Development and validation of a general health literacy test in Singapore.

Due to the concern of equating correct pronunciation with comprehension and the differences in health care systems, existing health literacy (HL) instruments may not be appropriate for or applicable to English-speaking countries other than the USA. The purpose of this study was to develop and validate the Health Literacy Test for Singapore (HLTS), which is an adapted version of the Short-Test of Functional Health Literacy in Adults. Three hundred and two patients were interviewed and administered the HLTS, the Newest Vital Sign (NVS), a demographic questionnaire, and a knowledge test of chronic diseases. The convergent validity of HLTS was determined by examining the association between HLTS and NVS HL levels, whereas predictive validity was tested by examining the difference in knowledge of chronic conditions between the two HLTS HL (i.e. adequate and inadequate HL) groups. Bivariate correlation of HLTS HL levels with age and education was assessed to test a priori hypotheses that patients with inadequate HL were older and less educated. The results showed that HLTS displayed good internal reliability (Cronbach's alpha = 0.87). The correlation between HLTS and NVS was moderate (γ = 0.55; P = 0.005) and individuals with inadequate HL were older (P = 0.002) and less educated (P = 0.007). In addition, patients with adequate HL had a higher mean score on the chronic disease knowledge test (P = 0.036). In conclusion, the HLTS is a valid and reliable measure for assessing Singaporeans ability to read and comprehend health-related materials written in English.

Bilingual Text With or Without Pictograms Improves Elderly Singaporeans' Understanding of Prescription Medication Labels.

BACKGROUND AND OBJECTIVES: In Singapore, primarily English-language prescription medication labels challenge elderly Singaporeans, many of whom are unable to read English. We investigated whether bilingual text and pictograms can help them understand prescription medication labels. RESEARCH DESIGN AND METHODS: We randomized 1,414 elderly respondents of a national survey into four prescription medication labels: English-text; English-text-and-pictograms; Bilingual-text; and Bilingual-text-and-pictograms, which were similar except for the addition of another language and/or pictograms (International Pharmaceutical Federation, FIP). Respondents answered 16 label-related questions; an expert panel rated answers for correctness. Outcomes were (1) complete understanding (16 correct); (2) any understanding (≥1 correct); and (3) number of incorrect answers among those with any understanding. We evaluated associations of each prescription medication label (vs. English-text) with outcomes (1), (2), and (3) using logistic and negative binomial regression, respectively. RESULTS: The elderly respondents were similar across the four prescription medication labels (English-text, English-text-and-pictograms, Bilingual-text, Bilingual-text-and-pictograms), for which the proportions with outcomes (1) and (2) were (17.9%, 25.6%, 36.9%, 40.1%) and (50.4%, 62.6%, 75.9%, 76.5%), respectively. We observed statistically significant higher odds of outcomes (1) and (2) among those assigned the three labels (vs. English-text): English-text-and-pictograms, 1.96 and 2.51; Bilingual-text, 3.54 and 6.73; and Bilingual-text-and-pictograms, 4.51 and 7.93. Those assigned the three labels also had 0.94, 1.98, and 2.12 fewer outcome (3) on average (vs. English-text). DISCUSSION AND IMPLICATIONS: Adding bilingual text with or without pictograms on prescription medication labels considerably improved elderly Singaporeans' understanding of the labels, strongly suggesting its application in practice. Other issues in prescription medication labels design and content, including adapting FIP pictograms for elderly Singaporeans, warrant further investigation.