Health Literacy and Perceptions of Stigma

A Critical Discourse Analysis of the Language of Stigmatization of Breast Cancer Patients in Nigeria

Breast cancer is a significant health concern globally, including in Nigeria, where its incidence is rising. An essential component of breast cancer care is the psychosocial wellbeing of patients, which is often shaped by the language used in healthcare and society. While some research has explored stigmatization of breast cancer patients, no study has focused on language as a tool for this stigmatization in Nigeria. This study examines how language perpetuates the stigmatization of breast cancer patients and explores ways to use language to improve their lives and health. Using Norman Fairclough's model of critical discourse analysis and a descriptive design, data was collected through interviews with 50 respondents at the University College Hospital in Ibadan, Nigeria. The study's discourse analysis revealed that stigmatization is perpetuated through language, including negative stereotypes, body shaming, spiritual interpretations, and derogatory terms. These discourses reflect broader social and cultural factors such as norms, beliefs, and power dynamics that reinforce stigmatization. The research highlights the effects of stigmatizing language, including denial, loss of femininity, shame, and fear of a new identity. The findings call for policies and interventions to reduce stigma, improve patient experiences, and raise public awareness of breast cancer.

Physiotherapist-targeted strategies and tools for recognising patients with limited health literacy and adapting physiotherapeutic communication: A scoping review

OBJECTIVE

To provide an overview of available strategies and tools that support physiotherapists to recognise patients with LHL and to adapt the physiotherapeutic communication during the diagnostic phase.

METHODS

PubMed, Embase, CINAHL and PsycINFO were searched for publications appearing between 2000 and June 2024. Additional grey literature was searched up till October 2022. Studies were included if they described strategies and tools aimed at supporting communication with patients with Limited Health Literacy in physiotherapy. Exclusion criteria focusing on general health literacy prevalence, behavioural interventions, or basic communication training.

RESULTS

Out of the 9960 unique studies identified by our literature searches, 314 full-text studies were assessed and 98 met the inclusion criteria. The data on strategies and tools were extracted into the following six categories: verbal communication (n = 3), written communication (n = 34), digital device (n = 9), questionnaire (n=19), interpreter (n = 22), and other media (n = 2). Within these categories, tools and strategies were further classified based on the communication aims. Some tools and strategies were uncategorisable.

CONCLUSION

While various strategies and tools exist for recognising patients with limited Health Literacy, they are often generic and not tailored to the physiotherapeutic context. This scoping review identifies a gab in physiotherapeutic approaches, particularly on those that go beyond information provision.

PRACTICE IMPLICATIONS

To improve communication in physiotherapy practice, there is a need for the development of tailored strategies and tools that reflect the specific dynamic of the physiotherapeutic process. We recommend engaging in design-based research that involves both patient and physiotherapist to co-create tools and strategies. In the meantime, physiotherapists are advised to use general communication strategies and tools and refer to our resources to select tools that best align with their specific goals.

Resilience and frailty among gynecological patients in oncological treatment: the chain mediating role of stigma and health literacy

Background

Frailty poses a significant threat to the health status among gynecological patients in oncological treatment. Previous studies have shown that resilience, stigma, and health literacy are associated with frailty. However, their effects and potential relationship with frailty among gynecological patients in oncological treatment have not been fully studied.

Objective

The study aimed to explore the mediation role of stigma and health literacy between resilience and frailty among gynecological patients in oncological treatment.

Methods

A total of 202 gynecological patients in oncological treatment in three gynecological wards of a tertiary hospital in Wuxi from March 2024 to May 2024 were selected for the study using a cross-sectional research method. A convenience sampling method was used. Information was collected on demographic characteristics, resilience, stigma, health literacy, and frailty. The PROCESS macro program was used to explore the mediating role of stigma and health literacy in the relationship between resilience and frailty.

Results

The prevalence of frailty among gynecological patients in oncological treatment was 27.2%. The mediation effect results demonstrated that resilience was not a direct predictor of frailty (β = -0.010, 95%CI: -0.084 ~0.065) but indirectly predicted frailty through health literacy (β = -0.100, 95%CI: -0.155 ~ -0.053) and stigma-health literacy (β = -0.056, 95%CI: -0.091 ~ -0.029). However, no significant mediating effect of stigma alone was found (β = -0.038, 95%CI: -0.085 ~ 0.005).

Conclusions

The findings reveal the impact and potential relationship of resilience and frailty among gynecological patients in oncological treatment in patients with gynecologic oncology. Health literacy mediated the effect between resilience and frailty. Stigma and health literacy were chain mediators in the link between resilience and frailty. Healthcare professionals should pay timely attention to the psychological and mental status of gynecological patients in oncological treatment patients with gynecologic oncology and take measures to improve health literacy.

The Mental Health Literacy and Stigma Scale-Bilingual Cultural Adaptation: Validity and Reliability Pilot Study in Nursing Students

AIM

To describe and evaluate the psychometric properties (reliability and construct validity) of the Mental Health Literacy and Stigma Scale-Bilingual (MHLaSS-B).

DESIGN

This is a methodological study designed in a convenience sample of 271 Portuguese and Spanish nursing students who volunteered to participate in the research.

METHODS

The Mental Health Literacy and Stigma Scale-Bilingual version (Spanish and Portuguese) was used for data collection. MHLaSS-B intercultural adaptation followed three stages: translation, back-translation and pilot test and the thinking-aloud techniques. Content validity was performed by Content Validity Index and Modified Kappa statistic. Construct validity and reliability tests were performed. Internal consistency was assessed by Cronbach's alpha. Data were analysed using SPSS programs. Ethics committee approval and permission from the institution involved were obtained.

RESULTS

The MHLaSS-B has 28 items of one-factor structure. Cronbach's alpha was 0.702. The cumulative variance explained was 23.14%. Respondents show High literacy and Low Stigma (M = 23.4).

PATIENT OR PUBLIC CONTRIBUTIONS

The availability of the MHLaSS-B allows the general population of Portugal and Spain to have a versatile instrument for assessing stigma and MHL. The MHLaSS-B presents good psychometric properties, and it can be a useful tool for novice health workers to better understand the aspects they should pay attention to manage MHL and stigma successfully. The MHLaSS-B is a reliable, adaptable instrument that is now available and it can be used in investigation, teaching and clinical practice.

Investigating Older Adults' Perceptions of AI Tools for Medication Decisions: Vignette-Based Experimental Survey

BACKGROUND

Given the public release of large language models, research is needed to explore whether older adults would be receptive to personalized medication advice given by artificial intelligence (AI) tools.

OBJECTIVE

This study aims to identify predictors of the likelihood of older adults stopping a medication and the influence of the source of the information.

METHODS

We conducted a web-based experimental survey in which US participants aged ≥65 years were asked to report their likelihood of stopping a medication based on the source of information using a 6-point Likert scale (scale anchors: 1=not at all likely; 6=extremely likely). In total, 3 medications were presented in a randomized order: aspirin (risk of bleeding), ranitidine (cancer-causing chemical), or simvastatin (lack of benefit with age). In total, 5 sources of information were presented: primary care provider (PCP), pharmacist, AI that connects with the electronic health record (EHR) and provides advice to the PCP ("EHR-PCP"), AI with EHR access that directly provides advice ("EHR-Direct"), and AI that asks questions to provide advice ("Questions-Direct") directly. We calculated descriptive statistics to identify participants who were extremely likely (score 6) to stop the medication and used logistic regression to identify demographic predictors of being likely (scores 4-6) as opposed to unlikely (scores 1-3) to stop a medication.

RESULTS

Older adults (n=1245) reported being extremely likely to stop a medication based on a PCP's recommendation (n=748, 60.1% [aspirin] to n=858, 68.9% [ranitidine]) compared to a pharmacist (n=227, 18.2% [simvastatin] to n=361, 29% [ranitidine]). They were infrequently extremely likely to stop a medication when recommended by AI (EHR-PCP: n=182, 14.6% [aspirin] to n=289, 23.2% [ranitidine]; EHR-Direct: n=118, 9.5% [simvastatin] to n=212, 17% [ranitidine]; Questions-Direct: n=121, 9.7% [aspirin] to n=204, 16.4% [ranitidine]). In adjusted analyses, characteristics that increased the likelihood of following an AI recommendation included being Black or African American as compared to White (Questions-Direct: odds ratio [OR] 1.28, 95% CI 1.06-1.54 to EHR-PCP: OR 1.42, 95% CI 1.17-1.73), having higher self-reported health (EHR-PCP: OR 1.09, 95% CI 1.01-1.18 to EHR-Direct: OR 1.13 95%, CI 1.05-1.23), having higher confidence in using an EHR (Questions-Direct: OR 1.36, 95% CI 1.16-1.58 to EHR-PCP: OR 1.55, 95% CI 1.33-1.80), and having higher confidence using apps (EHR-Direct: OR 1.38, 95% CI 1.18-1.62 to EHR-PCP: OR 1.49, 95% CI 1.27-1.74). Older adults with higher health literacy were less likely to stop a medication when recommended by AI (EHR-PCP: OR 0.81, 95% CI 0.75-0.88 to EHR-Direct: OR 0.85, 95% CI 0.78-0.92).

CONCLUSIONS

Older adults have reservations about following an AI recommendation to stop a medication. However, individuals who are Black or African American, have higher self-reported health, or have higher confidence in using an EHR or apps may be receptive to AI-based medication recommendations.

Physiotherapists' views and experiences of health literacy in clinical practice

OBJECTIVE

Using a qualitative design, this study aimed to explore the experience of physiotherapists' supporting patient health literacy in clinical practice, gain an understanding of their conceptualisation of health literacy, and make recommendations for improving health literacy support in clinical practice.

METHODS

Convenience sampling via social media was used to recruit eight participants who were all physiotherapists practicing in the United Kingdom. Semi-structured interviews took place on Zoom during the second Covid-19 lockdown. Interviews were audio-recorded, transcribed, coded, and thematically analysed to uncover physiotherapists' views on health literacy, experiences of supporting patients with health literacy and opinions and recommendations for practice.

RESULTS

Of the eight participants, five were female and the mean years of clinical experience as a qualified physiotherapist was 5.8. Four main themes were identified: physiotherapists' conceptualisation of health literacy, identification of health literacy and skills required to support patients, training and barriers to providing health literacy-sensitive care and recommendations for improvement.

CONCLUSION

The findings highlighted that physiotherapists identified a patient's health literacy abilities by picking up tacit clues throughout their consultations and they pre-dominantly viewed health literacy as the ability to read, write and communicate effectively. They reported having a limited exposure to health literacy training and recommended raising awareness and education as key to improve practice.

The Shift from Individual to Organizational Health Literacy: Implications for Kidney Healthcare Leaders and Clinicians

BACKGROUND

As a social determinant of health, health literacy has a vital role in the management of chronic disease management, including chronic kidney disease (CKD).

SUMMARY

To be able to manage their condition, patients with CKD need to be able to assess, comprehend, appraise, and utilize complex health-related information. Those patients are much more likely to understand and use health information appropriately, if it addresses their personal needs related to language, culture, educational background, and socioeconomic status. One aspect of health literacy, organizational health literacy (OHL), relates to the degree with which health organizations justifiably empower patients to locate, understand, and utilize health information and facilities to inform their decision-making and health behaviours. With increasing evidence-based about OHL as a way to improve healthcare, it is a new concept for kidney clinicians.

KEY MESSAGES

As producers of health-related information, the multidisciplinary kidney healthcare team have a responsibility to meet the needs of those in their care, as such, priority should be given to implementation of OHL initiatives. Through enhancing the clarity of information, OHL initiatives may provide a game plan for person-centred care for those with CKD.

Limited health literacy in primary care physiotherapy: Does a physiotherapist use techniques to improve communication?

OBJECTIVES

Research shows that health professionals should adapt their communication when addressing patients with limited health literacy (HL). However, the extent to which physiotherapists apply recommended communication techniques is unclear.

METHODS

We conducted a two phase mixed-method study, first holding focus group interviews among patients and experts on communication to explore the need for adjusted communication in physiotherapist-patient interaction. Second, we manually coded audio recordings of primary care physiotherapy consultations to investigate the extent to which physiotherapists applied these recommended communication techniques, and adjusted their communication towards patients with lower education.

RESULTS

Focus group interviews identified four categories of communication elements: the teach-back method, medical jargon explanation, summarizing patient's narratives, and checking patient's understanding. In 50 audio recordings we identified 2670 clauses. We report limited use of the recommended communication techniques; the teach-back method was used in 2% of consultations (95%CI: 0.4%-10.5%) while medical jargon explanation was used in 84% (95%CI: 71.5%-91.7%). Mixed effects logistic regression models showed no association between lower education and communication techniques.

CONCLUSION

Although physiotherapists need to adjust their communication to patients with lower education, they rarely apply the recommended communication techniques.

PRACTICE IMPLICATIONS

Knowledge about limited HL among physiotherapists needs to be increased.

Media and Social Factors Influencing Stigma towards Eczema Patients: A Survey Study in Singapore

ISSUE ADDRESSED

Eczema is a common skin health issue in Singapore. A salient challenge eczema patients are facing is the stigma towards them, which has been relatively unacknowledged. It is critical to reduce stigma towards eczema patients, and an essential step is to identify factors influencing stigmatizing behavior.

METHODS

With a general basis of the Integrative Model of Behavioral Prediction, we conducted a cross-sectional online survey (N=293) in the context of Singapore. The sample was recruited via the online panel of a survey company, Rakuten Insights. Our sample's age and education level generally fit with the population in Singapore.

RESULTS

Media exposure to eczema content did not influence stigmatizing behavior either directly or indirectly. However, personal connection with eczema patients reduced stigma indirectly, completely mediated by stigmatizing attitude towards eczema patients and health literacy. That is, personal connection with eczema patients had a negative relationship with stigmatizing attitude, which was positively associated with the intention of and actual stigmatizing behavior. On the other hand, personal connection increased health literacy, which in turn reduced stigmatizing intention and behavior.

CONCLUSIONS

We call for more future initiatives to fight against health stigma. Health promotion can take advantage of eczema patients' social network to educate the general public about the eczema issue to lower stigma. Public policy responses to prevent discrimination on the basis of skin health are also needed. Media organizations should use news media and social media to speak out against stigma towards eczema patients, and avoid using stigmatizing language.

Definitions and measurement of health literacy in health and medicine research: a systematic review

OBJECTIVES

The way health literacy is understood (conceptualised) should be closely linked to how it is measured (operationalised). This study aimed to gain insights into how health literacy is defined and measured in current health literacy research and to examine the relationship between health literacy definitions and instruments.

DESIGN

Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

The MEDLINE, PsycINFO, ERIC and CINAHL databases were searched for articles published during two randomly selected months (March and October) in 2019.

ELIGIBILITY CRITERIA

We included articles with a quantitative design that measured health literacy, were peer-reviewed and original, were published in the English language and included a study population older than 16 years.

DATA EXTRACTION AND SYNTHESIS

Six researchers screened the articles for eligibility and extracted the data independently. All health literacy definitions and instruments were considered in relation to category 1 (describing basic reading and writing skills, disease-specific knowledge and practical skills) and category 2 (social health literacy competence and the ability to interpret and critically assess health information). The categories were inspired by Nutbeam's descriptions of the different health literacy levels.

RESULTS

120 articles were included in the review: 60 within public health and 60 within clinical health. The majority of the articles (n=77) used instruments from category 1. In total, 79 of the studies provided a health literacy definition; of these, 71 were in category 2 and 8 were in category 1. In almost half of the studies (n=38), health literacy was defined in a broad perspective (category 2) but measured with a more narrow focus (category 1).

CONCLUSION

Due to the high degree of inconsistency between health literacy definitions and instruments in current health literacy research, there is a risk of missing important information about health literacy considered be important to the initial understanding of the concept recognised in the studies.

PROSPERO REGISTRATION NUMBER

CRD42020179699.

Validity Testing and Cultural Adaptation of the eHealth Literacy Questionnaire (eHLQ) Among People With Chronic Diseases in Taiwan: Mixed Methods Study

Background

Advancements in digital technologies seek to promote health and access to services. However, people lacking abilities and confidence to use technology are likely to be left behind, leading to health disparities. In providing digital health services, health care providers need to be aware of users’ diverse electronic health (eHealth) literacy to address their particular needs and ensure equitable uptake and use of digital services. To understand such needs, an instrument that captures users’ knowledge, skills, trust, motivation, and experiences in relation to technology is required. The eHealth Literacy Questionnaire (eHLQ) is a multidimensional tool with 7 scales covering diverse dimensions of eHealth literacy. The tool was simultaneously developed in English and Danish using a grounded and validity-driven approach and has been shown to have strong psychometric properties.

Objective

This study aims to translate and culturally adapt the eHLQ for application among Mandarin-speaking people with chronic diseases in Taiwan and then undertake a rigorous set of validity-testing procedures.

Methods

The cross-cultural adaptation of the eHLQ included translation and evaluation of the translations. The measurement properties were assessed using classical test theory and item response theory (IRT) approaches. Content validity, known-group validity, and internal consistency were explored, as well as item characteristic curves (ICCs), item discrimination, and item location/difficulty.

Results

The adapted version was reviewed, and a recommended forward translation was confirmed through consensus. The tool exhibited good content validity. A total of 420 people with 1 or more chronic diseases participated in a validity-testing survey. The eHLQ showed good internal consistency (Cronbach α=.75-.95). For known-group validity, all 7 eHLQ scales showed strong associations with education. Unidimensionality and local independence assumptions were met except for scale 2. IRT analysis showed that all items demonstrated good discrimination (range 0.27-12.15) and a good range of difficulty (range 0.59-1.67) except for 2 items in scale 7.

Conclusions

Using a rigorous process, the eHLQ was translated from English into a culturally appropriate tool for use in the Mandarin language. Validity testing provided evidence of satisfactory-to-strong psychometric properties of the eHLQ. The 7 scales are likely to be useful research tools for evaluating digital health interventions and for informing the development of health technology products and interventions that equitably suit diverse users’ needs.

Liver health literacy and social stigma of liver disease: A general population e-survey

BACKGROUND

Health literacy is increasingly recognized as an essential determinant for the health of the population. Liver patients report perceived stigma to be a considerable problem. Little is however known about liver health literacy in the general population and to what extent liver disease is considered stigmatizing in comparison with other chronic diseases. We aimed to explore these knowledge gaps.

METHODS

We performed an exploratory e-survey in a statistically representative sample of 500 Swedes from the general population. A questionnaire developed for this purpose investigated awareness, attention, knowledge and attitudes towards liver health and compared some aspects with other common health problems.

FINDINGS

Few worry (23%), think (28%), discuss with their doctor (31%) or hear about liver health in the news (19%). Few (18%) had a liver test in the last year and knew (23%) what is considered a normal liver test. More knew what is considered normal blood pressure (89%), blood sugar (74%) and BMI (73%). Few (22%) talk about liver health, mainly (50%) because abuse is presumed. Many (36%) believe that cirrhosis is only caused by alcohol, 31% that the liver produces urine and 21% that you can survive without a liver. Only mental illness (78%) and obesity (74%) were considered more stigmatizing than liver cirrhosis (61%).

INTERPRETATION

The study confirms often held views that liver health receives less attention than many other health areas. Knowledge about liver health is generally poor, and liver cirrhosis carries significant social stigma. Improving public awareness and knowledge about liver health, and thereby ameliorating stigma, should be essential parts of policy objectives and action plans to improve liver health in Europe.

FUNDING

This research was supported by a general grant from the Bengt Ihre Foundation.

COVID-19-related stigma and its influencing factors: a nationwide cross-sectional study during the early stage of the pandemic in China

OBJECTIVES

To describe the situation of COVID-19-related stigma towards patients with COVID-19 and people from the city of Wuhan in China and to assess the associations between COVID-19-related stigma, health literacy and sociodemographic characteristics during March 2020, the early stage of the pandemic.

DESIGN

A cross-sectional online survey.

SETTING

The study surveyed 31 provinces in China.

PARTICIPANTS

This study surveyed 5039 respondents in China.

OUTCOME MEASURES

Public stigma towards both patients with COVID-19 and Wuhan residents was measured. Binary logistic regression was used to identify the factors associated with public COVID-19-related stigma.

RESULTS

Among the participants, 122 (2.4%) reported themselves and 254 (5.0%) reported the communities they lived in as holding a stigmatising attitude towards patients with COVID-19, respectively. Additionally, 114 (2.5%) and 475 (10.3%) reported that themselves and the communities they lived in, respectively, held a stigma against people from Wuhan, which was the most severely affected area in China. People aged over 40, lived in areas with severe epidemics (adjusted OR (aOR)=2.03, 95% CI (1.05 to 3.92)) and who felt it difficult to find and understand information about COVID-19 (aOR=1.91, 95% CI (1.08 to 3.37); aOR=1.88, 95% CI (1.08 to 3.29)) were more likely to stigmatise patients with COVID-19. People who were male, aged 41-50 and had difficulty understanding information (aOR=2.08, 95% CI (1.17 to 3.69)) were more likely to stigmatise people from Wuhan.

CONCLUSIONS

Patients with COVID-19 and Wuhan residents suffered stigma at both the individual and the community levels. Those who had low health literacy, who lived in areas with a large number of COVID-19 cases and who were of ethnic minorities were more likely to stigmatise others. Tailored interventions are encouraged to improve health literacy and consequently to reduce public COVID-19-related stigma.

Health Literacy Within a Diverse Community-Based Cohort: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Health literacy has yet to be described in a non-clinical, racially diverse, community-based cohort.

METHODS

Four questions assessing health literacy were asked during annual phone encounters with Multi-Ethnic Study of Atherosclerosis (MESA) participants between 2016 and 2018 (n = 3629). We used prevalence ratios (PRs) with 95% confidence intervals (CIs) to characterize how demographic and acculturation factors related to limited health literacy. Models adjusted for age, sex, and race/ethnicity, and race/ethnicity-stratified models were also examined.

RESULTS

Limited health literacy was prevalent in 15.4% of the sample. Participants who were older, female, lower-income, or less acculturated were at greater risk for having limited health literacy. Chinese, Hispanic, and Black participants were more likely than White participants to have limited health literacy. Patterns were similar when stratified by race/ethnicity.

DISCUSSION

Within MESA limited health literacy was common, particularly among Chinese and Hispanic participants, with some of the variance explained by differences in acculturation.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.