Validation of the Short Assessment of Health Literacy in Portuguese-speaking adults in Portugal / Validación del Short Assessment of Health Literacy in Portuguese-speaking adults en Portugal

OBJECTIVE: To validate the Brazilian version of the Short Assessment of Health Literacy in Portuguese-speaking Adults (SAHLPA), a 50-item test proposed as a particularly helpful instrument to assess health literacy in people with limited skills, in the Portuguese population. METHODS: We used the standard procedure for cultural adaptation and administered the instrument to 249 participants. We examined construct validity using groups with expectedly increasing levels of health literacy (laypersons from the general population, engineering researchers, health researchers, and physicians), and through association with age and educational attainment, dichotomizing scores at the median of the layperson's group. RESULTS: Exploratory factor analysis revealed the instrument was one-dimensional and justified reduction to 33 items. SAHLPA-33 displayed adequate reliability (Cronbach's α = 0.73). The frequency of limited health literacy was highest among laypersons and lowest among physicians (p <0.001; p for trend <0.001). The proportion of participants with limited health literacy decreased with increasing education attainment (age- and sex-adjusted p for trend <0.001). Limited health literacy also tended to decrease with age, although the association was non-significant (sex- and education-adjusted p for trend = 0.067). CONCLUSION: We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and fairly reliable. In Portuguese low-literate adults, SAHLPA-33 fills the gap in health literacy assessment instruments, and may be used to guide communication strategies with vulnerable patients and communities

OBJETIVO: Validar la versión brasileña del Short Assessment of Health Literacy inPortuguese-speakingAdults (SAHLPA), una prueba de 50 ítems que ha sido propuesta como una herramienta particularmente útil para evaluar la alfabetización en salud en personas con bajas competencias, en la población portuguesa. MÉTODOS: Se usó el procedimiento habitual para la adaptación cultural. El instrumento fue administrado a 249 participantes. Se evaluó la validez de constructo utilizando grupos con niveles esperados crecientes de alfabetización en salud (personas no cualificadas de la población general, investigadores en el área de la ingeniería, investigadores en salud y médicos) y a través de la asociación con la edad y la escolaridad, dicotomizando las puntuaciones por la mediana de las del grupo de la población general. RESULTADOS: El análisis factorial exploratorio reveló que el instrumento era unidimensional y así ha sido reducido a 33 ítems. El SAHLPA-33 reveló una consistencia interna aceptable (α de Cronbach = 0,73). La frecuencia de alfabetización en salud limitada fue más elevada en la población general y menor en los médicos (p <0,001; p para la tendencia <0,001). La proporción de participantes con alfabetización en salud limitada disminuyó con el aumento de la escolaridad (p para la tendencia ajustada por edad y sexo <0,001). La alfabetización en salud también tendió a disminuir con la edad, aunque la asociación no era significativa (p para la tendencia ajustada por sexo y escolaridad = 0,067). CONCLUSIÓN: Se adaptó un instrumento simple y rápido para evaluar la alfabetización en salud individual y se mostró que era válido y razonablemente fiable. En los adultos portugueses con bajo nivel de alfabetización, SAHLPA-33 llena el vacío en instrumentos de evaluación de alfabetización en salud. Puede utilizarse para guiar estrategias de comunicación con personas y comunidades vulnerables

Validation of the Short Assessment of Health Literacy in Portuguese-speaking Adults in Portugal.

OBJECTIVE: To validate the Brazilian version of the Short Assessment of Health Literacy in Portuguese-speaking Adults (SAHLPA), a 50-item test proposed as a particularly helpful instrument to assess health literacy in people with limited skills, in the Portuguese population. METHODS: We used the standard procedure for cultural adaptation and administered the instrument to 249 participants. We examined construct validity using groups with expectedly increasing levels of health literacy (laypersons from the general population, engineering researchers, health researchers, and physicians), and through association with age and educational attainment, dichotomizing scores at the median of the layperson's group. RESULTS: Exploratory factor analysis revealed the instrument was one-dimensional and justified reduction to 33 items. SAHLPA-33 displayed adequate reliability (Cronbach's α = 0.73). The frequency of limited health literacy was highest among laypersons and lowest among physicians (p <0.001; p for trend <0.001). The proportion of participants with limited health literacy decreased with increasing education attainment (age- and sex-adjusted p for trend <0.001). Limited health literacy also tended to decrease with age, although the association was non-significant (sex- and education-adjusted p for trend = 0.067). CONCLUSION: We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and fairly reliable. In Portuguese low-literate adults, SAHLPA-33 fills the gap in health literacy assessment instruments, and may be used to guide communication strategies with vulnerable patients and communities.

Patient-centered communication in type 2 diabetes: The facilitating and constraining factors in clinical encounters.

OBJECTIVE: To explore the perceptions of the constraining and facilitating factors to patient-centered communication in clinical encounters of patients with type 2 diabetes and the providers involved in their care. DATA SOURCES/STUDY SETTING: Patients (n = 12) and providers (n = 33) involved in diabetes care in northern Portugal. STUDY DESIGN: Seven focus groups. DATA COLLECTION/EXTRACTION METHODS: Grounded theory, using open, axial, and selective coding. PRINCIPAL FINDINGS: Patients focused on the patient-provider relationship, while providers emphasized the constraining factors when exchanging information and the facilitating factors regarding disease and treatment-related behavior. Patients and providers both agreed on some constraints (power imbalance, avoidance of criticism, disease minimization, use of jargon, and insufficient competencies and consistency among providers) and facilitators (seeing patients as persons, providing tailored information in plain language, and recognizing the "wake-up call"). Patients perceived an aggressive attitude as a barrier to communication, but providers perceived it as a facilitator. Patients included issues related to trust, respect, and psychosocial support as important factors to them. Only providers mentioned the influence of macro-level interventions and patients' socioeconomic position as essential factors. CONCLUSIONS: Improvements in patient-centered communication depend on fostering the patient-provider relationship, patients' participation and involvement, and training providers' communication skills.

Translation and Validation of the Patient Activation Measure in Portuguese People with Type 2 Diabetes Mellitus.

INTRODUCTION: Management of diabetes mellitus is largely dependent on patients' active participation in care. The 'Patient Activation Measure 13' assesses patients' knowledge, skills, and confidence in self-care. We aimed to translate, culturally adapt, and validate the 'Patient Activation Measure 13' to Portuguese, in people with type 2 diabetes. MATERIAL AND METHODS: The translation and cultural adaptation occurred in six phases. A convenience sample of people with type 2 diabetes was recruited from the waiting rooms of a diabetes outpatient centre in Lisbon, between March and April 2014. The questionnaire was self-administered; medical records were reviewed to obtain glycated haemoglobin levels. Main statistical analyses were based on the Rasch rating scale model. RESULTS: The response rate for the final questionnaire was 76%. Rasch analysis was conducted on 193 respondents. Respondents had a mean age of 67.1 (SD 10.1) years, 42.7% were women, and the mean patient activation measure score (0 - 100) in the sample was 58.5 (SD 10.1). The sample was low to moderate in terms of activation: 40.4% were low in activation (levels 1 and 2), 49.7% were in level 3, and 9.8% were in level 4, the highest level of activation. All items had good fit and the response categories functioned well. Item reliability was 0.97 and person reliability was between 0.77 (real) and 0.83 (model). DISCUSSION: The 'Patient Activation Measure 13' was translated and culturally adapted to European Portuguese and validated in people with diabetes, showing good psychometric properties. Future research should aim at evaluating test-retest reliability of the Portuguese 'Patient Activation Measure 13', and exploring its ability to measure changes in activation over time. CONCLUSION: The 'Patient Activation Measure 13' is now available in European Portuguese and has good psychometric properties.

Introdução: A gestão da diabetes mellitus é, em grande parte, dependente da participação ativa dos doentes no processo de cuidados. O questionário de ativação do doente (Patient Activation Measure 13) avalia o conhecimento, capacidade técnica e confiança do doente nos auto-cuidados. Este estudo teve como objetivo a tradução, adaptação cultural e validação do questionário Patient Activation Measure 13 para português, em pessoas com diabetes tipo 2. Material e Métodos: A tradução e adaptação cultural ocorreu em seis fases. O recrutamento decorreu nas salas de espera da Associação Protetora dos Diabéticos de Portugal, entre março e abril de 2014 (amostra de conveniência). O questionário foi auto- administrado; os valores de hemoglobina glicada foram obtidos a partir do processo clínico eletrónico. A análise psicométrica baseou- se no modelo de Rasch. Resultados: A taxa de resposta foi de 76% e 193 indivíduos foram incluídos na análise psicométrica. A idade média dos participantes foi 67 (desvio padrão 10,1) anos, 42,7% eram mulheres, e a média do score do Patient Activation Measure (0 - 100) na amostra foi 58,5 (desvio padrão 10,1). A amostra apresentou níveis baixos a moderados de ativação. Todos os itens apresentaram bom ajuste e as categorias de resposta funcionaram adequadamente. A fiabilidade dos itens foi 0,97 e a fiabilidade das pessoas encontrou-se entre 0,77 (real) e 0,83 (modelo). Discussão: O Patient Activation Measure 13 foi traduzido e adaptado culturalmente para português, bem como validado em pessoas com diabetes mellitus tipo 2, revelando boas propriedades psicométricas. Estudos futuros deverão avaliar a fiabilidade teste-reteste do Patient Activation Measure 13 Português e explorar a capacidade do mesmo em avaliar alterações na ativação ao longo do tempo. Conclusão: O Patient Activation Measure 13 está agora disponível para utilização na população Portuguesa, apresentando boas propriedades psicométricas.

Limited Health Literacy in Portugal Assessed with the Newest Vital Sign.

INTRODUCTION: In Portugal, health literacy has started to be addressed through national policies, but research on the topic is still scarce. We aimed to estimate the prevalence and sociodemographic correlates of limited health literacy in Portugal using an existing health literacy instrument, the Newest Vital Sign. MATERIALS AND METHODS: Following cross-cultural adaptation of the instrument, a sample of 249 participants was evaluated to assess reliability and construct validity of the Newest Vital Sign; the latter was tested assuming physicians would score highest, followed by health researchers, then by engineering researchers and finally by laypersons from the general population. We applied this validated version in a representative sample of 1544 Portuguese-speaking residents in Portugal aged between 16 and 79 years and quantified the associations between limited health literacy and sociodemographic characteristics. RESULTS: The instrument showed high reliability (Cronbach's α = 0.85). Health-related occupation showed association with higher scores in the Newest Vital Sign (p trend < 0.001). The prevalence of limited health literacy in the Portuguese population was 72.9% (95% CI: 69.4 - 76.4). We found no differences between men and women, but persons with limited health literacy were significantly older (p < 0.001) and less educated (p < 0.001). DISCUSSION: The burden of limited health literacy in Portugal is higher than that in other European countries. It should drive a universal precautions approach to health communication at all levels of the health system. CONCLUSION: We validated a brief and simple instrument and estimated the prevalence of limited health literacy in the literate Portuguese population at roughly three out of four people.

Introdução: A literacia em saúde começa a ser alvo de políticas de saúde em Portugal, mas a investigação neste tema ainda é escassa. Pretendemos estimar a prevalência de literacia em saúde inadequada e os fatores sociodemográficos associados em Portugal, utilizando um instrumento de avaliação da literacia em saúde já existente, o Newest Vital Sign. Material e Métodos: Após adaptação transcultural do instrumento, avaliámos uma amostra de 249 participantes para examinar fiabilidade e validade de constructo do Newest Vital Sign; esta última foi testada assumindo que os médicos teriam pontuação máxima, seguidos por investigadores na área da saúde, investigadores na área da engenharia e finalmente por leigos da população geral. Em seguida, aplicámos a versão validada numa amostra representativa de 1554 pessoas, residentes em Portugal, entre os 16 e os 79 anos, e quantificámos as associações entre literacia em saúde inadequada e caraterísticas sociodemográficas. Resultados: O instrumento revelou elevada fiabilidade (α de Cronbach = 0,85). A profissão ligada à saúde associou-se a pontuações mais elevadas no Newest Vital Sign (p para a tendência < 0,001). A prevalência de literacia em saúde inadequada na população portuguesa foi de 72,9% (IC 95%: 69,4 - 76,4). Não encontrámos diferenças entre homens e mulheres, mas as pessoas com literacia em saúde inadequada eram significativamente mais velhas (p < 0,001) e com menor escolaridade (p < 0,001). Discussão: A carga de literacia em saúde inadequada em Portugal é mais alta do que a observada noutros países europeus. Esta deve conduzir a medidas de precaução universais no âmbito da comunicação em saúde, a todos os níveis de cuidados. Conclusão: Adaptámos um instrumento breve e simples e estimámos que, na população portuguesa alfabetizada, três em cada quatro pessoas possuem literacia em saúde inadequada.

Cross-cultural adaptation and validation of the health literacy assessment tool METER in the Portuguese adult population.

OBJECTIVE: We aimed to culturally adapt and validate METER in the Portuguese population, and to define cut-off values for adequate health literacy. METHODS: We used the standard procedure for the adaptation of the words and surveyed health professionals to select the non-words. The instrument was administered to a total sample of 249 participants and retested in a sub-sample of 45 after three months. Cut-offs were defined using the modified Angoff procedure. Construct validity was assessed through association with educational attainment and health-related occupation. RESULTS: Exploratory factor analysis revealed two dimensions of the instrument, one for words and another for non-words. METER showed a high degree of internal consistency, and acceptable test-retest reliability. Adequate health literacy was defined as scoring at least 35/40 in words and 18/30 in non-words. Physicians scored higher than any other group, followed by health researchers, researchers from other areas and by people with progressively lower levels of education (p<0.001). CONCLUSION: We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and reliable. PRACTICE IMPLICATIONS: The Portuguese version of METER can be used to assess health literacy in Portuguese adults and to explore associations with health outcomes.

Quality of health information on acute myocardial infarction and stroke in the world wide web.

INTRODUCTION: The quality of health information in the Internet may be low. This is a concerning issue in cardiovascular diseases which warrant patient self-management. We aimed to assess the quality of Portuguese websites as a source of health information on acute myocardial infarction and stroke. MATERIAL AND METHODS: We used the search terms 'enfarte miocardio' and 'acidente vascular cerebral' (Portuguese terms for myocardial infarction and stroke) on Google(®), on April 5th and 7th 2011, respectively, using Internet Explorer(®). The first 200 URL retrieved in each search were independently visited and Portuguese websites in Portuguese language were selected. We analysed and classified 121 websites for structural characteristics, information coverage and accuracy of the web pages with items defined a priori, trustworthiness in general according to the Health on the Net Foundation and regarding treatments using the DISCERN instrument (48 websites). RESULTS: Websites were most frequently commercial (49.5%), not exclusively dedicated to acute myocardial infarction/ stroke (94.2%), and with information on medical facts (59.5%), using images, video or animation (60.3%). Websites' trustworthiness was low. None of the websites displayed the Health on the Net Foundation seal. Acute myocardial infarction/ stroke websites differed in information coverage but the accuracy of the information was acceptable, although often incomplete. CONCLUSION: The quality of information on acute myocardial infarction/ stroke in Portuguese websites was acceptable. Trustworthiness was low, impairing users' capability of identifying potentially more reliable content.

Introdução: A informação sobre saúde disponível na Internet é de qualidade variável e frequentemente baixa. Esta questão é fundamental em doenças como as cardiovasculares em que a auto-gestão desempenha um papel importante. O objetivo deste estudo foi avaliar a qualidade dos sites portugueses como fonte de informação sobre enfarte agudo do miocárdio e acidente vascular cerebral.Material e Métodos: Utilizamos as expressões de pesquisa 'enfarte miocardio' e 'acidente vascular cerebral' no motor de busca Google® nos dias 5 e 7 de Abril de 2011, respetivamente, usando o Internet Explorer®. Os primeiros 200 URL que resultaram da pesquisa foram visitados de forma independente e foram selecionados sites de Portugal em língua portuguesa. Classificámos 121 sites de acordo com características estruturais, cobertura e validade da informação de acordo com itens previamente definidos, medidas de confiabilidade em geral de acordo com a Health on the Net Foundation e em relação aos tratamentos, utilizando o instrumento DISCERN (48 sites).Resultados: Os sites eram maioritariamente comerciais (49,5%), com parte do site dedicado a enfarte agudo do miocárdio/ acidente vascular cerebral (94,2%), com informações exclusivamente sobre factos médicos (59,5%) e apresentavam imagens, vídeos e animações para além do texto (60,3%). A confiabilidade dos sites foi baixa. Nenhum dos sites exibiu o selo da Health on the Net Foundation. Os sites de enfarte agudo do miocárdio/ acidente vascular cerebral diferiram na cobertura da informação. A validade da informação foi aceitável embora frequentemente incompleta.Conclusão: A qualidade da informação sobre enfarte agudo do miocárdio/ acidente vascular cerebral nos sites portugueses foi aceitável. A confiabilidade foi baixa o que pode comprometer a capacidade dos utilizadores em identificar conteúdos potencialmente mais credíveis.