Cultural and translation challenges in assessing health literacy in four language groups: The RxHL...
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Cultural and translation challenges in assessing health literacy in four language groups: The
RxHL study
Susan J. Shaw, Molly Totman, Dina Gavrilyuk, Josephine Korchmaros, Cristina Huebner Torres, Jeannie Lee
Overview
• Background/revious studies
• Methods
• Setting, participants
• Findings– Variation in correct scores across items by ethnic
groups
– Qualitative findings • Cultural context and translation
• Abstract thinking
• Conclusion
Background
• The Culture and Health Literacy Project– National Cancer Institute R01 CA128455, 2006-2011– Chronic disease self-management and health literacy
among four ethnic groups– SAHLSA, REALM, s-TOFHLA (English and Spanish,
translated into Vietnamese)– Vietnamese participants in particular struggled with
Cloze procedure in s-TOFHLA– Participants substituted personal experience for
numeracy examples (J Health Comm 17(S3), 2012, JIMH 11(6), 2009)
RxHL: Integrating multiple methodsQuantitative Methods: Manual 3-mo. pill countSelf-report Survey• Health literacy (SAHL-SE)• Beliefs about Medicines
Questionnaire (BMQ)• Morisky medication
adherence scale• USDA food insecurity• Social support scaleMedical chart abstraction • Clinical outcomes – Diabetes– Blood pressure– cholesterol – BMI
• Health insurance status
RxHL
Self-Report Survey
Chart Abstrac-
tion
Medica-tion
Diaries
Home Visits
In-depth Inter-views
Qualitative Methods:In-depth interviews
• facilitators / barriers to adherence• gaps in insurance
coverage• medication beliefs
Home visits • home medication
management practices• social support
• transportation barriersChronic disease diaries
• daily adherence record• experience using pharmacy
Health literacy measure: SAHL-S&E
• Short Assessment of Health Literacy-Spanish and English (Lee et al. 2010)
• Word pronunciation and comprehension– One stem word, one key,
one distracter
• Translated into Russian and Vietnamese, pre-tested with 5 participants
Medication
Instrument treatment
Setting: Caring Health Center
• Section 330 federally-qualified health center (FQHC)• Adult & pediatric primary care, women’s health, behavioral health, oral health,
nutrition & WIC, wellness education and other services• Largest refugee resettlement site in MA• 6 sites in Springfield, MA• >52% of adult patients require translation services
• CHC patients speak 25 different languages, 12 of which are offered on site
RxHL participants
Af-Am; 18%
Vietna-
mese, 28%
Latino; 30%
Fmr So-viet Unio
n; 14%
White; 10%
• 284 patients from 5 ethnic groups with chronic disease (diabetes, HPB, depression, high cholesterol)
• 40.5% have < high school education; • 36.6% have inadequate
health literacy• 64.4% speak a language other than
English at home• Mean age = 55 years• 60.6% female
$0-500
$501-1000$1001-1500
$1500-2000
$2000-2500: $2500-3000
Monthly HH Income
HL and education vary by ethnicity
Vietnam
ese
Russian
-spkg
Africa
n-Americ
an
Hispan
icW
hite0
102030405060708090
100
% adequate HLmore than HS ed
HL and study group: F(4, 242) = 8.71, p < .001, n=247
Item difficulty across ethnic groups
% of participants who answered each item correctly:
Yellow = Smallest %ages correct within each ethnic group group = most difficult for group
Blue = Largest %ages correct within each ethnic group = least difficult for group
Amount of variation in correct scores across items by ethnic group
Russian
-speak
ing
Africa
n-Americ
an
Vietnam
ese
Hispan
icW
hite0
10
20
30
40
50
60
70
80
%
Context makes difference• The medical context of a health literacy scale brings meaning
to English stem words that translators may not recognize– Directed (instruction, decision) (“Take as directed”)
• (Masc.) translation of “Directed” points to a person• Instruction (key word)
– “Instruction” [инструкция] = written instruction, e.g., a manual – “instruction” [указание] = verbal instruction
• Masculine endings for adjectives in Russian implicitly refer to a person rather than a thing or a situation (neutral or feminine ending) – Abnormal (different, similar)
• Masc. translation of “Abnormal” applies to a person rather than a thing• Different (key word)
– “different” [другой] = used when referring to things– “different” [иной] = used when referring to people
Concepts that don’t clearly translate
Russian• Nutrition (healthy, soda)
– Nutrition• Initially translated to Russian as “balanced/whole nourishment” [полноценное
питание] • Final translation was “nourishment” [питание]
– Soda (distracter)• Initially translated as “lemonade” [лимонад]• Final translation was “carbonated beverage” [газированный напиток]
Vietnamese• Kidney (urine, fever)
– Fever (distracter)• Has multiple meanings in Vietnamese, “fever” [sốt] or “sauce” [sốt] • Must be specified with the Vietnamese word for “high” or “hot” to preserve the meaning
Answering questions outside personal experience
• If Vietnamese-speaking participants do not personally identify with the words, they have difficulty recognizing the correct answer (key)
– Miscarriage (loss, marriage)– Pregnancy (birth, childhood)
• “I am a male, I can’t have a miscarriage (pregnancy)!”
– Alcoholism (addiction, recreation)• “Alcoholism is no good for me, not for addiction or
recreation”
Conclusions
• Cultural and linguistic differences may hinder Vietnamese and Russian-speaking participants’ performance on SAHL-S&E– medical context brings implicit meanings to terms
that are revealed during translation• Different groups had difficulty with different
items on SAHL-SE, even among English and Spanish speakers
AcknowledgementsRxHL team
University of Arizona• Josephine Korchmaros, PhD,
Southwest Institute for Research on Women
• Jeannie K. Lee, PharmD, School of Pharmacy
• Amanda Hilton, School of Anthropology
• Will Robertson, MA, School of Anthropology
Caring Health Center• Cristina Huebner Torres,
MA, ABD, VP for Research• Molly Totman, MPH,
Project Coordinator• Sabina Dakhal, MPH,
Ethnographer• Interviewers: Khanh
Nguyen, Dina Gavrilyuk, Yoeli Pachecos
NHLBI: This research was supported by grant #1R01HL120907-01.