Racial disparities in patient activation: Evaluating the mediating role of health literacy with path analyses

Primary and Emergency Care Use: The Roles of Health Literacy, Patient Activation, and Sleep Quality in a Latent Profile Analysis

BACKGROUND/OBJECTIVES

Healthcare utilization is a behavioral phenomenon influenced by psychosocial factors. This study took place in South Tyrol, a culturally diverse autonomous province in northern Italy, and aimed to identify latent profiles of primary healthcare users based on health literacy, patient activation, sleep quality, and service use, and to examine the sociodemographic and health-related predictors of profile membership.

METHODS

A cross-sectional survey was conducted with a representative adult sample (n = 2090). The participants completed the questionnaire in German or Italian. Latent profiles were identified via model-based clustering using Gaussian mixture modeling and four z-standardized indicators: total primary healthcare contacts (general practice and emergency room visits), HLS-EU-Q16 (health literacy), PAM-10 (patient activation), and B-PSQI (sleep quality). The optimal cluster solution was selected using the Bayesian Information Criterion (BIC). Kruskal-Wallis and chi-square tests were used for between-cluster comparisons of the data. Multinomial logistic regression was used to examine the predictors of cluster membership.

RESULTS

Among the 1645 respondents with complete data, a three-cluster solution showed a good model fit (BIC = 19,518; silhouette = 0.130). The identified profiles included 'Balanced Self-Regulators' (72.8%), 'Struggling Navigators' (25.8%), and 'Hyper-Engaged Users' (1.4%). Sleep quality could be used to differentiate between different levels of service use (p < 0.001), while low health literacy and patient activation were key features of the high-utilization groups. Poor sleep and inadequate health literacy were associated with increased healthcare contact.

CONCLUSIONS

The latent profiling revealed distinct patterns in health care engagement. Behavioral segmentation can inform more tailored and culturally sensitive public health interventions in diverse settings such as South Tyrol.

Validation of the Patient Activation Measure in kidney stone disease patients

INTRODUCTION

We aimed to validate the Patient Activation Measure (PAM) within a kidney stone disease (KSD) population, determine the variability of patient activation within this population, and characterize relationships between activation and variables such as health literacy, quality of life, and demographics.

METHODS

This cross-sectional study includes individuals 18 years or older followed for KSD at University of Montreal Hospital Center. Demographic data and responses for the PAM, Wisconsin Stone Quality of Life scale, and Health Literacy Questionnaire (HLQ) were acquired.

RESULTS

Females and those with poor medication adherence were found to have significantly lower activation. The HLQ dimensions "Actively managing my health," "Navigating the healthcare system," and "Understand health information well enough to know what to do" were associated with significantly higher activation. Rasch analysis revealed an item reliability of 0.81, a person reliability of 0.98, and a Cronbach's alpha of 0.88. Regarding item fit, only item 1 (When all is said and done, I am the person who is responsible for taking care of my health) fit poorly with the model. Principle component analysis revealed evidence of a second dimension, accounting for 9.0% of the variation in observed responses.

CONCLUSIONS

Female sex and poor medication adherence were associated with significantly lower activation. Aspects of health literacy concurring with the precise definition of "activation" were associated with significantly higher PAM scores. The PAM was found to have good person and item reliability, and good internal consistency; however, principal component analysis revealed that construct validity is possibly threatened by multidimensionality.

The role of patient activation in mediating the effects of health literacy level on quality of life among patients with gastrointestinal cancers

Gastrointestinal (GI) cancers present significant health challenges, necessitating strategies to improve patients' health-related quality of life (HRQoL). Health literacy (HL) and patient activation (PA) are key factors in patient self-management, yet their interplay and impact on HRQoL remain unclear. This study investigates the relationship between HL, PA, and HRQoL in GI cancer patients, with a focus on PA as a potential mediator between HL and HRQoL. We conducted a cross-sectional analysis using baseline data from the multicenter OptiScreen study. HL, PA, and HRQoL were assessed using validated instruments: the European Health Literacy Survey Questionnaire (HLS-EU-Q16), the Patient Activation Measure (PAM-13D), and the Short-Form Health Survey (SF-8). Statistical analyses included correlation tests and mediation modeling. Out of 854 eligible GI cancer patients, 397 (response rate = 46%) participated in the study. HL was positively correlated with PA, r(359) = 0.37, p < .001 and with physical and mental HRQoL, r(322) = 0.12, p = .035 and r(322) = 0.20, p < .001, respectively. We found that the relationship between HL and mental HRQoL is fully mediated by PA (indirect effect: 0.186, 95% CI [0.016, 0.385]). Our findings highlight the crucial role of PA in enhancing mental HRQoL in GI cancer patients, suggesting that interventions targeting both HL and PA could improve patient outcomes. Future research should explore phase-specific interventions and broader psychological factors affecting patient self-management and well-being.

Healthcare system navigation difficulties among informal caregivers of older adults: a logistic regression analysis of social capital, caregiving support and utilization factors

BACKGROUND

Informal caregivers of older adults play a vital role in improving the degree to which older adults access community and healthcare services in a seamless and timely manner. They are fulfilling important navigation and support roles for their older care recipients. However, there is still little knowledge of the most significant facilitators and barriers to effective and efficient system navigation among caregivers. This paper aims to fill these knowledge gaps through investigation of the key factors (i.e., social capital/cohesion, caregiving supports, and utilization factors) affecting navigation difficulties faced by informal caregivers of older adults.

METHODS

The Behavioural-Ecological Framework of Healthcare Access and Navigation (BEAN) model is used to frame the study. Using the General Social Survey on Caregiving and Care Receiving 2018, we analyzed 2,733 informal caregivers whose primary care recipients were aged 65 or older. Hierarchical logistic regression was conducted to identify the relationship between system navigation difficulties among informal caregivers and four sequentially ordered blocks of predictors: (1) sociodemographic (2), social capital/cohesion (3), caregiving supports, and (4) healthcare demand.

RESULTS

The fully adjusted model showed that the probability of reporting navigation difficulties was lower for caregivers with social capital/cohesion compared to those without social capital/cohesion. In comparison, the probability of reporting navigation difficulties was higher among caregivers with caregiving support and among caregivers whose care receivers use a higher amount of health service use. Several sociodemographic covariates were also identified.

CONCLUSION

Our findings support certain aspects of the BEAN model. This study extends our understanding of potential facilitators and barriers that informal caregivers of older adults face while navigating complex community and health systems. There is a need to implement coordinated schemes and health policies especially for older adults with mental/neurological issues to address the challenges of their caregivers given the specific vulnerability identified in this study. The need for further research using different approaches to examine the disproportionate impact of COVID-19 on caregivers' system navigation experience is crucial.

The African American Transplant Access Program: Mitigating Disparities in Solid Organ Transplantation

Black Americans experience end-stage kidney disease (ESKD) at a disproportionately higher rate than other racial and ethnic groups in the United States. Kidney transplantation provides the best outcomes for patients with ESKD. However, Black patients frequently have decreased access to kidney transplantation. This article summarizes the robust literature on disparities in transplantation for Black patients and presents a practical solution to this complex issue by redesigning the transplant access process for Black patients challenged by structural and institutional barriers. The authors provide a detailed overview of a novel African American Transplant Access Program (AATAP) with its pillars of cultural congruency, trust, health literacy, and psychosocial support. This overview includes a thorough description of the program's conceptualization, the process of creating the program, the preliminary results, and guidance to establish similarly culturally congruent transplant access programs.

Racial Composition of Past and Current Social Environments and Health Literacy

BACKGROUND

Research is needed to understand the impact of social determinants of health on health literacy throughout the life course. This study examined how racial composition of multiple past and current social environments was related to adults' health literacy.

METHODS

In this study, 546 adult patients at a primary care clinic in St. Louis, Missouri, completed a self-administered written questionnaire that assessed demographic characteristics and a verbally administered component that assessed health literacy with the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R) and Newest Vital Sign (NVS), and self-reported racial composition of six past and four current social environments. Multilevel logistic regression models were built to examine the relationships between racial composition of past and current social environments and health literacy.

RESULTS

Most participants identified as Black or multiracial (61%), had a high school diploma or less (54%), and household income <$20,000 (72%). About 56% had adequate health literacy based on REALM-R and 38% based on NVS. In regression models, participants with multiple past white environments (e.g., locations/conditions in which most of the people who live, go to school, work, and have leisure time are White) and (vs. 0 or 1) were more likely to have adequate health literacy based on REALM-R (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI]: 1.04-3.07). Similarly, participants who had multiple past white social environments were more likely (aOR = 1.94, 95% CI: 1.15-3.27) to have adequate health literacy based on NVS than those who had not. The racial composition of current social environments was not significantly associated with health literacy in either model.

CONCLUSIONS

Racial composition of past, but not current, educational and residential social environments was significantly associated with adult health literacy. The results highlight the importance of examining the impact of social determinants over the life course on health literacy. The findings suggest that policies ensuring equitable access to educational resources in school and community contexts is critical to improving equitable health literacy. [HLRP: Health Literacy Research and Practice. 2024;8(3):e130-e139.].

A qualitative exploration of facilitators and barriers to adopting a healthy lifestyle among Black, Hispanic, and American Indian males with diabetes or at risk for type 2 diabetes

OBJECTIVES

Higher prevalence of several chronic diseases occurs in men in the United States, including diabetes and prediabetes. Of the 34 million adults with diabetes and 88 million with prediabetes there is a higher prevalence of both conditions in men compared to women. Black, Hispanic, and American Indian men have some of the highest rates of diabetes and diabetes complications. Adopting a healthy lifestyle including healthy eating and physical activity, is important in preventing type 2 diabetes and diabetes complications.

DESIGN

This study included six focus groups that explored facilitators and barriers to adopting a healthy lifestyle in Black, Hispanic, and American Indian men with diabetes or at risk for type 2 diabetes. Thematic analysis was used to identify facilitators and barriers to adopting a healthy lifestyle.

RESULTS

Participants included males 18 years of age and older identifying as Black, Hispanic, or American Indian and diagnosed with prediabetes, diabetes, hypertension, or otherwise at risk for type 2 diabetes. Thirty-seven men participated, 19 diagnosed with diabetes and 18 at risk for type 2 diabetes. Fourteen Black, 14 Hispanic, and 9 American Indian men participated. The themes of facilitators to a healthy lifestyle included: family and the social network; psychosocial factors; health status, health priorities and beliefs about aging; knowledge about health and healthy behavior; and healthy community resources. Themes of barriers to a healthy lifestyle also included: mistrust of the health care system, cost, and low socioeconomic status.

CONCLUSIONS

This study underscores the complexity of factors involved in adopting a healthy lifestyle for some racial and ethnic minority men with diabetes or at risk for type 2 diabetes.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

Factors associated with patient activation among individuals with depression within racial/ethnic groups in the United States

Increasing patient activation may be vital for improving quality of care for individuals with depression. Among adults with depression who reside in the United States, we sought to examine the association of depression severity, race/ethnicity, and household income with patient activation and within identify factors associated with patient activation within race/ethnicity groups. Data from the 2020 US National Health and Wellness Survey, a cross-sectional, general population survey, were used to identify White, Black/African American, Asian, and Hispanic respondents with self-reported physician-diagnosed depression. Generalized linear models were used to identify factors associated with patient activation. Analyses included 8,216 respondents (mean age = 44 years, 68.0% female). Depression severity was negatively associated with patient activation (β = -0.29, p < 0.001). Patient activation was significantly higher in Black vs. White respondents (β = 1.50, p = 0.001) and in respondents with a household income of $25,000-$49,999 (β = 0.96, p = 0.015), $50,000-$99,000 (β = 0.88, p = 0.031), and ≥$100,000 (β = 1.78, p < 0.001) vs. <$25,000. Adjusted mean patient activation scores were highest among Black respondents (61.1), followed by Hispanic (60.2), White (59.6), and Asian (59.0) respondents. Neither race/ethnicity nor household income moderated the relationship between depression severity and patient activation; however, the factors most strongly associated with patient activation differed by race/ethnicity. These results indicate that the pathway to improving patient activation in individuals with depression may vary by race/ethnicity. Understanding factors associated with patient activation can help inform the design of interventions to increase patient activation in individuals with depression.

Demographic and socioeconomic disparities in receipt of ophthalmology consultation for facial trauma

OBJECTIVE

Functional outcomes following facial and ocular trauma are time-sensitive and require prompt evaluation to minimise long-term vision loss, yet few studies have systematically evaluated disparities in the management of these cases. This study investigates whether a patient's race/ethnicity, primary language, insurance status, gender or age affects receipt of ophthalmology consultation for facial trauma.

METHODS AND ANALYSIS

This study was a retrospective cohort analysis of patients from the Elmhurst City Hospital Trauma Registry in Queens, New York who were seen for facial trauma including open globe injuries and orbital fractures between January 2014 and May 2016.

RESULTS

Of the 264 patients included, 43% reported as Hispanic, 23% white, 11% Asian, 8% black and 15% other/unknown. After controlling for confounding variables by multivariable logistic regression, neither race/ethnicity, gender, nor primary language were significantly associated with the likelihood of receiving an ophthalmology consult. However, patients with private insurance had 2.57 times greater odds of receiving an ophthalmology consultation than those with Medicaid or state corrections insurance (95% CI 1.37 to 4.95). As age increased, the likelihood of receiving an ophthalmology consultation decreased (p=0.009); patients 60 years of age and older had one-third the odds of ophthalmology consultation as younger patients (OR 0.33; 95% CI 0.16 to 0.68).

CONCLUSIONS

This study highlights that lack of ophthalmology consultation in patients with facial trauma is linked to age and underinsurance. Extra attention must be paid during primary assessments to ensure elderly patients and those with public insurance have equitable access to timely and appropriate care for facial trauma.

Addressing Health Literacy in Pediatric Practice: A Health Equity Lens

Low health literacy has been linked to worse child health-related knowledge, behaviors, and outcomes across multiple health domains. As low health literacy is highly prevalent and an important mediator of income- and race/ethnicity-associated disparities, provider adoption of health literacy best practices advances health equity. A multidisciplinary effort involving all providers engaged in communication with families should include a universal precautions approach, with clear communication strategies employed with all patients, and advocacy for health system change.

Experiences of pain and pain management in advanced disease and serious illness for people from South Asian communities in Leeds and Bradford: a qualitative interview study

BACKGROUND

Pain is a significant problem for many people with advanced disease or a serious illness. Culture and ethnicity can affect the experience and management of pain. However, there is limited research in South Asian communities in the UK on their experiences of pain. The aim of this study is to explore the experiences and attitudes of patients and family carers from South Asian communities about pain and its management within advanced disease or serious illness.

METHODS

Qualitative thematic analysis based on descriptive phenomenology (Sundler et al. 2019). Qualitative semi-structured interviews with patients or family carers from South Asian communities (N = 15). Interviews were recorded, transcribed and analysed using an inductive approach. Public and Patient Involvement representatives from British South Asian communities were consulted for guidance.

RESULTS

There were five key themes from the interviews: The importance of communication about pain with healthcare professionals; Concerns about taking pain medication; Personal resilience, privacy and self-management; Gender, culture and pain; Home pain management as struggle and frustration.

CONCLUSION

To improve pain management for people from South Asian communities with advanced disease or a serious illness, there are a number of important issues for healthcare professionals from palliative and primary care services to address. These include: greater awareness around people's fears and concerns about pain medication; their potential use of alternative pain management strategies; and cultural issues such as resilience, privacy, dignity and gender roles. Effective communication between doctors, patients and family members could be improved by using a 'cultural humility' model; providing clear and accessible pain medication information; understanding and taking account of people with both low, and medium levels, of English language proficiency; and improving patient trust. Additionally, improvements to out of hours services could improve pain management for all patients managing their pain at home.

A survey study of adults with chronic conditions: Examining the correlation between patient activation and health locus of control

OBJECTIVES

This study aimed to examine (1) the association between patient activation (PA), health locus of control (HLOC), sociodemographic and clinical factors, and (2) the effect of HLOC dimensions, sociodemographic and clinical factors on PA.

METHODS

Three hundred U.S. adults, with at least one chronic condition (CC) were recruited through Amazon Mechanical Turk and completed an online survey which included sociodemographic questions, the Patient Activation Measure^® - 10, and the Multidimensional Locus of Control (MHLC) - Form B. Statistical analyses, including descriptive, correlation, and multiple linear regression, were conducted using IBM SPSS v25.

RESULTS

Of the 300 participants, more than half were male (66.3%), White (70.7%), with at least a college degree (76.0%), and employed full-time (79.0%). The average PA score was 68.8 ± 14.5. Multiple linear regression indicated that participants who reported they were Black, retired, with a greater number of CCs, and with higher scores in Chance MHLC had higher PA, while participants with higher scores in Internal MHLC, were unemployed and reported to have been affected by COVID-19-related worry or fear to manage their CC, had lower PA.

DISCUSSION

HLOC dimensions should be addressed concurrently with PA for patients with CCs, thus adding to a more patient-centered clinical approach.

MidCog study: a prospective, observational cohort study investigating health literacy, self-management skills and cognitive function in middle-aged adults

INTRODUCTION

The lack of definitive means to prevent or treat cognitive impairment or dementia is driving intense efforts to identify causal mechanisms. Recent evidence suggests clinically meaningful declines in cognition might present as early as middle age. Studying cognitive changes in middle adulthood could elucidate modifiable factors affecting later cognitive and health outcomes, yet few cognitive ageing studies include this age group. The purpose of the MidCog study is to begin investigations of less-studied and potentially modifiable midlife determinants of later life cognitive outcomes.

METHODS AND ANALYSIS

MidCog is a prospective cohort study of adults ages 35-64, with two in-person interviews 2.5 years apart. Data will be collected from interviews, electronic health records and pharmacy fill data. Measurements will include health literacy, self-management skills, cognitive function, lifestyle and health behaviours, healthcare use, health status and chronic disease outcomes. Associations of health literacy and self-management skills with health behaviours and cognitive/health outcomes will be examined in a series of regression models, and moderating effects of modifiable psychosocial factors.Finally, MidCog data will be linked to an ongoing, parallel cohort study of older adults recruited at ages 55-74 in 2008 ('LitCog'; ages 70-90 in 2023), to explore associations between age, health literacy, self-management skills, chronic diseases, health status and cognitive function among adults ages 35-90.

ETHICS AND DISSEMINATION

The Institutional Review Board at Northwestern University has approved the MidCog study protocol (STU00214736). Results will be published in peer-reviewed journals and summaries will be provided to the funders of the study as well as patients.

Scoping review: Influence of cisgender male and female genders on health literacy of the elderly people

This scoping review mapped out the relevant literature, identified gaps and made suggestions on the influence of cisgender on the health literacy (HL) of the elderly people. This scoping review was guided by the PRISMA-ScR checklist. The databases Wiley Online Library™ and Elsevier™ were searched for academic articles published in the English language between February 2011 and February 2021 that met a pre-set criteria of content. The process of selection of sources of evidence based on screening and eligibility of evidence reduced the initially identified 153 sources of evidence in the searched databases to 14 sources of evidence. The content of these 14 sources of evidence was mapped out on a charting table where data was summarised and synthesised individually and collectively by the authors. Repetitive and irrelevant data were deleted. Identified gaps include the lack of extensive exploration of male and female genders alone as a determinant of HL, how gender may be utilised to encourage elderly men and women to apply HL, how different sociocultural and sociodemographic backgrounds of elderly men and women would require separate academic research, the scarcity of social sciences based research and qualitative research methodologies on the subject as well as the use of mixed-methodologies and longitudinal studies. Future research directions were suggested and limitations of this scoping review are addressed in the discussion.

The Role of Medical Mistrust in Concerns about Tumor Genomic Profiling among Black and African American Cancer Patients

Tumor genomic profiling (TGP) is used in oncology practice to optimize cancer treatment and improve survival rates. However, TGP is underutilized among Black and African American (AA) patients, creating potential disparities in cancer treatment outcomes. Cost, accuracy, and privacy are barriers to genetic testing, but medical mistrust (MM) may also influence how Black and AA cancer patients perceive TGP. From December 2019 to February 2020, 112 Black and AA adults from two outpatient oncology sites in Philadelphia, PA without a known history of having TGP testing conducted completed a cross-sectional survey. Items queried included sociodemographic characteristics, clinical factors, patient-oncologist relationship quality, medical mistrust, and concerns about TGP. A k-means cluster analysis revealed two distinct psychographic clusters: high (MM-H) versus low (MM-L) medical mistrust. Clusters were not associated with any sociodemographic or clinical factors, except for age (MM-H patients older than MM-L patients, p = 0.006). Eleven TGP concerns were assessed; MM-H patients expressed greater concerns than MM-L patients, including distrust of the government, insurance carriers, and pharmaceutical companies. TGP concerns varied significantly based on level of medical mistrust, irrespective of sociodemographic characteristics. Targeted communications addressing TGP concerns may mitigate disparities in TGP uptake among those with medical mistrust.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes

IMPORTANCE

Health literacy is considered an important social determinant of health that may underlie many health disparities, but it is unclear whether inadequate health literacy among pregnant individuals is associated with adverse maternal and neonatal outcomes.

OBJECTIVE

To assess the association between maternal health literacy and maternal and neonatal outcomes among nulliparous individuals.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of a large, multicenter cohort study of 10 038 nulliparous individuals in the US (2010-2013). Participants underwent 3 antenatal study visits and had detailed maternal and neonatal data abstracted. Data analysis was performed from July to December 2019.

EXPOSURES

Between 16 and 21 weeks of gestation, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Short Form, a validated 7-item word recognition test. In accordance with standard scoring, results were dichotomized as inadequate vs adequate health literacy.

MAIN OUTCOMES AND MEASURES

On the basis of theoretical causal pathways between health literacy and health outcomes, a priori maternal and neonatal outcomes (determined via medical records) were selected for this analysis. Multivariable Poisson regression models were constructed to estimate the associations between health literacy and outcomes. Sensitivity analyses in which education was removed from models and that excluded individuals who spoke English as a second language were performed.

RESULTS

Of 9341 participants who completed the Rapid Estimate of Adult Literacy in Medicine-Short Form, the mean (SD) age was 27.0 (5.6) years, and 2540 (27.4%) had publicly funded prenatal care. Overall, 1638 participants (17.5%) had scores indicative of inadequate health literacy. Participants with inadequate health literacy were more likely to be younger (mean [SD] age, 22.9 [5.0] vs 27.9 [5.3] years), have less educational attainment (some college education or greater, 1149 participants [73.9%] vs 5279 participants [94.5%]), have publicly funded insurance (1008 participants [62.2%] vs 1532 participants [20.0%]), and report they were a member of an underrepresented racial or ethnic group (non-Hispanic Black, 506 participants [30.9%] vs 780 participants [10.1%]; Hispanic, 516 participants [31.5%] vs 948 participants [12.3%]) compared with those with adequate health literacy. Participants who had inadequate health literacy had greater risk of cesarean delivery (adjusted risk ratio [aRR], 1.11; 95% CI, 1.01-1.23) and major perineal laceration (aRR, 1.44; 95% CI, 1.03-2.01). The adjusted risks of small-for-gestational-age status (aRR, 1.34; 95% CI, 1.14-1.58), low birth weight (aRR, 1.33; 95% CI, 1.07-1.65), and 5-minute Apgar score less than 4 (aRR, 2.78; 95% CI, 1.16-6.65) were greater for neonates born to participants with inadequate health literacy. Sensitivity analyses confirmed these findings.

CONCLUSIONS AND RELEVANCE

These findings suggest that inadequate maternal health literacy is associated with a variety of adverse maternal and neonatal outcomes.

Social Determinants, Health Literacy, and Disparities: Intersections and Controversies

This article synthesizes what is known about the relationship between social disadvantage and measures of health literacy (HL), and reviews the research examining whether low HL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a United States perspective, this article offers a novel conceptual framework that presents how the social determinants of health might interact with HL to result in health disparities. The framework articulates relationships that reflect public health pathways and health care pathways, which include their related health literacies. The article continues with several cautionary statements based on the inherent limitations of current HL research, including problems and concerns specific to the attribution of HL as an explanatory factor for extant socioeconomic and racial/ethnic health disparities. The article closes with recommendations regarding future research directions. [HLRP: Health Literacy Research and Practice. 2021;5(3):e233–e243.]

Challenges for Latina Breast Cancer Patient Survivorship Care in a Rural US-Mexico Border Region

Rural US Latina breast cancer patients experience language barriers, health literacy issues, and limited access to health care resources that negatively impact survivorship care. This study explored the challenges to survivorship care for rural Latina breast cancer (BC) patients and approaches to supporting survivorship care plans (SCP) from the stakeholders’ perspectives. Data were collected via eight focus groups (n = 40) and individual interviews (n = 4) with Latina BC patients, family caregivers, and health care professionals in a rural US-Mexico Border region. Interviews were audio-taped, transcribed, translated, and analyzed using thematic analysis. Themes related to the patient’s SCP challenges included: (1) lack of knowledge of treatment information, (2) lack of proactive health behavior, (3) gaps in information for care coordination, (4) psychological distress, and (5) difficulty retaining health information. Respondents expressed that the SCP document could fill patient information gaps as well as support patient communication with their clinicians and family. Rural BC patients demonstrated an acute need for information and active engagement in their survivorship care. The findings indicate the importance of addressing challenges for survivorship care on multiple dimensions: Cognitive, behavioral, social, and structural. Developing a culturally tailored SCP intervention will be imperative to support survivorship care.

Health literacy and diabetes self-care activities: The mediating effect of knowledge and patient activation

BACKGROUND

An association between health literacy and health outcomes has been widely reported in the literature. However, models exploring the links between health literacy and the outcomes of health literacy need further testing. The purpose of this study was to examine the pathways of health literacy on diabetes self-care activities amongst patients with Type 2 diabetes.

METHODS

A cross-sectional survey using secondary data analysis was conducted on 155 patients with Type 2 diabetes recruited from the diabetes clinics of two university hospitals in a metropolitan city in South Korea. Structural equation modelling analysis using bootstrapping was carried out using the AMOS software.

RESULTS

Health literacy had no significant direct effect on diabetes self-care activities. Rather, health literacy had a significant indirect effect on diabetes self-care activities mediated through diabetes knowledge and patient activation.

CONCLUSION

These findings indicate that interventions intended to improve self-care activity amongst older adults with low health literacy should include strategies to enhance patients' knowledge, as well as their activation for diabetes self-care.

Health Literacy: An Interactive Outcome Among Secondary Students in Beijing

BACKGROUND

Health literacy enables a person to make good decisions regarding health care, disease prevention, and health promotion to maintain and improve health. Although health literacy research in China has gained increasing attention in recent years, most existing studies focus on adults rather than adolescents. In addition, little theory-driven empirical research has been conducted to fully understand the relationship among health literacy, its influencing factors, and health outcomes scored on a skills-based health literacy instrument.

OBJECTIVE

This study applied Manganello's framework to investigate how health literacy was related to its antecedents and health status in secondary students in Beijing, China.

METHODS

A cross-sectional study was conducted with 650 students in Years 7 to 9 (age 11-17 years) from four secondary schools. Students completed a self-administered questionnaire based on Manganello's health literacy framework, which measured key upstream determinants, including health literacy and self-report health status. Health literacy was measured on an 8-item skills-based instrument that assesses a person's ability to find, understand, appraise, and communicate health information in everyday life (scores range from 0-37). Descriptive statistics and path analysis were conducted to investigate the mediating role of health literacy in predicting health status.

KEY RESULTS

Overall, the average scores of students' health literacy was 26.37 (±5.89). Manganello's framework was supported by the data collected (χ2/df = 2.049, p = .001, comparative fix index = 0.966, root mean square error of approximation = 0.041). Personal self-efficacy (r = 0.11, p = .007), social support (r = 0.18, p < .001), and school environment (r = 0.27, p < .001) predicted health literacy, which in turn predicted students' health status (r = 0.12, p = .005).

CONCLUSIONS

Adolescent health literacy is not only a person's capability to protect health, but also an interactive outcome with the broader environment. Promoting health literacy could be a useful strategy to improve health status for adolescents; however, a holistic approach is needed to increase students' self-efficacy, promote social support, and create positive school environments to achieve optimal health literacy and health outcomes. [HLRP: Health Literacy Research and Practice. 2021;5(1):e1-e14.] PLAIN LANGUAGE SUMMARY: We investigated how health literacy was related to its influencing factors and health status among secondary students in Years 7 to 9 in Beijing, China. Students with low self-efficacy, low social support, and low perceptions of positive school environment were more likely to have low health literacy, which in turn predicted poor health status.

Unmet Needs of Healthcare Services and Associated Factors among a Cohort of Ghanaian Adults: A Nationally Stratified Cross-Sectional Study Design

We estimated the prevalence of unmet needs of healthcare services (UNHS) and its associated factors among a cohort of older Ghanaian adults. World Health Organization (WHO) Study on Global AGEing and Adult Health for Ghana was used with a total of 4735 participants. Logistics regression analysis was performed using Stata 16 to assess associated factors. The overall UNHS was 3.7% (95% CI = 2.7-4.8) and the prevalence was significantly high amongst older adults aged 60 to 69 years (5.9%). Could not afford the healthcare (56.4%) was the main contender for UNHS. UNHS was influenced by; those aged 60 to 69 years [OR (95% CI) = 1.86 (1.19-2.91)]; no formal educational [aOR (95% CI) = 4.71 (1.27-17.38)], and no NHIS [OR (95% CI) = 1.78 (1.03-3.09)]. Participants needed care for joint pain (25.4%), and communicable diseases (19.1%). The inability to access healthcare was relatively higher for older adults more advanced in age, with low education, and for those without health insurance. Health system strengthening including financial protection by expanding the National Health Insurance Scheme to all Ghanaians in line with Ghana's Universal Health Coverage Roadmap would reduce the unmet healthcare needs of older adults.

The Atrial Fibrillation Health Literacy Information Technology Trial: Pilot Trial of a Mobile Health App for Atrial Fibrillation

Background

Atrial fibrillation (AF) is a common arrhythmia that adversely affects health-related quality of life (HRQoL). We conducted a pilot trial of individuals with AF using a smartphone to provide a relational agent as well as rhythm monitoring. We employed our pilot to measure acceptability and adherence and to assess its effectiveness in improving HRQoL and adherence.

Objective

This study aims to measure acceptability and adherence and to assess its effectiveness to improve HRQoL and adherence.

Methods

Participants were recruited from ambulatory clinics and randomized to a 30-day intervention or usual care. We collected baseline characteristics and conducted baseline and 30-day assessments of HRQoL using the Atrial Fibrillation Effect on Quality of Life (AFEQT) measure and self-reported adherence to anticoagulation. The intervention consisted of a smartphone-based relational agent, which simulates face-to-face counseling and delivered content on AF education, adherence, and symptom monitoring with prompted rhythm monitoring. We compared differences in AFEQT and adherence at 30 days, adjusted for baseline values. We quantified participants’ use and acceptability of the intervention.

Results

A total of 120 participants were recruited and randomized (59 to control and 61 to intervention) to the pilot trial (mean age 72.1 years, SD 9.10; 62/120, 51.7% women). The control group had a 95% follow-up, and the intervention group had a 93% follow-up. The intervention group demonstrated significantly higher improvement in total AFEQT scores (adjusted mean difference 4.5; 95% CI 0.6-8.3; P=.03) and in daily activity (adjusted mean difference 7.1; 95% CI 1.8-12.4; P=.009) compared with the control between baseline and 30 days. The intervention group showed significantly improved self-reported adherence to anticoagulation therapy at 30 days (intervention 3.5%; control 23.2%; adjusted difference 16.6%; 95% CI 2.8%-30.4%; P<.001). Qualitative assessments of acceptability identified that participants found the relational agent useful, informative, and trustworthy.

Conclusions

Individuals randomized to a 30-day smartphone intervention with a relational agent and rhythm monitoring showed significant improvement in HRQoL and adherence. Participants had favorable acceptability of the intervention with both objective use and qualitative assessments of acceptability.

The Intersections Between Social Determinants of Health, Health Literacy, and Health Disparities

This chapter synthesizes what is known about the relationship between social disadvantage and measures of low health literacy (LHL), and reviews the research examining whether LHL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a U.S. perspective, the chapter then offers a novel conceptual framework that presents how the social determinants of health might interact with LHL to result in health disparities. The framework articulates relationships that reflect public health pathways and healthcare pathways, which include their related health literacies. In addition, the chapter highlights as an exemplar one important potential causal mechanism in the healthcare pathway by exploring the communication model in outpatient care, as communication has been very well-studied with respect to both health disparities and HL. The chapter then, provides two examples of HL interventions aligned with the conceptual framework, one of which addresses the health care literacy pathway, and the other addresses the public health literacy pathway. The chapter continues with a number of cautionary statements based on the inherent limitations of current HL research, including problems and concerns specific to the attribution of HL as an explanatory factor for extant socioeconomic and racial/ethnic health disparities. The chapter closes with recommendations regarding future research directions.

Self-management practice, associated factors and its relationship with health literacy and patient activation among multi-morbid COPD patients from rural Nepal

Background

Chronic Obstructive Pulmonary Disease (COPD) is a progressive and debilitating condition that affects individuals’ quality of life. COPD self-management and supports provided by carers is key to the quality of life people living with COPD. Health literacy (HL) and Patient Activation (PA) are main drivers of self-management practices (SMPs). However, their contribution remains to be fully explored. This study aimed to examine the level of self-management practices, and the relationship with socio-demographic factors, HL and PA among multi-morbid COPD patients from rural Nepal.

Methods

This is a cross-sectional study conducted between July 2018 and January 2019. Patients completed a survey, including Self-management Practices questionnaire (SMPQ), five domains of the Health Literacy Questionnaire (HLQ), and Patient Activation Measure (PAM). The relationship between HL, PAM, and SMPs was examined using univariate statistics. Multivariable analysis was conducted to identify the factors associated with SMPs.

Results

A total of 238 patients responded to the study. The mean score of SMPQ was 45.31(SD = 9.00). The HLQ and PAM scores were positively correlated with the total score of SMPQ. Low level of SMPs were found to be positively associated with being uneducated (β = − 0.43, p = .001), having a low family income (β = − 5.22, p = .002), and, negatively associated with the presence of more than one co-morbidity (β = 3.58, p = 0.007) after controlling for other socio-demographic variables in the multivariable analysis.

Conclusion

The overall SMPs among this sample of Nepalese with COPD were low. Our findings highlight the need to implement a self-management intervention program involving patient activation and health literacy-focused activities for COPD, creating a support system for patients from low-income families and low education.

Associations Between Engagement With an Online Health Community and Changes in Patient Activation and Health Care Utilization: Longitudinal Web-Based Survey

BACKGROUND

Participation in online health communities (OHCs) is a popular trend in the United Kingdom. However, so far, no evidence exists to indicate an association between participation in OHCs and improved health outcomes.

OBJECTIVE

This study aimed to (1) determine changes in patient activation over 3 months in new users of an OHC, (2) describe patterns of engagement with an OHC, (3) examine whether patients' characteristics at baseline were associated with subsequent patterns of engagement, and (4) determine if patterns of engagement during the 3 months were associated with changes in patient activation, health care utilization, and health status.

METHODS

Active new OHC users on HealthUnlocked (HU) were surveyed to measure demographics, levels of patient activation (describing a person's confidence in managing their own health; scale 0-100 with 4 categories), health care utilization, and health status using a Web-based survey at baseline and 3 months. Patient activation at baseline and 3 months was compared (aim 1). Alongside, for a sample of HU users and survey responders, daily OHC website usage data were automatically captured. This was used to identify clusters of engagement with HU (aim 2). For survey responders, baseline characteristics, patient activation, health care utilization, and health status were compared at baseline and 3 months, overall, and between engagement clusters using t tests and chi-square tests (aims 3 and 4).

RESULTS

In 329 people who completed both surveys, baseline activation was most frequently level 3, described as taking action but still lacking confidence. At follow-up, a change of 2.6 points was seen, with the greatest change seen in those at lowest baseline activation levels. In addition, 4 clusters of engagement were identified: low, medium, high, and very high, who were active on HU for a mean of 4, 12, 29, and 59 days, respectively. Survey responders were more commonly high or very high engagers. Baseline activation was highest in low and very high engagers. Overall activation increased over time in all engagement groups. Very high engagers had the greatest improvement in activation (5 points), although the average change was not above what is considered clinically meaningful for any group. Fewer accident and emergency visits were seen at follow-up in those with higher engagement, although this trend was not seen for other health care utilization measures. There was no change in health status at 3 months.

CONCLUSIONS

This observational study provides some insight into how patterns of engagement with OHCs are associated with changes in patient activation, health care utilization, and health status. Over 3 months, overall, the change in activation was not clinically significant, and there were some indications that OHCs may be of benefit to particular groups. However, the study limitations prevent firm conclusions about causal relationships.

High Patient Activation Is Associated With Remission in Patients With Inflammatory Bowel Disease

BACKGROUND

High levels of patient activation (having the knowledge, skills, and confidence to effectively manage one's care), have been associated with improved outcomes in many chronic conditions. There have been few studies of the effects of activation in patients with inflammatory bowel disease (IBD). We performed a large, prospective Internet-based study to assess the relationship between patient activation level and clinical remission in patients with Crohn's disease or ulcerative colitis.

METHODS

We administered the Patient Activation Measure (Insignia Health) to 1486 cohort participants. Patients completed a follow-up survey within 13 months (median, 189 days). We collected demographic and clinical data; anxiety and depression were assessed using Patient-Reported Outcomes Measurement Information System instruments. We used bivariate analyses and multivariable logistic regression to identify characteristics associated with low or high patient activation and to evaluate the association between levels of patient activation and subsequent disease activity.

RESULTS

Higher anxiety (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.29-0.36) and depression (aOR, 0.33; 95% CI, 0.29-0.37) scores were associated with a decreased odds of high patient activation. After we adjusted for education status, smoking, medication use, and other confounders, we found that patients with high activation at baseline were more likely to be in clinical remission during the follow-up period (aOR, 1.71; 95% CI, 1.20-2.45).

CONCLUSIONS

In a large, prospective Internet-based cohort of patients with IBD, we found a strong association between patient activation and clinical remission. These findings suggest that patient activation affects disease outcomes.

Cultural Considerations for Psychologists in Primary Care

Many health concerns in the United States (e.g., diabetes) are routinely managed in primary care settings. Regardless of the medical condition, patients' health is directly influenced by factors such as healthcare providers and cultural background. Training related to how behaviors influence health, coupled with training on how cultural diversity intersects with mental health, allows psychologists to have the relevant expertise to assist in the development of primary care behavioral health interventions. However, many psychologists in primary care struggle with how to integrate a culture-centered paradigm into their roles as behavioral health providers. This paper provides an introduction on how three culture-centered concepts (providers' cultural sensitivity, patient-provider cultural congruency, and patients' health literacy) can be applied in primary care using the Five A's Organizational Construct and a model of cultural competence. In addition, the paper includes a section on integration of cultural considerations into consultation and training and concludes with a discussion of how the three culture-centered concepts have implications for health equity.

Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE

BACKGROUND

Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated.

OBJECTIVE

To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy).

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly.

METHODS

A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy.

RESULTS

The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI - 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI - 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (- 4.6; 95% CI - 9.1, - 0.15; p = 0.04).

CONCLUSIONS

We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention. CLINICALTRIALS.

GOV IDENTIFIER

NCT01828567.

Effect of an mHealth Intervention to Improve Health Literacy in Immigrant Populations: A Quasi-experimental Study

Health literacy is a social determinant of the basic health of populations and is especially important to enhancing and developing the empowerment of migrant populations. To evaluate the effectiveness of an mHealth intervention to improve the cognitive and social skills that enable migrants to access and use health services, we developed a quasi-experimental design to encompass a single group of enrolled immigrants (N = 93). They completed preintervention and postintervention questionnaires of the European Health Literacy Survey Questionnaire, the self-created questionnaire HL-APP-Q14 (Health Literacy App Questionnaire), and a practical simulation test. Health literacy improved significantly after the intervention, increasing from a problematic level (mean, 9.55 [SD, 4.35]) to a sufficient level (mean, 14.03 [SD, 2.68]). Differences were statistically significant for males and females as well as for participants of all nationalities, except the Chinese group. The application e_SaludAble empowered the migrant participants through the improvement of their health literacy.

A descriptive, cross-sectional study examining treatment burden in people living with HIV

AIM

(1) describe the percentage of people living with HIV (PLWH) experiencing high levels of treatment burden who are at risk for self-management non-adherence, and (2) examine the relationship between known antecedent correlates (the number of chronic conditions, social capital, and age) of self-management and treatment burden while controlling for sample socio-demographics.

BACKGROUND

Chronic condition self-management is key to maintaining optimal health in the aging population of PLWH. Despite the efforts of providers, patients, and caregivers, self-management non-adherence is still a factor contributing to poor chronic condition self-management and subsequent poor health outcomes. Recent research has identified treatment burden as a risk factor of poor chronic disease self-management adherence.

METHOD

Cross-sectional, secondary analysis of a sub-sample of 103 community dwelling, men and women diagnosed with HIV/AIDS derived from a larger parent study examining physical activity patterns in PLWH.

RESULTS

Participants reported an overall low level of treatment burden (M = 22.84; SD = 24.57), although 16% (n = 16) of the sample indicated experiencing high treatment burden. The number of chronic conditions (r = 0.25; p ≤ .01) and social capital (r = -0.19; p = .03) were significantly correlated with treatment burden. Multivariate analysis testing known antecedent correlates of treatment burden was statistically significant (p < .05), but only explained 8% of treatment burden's variance.

CONCLUSION

Findings have implications for nursing care of PLWH demonstrating a subset of PLWH experience high treatment burden related to chronic condition self-management. Findings also identify characteristics of PLWH who may be at high risk for treatment burden and subsequent self-management non-adherence.

Limited Health Literacy Is Associated With Worse Patient-Reported Outcomes in Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) face complex health tasks and decisions. Limited health literacy is a risk factor for poor health outcomes, but this has not been examined in IBD. This study aims to assess the role of health literacy for patients with IBD.

METHODS

We prospectively enrolled adults with IBD receiving care from the Section of Gastroenterology at the Boston Medical Center. In-person, standardized questionnaires were administered to measure health literacy with the Newest Vital Sign, self-efficacy with the Medication Use and Self-Efficacy Scale, quality of life with the 10-question Short Inflammatory Bowel Disease Questionnaire, depression with the Patient-Reported Outcomes Measurement System Short Form, and clinical disease activity for patients with Crohn's disease with the Harvey-Bradshaw Index and for patients with ulcerative colitis with the Simple Clinical Colitis Activity Index (SCCAI). The relationships between health literacy and these variables were subsequently examined.

RESULTS

Of 112 patients invited to participate, 99 enrolled and completed the interview. Limited health literacy was identified in 40% (n = 40) of patients. Patients with limited health literacy reported significantly worse overall health (P = 0.03) and more depressive symptoms (P = 0.01). Of the 56 patients with Crohn's disease, those with adequate health literacy were more likely to be in clinical remission (mean Harvey-Bradshaw Index score < 5), compared with those with limited health literacy (odds ratio, 4.15; 95% confidence interval, 1.37 to 13.45; P = 0.01). There was no significant association between health literacy and clinical disease activity (SCCAI) in patients with ulcerative colitis.

CONCLUSIONS

Limited health literacy is associated with lower ratings of subjective health and depression in IBD and more symptoms of active disease in patients with Crohn's disease.

The relationship between health literacy and patient activation among frequent users of healthcare services: a cross-sectional study

BACKGROUND

Frequent users of healthcare services are a vulnerable population that deserves attention due to high costs and negative outcomes such as lower quality of life and higher mortality. Healthcare systems should offer interventions tailored to their needs and to their level of health literacy, including strategies to promote activation. The relationship between health literacy and patient activation remains to be explored. The aim of this study was to examine the association between health literacy and patient activation in a population of frequent users of healthcare services with chronic diseases.

METHODS

Cross-sectional data were collected (before randomization) through a clinical trial evaluating a case management intervention in primary care. Participants (n = 247) were recruited from the list of frequent users of 4 Family Medicine Groups (FMG) in the Saguenay-Lac-St-Jean region of Québec (Canada). They completed questionnaires by self-report during an encounter with a research assistant: (1) the Newest Vital Sign (NVS) to evaluate health literacy (independent variable); and (2) the Patient Activation Measure-13 (PAM-13) to evaluate patient activation (dependent variable). The relationship between health literacy and activation was examined using biserial correlations.

RESULTS

No association was found between health literacy (independent variable) and patient activation (rb = 0.075, ρ = 0.07) for this population of frequent users of healthcare services.

CONCLUSIONS

This study suggests that there is no relationship between health literacy and patient activation among frequent users of healthcare services.

TRIAL REGISTRATION

NCT01719991 . Registered October 25, 2012.

Increasing uptake of comparative effectiveness and patient-centered outcomes research among stakeholders: insights from conference discussion

The goal of comparative effectiveness research (CER) and patient-centered outcomes research (PCOR) is to improve health outcomes by providing stakeholders with evidence directly relevant to decision making. In January 2017, the Pharmaceutical Research and Manufacturers Association Foundation, alongside the Academy for Managed Care Pharmacy, organized a conference aimed at engaging experts and opinion leaders representing clinicians, patients and payers to identify and discuss barriers and strategies to enhancing uptake and use of CER/PCOR. This report summarizes the conference discussion in the following sections: preconference survey; summary of barriers and strategies to the uptake of CER/PCOR identified by conference attendees; and future perspectives on the field.

Health literacy in Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample, and to validate health literacy measures in the Italian language

INTRODUCTION

Health literacy (HL) concerns the knowledge and competences necessary for people to meet complex health demands. The aims of this study are to assess the level of HL in a sample using the Italian version of the Newest Vital Sign and the association of HL and selected antecedents with health outcomes, and to develop and validate the Italian version of the three Brief Health Literacy Screeners, two subjective numeracy items and the short form and the short-short form of the European Health Literacy Survey Questionnaire.

METHODS AND ANALYSIS

The study adopts a cross-sectional design and is being conducted in Florence, with information collected through telephone interviews. The population-based sample has been randomly selected using the registries of eight general practitioners (GPs). Based on a power calculation, 480 subjects will be included. Participants have been randomly offered two different questionnaires, each containing different HL measures. Data on sociodemographics and important antecedents and consequences of HL will be collected and the distribution of HL levels calculated. The mediating role of HL will be assessed using Preacher and Hayes' model. To assess the concurrent validity of the HL scales, correlation and receiver operating characteristic analyses will be performed.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of the Area Vasta Centro. Results will be disseminated via scientific journals and conference presentations, and individual data made available to the GPs.

A Conceptual Framework for Examining Healthcare Access and Navigation: A Behavioral-Ecological Perspective

This paper introduces a conceptual framework for investigating individual ability to navigate healthcare in the contexts of the built environment, social environment, and healthcare infrastructure in which a person is embedded. Given the complexity of healthcare delivery in the United States, consumers are expected to have an increasingly sophisticated set of skills in order to effectively navigate and benefit from the healthcare resources available to them. Addressing barriers to navigation in vulnerable populations may be essential to reducing health disparities. This paper builds on previous conceptual developments in the areas of healthcare use, navigation, and ecological perspectives on health in order to present a behavioral-ecological framework for examining healthcare navigation and access. The model posits that healthcare navigation is an ecologically informed process not only because of the spatial distribution of health services, but because of the spatial distribution of individual and environmental factors that influence decision-making and behavior with respect to service use. The paper discusses areas for further research on healthcare navigation, challenges for research, and implications for reducing health disparities.

Limited health literacy in advanced kidney disease

Limited health literacy may reduce the ability of patients with advanced kidney disease to understand their disease and treatment and take part in shared decision making. In dialysis and transplant patients, limited health literacy has been associated with low socioeconomic status, comorbidity, and mortality. Here, we investigated the prevalence and associations of limited health literacy using data from the United Kingdom-wide Access to Transplantation and Transplant Outcome Measures (ATTOM) program. Incident dialysis, incident transplant, and transplant wait-listed patients ages 18 to 75 were recruited from 2011 to 2013 and data were collected from patient questionnaires and case notes. A score >2 in the Single-Item Literacy Screener was used to define limited health literacy. Univariate and multivariate analyses were performed to identify patient factors associated with limited health literacy. We studied 6842 patients, 2621 were incident dialysis, 1959 were wait-listed, and 2262 were incident transplant. Limited health literacy prevalence was 20%, 15%, and 12% in each group, respectively. Limited health literacy was independently associated with low socioeconomic status, poor English fluency, and comorbidity. However, transplant wait-listing, preemptive transplantation, and live-donor transplantation were associated with increasing health literacy.

Patient Activation Mediates Health Literacy Associated with Hospital Utilization among Whites

Background:

Reducing the 30-day hospital readmission rate is a national priority, and patient activation has emerged as a modifiable target to reduce hospital readmissions.

Objective:

Prior studies demonstrate that low patient activation and low health literacy are each associated with higher rates of hospital utilization. The aim of this study was to use path analysis methods to assess if patient activation mediates the relationship between health literacy and hospital utilization in the 30 days after discharge.

Methods:

We performed a secondary analysis of data from a randomized controlled trial of patients receiving care at an urban safety net hospital. Path analyses were used to assess patient activation as a mediator of the relationship of education and health literacy with 30-day hospital utilization. The final model was stratified by race and ethnicity.

Key Results:

In the overall study sample, a patient activation measure (PAM) score that was one standard deviation (SD) higher was associated with 18% reduced odds of hospital utilization (odds ratio [OR] 0.82; 95% confidence interval [CI] [0.73, 0.91]; p < .001). PAM mediated the relationship between education level and health literacy and hospital utilization. When stratified by race, the mediating effect of PAM was evident among Whites, but not among non-Whites. Specifically, a one SD higher PAM score was significantly associated with a 33% reduced odds of utilization among Whites (OR 0.67, 95% CI [0.57, 0.79], p < .001). With the inclusion of PAM in the model, there was no direct relationship between either health literacy or education and 30-day hospital utilization.

Conclusions:

Patient activation is only associated with hospital utilization among Whites. Further research is needed to assess if this selective protection is seen in other cohorts. Potential interventions to reduce hospital readmissions may need to consider other modifiable factors in racially and ethnically diverse populations. [Health Literacy Research and Practice. 2017;1(3):e128–e135.]

Plain Language Summary:

In this study, among White patients, the relationship between health literacy and hospital utilization within 30 days after discharge was due to patient activation. However, for non-White patients, the relationship between health literacy and hospital utilization within 30 days after discharge was not due to patient activation.