Validation of the Newest Vital Sign in American Sign Language for Deaf Users

MICHAEL MCKEE MD, MPHDEPARTMENT OF FAMILY MEDICINE AND

NATIONAL CENTER FOR DEAF HEALTH RESEARCH

Rochester Prevention Research Center National Center for Deaf Health Research

Nothing to financially disclose

Rochester Prevention Research Center National Center for Deaf Health Research

Background• Deaf American Sign Language (ASL) users

• Visual based language• Cultural basis for hearing loss

• Fund of information issues despite normal intelligence• Social marginalization (similarities with other immigrant populations)• Lack of access to incidental learning opportunities

• Low English reading level• No available health literacy tool available for Deaf ASL users• Most current health literacy tools rely on phonetics, pronunciation

(REALM) or extensive reading comprehension (TOFHLA)

Research Objective • Creation and validation of a health literacy measure in

American Sign Language (ASL) to assess the prevalence of health literacy and its association with cardiovascular risk factors among Deaf ASL users

Rochester Prevention Research Center National Center for Deaf Health Research

Rochester Prevention Research Center National Center for Deaf Health Research

Newest Vital Sign (NVS)

(Weiss, 2005)

QUESTIONS1. If you eat the entire container, how many calories will you eat?

1,000

2. If you are allowed to eat 60 g of carbohydrates as a snack, how much ice cream could you have?Any of the following is correct: 1 cup; half the container; 2 servings

3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes 1 serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? 33

4. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? 10%

Pretend that you are allergic to the following substances: Penicillin, peanuts, latex gloves, and bee stings.5. Is it safe for you to eat this ice cream? No

6. (Ask only if the patient responds “no” to question 5): Why not?Because it has peanut oil.

Rochester Prevention Research Center National Center for Deaf Health Research

Methods• Adaption and Translation Work (NVS ASL-NVS version)

• Translation Work Group- translated (and back-translated)• Touch screen computer-based survey interface• In-depth cognitive interviews and beta-testing (n=14)• Modifications to ASL-NVS survey

• ASL-NVS Validation Analysis• Peabody Individual Achievement Test-Revised (PIAT-R)

reading comprehension subtest• Chew’s 3 Health Literacy Screener• Educational Attainment

Rochester Prevention Research Center National Center for Deaf Health Research

Rochester Prevention Research Center National Center for Deaf Health Research

Rochester Prevention Research Center National Center for Deaf Health Research

Study Population• Eligibility Criteria:

• Age (40-70) • Greater Rochester MSA, New York

• Deaf ASL users (n=133)• Hearing English speakers (n=211)• No demographic variable differences except race/ethnicity (p=0.0011)• Racial/ethnic predispositions comparable to national based surveys

Rochester Prevention Research Center National Center for Deaf Health Research

Table 1. Demographics by Hearing Status.

Demographic Variable Deaf (n = 133) Hearing (n = 211) p-value

Newest Vital Sign (Score) <.0001

Inadequate (0-1) 43.84 (64) 23.92 (50)

Indeterminate (2-4) 36.99 (54) 30.14 (63)

Adequate (5-6) 19.18 (96) 45.93 (96)

PIAT Grade Level Reading <.0001

Less than 8th grade 70.31 (90) 29.33 (61)

8th grade or more 29.69 (38) 70.67 (147)

*Adjustment for age, sex, race/ethnicity, education did not change the significance of this finding

NVS Score (0-1)– Inadequate after adjustmentDeaf: 41.0%Hearing: 22.8%

Rochester Prevention Research Center National Center for Deaf Health Research

Correlations with ASL-NVS and NVSCorrelations with NVS

Spearman Correlation Coefficients  Prob > |r| under H0: Rho=0  

Number of Observations  Deaf Hearing

  NVS CategoriesPIAT Grade Level (treated continuously) 0.59 0.64

<.0001 <.0001PIAT Grade Level (8th grade vs >8th grade ) 0.50 0.65

<.0001 <.0001EDUCATION (HS, some college, and 4 year and above

0.41 0.59

  <.0001 <.0001Chew’s Health Literacy Screener Questionnaire

-0.32 - (0.37-0.47)

.0002 <.0001

Rochester Prevention Research Center National Center for Deaf Health Research

Ordinal Logistic Regression Models (ASL-NVS and NVS)

Odds Ratio Estimates Probability of outcome decreasing

Effect Point Estimate

95% Wald Confidence Intervals

Pr > ChiSq

Age 1.065 1.031 1.101 0.0001

Female vs Male 0.725 0.453 1.159 0.179

Other including Multi-racial vs Non-Hispanic White 4.309 2.348 7.907 <.0001

EDUCATION 1: HS or less vs 4-year college or more 12.613 5.403 29.441 <.0001

EDUCATION 2: Some college vs 4-year college or more 2.867 1.701 4.834

INCOME 1: Less than $25k vs 3: $50k+ 4.547 2.505 8.255 <.0001

INCOME 2: $25k - < $50k vs 3: $50k+ 1.919 0.993 3.709

Deaf vs Hearing 6.038 3.574 10.202 <.0001

Rochester Prevention Research Center National Center for Deaf Health Research

Discussion• ASL-NVS and NVS both demonstrate high correlation with the PIAT-R

• Moderate correlation with Chew’s 3 health literacy questionnaire and educational attainment

• ASL-NVS appears to be a valid health literacy instrument for Deaf individuals

• Deaf ASL users appear to struggle with higher inadequate health literacy rates compared with hearing individuals even after adjustment for other factors

• Potential implications for linguistic and cultural adaptation and validation of health literacy instruments for linguistic minorities

• Limitations

Rochester Prevention Research Center National Center for Deaf Health Research

Future Directions• Use of ASL-NVS to measure effects of low health literacy on cardiovascular risk

• Testing of web- and computer-based NVS for wider dissemination

• Platform development for other linguistic minority groups• Developmental steps for health literacy mechanisms and interventions for Deaf ASL users

Rochester Prevention Research Center National Center for Deaf Health Research

Team and Support• Research Assistants:

• Martha Tuttle• Jackie Pransky

• Mentors:• Thomas Pearson, MD, MPH, PhD• Kevin Fiscella, MD, MPH• Michael Paasche-Orlow, MD• Philip Zazove, MD

• Consultant: Barry Weiss, MD• National Center for Deaf Health Research (U48 DP001910 and U48 DP000031 from the US

Centers for Disease Control and Prevention)• Grant Support: National Heart, Lung and Blood Institute at the National Institute of Health

(K01HL103140)

Rochester Prevention Research Center National Center for Deaf Health Research

Contact:Michael McKee, MD, MPH1381 South AvenueRochester, NY 14620585-506-9484 x 124585-568-6532 (vp)michael_mckee@urmc.rochester.eduwww.urmc.edu/ncdhrhttp://www.urmc.rochester.edu/people/?u=27088319

Dr. McKee is supported by the National Heart, Lung and Blood Institute at the National Institute of Health (K01HL103140).