health literacy: an integrative review of the literature. Nursing & Health Sciences, 11 (1), 77-89.

Marks, J. R., Schectman, J. M., Groninger, H., & Plews-Ogan, M. L. (2011). The association of health literacy and socio-demographic factors with medication knowledge. Patient Education and Counseling, 78 (3), 372-376.

McWhirter, J., Todd, L., & Hoffman-Goetz, L. (2011). Comparing Written and Oral Measures of Comprehension of Cancer Information by English-as-a-Second-Language Chinese Immigrant Women. Journal of Cancer Education, 26: 484-489.

Miller, D. P., Jr., Spangler, J. G., Case, L. D., Goff, D. C., Jr., Singh, S., & Pignone, M. P. (2011). Effectiveness of a Web-based colorectal cancer screening patient decision aid: a randomized controlled trial in a mixed-literacy population. American Journal of Preventive Medicine, 40 (6), 608-615.

Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, 21.

Ngo-Metzger, Q., Hayes, G. R., Yunan, C., Cygan, R., & Garfield, C. F. (2010). Improving communication between patients and providers using health information technology and other quality improvement strategies: focus on low-income children. Medical Care Research and Review, 67 (Suppl. 5), 246S-267S.

Nguyen, G. T., Barg, F. K., Armstrong, K., Holmes, J. H., & Hornik, R. C. (2008). Cancer and communication in the health care setting: experiences of older Vietnamese immigrants, a qualitative study. Journal of General Internal Medicine, 23 (1), 45-50.

Norman, C. D., & Skinner, H. A. (2006). eHealth Literacy: Essential Skills for Consumer Health in a Networked World. Journal of Medical Internet Research, 8 (2), e9.

Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67 (12), 2072-2078.

Paasche-Orlow, M. K., & Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. American Journal of Health Behavior, 31 (Suppl. 1), S19-26.

Parker, R. M., Baker, D. W., Williams, M. V., & Nurss, J. R. (1995). The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. Journal of General Internal Medicine, 10 (10), 537-541.

Ralston, J. D., Hirsch, I. B., Hoath, J., Mullen, M., Cheadle, A., & Goldberg, H. I. (2009). Web-based collaborative care for type 2 diabetes: a pilot randomized trial. Diabetes Care, 32 (2), 234-239.

Rosenfeld, L., Rudd, R., Emmons, K. M., Acevedo-Garcia, D., Martin, L., & Buka, S. (2011). Beyond reading alone: the relationship between aural literacy and asthma management. Patient Education and Counseling, 82 (1), 110-116.

Rudd, R. E. (2007). Health literacy skills of U.S. adults. American Journal of Health Behavior, 31 (Suppl. 1), S8-18.

Sarkar, U., Schillinger, D., Lopez, A., & Sudore, R. (2011). Validation of self-reported health literacy questions among diverse English and Spanish-speaking populations. Journal of General Internal Medicine, 26(3), 265-271.

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., et al. (2003). Closing the loop: physician communication with diabetic patients who have low health literacy. Archive of Internal Medicine, 163 (1), 83-90.

Sudore, R. L., Landefeld, C. S., Perez-Stable, E. J., Bibbins-Domingo, K., Williams, B. A., & Schillinger, D. (2009). Unraveling the relationship between literacy, language proficiency, and patient-physician communication. Patient Education and Counseling, 75 (3), 398-402.

Thomson, M. D., & Hoffman-Goetz, L. (2011). Cancer information comprehension by English-as-a-second-language immigrant women. Journal of Health Communication, 16 (1), 17-33.

Todd, L., & Hoffman-Goetz, L. (2011). Predicting health literacy among English-as-a-second-Language older Chinese immigrant women to Canada: comprehension of colon cancer prevention information. Journal of Cancer Education, 26 (2), 326-332.

U.S. Department of Commerce. (2000). Falling Through the Net: Toward Digital Inclusion. Washington, DC: National Telecommunications and Information Administration, Economics and Statistics Administration.

U.S. Census Bureau. (2010). Language Use in the US. 2007 American Community Survey. Washington, DC: U.S. Department of Commerce.

Wallace, L. S., Rogers, E. S., Roskos, S. E., Holiday, D. B., & Weiss, B. D. (2006). Brief report: screening items to identify patients with limited health literacy skills. Journal of General Internal Medicine, 21 (8), 874-877.

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., et al. (2005). Quick assessment of literacy in primary care: the newest vital sign. Annals of Family Medicine, 3 (6), 514-522.

White, R. O., Osborn, C. Y., Gebretsadik, T., Kripalani, S., & Rothman, R. L. (2011). Development and Validation of a Spanish Diabetes-Specific Numeracy Measure: DNT-15 Latino. Diabetes Technology Therapy,13 (9), 893-898.

Williams, M. V., Parker, R. M., Baker, D. W., Parikh, N. S., Pitkin, K., Coates, W. C., et al. (1995). Inadequate functional health literacy among patients at two public hospitals. Journal of the American Medical Association, 274 (21), 1677-1682.

Wolf, M. S., Davis, T. C., Osborn, C. Y., Skripkauskas, S., Bennett, C. L., & Makoul, G. (2007). Literacy, self-efficacy, and HIV medication adherence. Patient Education and Counseling, 65 (2), 253-260.

Zarcadoolas, C., Pleasant, A., & Greer, D. S. (2005). Understanding health literacy: an expanded model. Health Promotion International, 20 (2), 195-203.

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