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      The health literate health care organization 10 item questionnaire (HLHO-10): development and validation

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          Abstract

          Background

          While research on individual health literacy is steadily increasing, less attention has been paid to the context of care that may help to increase the patient’s ability to navigate health care or to compensate for their limited health literacy. In 2012, Brach et al. introduced the concept of health literate health care organizations (HLHOs) to describe the organizational context of care. This paper presents our effort in developing and validating an HLHO instrument.

          Method

          Ten items were developed to represent the ten attributes of HLHO (HLHO-10) based on a literature review, an expert workshop, a focus group discussion, and qualitative interviews. The instrument was applied in a key informant survey in 51 German hospitals as part of a larger study on patient information and training needs (PIAT-study). Item properties were analyzed and a confirmatory factor analysis (CFA) was conducted to test the instrument’s unidimensionality. To investigate the instrument’s predictive validity, a multilevel analysis was performed that used the HLHO-10 score to predict the adequacy of information provided to 1,224 newly-diagnosed breast cancer patients treated at the sample hospitals.

          Results

          Cronbach’s α of the resulting scale was 0.89. CFA verified the one-factor structure after allowing for the correlation for four pairs of error terms. In the multilevel model, HLHO-10 significantly predicted the adequacy of information as perceived by patients.

          Conclusion

          The instrument has satisfactory reliability and validity. It provides a useful tool to assess the degree to which health care organizations help patients to navigate, understand, and use information and services. Further validation should include participant observation in health care organizations and a sample that is not limited to breast cancer care.

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          Most cited references27

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          Brief questions to identify patients with inadequate health literacy.

          No practical method for identifying patients with low heath literacy exists. We sought to develop screening questions for identifying patients with inadequate or marginal health literacy. Patients (n=332) at a VA preoperative clinic completed in-person interviews that included 16 health literacy screening questions on a 5-point Likert scale, followed by a validated health literacy measure, the Short Test of Functional Health Literacy in Adults (STOHFLA). Based on the STOFHLA, patients were classified as having either inadequate, marginal, or adequate health literacy. Each of the 16 screening questions was evaluated and compared to two comparison standards: (1) inadequate health literacy and (2) inadequate or marginal health literacy on the STOHFLA. Fifteen participants (4.5%) had inadequate health literacy and 25 (7.5%) had marginal health literacy on the STOHFLA. Three of the screening questions, "How often do you have someone help you read hospital materials?" "How confident are you filling out medical forms by yourself?" and "How often do you have problems learning about your medical condition because of difficulty understanding written information?" were effective in detecting inadequate health literacy (area under the receiver operating characteristic curve of 0.87, 0.80, and 0.76, respectively). These questions were weaker for identifying patients with marginal health literacy. Three questions were each effective screening tests for inadequate health literacy in this population.
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            Development of a brief test to measure functional health literacy.

            We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.
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              Crossing the Quality Chasm : A New Health System for the 21st Century

              (2001)
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                Author and article information

                Contributors
                christoph.kowalski@uk-koeln.de
                sylee@umich.edu
                anna.schmidt@uk-koeln.de
                wesselmann@krebsgesellschaft.de
                markus.wirtz@ph-freiburg.de
                holger.pfaff@uk-koeln.de
                Nicole.ernstmann@uk-koeln.de
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                1 February 2015
                1 February 2015
                2015
                : 15
                : 47
                Affiliations
                [ ]Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933 Germany
                [ ]Department of Health Management and Policy, The University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109-2029 USA
                [ ]German Cancer Society, Kuno-Fischer-Straße 8, 14057 Berlin, Germany
                [ ]University of Education Freiburg, Kunzenweg 21, 79117 Freiburg, Germany
                Article
                707
                10.1186/s12913-015-0707-5
                4332719
                25638047
                5357ae8e-479e-4470-be9a-7ab72bf4a25e
                © Kowalski et al.; licensee BioMedCentral. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 2 June 2014
                : 19 January 2015
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2015

                Health & Social care
                health literate health care organization,instrument development,health literacy,hospitals,cancer care

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