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
Jan 20, 2016
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.