Health Literacy Tools Research Articles

건강정보 활용능력 활성화를 위한 선행 과제

Objectives: This study aimed to propose the necessary tasks and specific plans for activating health literacy in Korea based on international experience. Methods: This study is a qualitative research based on literature review. Helath Literacy Centre Europe, U.S. National Library of Medicine, Health Literacy Tool Shed, KISS, and RISS were searched for articles. 63 literatures that satisfied the inclusion criteria were reviewed. Results: This study suggested ‘geongang jeongbo hwalyong neunglyeog’ as the most appropriate Korean translation term for health literacy. It should be considered that inclusion of health literacy objectives in the National Health Plan 2030 and inclusion of HLS-EU16 or HLS-SF12 survey items in the Korean National Health and Nutrition Examination Survey and the Community Health Survey. Finally, the health education specialist takes charge of the health literacy work. Conclusions: In order to activate health literacy in Korea, the unification of translation terminology for health literacy, including health literacy objectives in National Health Plan, conducting health literacy surveys at the national level, and the training of professional personnel to take charge of health literacy should be given priority.

Assessing the Understandability and Actionability of Online Neurosurgical Patient Education Materials

Most Americans consult the Internet to address their health concerns. Limited health literacy among the public highlights the need for patient education Web sites to deliver understandable health information. We assessed the understandability and actionability of online neurosurgical patient education materials (PEMs) provided by the American Association of Neurological Surgeons (AANS) and MedlinePlus. Articles on neurosurgical conditions and treatments listed on both the AANS site and MedlinePlus were analyzed. Two reviewers scored articles using 2 validated health literacy tools, the Centers for Disease Control and Prevention Clear Communication Index (CCI) and the Agency for Healthcare Research and Quality (AHRQ) Patient Education Materials Assessment Tool (PEMAT). These tools evaluate the quality of written health information and assess for content, organization, and actionability of PEMs. One hundred and thirty-eight articles were evaluated from the AANS (n= 61) and MedlinePlus (n=77). The median CCI score for MedlinePlus and AANS articles was 68.9 (interquartile range [IQR], 62.5-81.3) and 56.3 [IQR, 46.7-73.7], respectively (P < 0.001). Only 1 article scored ≥90%, which is the CCI threshold for PEMs to be considered easy to read. Although the AANS and Medline performed similarly on the understandability component of the PEMAT (66.7 [IQR, 53.8-69.2] vs. 69.2 [IQR, 66.7-83.3], respectively; P < 0.001), significant differences were observed for the actionability section of the PEMAT (Medline 60 [IQR, 60-60] vs. AANS 0 [IQR, 0-60]; P < 0.001). Less than 13% of articles provided summaries, visual aids, and tangible tools to aid patient action. Neurosurgical online PEMs may be difficult to understand and potentially act as barriers for patients' engagement with health systems. There is a need to deliver patient-centered health information that effectively informs patients, aiding in meaningful health decision making.

Prevalence of limited health literacy among patients with type 2 diabetes mellitus: A systematic review.

BackgroundHealth literacy (HL) skills are essential to enable self-management and shared decision-making in patients with type 2 diabetes mellitus (T2DM). Limited HL in these patients is associated with poorer outcomes. It is not clear what the burden of limited HL in patients with T2DM across countries and what factors influence it.MethodsA systematic review was conducted according to the PRISMA guidelines. The study protocol was registered with PROSPERO (CRD42017056150). We searched MEDLINE, EMBASE, PsycINFO, CINAHL and ERIC for articles published up to January 2017. Articles that measured HL levels in adult patients with T2DM; that used validated HL tools; and that were reported in English were included. Two reviewers assessed studies for eligibility and quality, and extracted the data. Prevalence of limited HL is calculated from the number of patients with less than adequate HL over the total number of patients with T2DM in the study. Meta-analysis and meta-regression analysis were conducted using the Open Meta-analyst software.ResultsTwenty-nine studies involving 13,457 patients with T2DM from seven countries were included. In total, seven different HL measurement tools were used. The prevalence of limited HL ranged from 7.3% to 82%, lowest in Switzerland and the highest in Taiwan. Meta-regression analysis of all included studies showed the country of study (p<0.001), HL tool used (p = 0.002), and the country’s region (p<0.001) contributed to the variation findings. Thirteen studies in the USA measured functional HL. The pooled prevalence of inadequate functional HL among patients with T2DM in the USA was 28.9% (95% CI: 20.4–37.3), with high heterogeneity (I2 = 97.9%, p <0.001). Studies were done in the community as opposed to a hospital or primary care (p = 0.005) and populations with education level lower than high school education (p = 0.009) reported a higher prevalence of limited HL.ConclusionThe prevalence of limited HL in patients with T2DM varied widely between countries, HL tools used and the country’s region. Pooled prevalence showed nearly one in three patients with T2DM in the USA had limited functional HL. Interactions with healthcare providers and educational attainment were associated with reported of prevalence in the USA.

Establishment and validation of a mental health literacy measurement in Canadian educators

We aim to create the first mental health literacy measure addressing mental health knowledge of educators and assess its psychometric properties. We developed a 30-item multiple choice measure, Mental Health Literacy Tool for Educators (MHL-ED), with experts in both mental health and education. We administered it to educators (n = 909) from 6 Canadian provinces. We analysed the factor structure, internal consistency reliability, construct validity and responsiveness to change of MHL-ED. Factor analysis resulted in 4 factors of MHL-ED addressing: general mental illness and related treatment; assessment and diagnostic tools and treatments; causes and risk factors of mental illness; and epidemiology of mental health and mental illness. MHL-ED demonstrated strong internal consistency reliability. The construct validity was established because the hypothesis was supported that school based mental health professionals scored significantly higher than classroom teachers and school administrators/school support staff; and further MHL-ED scores were positively related with stigma measures. We did not identify floor or ceiling effects of MHL-ED. MHL-ED is reliable and valid to evaluate mental health literacy levels among educators working in junior high and secondary school settings, and may be considered for use in future research in this field.

The effect of health literacy on treatment adherence in maintenance haemodialysis patients: a cross-sectional study

Background: Treatment non-adherence may be prevalent in patients requiring haemodialysis (HD). Health literacy plays an important role in self-management. However, most research has only assessed basic literacy skills in the haemodialysis cohort. Aim: To determine the association between a multidimensional concept of health literacy and self-reported treatment adherence in HD patients. Method: A cross-sectional survey was undertaken with 42 maintenance HD patients from two South Australian dialysis centres. The Functional, Communicative and Critical Health Literacy (FCCHL) tool was used to assess health literacy. Treatment adherence was measured using a self-report tool developed by the researchers. Results: Higher overall health literacy was associated with increased adherence to food (OR 3.66; 95% CI 1.08–12.43; p=0.038), fluid (OR 4.92; 95% CI 1.13–21.35; p=0.033) and medications (OR 11.88; 95% CI 2.26–62.44; p=0.003). Conclusion: Interventions should be designed to facilitate a multidimensional concept of health literacy to assist patients to follow treatment recommendations.

A Scoping Review of Health Literacy Measurement Tools in the Context of Cardiovascular Health.

Background. Despite the strong link between health literacy and cardiovascular health outcomes, health literacy measurements remain flawed and fragmented. There exists a gap in the knowledge when formulating a valid measurement to capture the broad concept of health literacy. The existence of various tools for health literacy measurement also hampers the availability of health literacy data. Additionally, little research is available on a valid measurement tool for cardiovascular health literacy. Objective. This study aims to provide an overview of the health literacy measurement tools used in the context of cardiovascular health. Method. A scoping review was conducted. Two electronic databases, Medline and Embase, were searched to identify studies that described a tool for the measurement of health literacy in the context of cardiovascular health. Results. After reviewing the available studies, 53 studies met the inclusion criteria. A total of 26 health literacy measurement tools were identified in the studies. Among the 26 tools, 16 used an objective measurement approach, 9 adopted a subjective approach, and 1 employed a mixed approach. Additionally, 28 studies used tools to measure print literacy, 15 studies measured print literacy and numeracy, and 5 studies measured print literacy, oral literacy, and numeracy. Conclusions. STOFHLA, TOFHLA, and REALM were the mostly commonly used tools in the selected studies. The majority of tools were based heavily on reading skills and word recognition. Researchers should focus on the development of more comprehensive and reliable health literacy measurement tool(s) specific to cardiovascular health to assist health care providers to more efficiently and accurately identify people with cardiovascular problems who have inadequate health literacy.

Reliability and validity of the thai version of rapid estimate of adult literacy in dentistry

Aims: The study aimed to evaluate the reliability and validity of the Thai version of Rapid Estimate of Adult Literacy in Dentistry (ThREALD-30). Materials and Methods: The Rapid Estimate of Adult Literacy in Dentistry-30 items (REALD-30) was translated to Thai language and back-translation process to English version of REALD-30 by experts of dentistry and linguistics. This cross-sectional study was conducted with a sample of 1110 patients from the five provinces in Northeast of Thailand. All variables were performed by descriptive statistics. The quality of the development tool of ThREALD-30 was tested internal consistency, reliability, and validity from construct validity and predictive validity correlated with Thai Oral Health Impact Profile 14 items (Thai OHIP-14) and Oral health status, respectively. The statistics were analyzed using STATA version 10. Results: A total of 1110 adult patients with a mean age was 51.11 + 6.63 years old. The reliability of ThREALD-30 was excellent (α = 0.950; intraclass correlation coefficient = 0.970, 95% confidence interval: 0.939–1.000). The construct validity was evaluated to indicate the subscales of ThREALD-30 being trustable by showing the correlation coefficient with their own dimension between 0.345 and 0.773, and predictive validity from Spearman's with Thai OHIP-14 (rrho= −0.688, P < 0.001) and oral health status; decayed, missing, and filled teeth (rrho = −0.283, P < 0.001); Oral Hygiene Index Simplified (rrho = −0.432, P < 0.001); and clinical attachment loss (rrho= −0.470, P < 0.001), supporting the construct and criterion validity. Conclusion: ThREALD-30 is an oral health literacy tool that worked well in the Thai population. It offers a valid and reliable instrument for measuring oral health outcome of the individual in community settings.

The impact of health literacy on health outcomes in individuals with chronic pain: a cross-sectional study

ObjectiveTo establish if health literacy (HL) is linked to poorer outcomes and behaviours in patients with chronic pain. DesignA prospective cross-sectional observational study. SettingMultidisciplinary out-patient pain clinics in three university teaching hospitals. PatientsNew patients (n=131) referred to the pain clinic with a history of chronic pain (>12 weeks). MethodsA questionnaire was distributed to chronic pain patients attending their first appointment. Those eligible for inclusion were newly referred patients who had pain lasting longer than three months. The questionnaire comprised the following sections: demographics, chronic pain status and disease-related knowledge, quality of life (SF-36), beliefs (Beliefs About Pain Control Questionnaire), and a validated HL tool (Newest Vital Sign). ResultsOf the 131 participants recruited, 54% had inadequate HL. The group was subsequently stratified according to HL level. In bivariate analysis, inadequate HL was associated with older age (p<0.001), being unemployed or retired (p=0.005), less education (p<0.001), lower income, increased comorbidities (p=0.038), being less likely to utilise allied health services (p=0.001), poorer disease-related knowledge (p=0.002), and poorer beliefs about pain (p<0.05). In multivariate analysis, disease-related knowledge (OR 2.5, 95%CI 1.0 to 6.3, p=0.05) and beliefs about pain (B=−2.3, S.E=0.9, p=0.01) remained independently associated with HL. ConclusionInadequate HL is prevalent in chronic pain patients, and may impact on the development of certain characteristics necessary for effective self-management.

HEALTH LITERACY TOOLS: BARRIERS, FACILITATORS AND BENEFITS IN PHYSICAL THERAPY EXERCISE INTERVENTIONS

Health literacy is documented to impact older adult outcomes and effective rehabilitation may be minimized by low health literacy. The purpose of this phenomenological study is to understand the meaning in a physical therapist’s experience of using Teach Back and Ask Me 3, health literacy tools. This research study involves several parts. After therapists are trained to implement Teach Back and Ask Me 3, they are randomly assigned a tool to use with consenting patients. At the end of the project, therapists are interviewed about the health literacy tools related to patient collaboration, benefits to patients, and barriers/facilitators for therapists. Transcribed interviews are reviewed by four researchers both individually and as a group for key phrases. Next, themes are identified across all therapist responses to questions and then overarching themes are developed. Ten volunteer therapists from two different outpatient clinics participated. The mean age is 43.5 years, 8 were female, 9 identified as white and one as Asian. Most therapists preferred the familiar teach back method and identified ask me 3 as a tool to empower patients. Themes identified for collaborative relationships included patient inclusion and empowerment. Themes that emerged around patient benefits included improved outcomes and ownership. Barriers/ facilitators included time perceptions, routines with cues and reminders and method for process management in a busy environment. The qualitative findings suggest health literacy tools may improve quality of care through focused patient dialogue, enhanced patient understanding and empowerment. Interviews suggest there are unique aspects/ purposes to each health literacy tool.

Lessons learned from developing and applying health literacy tools in Portugal

Lessons learned from developing and applying health literacy tools in Portugal

Lessons learned from developing and applying health literacy tools in Portugal

Lessons learned from developing and applying health literacy tools in Portugal

Water fluoridation and the quality of information available online

The Internet has transformed the way in which people approach their health care, with online resources becoming a primary source of health information. Little work has assessed the quality of online information regarding community water fluoridation. This study sought to assess the information available to individuals searching online for information, with emphasis on the credibility and quality of websites. We identified the top 10 web pages returned from different search engines, using common fluoridation search terms (identified in Google Trends). Web pages were scored using a credibility, quality and health literacy tool based on Global Advisory Committee on Vaccine Safety (GAVCS) and Center for Disease Control and Prevention (CDC) criteria. Scores were compared according to their fluoridation stance and domain type, then ranked by quality. The functionality of the scoring tool was analysed via a Bland-Altman plot of inter-rater reliability. Five-hundred web pages were returned, of which 55 were scored following removal of duplicates and irrelevant pages. Of these, 28 (51%) were pro-fluoridation, 16 (29%) were neutral and 11 (20%) were anti-fluoridation. Pro, neutral and anti-fluoridation pages scored well against health literacy standards (0.91, 0.90 and 0.81/1 respectively). Neutral and pro-fluoridation web pages showed strong credibility, with mean scores of 0.80 and 0.85 respectively, while anti-fluoridation scored 0.62/1. Most pages scored poorly for content quality, providing a moderate amount of superficial information. Those seeking online information regarding water fluoridation are faced with comprehensible, yet poorly referenced, superficial information. Sites were credible and user friendly; however, our results suggest that online resources need to focus on providing more transparent information with appropriate figures to consolidate the information.

Assessment Tools for Health Literacy among the General Population: A Systematic Review.

Health literacy is an important determinant of health, and is one of the key indicators of a healthy city. Developing and improving methods to measure health literacy is prudent and necessary. This review summarizes the findings of published tools for assessing health literacy among the general population to provide a reference for establishing health literacy assessment tools in the future. In this systematic review, PubMed, Embase, and Web of Science were used to search articles regarding tools for assessing health literacy among the general population published up to 10 January 2018. Two researchers independently conducted literature screening, quality assessment of methodology, and data extraction according to preset inclusion and exclusion criteria. The quality assessment of the research was examined with the use of the specifications of the reporting guidelines for survey research (SURGE). Eleven articles met the inclusion criteria. All included instruments in monitoring the health literacy of the general population were presented through the form of questionnaires. The multistage process of making all the scales generally involved the following steps: item development, pre-testing, and evaluation of readability. However, the specific methods were different. Internal consistency for all the instruments was acceptable but with weak consistency among the subscales for some instruments. Most of the identified instruments derived from the definition of health literacy or were based on existing health literacy theory. Approximately 30% of the performed studies provided no description of the important features specified in the SURGE. This review indicates a trend in the increasing tools for assessing the health literacy of the general population by using multidimensional structures and comprehensive measurement approaches. However, no clear “consensus” was observed in the dimensions of health literacy tools.

Health literacy in a population-based sample of Australian women: a cross-sectional profile of the Geelong Osteoporosis Study

BackgroundThe term health literacy refers to the abilities and resources required to find, understand and use health information in managing health. This definition is reflected in the recent development of multidimensional health literacy tools that measure multiple facets of health literacy. The aim of this study was to determine the health literacy profile of a randomly selected, population-based sample of Australian women using a multidimensional tool, the Health Literacy Questionnaire (HLQ). A second aim was to investigate associations between independent HLQ scales, sociodemographic characteristics and lifestyle and anthropometric risk factors for chronic disease.MethodsWe surveyed women involved in the Geelong Osteoporosis Study (GOS), a longitudinal, population-based study. We included demographic data, lifestyle information and anthropometric measures as well as the HLQ. The HLQ has 44 items, scored on either 4- or 5-point scales, within nine conceptually distinct scales. Means for each scale were calculated, and HLQ scales were regressed on educational level and socioeconomic status. Risk factors for chronic disease were investigated using analysis of variance (ANOVA) and calculation of effect sizes.ResultsHigher mean scores were seen for the scales ‘Feeling understood and supported by healthcare professionals’ (mean 3.20, ± SD 0.52) and ‘Understanding health information well enough to know what to do’ (mean 4.28, ±SD 0.54), and lower mean scores were seen for ‘Appraisal of health information’ (mean 2.81, ±SD 0.48) and ‘Navigating the healthcare system’ (mean 4.09, ± SD 0.57). Associations were also seen between lower HLQ scores and poor health behaviours including smoking and being more sedentary, in addition to greater body mass index and waist circumference. Positive gradients were seen between several HLQ scales and education level, as well as SES. For some HLQ scales, these associations were non-linear.ConclusionsThe profile of this population-based cohort of women demonstrated associations between low health literacy and low SES, lower levels of education, increasing age, and anthropometric and lifestyle risk factors for chronic disease. These findings suggest implications of health literacy for health policy makers focusing on improving lifestyle prevention of chronic disease and promoting health equity at a population level.

Health literacy and quality of physician-trauma patient communication: Opportunity for improvement.

Although physician-patient communication and health literacy (HL) have been studied in diverse patient groups, there has been little focus on trauma patients. A quality improvement project was undertaken at our Level I trauma center to improve patient perception of physician-patient communication, with consideration of the effect of HL. We report the first phase of this project, namely the reference level of satisfaction with physician-patient communication as measured by levels of interpersonal care among patients at an urban Level I trauma center. Level I trauma center patients were interviewed during hospitalization (August 2016 to January 2017). Short Assessment of Health Literacy tool was used to stratify subjects by deficient versus adequate HL. Interpersonal Processes of Care survey was administered to assess perception of physician-patient communication. This survey allowed patients to rate physician-patient interaction across six domains: "clarity," "elicited concerns," "explained results," "worked together (on decision making)," "compassion and respect," and "lack of discrimination by race/ethnicity." Each is scored on a five-point scale. Frequencies of "top-box" (5/5) scores were compared for significance (p < 0.05) between HL-deficient and HL-adequate patients. One hundred ninety-nine patients participated. Average age was 42 years, 33% female. Forty-nine (25%) patients had deficient HL. The majority of patients in both groups rated communication below 5/5 across all domains except "compassion and respect" and "lack of discrimination by race/ethnicity." Health literacy-deficient patients were consistently less likely to give physicians top-box scores, most notably in the "elicited concerns" domain (35% vs. 54%, p = 0.012). Health literacy-deficient patients appear relatively less satisfied with physician communication, particularly with respect to perceiving that their concerns are being heard. Overall, however, the majority of patients in both groups were unlikely to score physician communication in the "top box." Efforts to improve physician-trauma patient communication are warranted, with attention directed toward meeting the needs of HL-deficient patients. Prognostic/Epidemiologic, level I.

The Relationship between Health Literacy and General Health Level of Hemodialysis Patients: A Case Study in Iran

Background: Health literacy includes the social cognitive skills that determine the motivation and ability of individuals in achieving, understanding, and utilizing information to maintain and enhance health. People with inadequate health literacy have a weaker health condition. The present study aimed at investigating the relationship between health literacy and the general health level of hemodialysis patients. Methods: This descriptive - analytical study was performed on 130 hemodialysis patients of Baharlu Hospital in Tehran. Data were collected using Health Literacy and General Health Assessment Tool. The collected data were analyzed using SPSS 21.0 software and Spearman correlation test. Results: The results revealed that the health literacy mean score was 46.81 ± 22.87 and that the studied individuals did not have sufficient health literacy. The general health mean score was 14.20 ± 6.50, and there was a statistically significant relationship between health literacy and general health (P < 0.05). Conclusions: In this study, it was found that those with higher health literacy score had better general health. Dialysis causes many clinical and psychological problems, limiting physical and mental activities of the patients. The decrease in health literacy is associated with a decrease in health including physical and psychological problems. In general, dialysis patients still need to learn more about health literacy and general health.

A paucity of strategies for developing health literate organisations: A systematic review.

IntroductionPeople with low health literacy are more likely to delay seeking care and experience adverse outcomes. While health literacy is the product of individuals’ capacities, it is also affected by the complexities of the health care system. System-level changes are needed to align health care demands better with the public’s skills and abilities. We aimed to identify the evidence base for effective strategies for creating health literate organisations.MethodsA systematic review and narrative synthesis of empirical studies was performed. Medline, Embase, PsychInfo and CINHAL databases were searched for empirical studies from OECD countries published from 2008 onwards, focusing on health literacy interventions at the organisational level. Analysis of the findings was informed by the National Academies’ five-dimensional framework for the attributes of a health literate organisation, which include: organisational commitment, accessible education and technology infrastructure, augmented workforce, embedded policies and practices, and effective bidirectional communication.ResultsThe title and abstract of 867 records were screened according to the selection criteria, leading to full text review of 125 articles. Seven studies were identified in the peer review literature. Adapting health literacy guidelines and tools was the most common approach to addressing organisational health literacy.ConclusionWhile the use of health literacy tools proved important for raising awareness of health literacy issues within organisations, these tools were insufficient for generating the organisational changes necessary to improve organisational health literacy.

Health Literacy Estimation of English and Spanish Language Caregivers.

Background:Provider ability to estimate caregiver health literacy (HL) in English-speaking caregivers has been shown to be poor, but estimation of HL in Spanish-speaking caregivers by physicians and staff has yet to be studied. Linguistic differences can further hinder communication in medical care.Objective:This study evaluated how well pediatric providers and staff predict caregiver HL as measured by two HL tools in a bilingual (English/Spanish) population.Method:For this study, we obtained a convenience sample of caregivers, evaluating one group with the Newest Vital Sign (NVS) and the second group with the Short Assessment of Health Literacy (SAHL). Physicians/nurse practitioners (NPs), and medical assistants (MAs) estimated caregiver scores for each tool. We dichotomized estimated and actual scores for each tool using published standards. We used McNemar's test and Cohen's Kappa to evaluate agreement between dichotomized predicted and actual scores. We used log binomial regression to examine how caregiver's language affected agreement between dichotomized caregiver scores and provider estimates. All physicians/NPs were native English speakers only and all MAs were native bilingual English/Spanish speakers. Physicians/NPs used interpretation services when appropriate.Key Results:Fifty caregivers were evaluated using the NVS and 50 using the SAHL. There was no overall association between dichotomized physician/NP or MA estimation and caregiver score for either tool. However, providers' estimates were less likely to match caregiver scores when the caregiver's language was Spanish (NVS: relative risk [RR] = 0.57 [95% CI 0.37, 0.87], SAHL: RR = 0.37 [95% CI 0.23,0.6]).Conclusion:Physician/NP and MA ability to estimate caregiver HL in English proficient and limited English proficiency caregivers is poor. The physician/NP group was less likely to estimate HL correctly if the caregivers spoke Spanish. Providers must use additional caution when providing cross-language care. [HLRP: Health Literacy Research and Practice. 2018;2(2):e107–e114.]Plain Language Summary:This study examined estimation of health literacy of English- and Spanish-speaking caregivers by pediatric providers and medical assistants. We found that both providers and staff estimate caregiver health literacy poorly, and that primary language discordance may be a factor. The results support the institution of universal health literacy precautions for all caregivers of pediatric patients.

Preferences of older adults and their families for Meaningful Use clinical summaries.

This study assessed the perceptions of older adults regarding the plan of care (POC) contained in the clinical summary mandated by the Electronic Health Records (EHR) Incentive Program. A qualitative descriptive design was selected for this study. Older adults (≥65) with chronic cardiac diagnoses were invited to participate. The investigator shadowed the physician during the patient encounter, interviewed the patients following their encounter, and asked patients to complete standard health literacy and cognitive screening tools and the Patient Activation Measure. Directed content analysis was used to analyze transcripts. Patients (n=40) found the clinical summary useful for sharing information with family members and other physicians, reminding and informing, and for engaging in behavior change. Seventy-six percent reported that they would not go online to access the clinical summary for multiple reasons, including not being "computer savvy" and privacy concerns. Participant recommendations for a re-designed, improved clinical summary are included. The clinical summary helps patients and families communicate among health care professionals in a complex, disjointed health care system that often burdens patients with that responsibility. The majority of participants were happy with the paper version and offered multiple reasons for not wanting online access that may help us to focus on more compelling reasons for patient portal use. Qualitatively, it appears that the clinical summary is a useful tool for engaging people with chronic disease in self-management. The participants in this study told us what many of us already know to be true; that the documentation we provide patients and families is less than ideal.

Short Assessment of Health Literacy (SAHL) in Portugal: development and validation of a self-administered tool.

The goal of this study was to adapt, improve and validate a short, self-administered health literacy assessment tool for European Portuguese-speaking adults. Health literacy tools are of great importance to health authorities and professionals, as low or inadequate health literacy, that is, a limited capacity to handle health-related information, is associated with higher morbidity and mortality. The 18-item Short Assessment of Health Literacy for Brazilian Portuguese-speaking adults (SAHLPA-18) was adapted into European Portuguese. The European Portuguese tool (SAHLPA-23) includes five additional items. The SAHLPA-23 was tested in a convenience sample of 503 participants from two Portuguese regions. Socio-demographic data, literacy and cognitive indicators were collected. Participants also completed a questionnaire on comprehension of written health materials. Construct validity was assessed through correlations between SAHLPA-23 scores and education, literacy, and cognitive variables and score on the comprehension questionnaire. The psychometric properties of the new tool were compared with those of the SAHLPA-18. The mean SAHLPA-18 and SAHLPA-23 scores were 13.9 (77.2%; SD=2.9) and 18.3 (79.6%; SD=3.8), respectively. Both tools showed adequate reliability (Cronbach's α>0.7). SAHLPA-23 was more highly correlated with all study variables than SAHLPA-18. Although both instruments displayed acceptable discriminative power, SAHLPA-23 had better accuracy than SAHLPA-18 (DeLong's method: ΔAUC=0.09, Z=3.36; P<0.001). The SAHLPA-23 is an independent, feasible and innovative tool for estimation of health literacy in the Portuguese adult population.