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Page 1: Development of functional oral health literacy assessment instruments: Application of literacy and cognitive theories

Development of functional oral health literacy assessmentinstruments: Application of literacy and cognitive theoriesSusan M. Bridges, BA, DipEd, MAAppl Ling, EdD; Divya S. Parthasarathy, BDS; Terry K.F. Au, BA, PhD;Hai Ming Wong, DDS, MDSc, AdvDipPaediatrDent, PhD, M Paed Dent RCSEd, MRACDS (Paed),FCDSHK, FHKAM; Cynthia K.Y. Yiu, BDS, MDS, PhD, FHKAM, FCDSHK; Colman P. McGrath,BA, BDentSc (Hons), FDSRCS, DDPHRCS, MSc, FFDRCS, PhD, MEd

Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

Keywordshealth literacy; functional literacy; literacytheory; assessment; reading comprehension;cognition; situated literacy; authentic literacy;multiliteracies.

CorrespondenceDr. Susan M. Bridges, Faculty of Dentistry, TheUniversity of Hong Kong, Hong Kong, China.Tel.: 85228590275; Fax: 85225599013;e-mail: [email protected]. Susan M. Bridges,Divya S. Parthasarathy, Terry K. Au, Hai MingWong, Cynthia K.Y. Yiu, and Colman P.McGrath are with the Faculty of Dentistry, TheUniversity of Hong Kong.

Received: 5/9/2013; accepted: 7/16/2013.

doi: 10.1111/jphd.12033

Journal of Public Health Dentistry 74 (2014) 110–119

Abstract

Objectives: This paper describes the development of a new literacy assessmentinstrument, the Hong Kong Oral Health Literacy Assessment Task forPaediatric Dentistry (HKOHLAT-P). Its relationship to literacy theory is analyzedto establish content and face validity. Implications for construct validity areexamined by analyzing cognitive demand to determine how “comprehension” ismeasured.Methods: Key influences from literacy assessment were identified to analyze itemdevelopment. Cognitive demand was analyzed using an established taxonomy.Results: The HKOHLAT-P focuses on the functional domain of health literacyassessment. Items had strong content and face validity reflecting established prin-ciples from modern literacy theory. Inclusion of new text types signified relevantdevelopments in the area of new literacies. Analysis of cognitive demand indicatedthat this instrument assesses the “comprehension” domain, specifically the areas offactual and procedural knowledge, with some assessment of conceptual knowledge.Metacognitive knowledge was not assessed.Conclusions: Comprehension tasks assessing patient health literacy predominantlyexamine functional health literacy at the lower levels of comprehension. Item devel-opment is influenced by the fields of situated and authentic literacy. Inclusion ofcontent regarding multiliteracies is suggested for further research. Development offunctional health literacy assessment instruments requires careful considerationof the clinical context in determining construct validity.

Introduction

Since its inception in the United States in the 1970s, health lit-eracy has emerged as a growing field in terms of both researchand applications to practice. One core premise of the healthliteracy agenda is that access to health care and thesustainability of health-care outcomes are associated withthe sociocognitive processing of health-care “messages.” Theimplications, therefore, extend not only to an individual’sability to “comprehend” messages received and to meaning-fully engage with health care but also to health-care provid-ers’ delivery of “comprehensible” messages at both individualand system levels. The core notions of message, sender andreceiver are evident in all theories of meaning-making orsemiosis (1). For the emerging field of health literacy, the

challenge is to identify what forms these messages take, whosends and who receives them, and how one can research thecomplex interaction that takes place as these componentscome together. A guiding definition has been Nutbeam’s (2)delineation of three levels of health literacy: basic/functional(reading and writing skills for daily life), communicative/interactional (cognitive and literacy skills combined withsocial skills), and critical (empowerment to handle informa-tion and have control over situations). Applied research todate has focused on the most basic of these – functionalhealth literacy – but this still remains in its infancy.

Studies in health literacy have indicated that low levels ofliteracy are associated with negative health outcomes (3), aslevels of individual health literacy have been found to affectpatients’ ability to understand and engage at a basic level with

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110 © 2013 American Association of Public Health Dentistry

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health-care systems (4). This encompasses requisite skillssuch as entering data on forms and locating providers ofhealth services, sharing personal information such as healthhistory with health-care providers, engaging in self-care anddisease management, and understanding basic mathematicalconcepts like probability and risk (5). Studies of the healthliteracy of individual patients have identified those who are atrisk as including older adults; people with low incomes, espe-cially those below the poverty line; people with limited educa-tion; minority populations; and persons with limited Englishproficiency (5). Inadequate health literacy has been associ-ated with poor health status and more frequent hospitaliza-tions in different patient populations (5). A growing numberof studies have linked low levels of health literacy to poorhealth outcomes and to lower self-reported health status(6-8). Investigations into the relationship between literacyand health in pediatric general health in the United Stateshave resulted in large-scale“health literacy” intervention pro-grams such as Reach Out and Read (9). However, the efficacyof these is yet to be gauged.

Oral health literacy has more recently emerged as an area ofallied research. It was first defined in the US Department ofHealth and Human Services policy, Healthy People 2010, asthe “degree to which individuals have the capacity to obtain,process and understand basic oral health information andservices needed to make appropriate health decisions,” a defi-nition consistent with that of general health literacy (4). Therelationship between oral health literacy and oral healthstatus and management is less understood than health lit-eracy. While research in North America (10-16) has devel-oped oral health literacy assessment instruments (10,11),limited work has been undertaken in Asia (17,18), with noclear examination of the functional literacy assessment prin-ciples guiding item development. While mainstream researchhas established “literacy” as a multidimensional conceptincluding “repertoires of literate capabilities” across a rangeof new text types generated by the phenomenon of screen-based interactions (19), health literacy and oral health literacyprojects have worked from less complex perspectives relyingon more limited definitions of literacy. Little work has beenundertaken to understand how mainstream literacy theoryand research have informed understandings of (oral) healthliteracy.

Because of the different linguistic features of Chinese(Cantonese) and the different geographical and culturalcontext, the available instruments could not be applieddirectly to our particular research site. The need, therefore,arose to create tailor-made health literacy assessment instru-ments specific to the literacy demands of this particularhealth-care context. This requirement stimulated andinformed the development of one such original instrument,the Hong Kong Oral Health Literacy Assessment Task for Pae-diatric Dentistry (HKOHLAT-P). Validation of this instru-

ment has been published elsewhere, with results indicatingthe instrument to be valid and reliable (18). The aim of thispaper, therefore, is to provide an in-depth analysis of thedevelopment of the HKOHLAT-P instrument.

In what follows, we first examine the development of thisparticular functional health literacy assessment instrumentin order to establish content and face validity. We have donethis by drawing on literacy theory as a basis for principledanalysis. The purpose, therefore, is to understand the under-lying principles at work in item design so that more relevantand therefore valid test instruments can be constructed.Second, we further examine HKOHLAT-P’s validity by ana-lyzing cognitive demand at item level to determine how“comprehension” (20) is measured and to determine levels ofchallenge or difficulty of the items. Understanding the level ofchallenge of each task is important both when consideringtest item construction and when ascertaining the overall cog-nitive load of the entire instrument on the participant. Twoversions of the HKOHLAT-P were created – a Chinese versionand an English translation, with testing conducted in Chinesein conjunction with the development of a Chinese version ofa rapid word recognition task (HKREALD-30) (17,18). Theresearch protocol was approved by the Institutional ReviewBoard of the University of Hong Kong/Hospital AuthorityHong Kong West Cluster (UW09-184).

Literacy theory: Implications fordevelopment of healthliteracy instruments

Mainstream conceptions and studies of literacy have devel-oped rapidly in response to new notions of what counts as lit-eracy, particularly with regard to the relationship betweenliteracy and learning (21). Definitions of what constitutesreading and reading comprehension have changed greatlyand have moved beyond mere explicit recall, word recogni-tion, and mastery of phonemic decoding to examination ofthe relationship between text types and the social world. Thishas given rise to new ways of describing language, includingnew grammar systems. These new perspectives explore ques-tions such as “Exactly what dimensions of context have animpact on language use? Which aspects of language useappear to be affected by particular dimensions of thecontext?” (22).

As these notions of language in context have developed,their logical impact on how literacy assessment instrumentsare designed has increased. In mainstream literacy studies,these principles have been included in such large-scale assess-ment exercises as the Programme for International StudentAssessment (23), the National Assessment of Adult Literacy(24), and the International Adult Literacy Survey (25). Onreflection, it becomes apparent that the notion of situatedpractice (i.e., language in context) has been, to date, central to

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the development of health literacy assessment instruments.However, this notion has not been explicitly described or ana-lyzed. In what follows, we undertake an analysis of one healthliteracy assessment instrument, the HKOHLAT-P, to examinehow three core developments in modern literacy theory havebeen applied in terms of both task design and task demand.These developments include authentic literacy, situated lit-eracy, and multiliteracies and are described below. Applica-tion of these principles to item development, their influenceon content and face validity, and their potential impact forconstruct validity are illustrated using the HKOHLAT-P as acase in point.

Authentic literacy, situated literacy,and multiliteracies

Authentic-literacy principles underpin the modern literacy-learning classroom. By definition, authentic literacy involves

reading and writing of real-life texts for real-life purposeswith “the direct examination of student performance onworthy, intellectual tasks” (26). The authentic literacy move-ment has its origins in reader response theory, which empha-sizes “a reciprocal relationship between reader and the text”(27) and draws on “real-world” relevance of students’ learn-ing outside the context of formal classroom teaching (28).The premise here is that a reader brings his/her social and cul-tural background to the text and that meaning-making is asynthesis between the text itself and the life context that thereader brings to it (29). A nationwide US study of adult learn-ers found that adults in programs with more authentic-literacy activities reported more reading and writing in theirout-of-school lives and a higher complexity in the types oftexts that were read and produced (30). Rosenblatt’s (29)description of two stances towards reading, efferent and aes-thetic, is also relevant to the notion of authentic literacy. Areader takes an efferent stance when the goal of reading is to

Figure 1 Corpus database (17).

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gain information from the text (textbooks, newspapers, refer-ence materials, etc.); on the other hand, an aesthetic stance ispertinent where the reader participates in the experiencebeing created by his or her personal transaction with the text.

The related notion of situated literacies (i.e., literacy associal practice) arose in the mid-20th century in the work ofScribner and Cole (31). In examining literacy practices ineveryday life, Barton and colleagues (32,33) also argued thatliterate practices “can be seen as located in particular timesand places” and are “indicative of broader social practices”(32). Concurrently, literacy theorists also have been rethink-ing what we define as a“text,”given our increasingly divergentuse of texts and screens throughout our social practices. Inendeavoring to define this trend, the New London Group(19), a team of academics who came together in 1996 to con-sider the future of literacy and literacy pedagogy, coined theterm “multiliteracies.” A three-element design frameworkwas proposed to describe the activities of individuals as theyidentify, read, and create new texts using varying semioticcodes. These available designs include the grammars of lan-guage and various semiotic systems. Linguistic issues relatedto text readability and decoding for instruments utilizing tra-ditional written Chinese are discussed elsewhere (17). Impor-

tantly for this paper’s focus on item development, themultiliteracies movement has accomplished much in recog-nizing the proliferation of new text types and new ways ofmeaning-making (1). Application of these theories to itemdevelopment in the case of the HKOHLAT-P is detailed in thefollowing section.

Authentic literacy, situated literacy, andmultiliteracies: An application

Application of the principles of authentic literacy, situated lit-eracy, and multiliteracies may assist the establishment ofcontent and face validity in the development of health assess-ment instruments, particularly in the selection of texts asstimuli for comprehension assessment. One example of this,the HKOHLAT-P, was developed to assess the literacy of adultcaregivers, with a particular focus on oral health knowledgeand comprehension of pediatric dentistry. Foundations fordevelopment are acknowledged in other recent instruments,TOFHLiD (12) and OHLI (16), but two specific issues arosein designing instruments for the first oral health literacyproject in Hong Kong. The first was the theoretical issueof situated and authentic literacy, which demanded local

Figure 2 Sample numeracy/literacy items from HKOHLAT-P: English version.

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relevance in item development. The second was recognitionthat materials were print-based and that in the context ofproliferating multimodal and multimedia sources of infor-mation, this was an important limitation. Based onmultiliteracies theory, the inclusion of stimulus materialsusing new modalities was considered critical.

As with items in other health literacy assessment instru-ments, the texts used in HKOHLAT-P were “real-life,” so areader is more likely to access held and appropriate knowl-edge schemas to decode the text (34). Making this possiblerequired the construction of a bank of authentic texts for itemdevelopment (17). Corpora are important in linguisticresearch (35), and to develop items for HKOHLAT-P, we con-structed our own corpus database of authentic spoken andwritten texts (36). Materials were collected from differentdentistry-related sources, including Cantonese TV and radioprograms on oral health from local Hong Kong broadcasters,Cantonese/English bilingual oral health education videosand oral health instructions in the major public dental hospi-tal, Cantonese/English bilingual oral health education andpromotion brochures from the Department of Health (37),

and local Hong Kong newspaper articles and advertisements(see Figure 1).

Chinese-reading project members determined the readinglevels to be similar to materials used for TOFHLiD (12) andOHLI (16). Items shown in Figures 2 and 3 are indicative oftasks drawn from the corpus (local prescription label andtooth-brushing guide).In terms of situation in place and time,both stimulus texts were obtained from Hong Kong sourcesand are in current usage. With regard to social practice, it isnoteworthy that both were presented bilingually and that thebrochure was available online (37).This leads to considerationof modalities and multiliteracies, and these were addressedusing two items unique among oral health literacy assessmenttasks to date – an Internet discussion forum and a web page.

As these texts were drawn from examples of reading andwriting skills for daily life as pertinent to pediatric dentistry inHong Kong, the HKOHLAT-P can therefore be seen as focus-ing on the functional domain (2) of health literacy assess-ment. In addition to understanding how literacy theory hasinformed instrument development, it was relevant alsoto consider the cognitive principles underpinning the

Figure 3 Sample reading comprehension item from HKOHLAT-P: English version.

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formulation of question types in a literacy comprehensionassessment. Further analysis of cognitive demand can assist infurther classifying items within the instrument in terms ofknowledge and cognitive processing.

Cognitive demand and itemdevelopment: Implications fromcognitive psychology

Bloom’s Taxonomy (38) was introduced in the 1950s tosupport the measurement of student knowledge and under-standing. It identified three overlapping domains, “the cog-nitive, psychomotor and affective, also known as knowledge,skills and attitudes (KSA)” (39). The cognitive and affectivedomains provided a way to organize thinking skills into sixlevels, from most basic to more complex. Utilization ofthe taxonomy for task design has been incorporated intomainstream educational practice, including assessmentinstrument design. More recent work to update the tax-onomy has generated the Revised Bloom’s Taxonomy(RBT), a one-dimensional cumulative hierarchy withachievement at each lower level considered necessary tomove up to the next level (20). Item development for afunctional health literacy assessment instrument such as the

HKOHLAT-P can be mapped against the taxonomy table,that is, from more basic to more complex, in order to indi-cate the levels of cognitive effort demanded by the questions(see Table 1).

The cognitive domain

Within the cognitive domain, the RBT (20) has two dimen-sions,“cognitive process” and “knowledge” (see Table 1). Thefirst reflects a participant’s cognitive and metacognitive activ-ity as expressed within the opportunities and constraints ofthe learning setting. Anderson et al. (20) argued that this“process of ‘making sense’ involves the activation of priorknowledge as well as various cognitive processes that operateon that knowledge”. Six stages have been identified within thecognitive process dimension: remember, understand, apply,analyze, evaluate, and create. Four types of knowledge consti-tute the knowledge dimension: factual, conceptual, proce-dural, and metacognitive knowledge. Analysis of items andquestion types as mapped against the cognitive domain of theRBT is given in the next section and in the partial matrix pro-vided in Table 1. Such an analysis can assist in further estab-lishing the validity of health literacy assessment instrumentsby clarifying levels of task demand.

Figure 4 Sample oral health knowledge items from HKOHLAT-P: Chinese version with English translation.

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The cognitive domain: An application

Health literacy instruments often test general oral healthknowledge as a predictor of functional health literacy. Whilethe US Institute of Medicine’s expert panel on health literacyviews health knowledge (vocabulary and conceptual knowl-edge) as a domain of health literacy, others view healthknowledge as a predisposing factor for health literacy but notnecessarily constituent in the capacity to understand and usehealth information (3). The knowledge test incorporated inthe HKOHLAT-P consists of the task of recognizing andlabeling four colour pictures of real oral conditions (seeFigure 4) with the inclusion of real, color photographs pro-viding improved semantic, “intervisual” connections (1).Two pictures are of normal dentition and the other two are ofcarious dentition. Participants are required to match thepicture and the name (below each picture) by putting thecorrect number in the box, and marks are allotted accordingto the correct answers.

The formation of these question types was based onBrady and Kennedy’s matching test (40), which involvesparticipants in relating or matching a series of stems (prem-ises) in one column to a series of answers (responses) inanother. Benefits claimed include efficiency, by which aseries of premises “fits” a series of responses, as well as easeand objectivity of marking. Limitations include the restric-tion of such items to knowledge outcomes and whatGroundlund (41) called “susceptibility to irrelevant clues.”In mapping these items against the RBT, the question typesrequired recognition and knowledge of terminology and so

were rated as testing the lower level of “remember” in thecognitive process dimension and the corresponding lowerlevel of “factual knowledge” in the knowledge dimension(see Table 1).

Other items involve multiple-choice responses. These testsare structured so that a participant chooses one answer fromthe menu given, allowing broad coverage of content(42,43). These tasks were mapped as “interpreting” or“inferring” under the “understand” cognitive process dimen-sion and at the “factual knowledge” level.

Figure 2 also displays a sample of items often referred to as“numeracy” items, as they involve more extended interpreta-tion of numerical, as well as written, data. Participants arerequired to use the information and instructions provided onthe label and write answers below each of the questions, forexample,“If your child’s symptoms are gone by the 3rd day oftaking the medication, should you stop giving him/her thismedication?” Such questions address “procedural knowl-edge” at the cognitive process level of “understand,” as theyrequire knowledge of criteria for determining when to useappropriate procedures.

A further question type was incorporated among theitems using standard cloze techniques for testing readability,reading comprehension, listening comprehension, andgeneral English proficiency (42,43). In acknowledgment ofthe critical importance of the multiliteracies agenda, a textmodeled on an actual online exchange in a parent adviceforum was used as the base text for the cloze item test.On mapping against the RBT, the task is at the level of“conceptual knowledge” within the cognitive process of

Table 1 Partial matrix mapping items against Revised Bloom’s Taxonomy (20)

Cognitive Process Dimension

Remember Understand Analyze

Recognizing Recalling Interpreting Inferring Organizing

Kn

ow

led

ge

Dim

ensi

on

s Fact

ual

Knowledge of terminology Part 2. Q 1 a–dPart 2. Q 2 a–bPart 2. Q 3 a–cPart 2. Q 4 a–c

Knowledge of specific details and elements Part 3. Q 5 e Part 3. Q 1 a–dPart 3. Q 2 a, cPart 3. Q 3 bPart 3. Q 4 b–f, hPart 3. Q 5 a–d

Co

nce

ptu

al Knowledge of classifications and categories Part 4. Q 1 a–i

Knowledge of principles and generalizations Part 3. Q 2 d Part 3. Q 3 a

Pro

ced

ura

l

Knowledge of criteria for determining when to useappropriate procedures

Part 3. Q 2 b Part 4. Q 2 a–ePart 3. Q 3 cPart 3. Q 4 a, g

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“understand,” as interpreting classifications of categories isrequired.

The final item also acknowledged multiliteracies whileaiming at a more challenging task (Figure 3). The sentencerearrangement was modified from an authentic web-basedtooth brushing guide (Part 4 Q2a-e) and follows the format ofa constructed-response task. This was considered as the mostcognitively challenging of the tasks, as it required organizingprocedural knowledge at the cognitive level of “analyze.” Ofinterest is the belief of some cognitive theorists (44) that pro-cedural knowledge is less explicitly attended to and developedin schooling and thus likely to be operating for many peopleat lower levels of conscious awareness and direction thanfactual knowledge.

Analysis of cognitive demand indicates that this functionalhealth literacy assessment instrument assesses many aspectsof the “comprehension” domain of the updated Bloom’s tax-onomy, specifically factual and procedural knowledge withsome assessment of conceptual knowledge. From the partialmatrix of the cognitive process dimension in Table 1, the twohigher levels of “evaluate” and “create” were not tested. Addi-tionally, the “apply” level of executing and implementing wasalso not evident. Of the four levels in the cognitive dimension,only the most complex level of metacognitive knowledge wasnot assessed in HKOHLAT-P.

Discussion

In considering reading assessment, Powell (45) argued thatsince the act of reading cannot be directly observed,“all scoresor data produced by the tests of reading are indirect measuresof the reading process.”While reading comprehension assess-ment intersects research fields and paradigms across educa-tion and cognitive sciences, a commonly identified challengeis that of creating authentic, holistic reading comprehensionassessments (46).We argue that the same holds true for healthliteracy assessment instruments. The analysis presentedabove indicates that the application of both literacy studiesand cognitive theories can support validity in development ofhealth literacy assessment tasks. Specifically, validity is sup-ported when assessment items are based upon authentic, real-life texts drawn from patients’ everyday experience of thespecific health-care context. To our knowledge, this is the firstattempt in oral health literacy to apply the principles ofmultiliteracies by incorporating web-contextual stimulusmaterials. Further development of multimodal texts foranalysis or in item development would be appropriate for21st-century consumers, particularly given the rise of thehealth informatics field.

Analysis indicates that the developed instrument focusesprimarily on functional literacy, which is one of possibly mul-tiple dimensions of health literacy/oral health literacy identi-fied in the literature to date (2). As noted by critics of

mainstream literacy testing, traditional standardized testingmethods depend on a participant’s memory, where knowl-edge is being supported increasingly by ever-present props,with such testing considered as measuring only limited kindsof intelligence (47). The results of the taxonomy mappingsupport this assertion, that is, that the instrument tests onlylower cognitive processes. However, given that the aim ofhealth literacy assessment is to measure if a patient under-stands basic health messages, this may not be a debilitatinglimitation.

The increasing amount of published research in recentyears indicates that oral health literacy is indeed an emergingfield; however, it remains in its infancy. In this paper we havepresented the nature and outcomes of our examination ofHKOHLAT-P’s development as a functional oral healthliteracy assessment instrument for the Chinese-readingpopulation in Hong Kong. This process has included thetheoretical justifications for text selection and the applicationof cognitive theories to analyze task demand. Item develop-ment was influenced predominantly by the fields of situatedand authentic literacy, with multiliteracies acknowledged inthe selection of multimodal texts. This remains a potentialresearch direction for future work.

The key implication for health literacy research is that thedevelopment of functional health literacy assessment instru-ments requires careful consideration of the clinical context indetermining construct validity. In the case of HKOHLAT-P,the tasks were all relevant to caregivers of pediatric dentalpatients. Analysis at item level of cognitive demand hasshown that HKOHLAT-P is an appropriate instrument forevaluating the functional oral health literacy of adult patientsinvolved in clinical research, albeit mainly at the lower levelsof cognitive processing. In terms of implications for practice,the application of valid health literacy assessment toolsshould inform the development of appropriate public healtheducation and promotion materials and practices with thedesired ultimate goal of improving health outcomes.

Acknowledgments

The authors acknowledge the financial support providedby the Research Grants Council of Hong Kong (Ref: 760009).The authors appreciate Ms. Lee Tsui Man, Jenny’s researchassistance and Professor Brendan Bartlett’s thoughtfulcomments on an early draft of this paper.

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