Abbreviated versions of the shortened assessment of health literacy for adult emergency department patients: Derivation and testing

Abstract

We aimed to derive and test abbreviated versions of the Shortened Assessment of Health Literacy-Spanish and English (SAHL-S&E) that accurately identify English- or Spanish-speaking lower health literacy adult emergency department (ED) patients. Recursive partitioning of the SAHL-S&E was used to derive four abbreviated versions of the SAHL-S&E by mode of administration (self-administered or staff-administered) and language (English or Spanish). Test performance characteristics of the four abbreviated versions of the SAHL-S&E in distinguishing persons with lower health literacy from those with higher health literacy were assessed against the original full version of the SAHL-S&E. The test performance characteristics of the self-administered English abbreviated SAHL-S&E were: AUC 0.84 (0.79, 0.89), sensitivity 0.84 (0.76, 0.91), and specificity 0.68 (0.61, 0.75); and for the self-administered Spanish version were: AUC 0.88 (0.85, 0.92), sensitivity 0.88 (0.82, 0.93), and specificity 0.78 (0.73, 0.83). For the staff-administered English version, the performance characteristics were: AUC 0.94 (0.91, 0.96), sensitivity 0.98 (0.95, 1.00), and specificity 0.74 (0.69, 0.80), and for the staff-administered Spanish version were AUC 0.89 (0.85, 0.92), sensitivity 0.89 (0.84, 0.94), and specificity 0.80 (0.75, 0.85). Although the four abbreviated versions of the SAHL-S&E performed well they differed by content, length, language and how they are administered, which could add complexity in their routine administration in emergency medicine practice.

Keywords:

• emergency medicine
• health literacy
• adult
• mass screening

PUBLIC INTEREST STATEMENT

People with lower health literacy are at higher risk of receiving healthcare that is not adequate for their needs, and consequently suffering poor health-related outcomes. An estimated 40% of adult emergency department patients in the United States have lower health literacy, but health literacy screening is not common in this setting. In this investigation, we sought to derive for English- or Spanish-speaking adult emergency department patients abbreviated health screening instruments from an established longer health screening tool, the Shortened Assessment for Health Literacy (SAHL-S&E). Our goal was to derive abbreviated instruments that ideally could be self-administered. Through a multi-step process, we produced four abbreviated versions of the SAHL-S&E that performed well, but differed by content, length, language and how they are administered (self- or staff-administered). Future research will be needed to determine what role they might have in their routine use for health literacy screening in emergency medicine practice.

Acknowledgements

Preliminary results from this investigation were presented at the American Public Health Association Annual Meeting and Exposition, San Diego, CA, November 10-14, 2018.

The authors gratefully acknowledge the invaluable assistance of the research staff and patients at Olive View/UCLA Medical Center, Rhode Island Hospital, the University of Alabama at Birmingham Medical Center, and the University of Cincinnati Medical Center.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed here

Notes

1. 8 people missing data on health insurance.

2. 7 people missing data on health insurance.

Additional information

Funding

This investigation was supported by a grant from the National Institute of Nursing Research [R01NR014782].

Notes on contributors

Roland C. Merchant

Dr. Roland C. Merchant is an emergency medicine physician, researcher and epidemiologist. Ms. Sarah J. Marks is a medical student. Dr. Melissa A. Clark is a survey methodologist and public health researcher. Dr. Michael P. Carey is a psychologist and researcher. Dr. Tao Liu is a biostatistician. The investigation reported in this manuscript is part of ongoing efforts by the research team to elucidate best practices to screen for and address health literacy concerns in the emergency medicine setting.