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.