Multifaceted Assessment of Health Literacy in People Receiving Dialysis: Associations With Psychological Stress and Quality of Life

Role of health literacy profiles in fluid management of individuals receiving haemodialysis: A cross-sectional study

AIMS

To identify health literacy profiles in individuals receiving haemodialysis and to explore how these profiles interact with individuals' self-efficacy, engagement with traditional dietary habits, self-reported fluid restriction and relative-interdialytic weight gain.

DESIGN

A cross-sectional study engaging nephrology departments from four hospitals in Guangdong Province, China.

METHODS

A sample of 433 individuals receiving haemodialysis participated between December 2018 and July 2019. We assessed health literacy, self-efficacy and self-reported fluid restriction using the Health Literacy Questionnaire, the Fluid Self-efficacy Scale and the Fluid Adherence Subscale, respectively. Traditional dietary habits, including daily tea drinking, soup drinking and preserved food consumption, were measured using three yes/no questions. Relative-interdialytic weight gain was calculated by dividing the mean interdialytic weight gain (from three recent intervals) by dry weight. Latent profile analysis and structural equation modelling were performed.

RESULTS

Three health literacy profiles were identified: low, moderate and high. Compared to those in the low health literacy profile, individuals in high and moderate health literacy profiles demonstrated an indirect association with reduced relative-interdialytic weight gain. This reduction can be attributed to their higher self-efficacy levels, decreased reliance on dietary habits and higher self-reported fluid restrictions.

CONCLUSIONS

Most participants exhibited either low or moderate levels of health literacy. Improving health literacy has the potential to promote self-efficacy and foster effective fluid restriction, ultimately leading to a reduction in relative-interdialytic weight gain in individuals receiving haemodialysis.

IMPACT

This study reveals heterogeneity in health literacy levels among individuals receiving haemodialysis and illuminates the connections between an individual's entire spectrum of health literacy and fluid management. These findings provide valuable insights for developing person-centred fluid management interventions, especially for individuals with diverse cultural dietary backgrounds within the haemodialysis population.

REPORTING METHOD

We adhered to the STROBE guideline.

PATIENT OR PUBLIC CONTRIBUTION

Patients were included only for collecting their data.

Educational level and gender are associated with emotional well-being in a cohort of Dutch dialysis patients

BACKGROUND

Patients undergoing dialysis have an impaired health-related quality of life (HRQOL). There are conflicting data from small series on whether patient-related factors such as educational level have an impact on experienced HRQOL. The aim of this study was to investigate the association between educational level and HRQOL in dialysis patients.

METHODS

In a single-center retrospective cross-sectional study HRQOL was measured using the Kidney Disease Quality of Life Short Form-36 (KDQOL-SF36) in prevalent chronic dialysis patients. Educational level was categorized into low, intermediate and high subgroups. Univariate and multivariate regression analyses were performed to assess the effects of age, gender, ethnicity, and dialysis vintage on the association between HRQOL and educational level.

RESULTS

One hundred twenty-nine chronic dialysis patients were included. Patients with an intermediate educational level had significantly higher odds of a higher emotional well-being than patients with a low educational level 4.37 (1.-89-10.13). A similar trend was found for a high educational level (OR 4.13 (1.04-16.42), p = 0.044) The odds for women compared to men were 2.83 (1.32-6.06) for better general health and 2.59 (1.15-5,84) for emotional well-being. There was no interaction between gender and educational level for both subdomains. Each year of increasing age significantly decreased physical functioning (OR 0.94 (0.91-0.97)).

CONCLUSIONS

Educational level and sex were associated with emotional well-being, since patients with intermediate and high educational level and females had better emotional well-being in comparison to patients with low educational level and males. Physical functioning decreased with increasing age.

Relationship between health literacy and generalized anxiety disorder during the COVID-19 pandemic in Khuzestan province, Iran

Introduction

During the COVID-19 pandemic, many changes occurred in various cultural, social, and economic fields, leading to the creation of psychological effects, especially anxiety, in the community. Fear and anxiety about emerging diseases (COVID-19) and less participation in preventive behaviors reduce individual resistance and ultimately lower one's quality of life. Therefore, we aimed to investigate the relationship between health literacy and generalized anxiety disorder during the COVID-19 pandemic in Khuzestan province, Iran.

Methods

This was a descriptive-analytical (cross-sectional) study conducted among participants aged 18-65 in Khuzestan province during the years 2020-2021 through online sampling. Due to the prevalence of COVID-19 and the impossibility of face-to-face communication, the questionnaire was designed on the Porseline Survey website and the questionnaire link was provided to participants through WhatsApp and Telegram. The data collection tool includes the Iranian Health Literacy Questionnaire, which includes 33 items, and the Generalized Anxiety Disorder-7 scale, which has 7 items based on a Likert scale. Data analysis was performed using STATA14 software and descriptive and analytical statistical tests at a significant level less than 0.05.

Results

The mean (standard deviation) score for health literacy was 52.9 ± 9.3 and for generalized anxiety disorder was 5.2 ± 3.1. A significant negative correlation was found between the mean of anxiety disorder and health literacy (p < 0.05). The frequency of health literacy in individuals included 427 (37.8%) with inadequate health literacy, 628 (55.6%) with marginal health literacy, and 75 (6.6%) with sufficient health literacy. There was a statistically significant difference between the mean of generalized anxiety disorder among individuals with different levels of health literacy (p < 0.05).

Conclusion

As the level of health literacy increases, the prevalence of generalized anxiety disorder caused by fear of COVID-19 decreases. Therefore, increasing awareness and health literacy about this virus, its transmission, and prevention methods is very effective in managing anxiety and stress caused by COVID-19. Paying attention to the issue of health literacy and generalized anxiety disorder, and promoting preventive behaviors can be effective tools for planners, health officials, and policymakers to promote health literacy for any type of disease.

Assessment Tools for Measuring Health Literacy and Digital Health Literacy in a Hospital Setting: A Scoping Review

Assessment of (digital) health literacy in the hospital can raise staff awareness and facilitate tailored communication, leading to improved health outcomes. Assessment tools should ideally address multiple domains of health literacy, fit to the complex hospital context and have a short administration time, to enable routine assessment. This review aims to create an overview of tools for measuring (digital) health literacy in hospitals. A search in Scopus, PubMed, WoS and CINAHL, following PRISMA guidelines, generated 7252 hits; 251 studies were included in which 44 assessment tools were used. Most tools (57%) were self-reported and 27% reported an administration time of <5 min. Almost all tools addressed the domain 'understanding' (98%), followed by 'access' (52%), 'apply' (50%), 'appraise' (32%), 'numeracy' (18%), and 'digital' (18%). Only four tools were frequently used: the Newest Vital Sign (NVS), the Short Test of Functional Health Literacy for Adults ((S)TOFHLA), the Brief Health Literacy Screener (BHLS), and the Health Literacy Questionnaire (HLQ). While the NVS and BHLS have a low administration time, they cover only two domains. HLQ covers the most domains: access, understanding, appraise, and apply. None of these four most frequently used tools measured digital skills. This review can guide health professionals in choosing an instrument that is feasible in their daily practice, and measures the required domains.

Healthcare providers' support and outcomes in hemodialysis patients: The mediating effect of health literacy

OBJECTIVE

This study aimed to identify the mediating effect of health literacy (HL) on the relationship between healthcare providers' support and outcomes in patients on hemodialysis.

METHODS

A convenience sample of 149 hemodialysis patients participated in a cross-sectional survey. Mediation analysis with the percentile bootstrap method was used to identify the mediating effect of HL on the relationship between healthcare providers' support and patient outcomes.

RESULTS

Healthcare providers' support and HL were significant predictors of patient outcomes. HL mediated the relationship between healthcare providers' support and patient outcomes.

CONCLUSION

The HL of hemodialysis patients is essential in the relationship between healthcare providers' support and patient outcomes. Patient educators should implement a multifaceted HL-tailored intervention strategy to improve the HL of hemodialysis patients.

PRACTICE IMPLICATIONS

Hemodialysis patients' HL is a crucial mediating factor in the relationship between healthcare providers' support and patient outcomes. A multifaceted HL-tailored intervention strategy is needed to improve HL and, thus, health outcomes among hemodialysis patients.

Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: a systematic review

INTRODUCTION

Low health literacy is widely reported in people with chronic kidney disease (CKD) and has been associated with reduced disease self-management, poor health outcomes, increased mortality and poorer quality of life. However, these associations are still not well understood.

METHODS

Electronic-based systematic searches were performed to identify studies examining associations between health literacy and self-management behaviours and/or health outcomes in patients with CKD. A tabular and narrative synthesis of the data was performed. Meta-analysis was not appropriate due to the heterogeneity of study designs and methods.

RESULTS

Searches identified 48 studies that met the inclusion criteria. A total of 41 published articles, six conference abstracts, and one thesis were included. Of the 48 studies, 11 were cohort and 37 were cross-sectional. In total there were 25,671 patients; 16,952 from cohort studies. Median study sample size was 159 (IQR 92-275). Study quality was high (5), moderate (24) and poor (19). Thirteen measures of health literacy were used. Despite the limitations of the available evidence, there appear to be consistent relationships between higher health literacy and favourable self-management behaviours for patients with CKD. Definitive relationships between health literacy and patient outcomes are far less clear and remain incompletely understood.

DISCUSSION

Conclusive evidence describing a causal link between health literacy and patient outcomes remains limited, but for many outcomes, a consistent association is described. In addition to associations with mortality, hospitalisation and clinical events, there were consistent associations between health literacy and favourable self-management behaviours which could support the development of patient education aimed at improving health literacy.

Association of health literacy with physical and mental health in people with chronic diseases

OBJECTIVE

to explore the association of health literacy domains with physical and mental quality of life in people with selected chronic diseases.

METHODS

Community-dwelling people with selected chronic diseases planned for immunization against influenza in 2017/2018 were included in the study. All non-vaccinated people and the corresponding number of randomly selected vaccinated people matched on town of residence were included. Data were collected by means of socio-demographic questionnaire, Health Literacy Questionnaire (HLQ) and Short Form-36 (SF-36). The Physical and Mental Composite Scores as well as their domains were observed as the study outcomes.

RESULTS

A total of 295 people were studied. The adjusted logistic regression showed that Physical and Mental composite scores were associated with all HLQ domains except 5) Appraisal of health information. Better Physical Functioning was associated with higher scores on 1) Feeling understood and supported by healthcare providers, 6) Ability to actively engage with healthcare providers, 7) Navigating the healthcare system and 8) Ability to find good health information. Better scores on Vitality, Social Functioning, Role Emotional and Mental Health were associated with higher scores on all HLQ domains except 5) Appraisal of health information.

CONCLUSION

Health literacy is important for physical and mental quality of life among people with chronic diseases. Health care providers and other stakeholders should continuously work to improve health literacy of their patients.

Low Health Literacy Is Associated with Poorer Physical and Mental Health-Related Quality of Life in Dialysed Patients

Health-related quality of life (HRQoL) is an important health indicator in chronic diseases like kidney diseases. Health literacy (HL) may strongly affect HRQoL, but evidence is scarce. Therefore, we assessed the associations of HL with HRQoL in dialysed patients. We performed a cross-sectional study in 20 dialysis clinics across Slovakia (n = 542 patients, mean age = 63.6 years, males = 60.7%). We assessed the association of categorised HL (low, moderate, high) with the SF36 physical component score (PCS) and mental component score (MCS) using generalised linear models adjusted for age, gender, education, and comorbidity (Charlson Comorbidity Index, CCI). We found significant associations of HL with PCS and MCS in dialysed patients, adjusted for age, gender, education, and CCI. Low-HL patients had a lower PCS (B = -3.27, 95%-confidence interval, CI: -5.76/-0.79) and MCS (B = -6.05, 95%-CI: -8.82/-3.29) than high-HL patients. Moderate-HL patients had a lower MCS (B = -4.26, 95%-CI: -6.83/-1.69) than high-HL patients. HL is associated with physical and mental HRQoL; this indicates that dialysed patients with lower HL deserve specific attention and tailored care to have their HRQoL increased.

The Associations of Suspected COVID-19 Symptoms with Anxiety and Depression as Modified by Hemodialysis Dietary Knowledge: A Multi-Dialysis Center Study

During the COVID-19 pandemic, it is essential to evaluate hemodialysis patients’ dietary knowledge, especially among those with COVID-19 related symptoms, in order to identify appropriate strategies in managing their mental health. The study’s purposes were to test the psychometric properties of the hemodialysis dietary knowledge (HDK) scale, and to investigate the modifying impact of HDK on the associations of suspected COVID-19 symptoms (S-COVID-19-S) with anxiety and depression among hemodialysis patients. A cross-sectional study was conducted from July 2020 to March 2021 at eight hospitals across Vietnam. Data of 875 hemodialysis patients were analyzed, including socio-demographic, anxiety (the generalized anxiety disorder scale, GAD-7), depression (the patient health questionnaire, PHQ-9), S-COVID-19-S, HDK, health literacy, and digital healthy diet literacy. Confirmatory factor analysis (CFA) and logistic regression models were used to analyze the data. The HDK scale demonstrates the satisfactory construct validity with good model fit (Goodness of Fit Index, GFI = 0.96; Adjusted Goodness of Fit Index, AGFI = 0.90; Standardized Root Mean Square Residual, SRMR = 0.05; Root Mean Square Error of Approximation, RMSEA = 0.09; Normed Fit Index, NFI = 0.96; Comparative Fit Index, CFI = 0.96, and Parsimony goodness of Fit Index, PGFI = 0.43), criterion validity (as correlated with HL (r = 0.22, p < 0.01) and DDL (r = 0.19, p < 0.01), and reliability (Cronbach alpha = 0.70)). In the multivariate analysis, S-COVID-19-S was associated with a higher likelihood of anxiety (odds ratio, OR, 20.76; 95% confidence interval, 95%CI, 8.85, 48.70; p < 0.001) and depression (OR, 12.95; 95%CI, 6.67, 25.14, p < 0.001). A higher HDK score was associated with a lower likelihood of anxiety (OR, 0.70; 95%CI, 0.64, 0.77; p < 0.001) and depression (OR, 0.72; 95%CI, 0.66, 0.79; p < 0.001). In the interaction analysis, the negative impacts of S-COVID-19-S on anxiety and depression were mitigated by higher HDK scores (p < 0.001). In conclusion, HDK is a valid and reliable tool to measure dietary knowledge in hemodialysis patients. Higher HDK scores potentially protect patients with S-COVID-19-S from anxiety and depression during the pandemic.

Validation and measurement invariance of the Arabic Health Literacy Questionnaire

Health literacy plays a key role in empowering individuals and enabling them to make health-related decisions. Despite the advances in health literacy research, there are gaps in the literature that require further inquiry, and establishing comprehensive and valid measurements is one of them. Thus, this research was conducted to examine the psychometric properties of the Arabic Health Literacy Questionnaire (HLQ), including the reliability, validity, and measurement invariances of the nine HLQ scales. A cross-sectional design was used in this study. A sample of university students (N = 1011) was recruited, the mean of age was 21.1 years old (SD = 2.28). The Arabic HLQ and a demographics questionnaire were completed by the participants. Confirmatory factor analyses (CFA) and measurement invariances were performed for each HLQ scale. The values of Cronbach's α and composite reliability were above .70 for all HLQ scales. The CFA analyses showed that all HLQ scales meet the criteria that were set a priori: RMSEA ≤.07, CFI ≥.95, and Chisq/df < 5. In addition, all standardized factor loadings were above .50. Regarding the measurement invariance, the results supported the equal form measurement invariance for all HLQ scales. The equality of factor loadings measurement invariance across gender was also supported for all HLQ scales. Measurement invariance of factor loadings and equality of indicator intercepts was partially supported. These results show that the internal consistency, convergence, and factor structure of the HLQ are all supported. The Arabic HLQ is a reliable, valid tool to measure health literacy among Arabic-speaking populations.

Health Literacy and Change in Health-Related Quality of Life in Dialysed Patients

Health-related quality of life (HRQoL) is likely to deteriorate with the progression of chronic kidney disease (CKD). This change may be worsened by low health literacy (HL). We performed a longitudinal study at over 20 dialysis clinics in Slovakia (n = 413; mean age = 64.8 years; males = 58.4%). We assessed the association of three HL groups with a change in HRQoL over two years using binary logistic regression adjusted for type of vascular access, dialysis effectiveness, comorbidity, age and gender. We found that patients with low HL had poorer HRQoL at baseline in comparison to high-HL patients. We did not find significant associations of lower HL with the deterioration of mental or physical HRQoL after two years. In the adjusted model, patients with lower HL were not more likely to have deteriorated physical (low-HL patients: odds ratio/95% confidence interval: 0.99/0.53–1.84; moderate-HL patients: 0.97/0.55–1.73) or mental HRQoL (low-HL patients: 1.00/0.53–1.87; moderate-HL patients: 0.95/0.53–1.70) in comparison to high-HL patients. The HRQoL of lower-HL patients is worse at baseline but develops similarly to that of high-HL patients during dialysis treatment. Their relative HRQoL, thus, does not worsen further, but it does not improve either. Tailoring care to their needs may help to decrease the burden of low HL in dialysed patients.

The Protective Effect of Health Literacy on Reducing College Students' Stress and Anxiety During the COVID-19 Pandemic

BACKGROUND

The coronavirus (COVID-19) pandemic threatens people's health and well-being all around the world, resulting in increased stress and anxiety. Existing literature has found health literacy has a protective effect on health, and the study has taken a closer look at the effects of health literacy on perceived stress and anxiety among Chinese college students.

METHODS

With structural questionnaires, a cross-sectional survey was conducted to collect the responses of 1,251 participants from different universities in Hubei and Guangdong, China. Participants' health literacy and perceived stress and anxiety symptoms were evaluated.

RESULTS

Only 11.83% of the participants reported sufficient health literacy. Compared with college students from Hubei and Guangdong with a major in medicine showed a higher percentage of having sufficient literacy. Moreover, having sufficient health literacy showed a protective effect in reducing the risk of stress (OR = 0.14, 95%CI= 0.01-0.04; p < 0.001) and anxiety (OR = 0.02, 95%CI = 0-0.61; p < 0.001).

CONCLUSION

Health literacy was found to have a protective effect in reducing anxiety and stress among college students. This effect has remained among students from different majors and locations. However, it is noteworthy that the overall level of health literacy is relatively low among college students, particularly among those from Hubei Province or with non-medical majors. Therefore, more effort should be put into developing health education programs promoting health literacy and mental health on campus.

Health-Related Quality of Life Profiles in Dialyzed Patients With Varying Health Literacy. A Cross-Sectional Study on Slovak Haemodialyzed Population

Objectives: Chronic kidney disease (CKD) strongly affects patients’ health-related quality of life (HRQoL), mostly in the advanced stages of CKD. Health literacy (HL) may affect this association, in particular for some aspects of HRQoL. The aim of this study is to compare the profiles of HRQoL in dialyzed patients with varying HL.

Methods: We obtained data on HL using the Health Literacy Questionnaire (HLQ) and on HRQoL using the Kidney Disease Quality of Life – Short Form (KDQoL-SF 1.3) in a multicentre cross-sectional study in 20 dialysis clinics in Slovakia (n = 542; mean age = 63.6 years; males: 60.7%). We compared HRQoL for three HL groups using ANOVA and the Kruskal-Wallis test.

Results: Patients with low HL reported worse HRQoL than patients with moderate and high HL. The greatest differences between HL groups were found in the scales Effect of kidney disease, Cognitive function, Quality of social interaction, Social support, Dialysis staff encouragement, Patient satisfaction, Physical functioning, Pain, Emotional well-being and Social function. p-values in all cases were <0.001.

Conclusion: Patients with low HL have a worse HRQoL in several domains than patients with a higher HL. Increasing HL capacities and better supporting patients with low HL should thus be given priority to support their HRQoL and at least maintain its level.

Codesign and implementation of an equity-promoting national health literacy programme for people living with inflammatory bowel disease (IBD): a protocol for the application of the Optimising Health Literacy and Access (Ophelia) process

INTRODUCTION

Non-government organisations (NGOs) often represent people who are underserved or experiencing vulnerability. Crohn's & Colitis Australia (CCA) is aware that many Australians with inflammatory bowel disease (IBD) are not reached by current communication and engagement activities. The aim of the CCA IBD project is to implement the Optimising Health Literacy and Access (Ophelia) process over 3 years to collaboratively codesign ways to improve delivery of information, services and resources for people with IBD and their carers.

METHODS AND ANALYSIS

Health literacy and other data for phase 1 will be collected using the Health Literacy Questionnaire, eHealth Literacy Questionnaire, IBD-related questions and qualitative interviews with people with IBD and their carers to ascertain their lived experience. Quantitative data will be analysed using descriptive statistics and cluster analysis. Identified clusters will be combined with qualitative data to develop vignettes (narratives of people's experiences of living with IBD) for stakeholder workshops to generate ideas for useful, accessible and sustainable solutions for identified health literacy needs. Selection and testing of health literacy actions happens in phase 2 and implementation and evaluation in phase 3 (2021-2023). Outcomes of this project include giving voice to people living with IBD, their carers and frontline healthcare practitioners. Genuine codesign informs the development and implementation of what is needed and wanted to improve access to and availability and quality of information and resources that support people to manage their health. There is potential for other NGOs to use the CCA Ophelia model in other health contexts to improve engagement with and understanding of the needs of the people they serve and to reduce health inequalities and improve health outcomes.

ETHICS AND DISSEMINATION

Ethics approval for Ophelia phase 1 has been obtained from the Human Research Ethics Committee of Swinburne University of Technology (Ref: 20202968-4652) and by the South West Sydney Local Health District Research and Ethics Office for the purposes of questionnaire recruitment at Liverpool Hospital (Ref: 20202968-4652). Dissemination of the study findings will be the national codesign process and ownership development across the CCA community and through the genuine engagement of clinicians and relevant managers across Australia. The model and process will be directly distributed to international IBD associations and to other NGOs. It will also be disseminated through publication in a peer-reviewed journal, conference presentations and public reports on the CCA and Swinburne University of Technology website.

Healthcare systems and professionals are key to improving health literacy in chronic kidney disease

BACKGROUND

Comorbidity is prevalent in people with chronic kidney disease (CKD) and this status burdens one's health literacy skills to understand about their health, make decisions, and to adhere with treatment.

OBJECTIVES

To examine health literacy in people with CKD and comorbidities.

DESIGN

A cross-sectional study was conducted between November 2018 and April 2019.

PARTICIPANTS

Convenience sampling recruited 367 adults with CKD and at least one comorbid disease.

MEASUREMENTS

Data were collected using the 9-domain Health Literacy Questionnaire. Demographic and clinical characteristics were also collected. Charlson Comorbidity Index calculated comorbidity status. Parametric tests were used to distinguish health literacy between various groups.

RESULTS

Participants' average age was 58.8 years, 54.7% had CKD Grade 5, 72.5% had a severe comorbidity index (≥6), and nearly 40% were on haemodialysis. Lower health literacy proportions were found in domains related to Healthcare providers' support (58.3%) and Appraisal of health information (38.4%). Lower levels of education, income, or living in rural areas were each significantly more likely to contribute to lower health literacy levels (range 4-7 domains). Greater comorbidity severity was also significantly associated with lower health literacy in two domains.

CONCLUSION

People with CKD had difficulties in various health literacy domains primarily related to communication and critical appraisal. These domains can be improved by healthcare professionals and changes in hospital policies. Due to frequent contact with patients in kidney services, renal clinicians have a crucial role in ensuring greater communication occurs as this will better assist patients to understand their healthcare needs.

Health literacy level in a various nephrology population from Québec: predialysis clinic, in-centre hemodialysis and home dialysis; a transversal monocentric observational study

Background

Health literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. It is especially important in nephrology due to the complexity of chronic kidney disease (CKD). The present study sought to define health literacy levels in patients followed in predialysis clinic, in-center dialysis (ICHD), peritoneal dialysis (PD) and home hemodialysis (HHD).

Methods

This transversal monocentric observational study analysed 363 patients between October 2016 and April 2017. The Brief Health Literacy Screen (BHLS) and the Health Literacy Questionnaire (HLQ) were used to measure health literacy. Multivariate linear regressions were used to compare the mean scores on the BHLS and HLQ, across the four groups.

Results

Patients on PD had a significantly higher BHLS’score than patients on ICHD (p = 0.04). HLQ’s scores differed across the groups: patients on HHD (p = 0.01) and PD (p = 0.002) were more likely to feel understood by their healthcare providers. Compared to ICHD, patients on HHD were more likely to have sufficient information to manage their health (p = 0.02), and patients in the predialysis clinic were more likely to report high abilities for health information appraisal (p < 0.001).

Conclusion

In a monocentric study, there is a significant proportion of CKD patients, especially in predialysis clinic and in-centre hemodialysis, with limited health literacy. Patients on home dialysis (HHD and PD) had a higher level of health literacy compared to the other groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02464-1.

Health literacy as predictors of fluid management in people receiving hemodialysis in China: A structural equation modeling analysis

OBJECTIVES

To explore the impact of health literacy (HL) on perceived benefits of fluid restriction (PBFR), self-reported fluid restriction (SRFR) and relative-interdialytic weight gain (R-IDWG) in people receiving hemodialysis (HD).

METHODS

We conducted a cross-sectional study in two nephrology departments from two hospitals in Guangzhou, China (n = 226). The HL questionnaire, PBFR Subscale of Health Belief Model Constructs and Fluid Adherence Subscale of the HD Patients Therapy Adherence Scale were used. R-IDWG was calculated by the mean IDWG (from 3 consecutive HD), divided by the dry weight.

RESULTS

In structural equation modeling, three domains of the HL questionnaire, namely Actively Managing My Health, Social Support and Actively Engaging with Healthcare Providers (HCPs), were directly and positively associated with PBFR. Higher Actively Managing My Health predicted higher SRFR both directly and indirectly. Sufficient Social Support and adequate Actively Engaging with HCPs predicted higher SRFR indirectly. All three HL domains predicted R-IDWG indirectly.

CONCLUSION

Improving patients' HL could increase their understanding of PBFR and be more apt to follow fluid restrictions and reduce R-IDWG.

PRACTICE IMPLICATIONS

A better understanding of the relationships among HL, PBFR, SRFR and R-IDWG will allow for tailored interventions to decrease R-IDWG in people receiving HD.

Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis

In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.

A scoping review of the role of health literacy in chronic kidney disease self-management

BACKGROUND

Chronic kidney disease is a serious health condition and is increasing globally. Effective self-management could slow disease progression and improve health outcomes, although the contribution of health literacy and knowledge for self-management is not well known.

AIM

To investigate the recent evidence of health literacy and the relationship between health literacy, knowledge and self-management of chronic kidney disease.

METHODS

Arksey and O'Malley's framework informed this scoping review. Eligible studies involving adults with any grade of chronic kidney disease, measuring all dimensions of health literacy (i.e., functional, communicative, and critical), disease-specific knowledge and self-management, published in English between January 2005 and March 2020, were included.

RESULTS

The scoping review found 12 eligible studies, with 11 assessing all dimensions of health literacy. No study examined health literacy, knowledge and self-management. When individuals had greater health literacy, this was associated with greater knowledge about the disease. Communicative health literacy was a significant predictor of medication, diet and fluid adherence, and overall self-management behaviours.

CONCLUSION

This scoping review shows that disease-specific knowledge is important for health literacy and that health literacy is essential for effective self-management of chronic kidney disease. The implications of these relationships can inform strategies for the development of evidence-based patient education to support increased self-management. There is also a need for further research to explore these associations.

How to tackle health literacy problems in chronic kidney disease patients? A systematic review to identify promising intervention targets and strategies

BACKGROUND

Limited health literacy (LHL) is associated with multiple adverse health outcomes in chronic kidney disease (CKD). Interventions are needed to improve this situation, but evidence on intervention targets and strategies is lacking. This systematic review aims to identify potential targets and strategies by summarizing the evidence on: (i) patient- and system-level factors potentially mediating the relation between LHL and health outcomes; and (ii) the effectiveness of health literacy interventions customized to CKD patients.

METHODS

We performed a systematic review of peer-reviewed research articles in Medline, Embase and Web of Science, 2009-19. We assessed the quality of the studies and conducted a best-evidence synthesis.

RESULTS

We identified 860 publications and included 48 studies. Most studies were of low quality (n = 26) and focused on dialysis and transplantation (n = 38). We found strong evidence for an association of LHL with smoking and having a suboptimal transplantation process. Evidence was weak for associations between LHL and a variety of factors related to self-care management (n = 25), utilization of care (n = 23), patient-provider interaction (n = 8) and social context (n = 5). Six interventions were aimed at improving knowledge, decision-making and health behaviours, but evidence for their effectiveness was weak.

CONCLUSIONS

Study heterogeneity, low quality and focus on kidney failure largely impede the identification of intervention targets and strategies for LHL. More and higher quality studies in earlier CKD stages are needed to unravel how LHL leads to worse health outcomes, and to identify targets and strategies to prevent disease deterioration. Healthcare organizations need to develop and evaluate efforts to support LHL patients.

The relationship between health literacy and quality of life among hemodialysis patients: An integrative review

BACKGROUND

Various studies have highlighted the correlates to health literacy and quality of life among patients receiving hemodialysis therapy. However, evidence of how these two outcomes could influence each other is not clear.

OBJECTIVE

This study aimed to assess the correlation between health literacy and quality of life among patients receiving hemodialysis.

METHODS

This is an integrative review of correlational studies. This study conforms to the preferred reporting items for integrative reviews described by Whitemore and Knafl. We search for studies reporting on the correlation of health literacy and quality of life among patients receiving hemodialysis in six databases, that is PubMed, Web of Science/Knowledge, Scopus and Embase, Google Scholar and Ovid MEDLINE.

RESULTS

In this review five studies were included after screening them against the inclusion criteria. Two studies were identified from Iran, and one study was identified each from Australia, Turkey, and the USA. Most studies were descriptive comparative in nature, while two studies were experimental. Shayan's study had the highest number of participants. This study reports on 1,063 patients receiving dialysis. Most studies were conducted at different centers. Findings from three studies showed that there was a significant relationship between health literacy and quality of life among patients receiving hemodialysis.

CONCLUSION

There is a relationship between health literacy and quality of life among patients receiving hemodialysis. Conclusively, addressing health literacy may improve the quality of life among patients receiving hemodialysis.

Comparison of health literacy profile of patients with end-stage kidney disease on dialysis versus non-dialysis chronic kidney disease and the influencing factors: a cross-sectional study

OBJECTIVES

Lower health literacy (HL) is associated with poor outcomes in patients with kidney disease. Since HL matches the patient's competencies with the complexities of the care package, the level of HL sufficient in earlier stages of chronic kidney disease (CKD) may be inadequate for patients with end-stage kidney disease (ESKD) on dialysis. We aimed to analyse the HL profile of patients with ESKD and non-dialysis CKD and examine if there were significant associations with covariates which could be targeted to address HL deficits, thereby improving patient outcomes.

DESIGN AND SETTING

Cross-sectional study of patients with CKD and ESKD from a single Australian health district.

METHODS

We assessed the HL profile of 114 patients with CKD and 109 patients with ESKD using a 44-item multidomain Health Literacy Questionnaire (HLQ) and examined its association with demographic factors (age, gender, race), smoking, income, education, comorbidities, carer status, cognitive function and depression. Using multivariable logistic regression models, HL profiles of patients with CKD and ESKD were evaluated after adjusting for covariates.

RESULTS

Patients with ESKD had similar demographics and educational levels compared with patients with CKD. ESKD had significantly higher frequency of vascular disease, cognitive impairment and depression. Patients with ESKD had better HL scores for the social support domain (37.1% vs 19.5% in higher HLQ4 tertile, p=0.004), whereas all other HL domains including engagement with healthcare providers were comparable to CKD. Depression was independently associated with nearly all of the HL domains (HLQ1: OR 2.6, p=0.030; HLQ2: OR 7.9, p=<0.001; HLQ3: OR 7.6, p<0.001; HLQ4: OR 3.5, p=0.010; HLQ5: OR 8.9, p=0.001; HLQ6: OR 3.9, p=0.002; HLQ7: OR 4.8, p=0.001; HLQ8: OR 5.3, p=0.001) and education with HL domains relevant to processing health-related information (HLQ8: OR 2.6, p=0.008; HLQ9: OR 2.5, p=0.006).

CONCLUSIONS

Despite very frequent interactions with health systems, patients with ESKD on dialysis did not have higher HL in engagement with health providers and most other HL domains, compared with patients with CKD. Strategies promoting patient-provider engagement and managing depression which strongly associates with lower HL may address the impact of HL deficits and favourably modify clinical outcomes in renal patients.

Does Depression and Anxiety Mediate the Relation between Limited Health Literacy and Diet Non-Adherence?

Limited health literacy (HL), depression and anxiety are common in dialyzed patients and affect health outcomes and self-management. We explored whether depression and anxiety mediate the association of HL with diet non-adherence (DN-A) in dialyzed patients. We performed a cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; mean age: 63.6 years; males: 60.7%). Hierarchical cluster analysis was performed to create three HL groups. Logistic regression adjusted for age, gender and education was used to explore whether depression and anxiety mediate the association of HL with DN-A. Patients in the moderate HL group were more likely to be non-adherent to diet (OR (Odds Ratio)/95% CI: 2.19/1.21-3.99) than patients in the high HL group. Patients in the low HL and moderate HL group more likely reported depression or anxiety. Patients reporting depression (OR/95% CI: 1.94/1.26-2.98) or anxiety (OR/95% CI: 1.81/1.22-2.69) were more likely to be non-adherent with diet. Adjustment for depression reduced the association between moderate HL and DN-A by 19.5%. Adjustment for anxiety reduced the association between moderate HL and DN-A by 11.8%. Anxiety and depression partly mediated the association of HL with DN-A. More attention should be paid to treating patients' psychological distress to ensure adequate adherence with recommended diet.

Examining the relationship between nutrition, quality of life, and depression in hemodialysis patients

PURPOSE

Lifestyle changes associated with end-stage renal disease may be a factor in depression and quality of life (QOL) for patients receiving hemodialysis. This cross-sectional study examined the relationship between nutritional status, QOL, and depression in 124 hemodialysis patients.

METHODS

Nutritional markers included serum albumin, normalized protein catabolic rate (nPCR), body mass index (BMI), body fat percentage, and daily protein intake. Physical and Mental dimension scores of the Kidney Disease QOL-Short Form (KDQOL-SF), and the Center for Epidemiological Studies of Depression (CESD) survey were used to measure QOL and depression, respectively. Data were analyzed using regression analyses. Measures of effect size were used for interpretation.

RESULTS

Nutritional status indicators explained a moderate amount of the variability of the Physical dimension of QOL (crude R² = .14, covariate-adjusted ΔR² = .06) but had weak explanatory ability for the Mental dimension of QOL (crude R² = .05, covariate-adjusted ΔR² = .02) and CESD (crude R² = .02, covariate-adjusted ΔR² = .005). Additional findings suggested the presence of non-linear relationships between protein intake and both the Physical and Mental QOL dimension scores. Longer dialysis vintage was also correlated with lower psychosocial patient outcomes.

CONCLUSION

While nutritional status is an important element in predicting hemodialysis patient outcomes, its relationship to depression and QOL, in this sample, demonstrated only moderate explanatory ability. However, dialysis vintage and level of education had a significant relationship with depression and QOL. These findings suggest that patients with longer dialysis vintage and limited health literacy require unique plans of care. Future studies aimed at understanding the interrelationships between non-modifiable patient characteristics and psychosocial outcomes are imperative.

Exploring health literacy in patients with chronic kidney disease: a qualitative study

Background

Patients with chronic kidney disease make day-to-day decisions about how to self-manage their disease. Chronic kidney disease (CKD) includes a risk for progression towards end-stage renal disease and the development of comorbidities, such as cardiovascular disease, which represents the leading cause of death among these patients. To reduce these risks, CKD patients are recommended to follow a healthy lifestyle with physical activity, food and fluid restrictions, and adherence to complex medication regimes throughout all phases of the disease. To manage the complexity of this health situation, health literacy (HL) is considered essential. The current prevailing understanding is that HL is a multidimensional concept and comprises a range of cognitive, affective, social, and personal skills that determine the motivation and ability to gain access to, understand, and use health information. Recently, we investigated multiple aspects of HL in CKD patients in a quantitative cross-sectional study utilizing the Health Literacy Questionnaire (HLQ) and observed that finding good health information and appraising health information were the most challenging aspects of HL. This study aimed to explore CKD patients’ lived experiences of different dimensions of HL presented in the HLQ.

Methods

This qualitative study utilized in-depth semistructured interviews. Twelve patients with different levels of HL were included. The interviews were analyzed using thematic analysis as described by Braun and Clarke.

Results

We identified three main themes that were significant for CKD patients’ HL: 1. Variation in people’s attitudes and behavior as health information seekers, 2. The problem of fragmented healthcare in the context of multimorbidity makes the healthcare system challenging to navigate, and 3. The value of a good relationship with healthcare providers.

Conclusion

CKD patients take different approaches to health information. Limiting or avoiding health information may be a strategy used by some individuals to cope with the disease and does not necessarily mean that health information is inaccessible or difficult to understand. Comorbidity and a fragmented healthcare system can make the healthcare system challenging to navigate. A good and trusting relationship with healthcare providers seems to promote several aspects of HL and should be promoted to optimize CKD patients’ HL.

Patient and Caregiver Perspectives on Terms Used to Describe Kidney Health

BACKGROUND AND OBJECTIVES

The language used to communicate important aspects of kidney health is inconsistent and may be conceptualized differently by patients and health professionals. These problems may impair the quality of communication, care, and patient outcomes. We aimed to describe the perspectives of patients on terms used to describe kidney health.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with CKD (n=54) and caregivers (n=13) from the United States, United Kingdom, and Australia participated in ten focus groups to discuss terms for kidney health (including kidney, renal, CKD, ESKD, kidney failure, and descriptors for kidney function). We analyzed the data using thematic analysis.

RESULTS

We identified four themes: provoking and exacerbating undue trauma (fear of the unknown, denoting impending death, despair in having incurable or untreatable disease, premature labeling and assumptions, judgment, stigma, and failure of self); frustrated by ambiguity (confused by medicalized language, lacking personal relevance, baffled by imprecision in meaning, and/or opposed to obsolete terms); making sense of the prognostic enigma (conceptualizing level of kidney function, correlating with symptoms and effect on life, predicting progression, and need for intervention); and mobilizing self-management (confronting reality, enabling planning and preparation, taking ownership for change, learning medical terms for self-advocacy, and educating others).

CONCLUSIONS

The obscurity and imprecision of terms in CKD can be unduly distressing and traumatizing for patients, which can impair decision making and self-management. Consistent and meaningful patient-centered terminology may improve patient autonomy, satisfaction, and outcomes.

Parental anxiety in pediatric surgery consultations: the role of health literacy and need for information

INTRODUCTION

Although important, parental anxiety, health literacy and need-for-information in pediatric surgery outpatient clinics have not been extensively studied. Lower educational attainments, minorities and lower socioeconomic status have been associated with limited health literacy. Parental anxiety has been related to health literacy, sex, education and information needs. The aim of this study is to investigate health literacy and need-for-information and their association to parental anxiety in consultations of pediatric surgery.

MATERIALS & METHODS

We conducted an observational, cross-sectional study in the outpatient pediatric surgery clinic from December 2016 to October 2017. Health literacy, anxiety and need-for-information of parents/guardians of children waiting for pediatric surgical consultation were evaluated. Multivariate regression analysis was used to examine the impact of health literacy and need-for-information on parental/guardian anxiety considering sociodemographic and clinical characteristics of the participants.

RESULTS

Almost half (46.1%) of the 664 parents/guardians recruited had limited or problematic health literacy and 79.8% of the sample was classified as being anxious. Parental/guardian anxiety was associated at the multiple regression analysis with parental health literacy level (β = -0.282, p < 0.001), need-for-information preoperatively (β = 0.907, p < 0.001), educational level (β = -0.716, p = 0.001), sex (β = 1.563, p < 0.001), and severity of the condition of the child (β = 0.379, p < 0.001).

CONCLUSION

Parents/guardians experience high levels of anxiety, which is associated to health literacy and need-for-information. These factors should be considered in pediatric surgical consultations, aiming to reduce parental anxiety.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

Level II.

Health-Related Quality of Life in Home Dialysis Patients Compared to In-Center Hemodialysis Patients: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Dialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & STUDY POPULATIONS

Search strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients.

DATA EXTRACTION

The data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent.

ANALYTICAL APPROACH

Data were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses.

RESULTS

Forty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I 2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, -0.20; 95% CI, -0.28 to -0.12). Mental HRQoL showed no difference in all analyses.

LIMITATIONS

No randomized controlled trials were found and high heterogeneity among studies existed.

CONCLUSIONS

Although pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL.

TRIAL REGISTRATION

PROSPERO 95985.

Both trusting and understanding medical advice: Assessing patient alliance and confusion after medical consultations

OBJECTIVE

The current objective is to validate the Medical Consultation Experience Questionnaire (MCEQ) and to examine distinctions between constructs of patient perceived alliance and experienced confusion in relation to key health outcomes.

METHODS

A total of 857 participants were recruited online across two samples (adults with various medical conditions and with diabetes and/or hypertension specifically).

RESULTS

A confirmatory factor analysis demonstrated good fit and high item loadings for the theoretical bifactor model. Item response theory analyses showed very high individual item discrimination and good test information across a wide range of values. Confusion was uniquely and significantly more strongly related to psychological distress than was alliance; the same was true for alliance with positive affect. Both alliance and confusion significantly contributed to treatment motivation. Only confusion explained unique variance in control of HbA1C levels and blood pressure after controlling for alliance and other variables.

CONCLUSIONS

The MCEQ is a valid instrument for assessing distinct constructs of alliance and confusion. Future research should focus on the unique role of confusion for patient outcomes.

PRACTICE IMPLICATIONS

By using the MCEQ to assess patient alliance and confusion, it may be possible to detect and prioritize individual patient needs and improve patient outcomes.

Letramento em saúde: avaliação de pacientes em terapia renal substitutiva

Introdução: considerando a prevalência de pacientes em terapia renal substitutiva, torna-se extremamente revelevante a avaliação da capacidade de entendimento e aplicacação das orientações que esses indíviduos recebem nos serviços de saúde. Objetivo: estudar o impacto do nível de letramento em saúde de pacientes submetidos à hemodiálise, diálise peritoneal e transplante renal, associado aos aspectos cognitivos, adesão medicamentosa e qualidade de vida. Método: estudo transversal, realizado com indivíduos acima de 18 anos, submetidos a algum tipo de terapia renal substitutiva, há três meses consecutivos. Foram aplicadas as versões brasileiras dos instrumentos: Short Assessment of Health Literacy for Portuguese-speaking Adults-18, Mini Exame do Estado Mental, 36-Item Short Form e a escala de Morisky, além de um questionário sobre dados clínicos e sociodemográficos. Resultados: foram avaliados 138 pacientes, sendo 50 (36,2) submetidos à hemodiálise, 23 (16,7%) a diálise peritoneal e 65 (47,1%) ao transplante renal. A média de idade foi 52,0±15,5 anos e 58,0% do sexo masculino. Os pacientes com letramento inadequado (51,4%) tinham renda igual ou inferior a um salário mínimo (P=0,002) e ensino fundamental completo ou inferior (P<0,001). Os indivíduos com letramento adequado apresentavam ensino médio incompleto ou maior escolaridade, renda igual ou superior a cinco salários mínimos e maior escore no domínio dos aspectos emocionais referente a qualidade de vida (P=0,052). Conclusões: nossos resultados sugerem que o nível de letramento está associado com a renda e escolaridade nos pacientes que realizam a substituição da função renal.

Is Health Literacy of Dialyzed Patients Related to Their Adherence to Dietary and Fluid Intake Recommendations?

Non-adherence to dietary and fluid intake recommendations (NADFIR) is an important factor for the effective treatment of dialyzed patients and may be hindered by low health literacy (HL). Therefore, we assessed whether low HL of dialyzed patients is associated with their NADFIR. We performed a multicentric cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; response rate: 70.1%; mean age = 63.6 years; males: 60.7%). We assessed the association between nine domains of HL and non-adherence (high serum potassium, high serum phosphate, relative overhydration, and self-reported NADFIR) using general linear models adjusted for age and gender. Moreover, we assessed the moderation by socioeconomic status (SES). We found higher NADFIR among patients with less sufficient information for health management (high serum phosphate level; odds ratio (OR): 0.77; 95% confidence interval (CI): 0.63-0.94), with a lower ability to actively manage their health (self-reported diet non-adherence; OR: 0.74; 95% CI: 0.62-0.89), and those less able to actively engage with healthcare providers (overhydrated; OR: 0.78; 95% CI: 0.65-0.94). Moreover, SES modified this relation. Low HL affects the adherence of dialyzed patients. This shows a need to support patients with low HL and to train healthcare providers to work with these patients, taking into account their SES.

A cross-sectional study of health literacy in patients with chronic kidney disease: Associations with demographic and clinical variables

AIM

The aim of this study was to investigate health literacy in patients with chronic kidney disease in a multidimensional perspective.

DESIGN

A descriptive, cross-sectional study.

METHODS

Patients with chronic kidney disease at stages 3-5 were included in the study between February-August 2017 (N = 187). Health literacy was measured by the Health Literacy Questionnaire (HLQ). Multiple linear regression analysis was performed to identify associations between health literacy and demographic and clinical variables. Hierarchical cluster analysis was performed to identify characteristics of groups with high and low health literacy.

RESULTS

Finding and critical appraise health information were the most challenging dimensions of health literacy. Female gender, lower level of education, greater number of prescribed medications and depressive symptoms were associated with lower health literacy. The group identified with lowest health literacy was further characterized by living alone and presence of comorbidity.

Health-related quality of life in peritoneal dialysis patients: A narrative review

Health-related quality of life (HRQOL) is an important aspect of patients´ health that should be an integral part of the evaluation of patient-centered outcomes, not least because HRQOL associates with patients´ morbidity and mortality. This applies also to chronic kidney disease patients, including those dependent on renal replacement therapies, the type of which may influence patients´ perception of HRQOL. Several studies have addressed HRQOL in chronic kidney disease patients undergoing renal replacement therapies, especially transplanted patients and hemodialysis patients, while publications concerning peritoneal dialysis (PD) patients are scarcer. This review describes some of the methods used to assess HRQOL, factors influencing HRQOL in PD patients, HRQOL in PD vs hemodialysis, and the relation between HRQOL and patient outcomes. We conclude that assessment of HRQOL-often neglected at present-should be included as a standard measure of patient-centered outcomes and when monitoring the quality and effectiveness of renal care including PD treatment.

Health literacy and uptake of anti-fracture medications in a population-based sample of Australian women

This study investigated associations between health literacy and use of anti-fracture medications in women with osteoporosis. Data were collected for women participating in the population-based Geelong Osteoporosis Study in Australia. Health literacy was ascertained using the Health Literacy Questionnaire (HLQ) and bone mineral density by dual x-ray absorptiometry. Self-reported current medications were classified using MIMS codes, with the category 'Agent affecting calcium and bone metabolism' indicating osteoporosis treatment. Analysis of Variance (p-value <0.1 indicating a trend) and Cohen's d effect sizes (ES [95%CI]) (categorised; Small >0.2-<0.5, Moderate >0.5-0.8, Large >0.8) were calculated for differences in HLQ scale scores between participants who did vs. did not self-report medication use. Among 620 women, 134 (21.6%) had osteoporosis, 14 (10.5%) of whom self-reported current anti-fracture medication use. Small/moderate ES indicated women taking medication had lower HLQ scores in scales 'Navigating the healthcare system', 'Ability to find health information' and 'Understand health information' (ES 0.36 [0.25-0.79], 0.41 [0.29-0.87] and 0.64 [0.54-1.03], respectively). A trend was observed (p = 0.09) for 'Understand health information' scale scores and utilisation of medication. These data suggest women with less confidence in their ability to find and understand health information may follow healthcare provider recommendations and utilise anti-fracture medications more readily.

Health Literacy in a Social Context: Review of Quantitative Evidence

Background

Conceptual literature has consistently noted that health literacy exists within a social context. This review examined how the intersection of social context and health literacy has been operationalized in quantitative, empirical research.

Methods

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched seven databases, including PubMed and CINAHL (The Cumulative Index to Nursing and Allied Health Literature), using a range of potentially relevant keywords, and we hand-searched bibliographies. Inclusion criteria were quantitative studies of any design in which measurement of health literacy and measurement of social context intersected. We identified 1,052 unduplicated articles; 34 met inclusion criteria.

Key Results

We found three distinct perspectives on the intersection between health literacy and social context. Most common (n = 23) were studies measuring an association between individual health literacy and individual social capital, social support, or social engagement, particularly whether social support varied by health literacy and/or if this relationship mediated health outcomes. Another group of studies (n = 6) took the perspective that being health literate by definition included social context, including access to and/or use of social support as a domain in individual health literacy assessment. Five studies considered the social context of health literacy as an independent property measured beyond the individual level; two measured community-level health literacy and three measured health literacy capacity/concordance in caregiving dyads. The studies showed significant definitional and measurement complexity and overlap. In the most dramatic example, a similar question was used across various studies to measure (1) health literacy, (2) a social support domain in health literacy, (3) social support, and (4) a study outcome distinct from, but associated with, health literacy. Potential useful methods, such as social network analyses, were missing from the literature.

Discussion

Existing quantitative research on health literacy in a social context supports more attention to this topic. This review quantified evidence, revealed gaps, noted limitations, and identified important questions for future research. [Health Literacy Research and Practice . 2017;1(2):e41-e70.].

Plain Language Summary

This study systemically compiles existing quantitative empirical research (34 articles) focusing on the intersection of health literacy in the social context. We find considerable measurement complexity in the current body of work on this topic and identify three distinct perspectives that researchers have taken while considering this topic. This information will be useful for future development of this important research area.