Critical health literacy in American deaf college students

Summary

This study investigates the relationship between critical health literacy (CHL) and discussion of health information among college deaf students who use American Sign Language. CHL is crucial in making appropriate health-related decisions for oneself and aiding others in making good health-choices. Research on general youth population shows that frequent health-related discussions with both friends and family is associated with higher health literacy. However, for our sample of deaf college-aged students who might have had less access to communication at home, we hypothesize that health-related discussions with same-age peers may be more important for critical health literacy. We asked two questions to assess the frequency of health-related discussions with friends and families: “How often do you discuss health-related information with your friends” and “How often do you discuss your family medical history with your family?”. Participants rated their experience on a scale from 1-5 (1=never, 5=always). To assess CHL, 38 deaf and 38 hearing participants were shown a short scenario that showed a woman confiding in her friend after finding a lump in her breast. Participants were then asked what the friend should say. Responses were scored by a team of 3 raters using a CHL rubric. As predicted, results showed a strong relationship between discussion of health-related information with friends and CHL in both deaf and hearing samples. Discussion with family was linked to CHL only for hearing participants, but not deaf participants in our study. These findings underscore the importance of socializing with health-literate, accessible peers to improve the health literacy and health outcomes of all deaf people.

INTRODUCTION

Health literacy is a key determinant of health outcomes and is influenced by health communication. Health communication is a key public health issue that impacts low-literate patients, including deaf people who use sign language. Access to health communication allows deaf individuals to effectively use health information to engage in preventative healthcare techniques, seek appropriate medical attention when symptoms arise, and participate in physical activities to reduce or avoid significant health risks. As one accesses health information, strong health literacy skills help with making informed health-related decisions (Brice et al., 2008; Kripalani et al., 2010; Berkman et al., 2004.) Health information and health literacy are closely intertwined, when the development of the three dimensions of health literacy (functional, interactive, and critical) relies on an individual’s access to health information and messages (Nutbeam, 2000).

Functional health literacy (FHL) skills relate to the individual’s ability to effectively read and understand health information (Sorensen et al., 2012). Interactive health literacy (IHL) skills allow an individual to access and use health information from other people to improve their health (Chinn, 2011; Sorensen et al, 2012; Nutbeam, 2000). To develop strong critical health literacy (CHL) skills, the individual should be able to integrate knowledge about human health rights with health advocacy goals to make appropriate health-related actions at both individual and community levels (Mogford et al., 2010). CHL can also include self-efficacy in making decisions as well as supporting other people in making appropriate health choices.

Adequate knowledge about family health history allows a college student to make decisions about preventative health behaviors (Campbell and McClain, 2013). As college students begin to transition to living independently from their family, they learn to be accountable for making appropriate health-related decisions and maintaining good health. This health knowledge can be transferred through peers and others. This appears to be the case in a health insurance survey where a majority of 1367 undergraduate students shared similar opinion as the general adult population regarding the importance of health insurance (Price et al., 2010). With health education and training, college students’ views on maintaining better health can be brought closer to that of health care professionals’ views (Freudenberg et al., 2013). For deaf college students who are not able to easily acquire information in a primarily speaking society, health education and training need to take into consideration the malleable social factors that place this group at disparity for health literacy.

Many deaf individuals have inadequate exposure to health information due to inability to hear health-related messages through TV, radio, and public announcements (Tamaskar et al., 2000). To compensate for this absence, these individuals participate in health-related discussions to acquire health information from family or peers who have greater health knowledge. Upstate New York deaf high school students who discussed health-related information with their family at home were more likely to demonstrate higher health knowledge of cardiovascular information (Smith et al., 2015). Berman et al. (2013) found that deaf women who had not seen a doctor in the past year and deaf women with lower education levels more frequently responded correctly to some breast cancer knowledge questions. The authors speculate that these correct responses resulted from the deaf participant’s access to the deaf interviewer’s assistance with understanding the concept of the questions that were presented in American Sign Language (ASL). The behavior of accessing another deaf person’s health knowledge and then using this information to select the best answer exemplifies an aspect of interactive health literacy.

Interactive health literacy is linked to critical health literacy in the general population (Chinn and McCarthy, 2013). When an individual is armed with health information, the individual may be motivated to take actions to improve the health of oneself and others. These actions can be taken to a higher level such as critical health literacy where the individual takes actions to promote better health within the community or society. Health promotion actions at the community level are especially valuable for the deaf community. A review of the literature suggests that deaf people who use primarily sign language are at disparity for health knowledge and literacy. Deaf young adults who experience communication difficulties or limited access to information at home may arrive at college with piecemeal health knowledge or inadequate health literacy. They may have to seek out and access literate peers’ knowledge to fill the information gap. Discussion of health information with health literate peers who share the same communication method may be the most important social malleable factor in developing or strengthening their CHL skills. Therefore, the study aim is to examine whether stronger IHL with friends is associated with higher CHL skills. Given the complex role of communication that takes place between a deaf person and his/her hearing family (e.g. missing out on dinner family conversations; poor access to incidental information), we predict that the frequency of family discussions of health history will not be associated with the deaf college student’s critical health literacy. If this is found to be true, then the future health literacy interventions with deaf college students should include peer-based skill building activity as a malleable social factor for improving interactive and critical health literacy outcomes.

METHODS

Participants and procedure

A total of 38 deaf undergraduate students who use ASL participated in this study. Demographic and functional health literacy data for this paper was taken from a study on health text accessibility (see Kushalnagar et al., 2016) and analyzed in addition to interactive health literacy and critical health literacy data. In this study, participants were recruited through flyers, social media advertisement, and word of mouth. A deaf research assistant explained the informed consent procedures in ASL and then presented a consent form in print. If the participant was interested, he/she consented by signing the informed consent form. Each session took ∼30 min to complete.

After unique alphanumeric identification codes were assigned, participants were asked to fill out online questionnaires about their communication and health histories. We also gathered background information such as hearing level, preferred language, and onset age for hearing loss. No names were collected or documented on any of the questionnaires. After the session ended, participants were given a gratuity for their time and participation.

Measures

Functional health literacy

After completing the background questionnaire, participants took a 7-min Short Test of Functional Health Literacy in Adults (S-TOFHLA; 36 items; Baker, et al., 1999). The S-TOFHLA is a gold standard, widely used test of functional health literacy, which measures the participant’s ability to read and comprehend health information in the English language. The reading level for the first passage is at the 4th grade level, and the second passage is at the 10th grade level. Internal consistency for the S-TOFHLA is high (α = 0.97). This test was found to be feasible for use with deaf college students (Thew, 2013).

Interactive health literacy

We included two questions to assess interactive health literacy: (i) IHL-family: ‘How often do you discuss family medical history with your family?’ and (ii) IHL-friends: ‘How often do you discuss health issues with your friends?’. These questions were shown as text on a computer and then signed to the deaf participants. Participants rated their experience on a scale from 1 to 5 (1 = never, 5 = always). The scores from two questions were entered as family and friends variables in the statistical model.

Critical health literacy

We took an excerpt of a 90-s captioned video of a deaf woman who recently discovered a lump on her breast (Retrieved 1 June 2015, from http://stream.advocatehealth.com/flashFiles/deafWeb/deafFile.html). In this ASL dialogue between the affected woman and her friend, the woman explained her symptoms and asked her friend what she should do. At this point, the research assistant paused the video and asked the participant, ‘If this was your friend, what would you tell her to do?’ Because we did not video record the participant’s responses, the deaf bilingual research assistant immediately wrote exactly what the participant signed word for word.

A team of bilingual team members developed a scoring rubric to assess participants’ CHL skills based on his/her narrative response to the question, ‘If this was your friend, what would you tell her to do?’. Each qualitative response was independently reviewed and assigned a total score of 0–4 based on the scoring rubric criteria. The rubric consisted of three criteria to assess CHL in our sample: (i) recommending a visit to the doctor (two points); (ii) providing support, reassurance, and/or comfort (one point) and (iii) refraining from giving any wrong information that can potentially interfere with or mislead the friend’s decision (one point). For example, if the participant recommended visiting the ER or urgent care (instead of their primary care doctor), this was assigned a score of one point instead of two points for ‘criterion a’ because this response represented an incorrect judgement of appropriate utilization of health care system (which is related to CHL).

To receive a full score of four points that met all criteria, this would include a response such as ‘I would tell her to go see a doctor and not jump to a conclusion until we know the results’. This includes advising the friend to see a doctor (two points) and providing some resemblance of support and/or reassurance (one point) without added misinformation (one point). If participants’ responses included incorrect information such as ‘Maybe the milk in her breast are damaged,’ then this would result in losing one point for the misinformation.

Statistical methods

All analyses were conducted with SPSS version 19. A p value of 0.05 was chosen for significance. Since previous literature showed that parent SES plays a role in adolescents’ health literacy (Nielsen-Bohlman et al., 2004; Manganello, 2007), we included parent education variable as a covariate in our analyses. Years of mother’s and fathers’ of education were strongly correlated (r = 0.74, p < 0.001) in our sample, suggesting an overlap in shared variances. Therefore, the mother and father education variables were merged as an index variable, ‘parent education’. Parent education was entered as a covariate in all regression analyses. FHL was also entered as a covariant to factor out its possible influence on the relationship between IHL and CHL in the initial model. A diagnostic test was run on the analyses to confirm that the assumptions for regression were met; no multicollinearity and influential data points were present.

We predicted that reported frequent health-related discussions amongst friends, but not family, is associated with CHL in college aged students who are deaf. To test these two predictions, a hierarchical regression model was run with demographic variables and predictors regressing on CHL as a dependent measure. Each variable was entered in a regression model in the order: Parent education, race, age onset of deafness, hearing level, parent hearing status, age learned ASL, age learned English, FHL, IHL-family and IHL-friends. Linear regression was used to identify a set of significant predictors (p < 0.05) of critical health literacy in deaf college students. Using G*power analysis for F-test with a significance level of 0.05, our sample size of 37 provided 90% power to detect an R-squared of 0.47 for two significant predictors in the final regression analysis.

RESULTS

For this study, we report descriptive and analytical statistics for the ASL deaf group. Most deaf students reported their hearing loss to be severe or profound. A majority have adequate functional health literacy. However, only 30% of the deaf sample often or always discussed health with their family whereas 41% often or always discussed health with their friends. Table 1 displays the demographic characteristics of deaf participants. Table 2 displays the regression analysis among demographic variables, IHL, and CHL for this college sample.

Table 1:

Demographic and health literacy characteristics by gender

Variable		Female	Male
	N = 37	(n = 20)	(n = 17)
	M (SD)	M (SD)	M (SD)
Age (in years)	22.38 (2.68)	22.30 (2.39)	22.48 (3.06)
Parent years of education (in years)	13.91 (3.34)	13.76 (3.76)	14.09 (2.85)
Age at onset of deafness	1.78 (1.69)	2.20 (1.53)	1.29 (1.77)
Age learned ASL	4.00	5.50	1.50
(median in years)	(age range: 0–19)	(age range: 0–19)	(age range: 0–16)
Age learned English	4.00	4.00	3.00
(median in years)	(age range: 0–12)	(age range: 2–12)	(age range: 0–8)
	%	%	%
Race
White	46	35	59
Non-white	54	65	41
Hearing level
Mild	11	15	6
Moderately Severe	5	10	0
Severe	32	35	29
Profound	51	40	65
Parent hearing status
Hearing	59	65	53
Deaf	41	35	47
Functional health literacy
Adequate	95	95	94
Interactive health literacy (discussed health with family)
Never	8	10	6
Rarely	19	30	6
Sometimes	43	30	59
Often	14	15	12
Always	16	15	18
Interactive health literacy (discussed health with friends)
Never	5	10	0
Rarely	14	15	12
Sometimes	41	50	29
Often	30	20	41
Always	11	5	18
Critical health literacy
Did not meet criteria	5	10	0
Met some criteria	46	45	47
Met all criteria	49	45	53

Table 2:

Exploring the role of predictors of deaf college students’ critical health literacy

Variable	Beta	t	p
Parent education	−0.135	−0.876	0.389
Race	0.143	0.894	0.379
Age onset of deafness	0.057	0.371	0.714
Hearing level	−0.336	−1.781	0.087
Parent hearing status	0.089	0.473	0.640
Age learned ASL	−0.464	−2.690	0.012
Age learned English	−0.168	−1.037	0.309
FHL	0.180	0.939	0.356
IHL-Family	−0.031	−0.186	0.854
IHL-Friends	0.392	2.386	0.025

The significance of bold values represent p < .05.

FHL did not contribute to CHL score ($\beta$ = 0.180, p = 0.36, NS). No effect emerged for the age at onset of deafness ($\beta$ = 0.06, p = 0.71, NS). Additionally, there were no differences in CHL across racial groups $(\beta$ = 0.14, p = 0.379, NS), parent years of education ($\beta$=-.13, p=.40, NS), and hearing level$(\beta$ = −0.34, p = 0.087, NS). Age learned ASL had a strong effect on CHL score ($\beta$ = −0.46, p < 0.05), while age learned English did not predict CHL score ($\beta$ = −0.17, p = 0.31). Having hearing or deaf parents had no effect on CHL score ($\beta =0.09,, p=0$.64, NS). As predicted, health-related discussions with friends was found to be moderately associated with CHL score ($\beta$ = 0.39, p < 0.05). Discussions with family about medical history did not contribute to CHL score ($\beta$ = −0.03, p = 0.85, NS).

DISCUSSION

This study provides a better understanding of critical health literacy in deaf college students who use ASL. In our study, neither discussion of medical history with family nor FHL was associated with CHL skills. However, greater frequency of health-related discussions with friends was significantly associated with better CHL score in deaf college students. This suggests that deaf college students can still achieve strong CHL skills by improving their IHL skills, even if they may have poor FHL. When a person is not able to easily access incidental learning of health information through family conversations, the person can still access their health-literate friends to compensate for the missed information.

Our sample included health literate deaf people who reported engaging in family discussions about health. As shown in Table 2, critical health literacy is independent of whether the family members are deaf or not. This suggests that the participation in family discussions about health is supported by other important social characteristics such as the parents’ effort to communicate with the deaf individual. When the deaf person reports being able to understand family conversations regardless of the modality used, the deaf person is more likely to also report healthy outcomes (Hintermair, 2015; Brice and Strauss, 2016; Kushalnagar et al., 2016). Similarly, deaf adolescents who demonstrated better cardiovascular health knowledge were those who participated in health-related discussions with their parents (Smith et al., 2015). Once these health-literate deaf individuals enter college and become independent from their family, they have the potential to pass on their knowledge to other deaf individuals who demonstrate relatively lower health literacy due to communication barriers.

At risk and/or low income youths who retrieve health information from friends, not just family, demonstrate better health literacy (Paek et al., 2011). These youths often have limited access to quality health information and education that result from having less educated parents and reduced access to quality health education in a low-income environment. Since some deaf people have reduced access to health information due to communication barriers in their home or health environment, it is likely that, like low-income youths, they rely on peers to acquire vital health information and develop health literacy skills. Engaging in health-related discussions with health-literate peers who share a common language is a valuable alternate source of health information that some deaf people may have missed due to communication barriers or weak FHL. This alternative source of IHL appears to promote the advancement of CHL skills in deaf college students, which improves their overall health literacy. Socializing with health-literate, accessible peers should be an important target for future interventions to improve the health literacy and health outcomes of all deaf people.

The contributory role of early ASL exposure in deaf individuals’ CHL skills aligns with prior evidence that ASL is valuable for the development of theory of mind and psychosocial well-being in deaf children (Courtin, 2000; Dammeyer, 2009; Stanzione and Schick, 2014). The benefits of having an accessible language during childhood needs to be considered in relation to the development of CHL skills for deaf people. Learning ASL at an early age provides rich opportunity for deaf children to partake in social interactions with other ASL users without barriers. Early exposure to language and partaking in reciprocal dialogue can also enhance cognitive development and critical thinking competency. Our findings suggest that ASL allows for the engagement in social conversations at an early age, which increases the likelihood of engaging in health-related discussions with peers and fortifies the development of CHL skills.

Social activities within college student populations are not limited to in-person contacts. Social media networks have become a popular place for virtual online interactions. Public health has recognized social media as a promising opportunity to educate users on health information and health care services (Thackeray et al., 2008). Paek and colleagues (2011) found that, along with discussions with friends and family, receiving health information from media sources contributes to adolescents’ health literacy. However, the current health information sites are not always accessible and might be difficult to find for some deaf ASL users (Kushalnagar et al., 2014, 2016). Social network sites with ASL vlogs have great potential to disperse health information as well as stimulate online interactions between peers. Implementing interactive health literacy activities through the social media that is accessible in ASL has the potential to enhance health awareness and self-advocating health care techniques, which can support CHL in deaf people.

Limitations of this study include small sample sizes of college students. Most deaf students in this sample use ASL daily. This study did not gather data related to parents’ income, which may clarify the role of parental socioeconomic status in the college student’s critical health literacy outcomes. Inclusion of deaf people from other age groups is highly encouraged for future studies. The results of this study reinforce peer socialization as a key factor for critical health literacy skill in deaf college students. For this reason, we recommend that future health education interventions include health-literate deaf people as agents to stimulate growth in health knowledge and critical health literacy skills among low-literate deaf peers.