The Effects of Pictograph in Combination with an Adapted SKILLD Questionnaire Among the Low Literacy Hispanic Population

Written by Marjorie Kozlowski, Anna Richmond, & Melissa Glassford

doi: https://doi.org/10.13178/jnparr. 2020.10.02.1007

Abstract

Background: According to 2017 data from the U.S. Centers for Disease Control and Prevention (CDC), 30.3 million people, or 9.4% of the U.S. population, are estimated to have diabetes (CDC, 2017). The prevalence of diabetes among the Hispanic population is higher than the national average (Aguayo-Mazzucato et al., 2019). In order to educate patients on how to best care for themselves, it is essential to first assess their fundamental knowledge of diabetes. One of the tools to make this assessment is the Spoken Knowledge in Low Literacy in Diabetes (SKILLD) questionnaire (Garcia et al., 2015; Michigan Diabetes Research Center, 2015). Not all patients are able to read or write in their own native language. One way to assess knowledge to mitigate this is by pictographs which are simple line drawings showing healthcare actions (Choi et al., 2017).

Objective: The purpose of this study was to assess whether diabetic Hispanic Americans with low literacy rates can demonstrate their knowledge of diabetes better through use of an adapted SKILLD questionnaire with pictographs rather than a validated multiple-choice SKILLD ques-
tionnaire. The current questionnaire used to assess this population’s diabetic knowledge is the Spoken Knowledge in Low Literacy for Diabetes (SKILLD) tool. Many patients at a primary care clinic in Highwood, IL have very little education and are unable to read in their own language. Therefore, the purpose of this study was to determine if the use of pictographs is a better way to assess existing knowledge about diabetes to provide further education.

Methods: The study employed a pre-test and post-test study design. Thirteen diabetic patients in an outpatient primary care clinic in Highwood, IL with a Hemoglobin A1c level greater than 8.0 mg/dL were interviewed after their routine appointment with their Primary Care Provider. Of the thirteen patients, eight of them had less than a 6th-grade education, and five of them completed grades 7th-12th. The SKILLD questionnaire was verbally administered to the patients and they were given ten questions with multiple-choice answers (pre-test). The patients were then given an adapted questionnaire with the same ten questions, but the answers were pictographs (post-test). Descriptive statistics such as frequencies, percentages, means, standard deviations were used to describe data distribution. Paired t-test and Cohen’s D statistics were used to assess the statistical significance between pre- and post-test mean scores at 0.05 alpha level and to determine the effect size of the pictographs, respectively.

Results: The post-test mean score was 0.78 (SD = 0.17; n =13) whereas the pre-test mean score was 0.53 (SD = 0.14; n = 13). The paired t-test showed a statistically significant difference in the pre and post-test means score (p = < 0.01; t = 7.23; df = 12). The computed Cohen’s D value of 2.0 demonstrated a large effect size of the pictographs in improving the participants’ basic diabetic knowledge. The Kuder-Richardson (KR) value for the adapted SKILLD questionnaire with the pictographs was at 0.589, supporting adequate reliability. In comparison, the K-R value for the SKILLD questionnaire without pictographs was 0.09, indicating very poor internal consistency or lack of reliability.

Conclusion: The basic diabetic knowledge level among Hispanic patients with very low literacy can be assessed efficiently and accurately with the use of the SKILLD questionnaire with pictographs. Without the pictographs, the SKILLD questionnaire may not be appropriate for use in this patient population and this warrants further investigation.

Keywords: diabetes, Hispanic, low literacy, SKILLD, pictograph