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Patient Educ Couns. 2008 Oct;73(1):132-40. doi: 10.1016/j.pec.2008.03.026. Epub 2008 May 16.

Adapting a patient satisfaction instrument for low literate and Spanish-speaking populations: comparison of three formats.

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Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.



To compare responses to print versions of the Consumer Assessment of Healthcare Providers and Systems 2.0 survey (CAHPS) to those for an illustration enhanced format and a telephone based interactive voice response format.


First, 2015 adult patients awaiting primary care visits completed: demographic information, Test of Functional Health Literacy (S-TOFHLA), CAHPS in one of three formats: print, illustrated, or interactive voice. A second sample of 4800 active patients was randomized to receive alternative formats.


Response rates for the illustrated (31.3%) and print (30.4%) formats were significantly higher than for the interactive voice format (18.1%). The results of the illustrated format were comparable to the traditional text version, but required about 2 min more to complete by both low and high literacy groups. There were almost no invalid responses for the interactive voice format, but the format was associated with lower CAHPS satisfaction scores.


Despite extensive efforts to produce formats tailored to individuals with limited literacy, surprisingly we found no consistent advantages to either alternative format. In fact, the interactive voice format yielded lower satisfaction scores and lower response rates.


Practitioners need to ensure the health instruments they use are aligned with literacy skills and delivery preferences of their consumers. The lack of benefit of the illustrated form does not support investment of resources in these formats to measure satisfaction. The interactive voice response deserves more study--do lower scores register limited access to or use of telephones, irritation or true signal?

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