The growing emphasis on patient-centered care has accelerated the demand for high-quality data from patient-reported outcome (PRO) measures. Traditionally, the development and validation of these measures has been guided by classical test theory. However, item response theory (IRT), an alternate measurement framework, offers promise for addressing practical measurement problems found in health-related research that have been difficult to solve through classical methods. This paper introduces foundational concepts in IRT, as well as commonly used models and their assumptions. Existing data on a combined sample (n = 636) of Korean American and Vietnamese American adults who responded to the High Blood Pressure Health Literacy Scale and the Patient Health Questionnaire-9 are used to exemplify typical applications of IRT. These examples illustrate how IRT can be used to improve the development, refinement, and evaluation of PRO measures. Greater use of methods based on this framework can increase the accuracy and efficiency with which PROs are measured.

Abstract. Advancing health literacy (HL) research requires high-quality HL measures. This article provides an overview of the state of the science of HL measurement at the level of the individual: where the field started, currently is, and should be going. It is divided into eight key sections looking at (1) the history of HL measurement, (2) the relationship between HL definitions and measurement, (3) the HL conceptual domains most and least frequently measured, (4) the methods used to validate HL measures, (5) the characteristics of the participants in the measurement validation studies, (6) the practical considerations related to administering HL measures, (7) the advantages and disadvantages of using objective versus subjective HL measures, and (8) future directions for HL measurement.Based on the material presented in this article, the following conclusions can be drawn. First, there is an enormous proliferation of HL measures and this growth presents both opportunities and challenges for the field. Second, to move the field forward, there is an urgent need to better align HL measurement with definitions of HL. Third, some HL domains, such as numeracy, are measured more often than others, such as speaking and listening. Consequently, it is important to think about novel mechanisms to measure HL domains that are rarely measured. Fourth, HL measures are most often developed, validated, and refined using classical measurement approaches. However, strong empirical and practical rationales suggest making an assertive shift toward using modern measurement approaches. Fifth, most HL measures are not well validated for use in minority populations; consequently, future validation studies should be mindful of validation samples. Sixth, HL measures can be administered using multiple modes, most frequently via paper-and-pencil surveys. Identifying which mode of administration is most suitable requires reflecting on the underlying measurement purpose and the characteristics of the participants being measured. These considerations should also be made when deciding between a subjective versus objective HL measure.Cumulatively, this article provides tools to help readers select and use the most appropriate measures of HL for their needs. It also provides rationale and strategies for moving the science of HL measurement forward. Numerous scientific calls and proposals followed to develop and test HL measures in support of that recommendation [30]. Now, more than a decade later, over 150 HL measures exist, demonstrating a sweeping response to the scientific calls and reflecting tremendous productivity in this area [17,34,37]. This growth presents both opportunities and challenges for the field [26,42]. In one respect, each of

NCT00406614.

Introduction Korean Americans are one of the most underserved ethnic/linguistic minority groups owing to cultural and institutional barriers; there is an urgent need for culturally competent diabetes management programs in the Korean American community for those with type 2 diabetes. The purpose of this study was to test the effectiveness of a community-based, culturally tailored, multimodal behavioral intervention program in an ethnic/linguistic minority group with type 2 diabetes. Design A RCT with waitlist comparison based on the Predisposing, Reinforcing, and Enabling Constructs in Education/environmental Diagnosis and Evaluation (PRECEDE)–Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PROCEED) and self-help models. Data were collected between September 2010 and June 2013 and were analyzed in August–December 2014. Statistical significance was set at p<0.05. Setting/participants In a naturally occurring community setting, a total of 250 Korean Americans with type 2 diabetes were randomized into an intervention group (n=120) or a control group (n=130). Intervention The intervention consisted of key self-management skill-building activities through 12 hours of group education sessions, followed by integrated counseling and behavioral coaching by a team of RNs and community health workers. Main outcome measures Primary (clinical) outcomes were hemoglobin A1c, glucose, total cholesterol, and low-density lipoprotein at baseline and 3, 6, 9, and 12 months. Secondary (psychosocial and behavioral) outcomes included diabetes-related quality of life, self-efficacy, adherence to diabetes management regimen, and health literacy. Results During the 12-month project, the intervention group demonstrated 1.0%–1.3% (10.9–14.2 mmol/mol) reductions in hemoglobin A1c, whereas the control group achieved reductions of 0.5%–0.7% (5.5–7.7 mmol/mol). The differences between the two groups were statistically significant. The intervention group showed statistically significant improvement in diabetes-related self-efficacy and quality of life when compared with the control group. Conclusions RN/community health worker teams equipped with culturally tailored training can be effective in helping an ethnic/linguistic minority group manage diabetes in the community.

Objectives To review the evidence supporting the validity of health literacy (HL) measures for ethnic minority populations. Methods PubMed, CINAHL, and PsycINFO databases were searched for HL measures between 1965 and 2013. Results A total of 109HL measures were identified; 37 were non-English HL measures and 72 were English language measures. Of the 72 English language measures, 17 did not specify the racial/ethnic characteristic of their sample. Of the remaining 55 measures, 10 (18%) did not include blacks, 30 (55%) did not include Hispanics, and 35 (64%) did not include Asians in their validation sample. When Hispanic and Asian Americans were included, they accounted for small percentages in the overall sample. Between 2005–2013, a growing number of REALM and TOFHLA translations were identified, and new HL measures for specific cultural/linguistic groups within and outside the United States were developed. Conclusions While there are a growing number of new and translated HL measures for minority populations, many existing HL measures have not been properly validated for minority groups. Practice Implications HL measures that have not been properly validated for a given population should be piloted before wider use. In addition, improving HL instrument development/validation methods are imperative to increase the validity of these measures for minority populations.

Objective While the role of health literacy in chronic disease management is well documented, few intervention studies have been reported. A major barrier to designing and implementing such interventions is the lack of valid health literacy tools. This study developed and tested a novel health literacy scale for individuals with high blood pressure (HBP). Methods A two-step design process was used: In the construction phase, focus group studies and a literature review were conducted to generate a pool of items. The testing phase involved a psychometric evaluation and pilot-testing of the scale on hypertensive Korean Americans (n=386). The end product was a HBP-health literacy scale (HBP-HLS) with two essential domains, print literacy and functional health literacy. Results Psychometric testing indicated that the scale was reliable (Kuder-Richardson-20 coefficient=0.98), valid (content validity index ≥0.8), and significantly correlated with theoretically selected variables (education, r=0.67, p<0.01; HBP knowledge, r= 0.33, p<0.01). Conclusion The HBP-HLS demonstrated its utility for evaluating HBP management interventions in the community setting. Practice Implications: Utilizing the HBP-HLS should be considered as a potential tool for improving health literacy and evaluating intervention studies in the context of HBP management.

Purpose The purpose of this article is to describe the process of translating evidence-based dietary guidelines into a tailored nutrition education program for Korean American immigrants (KAI) with type 2 diabetes mellitus (DM). Methods Community-based participatory research (CBPR) is a research process involving researchers and communities to build a collaborative partnership. The study was conducted at a community-based organization. In a total of 79 KAI (intervention, n = 40; control, n = 39) with uncontrolled type 2 DM (A1C ≥7.5%), 44.3% were female and the mean age was 56. 5 ± 7.9 years. A culturally tailored nutrition education was developed by identifying community needs and evaluating research evidence. The efficacy and acceptability of the program was assessed. Results In translating dietary guidelines into a culturally relevant nutrition education, culturally tailored dietary recommendations and education instruments were used. While dietary guidelines from the American Diabetes Association (ADA) were used to frame nutrition recommendations, additional content was adopted from the Korean Diabetes Association (KDA) guidelines. Culturally relevant intervention materials, such as Korean food models and an individually tailored serving table, were utilized to solidify nutritional concepts as well as to facilitate meal planning. Evaluation of the education revealed significantly increased DM-specific nutrition knowledge in the intervention group. The participants' satisfaction with the education was 9.7 on a 0 to 10-point scale. Conclusion The systematic translation approach was useful for producing a culturally tailored nutrition education program for KAI. The program was effective in improving the participants' DM-specific nutrition knowledge and yielded a high level of satisfaction. Future research is warranted to determine the effect of a culturally tailored nutrition education on other clinical outcomes.

The current assessment tools do not capture all the critical elements of HBP self-care. The few instruments that attempted to measure the multiple behavioral dimensions of HBP self-care failed to report adequate levels of psychometric properties of those domains because of their incompleteness. Challenges remain in translating the HBP self-care guidelines into effective intervention and relevant assessment tools. Developing a valid and reliable instrument that captures the multidimensional nature of HBP self-care is urgently needed.