Psychometric properties of the brief health literacy screen in clinical practice

Abstract

Background: The three-item Brief Health Literacy Screen (BHLS) has been validated in research settings, but not in routine practice, administered by clinical personnel.

Objective: As part of the Health Literacy Screening (HEALS) study, we evaluated psychometric properties of the BHLS to validate its administration by clinical nurses in both clinic and hospital settings.

Participants: Beginning in October 2010, nurses in clinics and the hospital at an academic medical center have administered the BHLS during patient intake and recorded responses in the electronic health record.

Measures: Trained research assistants (RAs) administered the short Test of Functional Health Literacy in Adults (S-TOFHLA) and re-administered the BHLS to convenience samples of hospital and clinic patients. Analyses included tests of internal consistency reliability, inter-administrator reliability, and concurrent validity by comparing the nurse-administered versus RA-administered BHLS scores (BHLS-RN and BHLS-RA, respectively) to the S-TOFHLA.

Key results: Cronbach's alpha for the BHLS-RN was 0.80 among hospital patients (N = 498) and 0.76 among clinic patients (N = 295), indicating high internal consistency reliability. Intraclass correlation between the BHLS-RN and BHLS-RA among clinic patients was 0.77 (95 % CI 0.71-0.82) and 0.49 (95 % CI 0.40-0.58) among hospital patients. BHLS-RN scores correlated significantly with BHLS-RA scores (r = 0.33 among hospital patients; r = 0.62 among clinic patients), and with S-TOFHLA scores (r = 0.35 among both hospital and clinic patients), providing evidence of inter-administrator reliability and concurrent validity. In regression models, BHLS-RN scores were significant predictors of S-TOFHLA scores after adjustment for age, education, gender, and race. Area under the receiver operating characteristic curve for BHLS-RN to predict adequate health literacy on the S-TOFHLA was 0.71 in the hospital and 0.76 in the clinic.

Conclusions: The BHLS, administered by nurses during routine clinical care, demonstrates adequate reliability and validity to be used as a health literacy measure.

Figures

Figure 1.

Selection of study samples. Abbreviations: N number; BHLS-RN nurse-administered Brief Health Literacy Screen; BHLS-RA research assistant-administered Brief Health Literacy Screen; S-TOFHLA Short test of functional health literacy in adults.

Figure 2.

Area under the Receiver-operating characteristic curve for the Brief Health Literacy Screen vs. S-TOFHLA. BHLS administered (a) to hospitalized patients by nurses, (b) to clinic patients by nurses, (c) to hospitalized patients by research assistants, and (d) to clinic patients by research assistants. Abbreviations: BHLS-RN nurse-administered Brief Health Literacy Screen; BHLS-RA research assistant-administered Brief Health Literacy Screen; S-TOFHLA Short test of functional health literacy in adults.