The impact of literacy on health-related quality of life measurement and outcomes in cancer outpatients

Elizabeth A. Hahn*, David Cella, Deborah G. Dobrez, Barry D. Weiss, Hongyan Du, Jin Shei Lai, David Victorson, Sofia F. Garcia

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

30 Scopus citations


Background: Limited evidence exists regarding the relationship between literacy and health-related quality of life (HRQL). Research is needed to develop measurement techniques for low literacy populations and to evaluate potential literacy-related measurement bias. Methods: A Talking Touchscreen (TT) was developed for an HRQL study. Low (n = 214) and high literacy (n = 201) adult cancer outpatients participated, 70% of whom were from racial/ethnic minorities. Patients completed three questionnaires by TT: FACT-G (cancer-specific), SF-36 (generic health status), and a standard gamble utility questionnaire. Measurement bias was evaluated using item response theory (IRT). Effects of literacy on HRQL were evaluated using regression models. Results: Most (97%) patients rated the TT easy to use. In IRT analysis, 6/27 FACT-G and 12/31 SF-36 items demonstrated literacy bias; this was relatively balanced (10 items 'biased against' low literacy; 8 'biased against' high literacy). Mean literacy group differences were statistically and clinically non-significant for 9/14 HRQL outcomes. Adjustment for bias and/or covariates eliminated most remaining differences. Conclusions: The TT is valid and useful for HRQL assessment in low literacy populations. There appears to be no systematic literacy bias in reporting HRQL, and low literacy is not an independent risk factor for poorer HRQL.

Original languageEnglish (US)
Pages (from-to)495-507
Number of pages13
JournalQuality of Life Research
Issue number3
StatePublished - Apr 2007


  • Literacy
  • Measurement
  • Outcomes
  • Quality of life
  • Underserved populations

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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