Development of an Easy-to-Use
Spanish Health Literacy
Assessment Tool
Shoou-Yih D. Lee, PhD 1
Deborah E. Bender, PhD 1
Rafael Ruiz, ScM 1
Young Ik Cho, PhD 2
1 University of North Carolina at Chapel
2 University of Illinois at Chicago
Hill
Problems of Low Health Literacy

Health literacy means “the degree to which individuals
have the capacity to obtain, process, and understand
basic health information and services needed to make
appropriate health decisions.”

Inadequate health literacy may reduce health status, and
possibly threaten health care quality and increase the use
of unnecessary high-cost services.

Inadequate health literacy may cost $30 billion to $73
billion in 1998 U.S. dollars, or about 3.2 to 7.6 percent
of personal health care expenditures
Health Literacy Among Latinos

Latinos are the fastest growing ethnic group in the U.S.
In 2003, they surpassed African Americans to become
the nation’s largest minority group. Their share of the
U.S. population is expected to rise to more than 21% in
the mid-2000s.

The growth of the Latino population has created new
demands on our health care system.

Low health literacy may be a particularly salient problem
among Latinos. What is the extent of the problem?
What is its health impact?... NOT MUCH IS KNOWN!
Assessment of Spanish Health Literacy

One existing instrument: Spanish Test of Functional Health
Literacy in Adults (S-TOFHLA)
- a comprehension test, containing sections on reading
comprehension and a numeracy.
- lengthy, cumbersome to administer and score

Rapid Estimate of Adult Literacy in Medicine (REALM)
- a word recognition test (if examinees have trouble pronouncing
words, which is a beginning-level reading skills, they are likely to
have difficulty with comprehension, which is a higher order skill)
- short, easy to use
- construction of a Spanish version failed because of regular
phoneme-grapheme correspondence in the Spanish language
- lack of a correspondence between the reading and
comprehension abilities in Spanish-speaking Latinos
Rapid Estimate of Adult Literacy in
Medicine (REALM)
ASK THE RESPONDENT TO READ ALOUD THE FOLLOWING WORDS,
STARTING FROM LIST 1 AND THEN LIST 2 AND LIST 3.
Here are three lists of words. Please read them aloud to me. (GIVE EACH LIST TO
RESPONDENT. CHECK WORDS HE/SHE CAN READ/PRONOUNCE
CORRECTLY.)
List 1
fat
flu
pill
dose
________
________
________
________
List 2
fatigue
pelvic
jaundice
infection
________
________
________
________
List 3
allergic
menstrual
testicle
colitis
________
________
________
________
Short Assessment of Health Literacy for
Spanish Adults (SAHLSA)

A modification of REALM by incorporating questions that
test the examinee’s understanding of the meanings of the
words.

The test is analogous to multiple-choice questions. It
consists of a stem (in the form of a question or command)
and choices (in the form of an answer to the question or
command)
- Stem: question or command
- Key: correct choice
- Distractor: incorrect but plausible choice
SAHLSA
I’m going to show you cards with 3 words on them. First I would like you to
read the word on the top out loud. Then I will read the two words on the bottom
to you and I would like you to tell me which on of the two words is more
similar to the word on the top. If you do not know the answer, please say,
“don’t know.” Do not guess.
fat
flu
pill
dose
eye
stress
pap smear
nerves
germs
meals
disease
cancer
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
___orange
___well
___tablet
___sleep
___listen
___worry
___test
___bored
___bacteria
___dinner
___diabetes
___tumor
___butter
___sick
___cookie
___amount
___see
___happy
___vaccine
___anxiety
___mood
___walk
___exercise
___fracture
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
___don’t know
Procedures for the Development of
SAHLSA

Instrument development: the Delphi process
- Translation of the 66 medical terms in REALM
- Selection of the appropriate key and distractor for each of
the 66 medical terms in English
- Translation and back translation of the selected keys and
distractors

Validation of the instrument
- Pilot-testing with 10 English-speaking and 10 Spanishspeaking patients at the UNC Ambulatory Care Center
- Interviewing 202 English-speaking and 201 Spanishspeaking patients to test the instrument’s validity and
reliability
Results
Spanish-Speaking
English-Speaking
N
201
202
Age (mean)
34.2
43.7
Male
44.8%
43.6%
Female
55.2%
56.4%
Single
36.3%
30.7%
Married
50.7%
38.6%
Separated
5.5%
7.4%
Divorced
6.0%
17.3%
Widowed
1.5%
5.9%
10.1
13.0
Gender
Marital status
Years of education (mean)
Spanish-REALM
Fraction
.557214
0
0
66
REALM_score
Spanish-SAHLSA
Fraction
.114428
0
0
66
SAHLSA_score
Results (cont.)

Item response analysis and OLS were used to reduce the
number of items while increasing the discriminatory power
of SAHLSA

Reduced to 37 items

Correlated with TOFHLA at r=0.72

Significantly correlated with health status at r=0.17
(correlation between TOFHLA and health status is r=0.15)

Correlated with education at r=0.53 (correlation between
TOFHLA and education is r=0.52 in Spanish speakers and
r=0.40 in English speakers)

Test-retest reliability is r=0.80
Discussion

Healthy People 2010 Objectives: Draft for the Public
Comment notes that health literacy is "increasingly vital to
help people critically evaluate health information"

Rapid growth of Hispanic residents in the nation makes the
development of a reliable and easy-to-use health literacy
assessment tool in Spanish an important task

Results suggest SAHLSA is valid and reliable

Further improvement will make SAHLSA an easy-to-use
screening tool in clinical and community settings