English-Language Competency Using Written Tests of Health Literacy: METHODS

Study Design and Setting

The convenience study was performed in the ED of an inner-city, level-1 pediatric and adult trauma ED with 45,000 patient visits per year in a community teaching hospital with affiliated emergency medicine residencies. The ED serves a patient population of approximately 40% Hispanics and 50% African Americans. A research assistant approached patients or parents (if the patient was a minor) with Hispanic surnames in order to determine their self-declared ability to speak English and their interest in participating in the study. Basic demographic information (i.e., age and gender) was obtained from both English and non-English speakers.

Methods of Measurement

The best means to determine a patient’s proficiency with the English language would be to perform a verbal test of competency. However, a Medline literature search for verbal tests of English language competency in the last 20 years could not be found using the key words: “verbal tests,” “English language competency,” and “tests for language.” Therefore, two written language tests were used as surrogate for oral competency testing: the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Short Test of Functional Health Literacy in Adults (STOFHLA). The REALM and the Eng­lish version of the STOFHLA tests were chosen for this study because of their reliability and ease of use. The REALM scores are based on the correct, dictionary pronunciation of 66 medically related words and correlated with grade estimates. The REALM measures health literacy but not understanding. STOFHLA is scored by the number of correct responses to a fill-in-the-blank exercise with a medically related passage. This test has two scales: numeracy and reading comprehension. It is used to measure health literacy and is associated with poor physical and mental health.

Outcome Measures

The scores for the STOFHLA and the REALM were on a continuum, but the study used the recommended cutoffs for each scale. The STOFHLA exam is scored from 0-36, with level >22 considered adequate functional health literacy. Adequate functional health literacy is defined as the ability to read and interpret most health texts. The REALM exam is scored from 0-66. Competency in reading medical information, seventh grade and higher equivalent reading level, has a cut-off of >45.

The research assistant asked each patient the following statement: “Habla usted ingles, espanolо los dos idiomas____ ?” Those patients that said thatthey spoke both languages were given the REALM and STOFHLA interviews. Following each interview, a research assistant questioned the attending physician and the primary nurse caring for the patient regarding the care provider’s perception of the patient’s English-language competency and satisfaction with the communication using a “yes”-or-“no” format. Physicians and nurses were asked eight questions concerning their perception of the patient’s ability to communicate in English. These questions included whether they thought the patient spoke and understood English and whether the patient needed an interpreter. This information was documented on the data collection sheet. The 11 physicians working in the ED are all board certified or prepared. All but one was residency trained in emergency medicine with 1-19 years of experience. Forty-five nurses working in the ED were trained in the Trauma Nurse Specialist and Certified Emergency Nurse programs and had varying years of experience.

Selection of Participants

An N of 100 was calculated based on achieving a power of 80% with an alpha of 0.05, and f of 0.25, for a minimum of 50 subjects per group. The criteria for participation included adult patients or parents of children being seen in the ED who were medically stable, able to communicate and willing to answer a questionnaire. The exclusion criteria eliminated those patients who were unable to speak, unwilling to participate or unstable. Patients were enrolled in this study when the research fellows were available to enroll patients in the ED, usually daytime hours during the summer months of 2003. Hispanic patients who did not admit to speaking English were enrolled in the database but had no further assessment performed. The study was considered exempt from consent requirements for enrollment by the institutional review board.

Primary Data Analysis

The data was input into SPSS® (version 10, Chicago, IL). We planned to approach as many Hispanic patients as needed to enroll 100 patients into the study group. Care providers perceived patients’ English competency was compared to the scores from both the REALM and the STOFHLA. ANOVA testing was used to distinguish differences between and within groups.