To the Editor

To the Editor: —The recent study by Chew et al.¹ showed us that a single question may be useful for detecting patients with inadequate health literacy. The study looked at a primarily white, male population with a relatively high education level (40% had completed some college). Recently, we utilized Chew’s previous study² to conduct a study to validate her key questions with the s-TOHFLA in a Spanish-speaking population. Our small pilot study consisted of 116 patients. A demographic survey revealed that our population had a high percentage of low income (95% earned less than $ 20,000 per year). The vast majority (95%) did not complete a high school education; 38% completed the 4th–7th grade, and 31% completed less than the third grade. Overall, s-TOFHLA results showed a high prevalence of inadequate health literacy (45%). We found the screening questions to be equally as effective in a Spanish-speaking population compared with Chew’s results. The area under the receiver operator curve (AUROC) was calculated using Excel. The AUROC was determined to be 0.7939 for the “Need help reading” question, 0.73 for the question “How confident are you filling out medical forms?”, and 0.6618 for the “Problems learning about your medical condition” question.

Although this is a relatively small study, it looks at a unique population that is relevant for many areas with a large Hispanic population. It emphasizes the importance of screening for inadequate health literacy in this patient population where the prevalence was found to be much higher than in the Chew study. In the Rio Grande Valley, where our study was conducted, physicians see an abundance of low-income, uneducated patients. Often these patients suffer from multiple chronic medical conditions. As physicians we often times rely on giving complex explanations or providing written handouts in an effort to provide the best care possible. We feel this is sufficient, because we expect that our patients will demand clearer explanations when necessary. Many times, out of a culture of respect that we see in this community, patients never ask. Later, when these patients fail to follow medical advice accurately, they are labeled as “noncompliant.” When our patients read only at a fourth grade level, it is unrealistic to simply give our patients written handouts and expect them to understand their medical condition or how to take their medicines properly, or keep accurate medical diaries. Chew’s study gives physicians a practical guide for addressing the first step in this overwhelming problem: identifying those individuals who need intervention strategies to empower their own health management. Our study suggests that this is also valid in our Spanish-speaking patients. The challenge we face is beyond identifying their health literacy but delivering the best care in an effective manner.