Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review

Socioeconomic disparities in childhood vaccine hesitancy among parents in China: The mediating role of social support and health literacy

Parental vaccine hesitancy is a major obstacle to childhood vaccination. We examined parental socioeconomic status (SES) disparities in vaccine hesitancy, and the potential mediating roles of perceived social support and health literacy. A questionnaire survey was given to parents with children aged below 6 years from six provinces in China. SES was examined by educational attainment, annual household income, and a subjective measure of SES (using a scale of 1-10). Linear regression was applied to assess the association between SES and vaccine hesitancy. Bootstrapping mediation analysis was performed with 5,000 samples bootstrapped. A total of 1,638 parents were included. Using annual household income > 200,000 Chinese yuan (CNY) as a reference, parents with lower household income (CNY 100,001-150,000) experienced higher vaccine hesitancy. Educational attainment was not associated with vaccine hesitancy. Subjective SES had a U-shaped relationship with vaccine hesitancy. Perceived social support and health literacy independently and sequentially mediated the effects of subjective SES (indirect effect: -0.240) and annual household income (indirect effect: 1.250 for ≤ CNY 100,000 and 0.759 for CNY 100,001-150,000) on vaccine hesitancy. Socioeconomic disparities influenced parental vaccine hesitancy in China, which were mediated by perceptions of social support and health literacy.

Reporting and incorporation of social risks in low back pain and exercise studies: A scoping review

BACKGROUND

Exercise is a common intervention for low back pain, but its effect sizes are small to modest. Social risk factors significantly influence health outcomes, yet their consideration in randomized controlled trials on exercise for low back pain is often neglected. Determining their relationship to outcomes may provide better insight into exercise effectiveness.

OBJECTIVES

To assess the reporting of social risk factors (SRFs) in randomized controlled trials (RCTs) of exercise interventions for low back pain (LBP) in adults and explore associations between SRFs and outcomes.

DESIGN

Scoping Review.

METHODS

The databases MEDLINE, CINAHL and Cochrane were searched for studies published between January 2014 to March 2025. RCTs were included if exercise was the primary intervention for LBP treatment and had a minimum follow-up of 12 weeks. A planned analysis of SRF and outcome associations was not conducted due to insufficient data.

RESULTS

A total of 10,292 studies were identified and 157 studies included. Fewer than half (47.1 %) reported any SRFs at baseline. Socioeconomic position (42.7 %) was most frequently reported, followed by social relationships (17.8 %), race/ethnicity/cultural context (8.3 %), residential/community context (1.3 %), and gender (0.6 %). Four studies incorporated SRFs in their outcome analyses; one examined associations with outcomes and found no significant association.

CONCLUSION

SRFs are underreported in RCTs of exercise interventions for LBP and are rarely analyzed in relation to primary outcomes, limiting our understanding of their impact. Future trials should prioritize collecting and reporting SRFs at baseline and incorporating them in outcome analyses to assess their influence on outcomes.

Characteristics of teeth and patients receiving root canal treatment in National Dental PBRN practices: Comparison between Endodontist and general dentist practices

PURPOSE

To describe and compare patient and tooth characteristics determined prior to treatment among those receiving root canal treatment (RCT) from general dentists (GD) versus endodontists within the National Dental Practice-Based Research (PBRN) Network.

METHODS

This National Dental PBRN study involved 153 practitioners (104 GDs and 49 endodontists) who used a consecutive enrollment strategy to enroll patients. Practitioners recorded details about pre-operative tooth characteristics. Prior to RCT, patients provided data about their socio-demographic, medication use, temporomandibular disorder (TMD), and psycho-social characteristics. We describe the overall prevalence of these characteristics and compare them by provider type.

RESULTS

1,723 patients were enrolled; 788 by GDs and 935 by endodontists. Endodontists treated higher proportions of female, non-Hispanic white, better-educated patients, patients from the Midwest and Southwest regions, and molar teeth compared to GDs. GDs saw a higher proportion of patients from the Northeast region and whose teeth had a probing depth of 5 mm or more. All of these characteristics were independently and significantly (at p <.05) associated with provider type. Endodontists were more likely than GDs to see patients with TMD symptoms in bivariate comparisons, but their patient groups were similar with regard to treatment outcome expectation, dental fear, depression, and anxiety.

CONCLUSION

Significant differences exist between endodontists and GDs in patient demographics, tooth characteristics, and treatment patterns, with endodontists treating more molars, female, non-Hispanic white, and educated patients, while GDs manage more cases involving antibiotics use and teeth with deep probing depths, highlighting variations in referral patterns and treatment accessibility.

Readability of written information for patients across 30 years: A systematic review of systematic reviews

OBJECTIVE

This study conducted a systematic review of the systematic reviews of readability assessment studies to contribute to future readability research and practice by providing a comprehensive overview of information readability for patients.

METHODS

We searched multiple databases. We included systematic reviews of studies that quantitatively assessed the readability of health information.

RESULTS

This study included 24 systematic reviews, which assessed the readability of 29,424 materials across 438 studies from 1990 to 2022. All systematic reviews reported that the readability of most materials exceeded the recommended sixth to eight-grade reading level. The readability level did not improve between 2001 and 2022, when the included systematic reviews were published.

CONCLUSIONS

We found that the required reading level of information was too high for patients in all clinical areas included in this systematic review. We also identified gaps in readability assessment research in clinical areas and across media types and languages, which should be addressed by future studies.

PRACTICE IMPLICATIONS

Health professionals should use available guidelines to make existing patient information easy to read and to write easy-to-read patient information, thereby improving readability. Such efforts are needed regardless of the organizations these professionals work at.

Attitudes towards being offered a choice of self-sampling or clinician sampling for cervical screening: A cross-sectional survey of women taking part in a clinical validation of HPV self-collection devices

ObjectivesPrimary human papillomavirus (HPV) testing in cervical screening offers the opportunity for women to be given a choice between HPV self-sampling and traditional clinician screening. This study assessed attitudes towards a choice and anticipated future preference among women who had collected a vaginal self-sample alongside their usual cervical screen.SettingThirty-eight general practices across five areas in England.MethodsOverall, 2323 women (24-65 years; response rate: 48%) completed a survey after collecting a self-sample and having a clinician screen at their GP practice. We asked which test they preferred and assessed attitudes to being offered a choice. We explored age, education, ethnicity and screening experience as predictors of attitudes towards a choice and anticipated future choice.ResultsMost participants felt they would like a choice between self-sampling and clinician screening (85%) and thought this would improve screening for them (72%). However, 23% felt it would be difficult to choose, 15% would worry about making a choice, and nearly half would prefer a recommendation (48%). Compared with women with degree-level education, those with fewer qualifications were more likely to say they would worry about having a choice or would not want a choice (p < 0.001). The majority said they would choose to self-sample at home if offered a choice in the future (69%; n = 1602/2320).ConclusionsSelf-sampling is likely to be popular, but offering a choice could cause worry for some people and many would prefer a recommendation. Supporting people to make a choice will be important, particularly for those with lower levels of education.

Social determinants of health as risk factors for keratoconus in the All of Us database

BACKGROUND/AIMS

Clinical risk factors for keratoconus (KCN) have previously been established. While the impact of the social determinants of health on the epidemiology and pathophysiology of KCN has been explored, further study of these associations is needed in large and diverse populations. This cross-sectional study determines how education level and income impact the prevalence of KCN in the USA using the National Institutes of Health 'All of Us' database.

METHODS

Exposures included the highest level of education and annual household income. Multivariable logistic regression was used to examine the odds of KCN diagnosis at different levels of education and income, adjusting for sex assigned at birth, race, ethnicity, age, atopic conditions and eyecare access.

RESULTS

The overall prevalence of KCN was 0.17% (429/255 334). In multivariable logistic regression, individuals with more than a high school education had a greater risk of having KCN than those with less than a high school equivalent (college 1-3 years: adjusted OR (aOR): 1.96; 95% CI 1.46 to 2.65; college graduate or advanced degree: aOR:2.19; 95% CI 1.61 to 3.00). There were no significant associations between income level and odds of keratoconus.

CONCLUSION

In the study population, higher education level was associated with an increased likelihood of keratoconus, while no correlation was seen between income and KCN prevalence. After adjusting for access to eye care in a secondary analysis, there was an association between increased education level and increased prevalence of KCN. Further studies are needed to fully understand the mechanism of this finding such as increased levels of dry eye secondary to computer vision syndrome in highly educated people.

Health Literacy and Preventive Health Behaviors Among Hispanics: Path Analysis Approach

INTRODUCTION

Health literacy is crucial for understanding and acting on health information. Inadequate health literacy is associated with poor health outcomes, particularly in underserved groups like Hispanics.

METHODS

This descriptive, cross-sectional study explored the relationship between health literacy, demographics, and adherence to preventive health behaviors among Hispanic adults in spring 2021. Participants were recruited through convenience sampling in Southern California. Data were collected using the Newest Vital Sign and a self-administered health survey, with path analysis assessing health literacy and adherence predictors.

RESULTS

Among 149 adults, the model explained 62% of the variance in health literacy and 56.1% in adherence. Higher education (β = .74) and speaking English at home (β = .25) were statistically significant predictors of greater health literacy, which was strongly associated with better adherence (β = .51). Employment status negatively affected adherence (β = -.28, p = .001).

DISCUSSION

Organizational resources, education, and language proficiency are crucial for enhancing health literacy and promoting preventive behaviors. Tailored bilingual programs and educational initiatives should be prioritized to address these disparities.

Application of AI Chatbot in Responding to Asynchronous Text-Based Messages From Patients With Cancer: Comparative Study

BACKGROUND

Telemedicine, which incorporates artificial intelligence such as chatbots, offers significant potential for enhancing health care delivery. However, the efficacy of artificial intelligence chatbots compared to human physicians in clinical settings remains underexplored, particularly in complex scenarios involving patients with cancer and asynchronous text-based interactions.

OBJECTIVE

This study aimed to evaluate the performance of the GPT-4 (OpenAI) chatbot in responding to asynchronous text-based medical messages from patients with cancer by comparing its responses with those of physicians across two clinical scenarios: patient education and medical decision-making.

METHODS

We collected 4257 deidentified asynchronous text-based medical consultation records from 17 oncologists across China between January 1, 2020, and March 31, 2024. Each record included patient questions, demographic data, and disease-related details. The records were categorized into two scenarios: patient education (eg, symptom explanations and test interpretations) and medical decision-making (eg, treatment planning). The GPT-4 chatbot was used to simulate physician responses to these records, with each session conducted in a new conversation to avoid cross-session interference. The chatbot responses, along with the original physician responses, were evaluated by a medical review panel (3 oncologists) and a patient panel (20 patients with cancer). The medical panel assessed completeness, accuracy, and safety using a 3-level scale, whereas the patient panel rated completeness, trustworthiness, and empathy on a 5-point ordinal scale. Statistical analyses included chi-square tests for categorical variables and Wilcoxon signed-rank tests for ordinal ratings.

RESULTS

In the patient education scenario (n=2364), the chatbot scored higher than physicians in completeness (n=2301, 97.34% vs n=2213, 93.61% for fully complete responses; P=.002), with no significant differences in accuracy or safety (P>.05). In the medical decision-making scenario (n=1893), the chatbot exhibited lower accuracy (n=1834, 96.88% vs n=1855, 97.99% for fully accurate responses; P<.001) and trustworthiness (n=860, 50.71% vs n=1766, 93.29% rated as "Moderately trustworthy" or higher; P<.001) compared with physicians. Regarding empathy, the medical review panel rated the chatbot as demonstrating higher empathy scores across both scenarios, whereas the patient review panel reached the opposite conclusion, consistently favoring physicians in empathetic communication. Errors in chatbot responses were primarily due to misinterpretations of medical terminology or the lack of updated guidelines, with 3.12% (59/1893) of its responses potentially leading to adverse outcomes, compared with 2.01% (38/1893) for physicians.

CONCLUSIONS

The GPT-4 chatbot performs comparably to physicians in patient education by providing comprehensive and empathetic responses. However, its reliability in medical decision-making remains limited, particularly in complex scenarios requiring nuanced clinical judgment. These findings underscore the chatbot's potential as a supplementary tool in telemedicine while highlighting the need for physician oversight to ensure patient safety and accuracy.

Association of health literacy with quality of life and health outcomes among school-age children in Japan: A cross-sectional study

Health literacy is a modifiable determinant of health with the potential to enhance public health. An association between health literacy and health-related quality of life has been reported. Although each country has developed their own original health literacy scales, the assessment of adolescent health literacy using the Health Literacy Scale for School-Aged Children has not yet been studied in Japan. In this study, we aimed to clarify the factors associated with adolescents' health literacy and examine the relationship between health literacy, health-related behaviors, and health-related quality of life in Japan. Participants were recruited by a research company using registered monitors (1st- to 3rd-year junior high school students and their mothers living in Japan in August 2023). Multivariate regression analysis was performed using the total EuroQoL Five Dimensions, Youth Version scores. SAS software was used for data analysis. Overall, 1,854 adolescents and their mothers participated in the online survey. Factors associated with Health Literacy Scale for School-Aged Children included physical activity, sleep conditions in health-related behaviors, parental communication, parental health literacy, and health-related quality of life. Furthermore, parental health literacy was associated to children's quality of life. Our study showed the influence of family variables, highlighting the need for tailored approaches that consider parents' health literacy levels.

Association of individual and community-level socioeconomic status and education with medication use: a multilevel analysis in the PERSIAN cohort

BACKGROUND

Socioeconomic status (SES) and education influence medication use, but their effects at both individual and community levels remain poorly understood. This study investigates the association between medication count and polypharmacy with SES and education at both levels.

METHODS

We used data from the Prospective Epidemiological Research Studies in IrAN (PERSIAN), comprising 163,770 individuals aged 35-70 from 18 sites in Iran. Individual SES was evaluated using asset analysis, while community SES was determined based on the prevalence of low SES individuals in each site. Individual education level was dichotomized into having at least 5 years of schooling or not, while community education level was determined by the frequency of individuals with high education level in each site. Multi-level Poisson regressions, were conducted to explore the association between these variables and medication count in this cross-sectional study.

RESULTS

Approximately 45% of participants used at least one medication, with an average of 1.32 medications per person. Polypharmacy was observed in 8.85% of the population. Higher individual SES was associated with a slightly increased medication count (PR 1.05; 95% CI: 1.02-1.08) and a modest increase in polypharmacy risk (PR 1.08; 95% CI: 1.03-1.14). Residing in middle-SES communities was linked to lower medication use (PR 0.88; 95% CI: 0.85-0.91) but was not significantly associated with polypharmacy. Higher individual education was associated with reduced medication count (PR 0.92; 95% CI: 0.88-0.96) and a lower likelihood of polypharmacy (PR 0.85; 95% CI: 0.79-0.91). However, living in highly educated communities was associated with increased medication count (PR 1.70; 95% CI: 1.62-1.78) and a higher risk of polypharmacy (PR 1.81; 95% CI: 1.16-2.81). The models were adjusted for age, gender, residence, ethnicity, marital status, body mass index, physical activity level, smoking status, opium use, hookah use, and alcohol consumption.

CONCLUSION

Higher education was associated with lower medication use, whereas living in more educated communities was linked to higher usage. Although the association between individual SES and medication use was relatively weak, residing in middle-SES communities was associated with lower medication usage. These findings show the importance of addressing community-level factors in health research and policymaking.

Health literacy disparities in South Korea: insights from a latent profile analysis

BACKGROUND

Health literacy has been empirically linked to overall health outcomes. Existing interventions generally employ a variable-centred approach, often neglecting the cumulative impact of various factors and the ways different groups interact with health information. We aimed to explore health literacy in the general population of South Korea by identifying and characterising distinct health literacy profiles using latent profile analysis.

METHODS

A cross-sectional design was utilised, analysing health literacy data from the second wave of the Korea Health Panel Survey (collected between March and July 2021) with responses from 9,509 adults. Health literacy was assessed in the domains of health management, disease prevention, and health promotion using the 16-item European Health Literacy Survey Questionnaire. Latent profile analysis was used to identify health literacy profiles, and multinomial logistic regression analysis was used to examine sociodemographic and health-related factors associated with profile membership.

RESULTS

Latent profile analysis revealed three distinct health literacy groups: low (27.91%), moderate (63.51%), and high (8.58%). A social gradient was observed, with disparities in age, education, income, and residence observed across the groups. Membership in the low health literacy group was associated with being older, disability, and chronic disease-populations with heightened healthcare needs.

CONCLUSIONS

The findings underscore the need for targeted interventions to address the unique challenges faced by populations with low health literacy in a universal health coverage system such as that of South Korea. By identifying those at highest risk for low HLit and targeting policy measures accordingly, healthcare systems can allocate resources more effectively and make health information genuinely accessible for all. In doing so, such strategies can ultimately help mitigate the disparities highlighted in this study. These insights provide a foundation for policies aimed at promoting health equity through focused health literacy initiatives.

Navigational health literacy and health service use among higher education students in Alentejo, Portugal - A cross-sectional study

INTRODUCTION

The navigational health literacy of higher education students is fundamental to effective health management and successful health navigation, thereby improving health outcomes and overall well-being. Assessing the general and navigational health literacy levels of these students is crucial for developing targeted interventions and facilitating informed decision-making on health-related issues. This study aimed to identify the levels of general and navigational health literacy, characterise access to and utilisation of healthcare services, and analyse the differences between the mean general and navigational health literacy indices and determinants among higher education students in the Alentejo region of southern Portugal.

METHODOLOGY

A descriptive and cross-sectional study was conducted between 25 May and 12 September 2023 with 1979 higher education students. An online structured questionnaire comprising the Portuguese version of the European Health Literacy Survey Questionnaire - 16 items (HLS-EU-PT-Q16) and the Navigational Health Literacy Scale (HLS19-NAV), both from the European Consortium, was used. Sociodemographic data, presence of chronic disease, perceived health status, perceived availability of money for expenses, and healthcare access and utilisation variables were included. The study data were analysed using independent samples t-test, one-way ANOVA, and post hoc Bonferroni test, followed by multiple linear regression analyses at a significance level of 0.05. Multiple linear regression analysis was performed to identify factors associated with both general and navigational health literacy. The study protocol was approved by the ethics committee of the University of Évora, and all participants provided written informed consent.

RESULTS

Most students (86.8%) exhibited limited general health literacy, while 13.2% demonstrated adequate health literacy. Inadequate navigational health literacy was observed in 73.4% of students. Students with lower mean general and navigational health literacy were more likely to have utilised health services. Students with chronic conditions, recent use of urgent or emergency services, and difficulties in accessing healthcare had lower health literacy. Conversely, those enrolled in health-related courses, those with good financial resources and those who had not used health services during their course had higher health literacy. In addition, lower navigational health literacy was found among displaced students, those with chronic conditions and those who had recently consulted a doctor. Higher navigational health literacy was associated with enrolment in health-related courses and adequate general health literacy.

CONCLUSION

The findings highlight the significant influence of demographic and academic factors on general and navigational health literacy among higher education students. The prevalence of limited general and navigational health literacy underscores a significant challenge for students, institutions, and health policy makers. Effective health literacy interventions should take these factors into account. Future research should examine longitudinal changes in health literacy and evaluate the impact of targeted educational programmes.

Impact of functional, communicative, critical and distributed health literacy on self-management behaviors in chronic disease patients across socioeconomic groups

BACKGROUND

Effective self-management behaviors offer a promising pathway to address the health challenges faced by patients with chronic diseases. As a key factor influencing self-management behaviors, multidimensional health literacy has yet to be systematically studied in relation to its impact on patients with chronic diseases across different socioeconomic statuses.

OBJECTIVE

To systematically investigate the influence of functional, communicative, critical, and distributed health literacy on self-management behaviors among patients with chronic diseases from different socioeconomic statuses.

METHODS

A modified multidimensional health literacy and self-management behavior questionnaire was used to assess the health literacy and self-management behaviors of patients with chronic diseases. A total of 590 valid samples were obtained, and participants were divided into high and low socioeconomic status groups based on their socioeconomic background. Correlation analysis and multiple linear regression were conducted to explore the influence of various dimensions of health literacy on self-management behaviors across different socioeconomic statuses.

RESULTS

After controlling for confounding variables, the communicative (β = 0.262, P < 0.01) and distributed (β = 0.343, P < 0.01) health literacy dimensions showed a significant positive impact on self-management behaviors in the low socioeconomic status group. In the high socioeconomic status group, critical (β = 0.253, P < 0.05) and distributed (β = 0.267, P < 0.01) health literacy demonstrated a significant positive effect on self-management behaviors. No significant impact was observed for functional health literacy in either group.

CONCLUSIONS

The study comprehensively reveals the distinct effects of different dimensions of health literacy on self-management behaviors among patients with chronic diseases from varying socioeconomic statuses. These findings provide a theoretical basis for developing strategies aimed at improving self-management behaviors through health literacy enhancement, particularly tailored to patients from different socioeconomic backgrounds.

Evaluating the Association Between Health Literacy and Patient-Reported Outcome Measures After Distal Radius Fracture

PURPOSE

Patient-reported outcome measures (PROMs) are used to assess patients' outcomes during the treatment of distal radius fractures (DRFs). Limited health literacy is linked to poorer health outcomes. We asked whether limited health literacy is associated with PROM scores in patients with a DRF.

METHODS

This cross-sectional study enrolled adults ≥18 years of age with an isolated DRF from two urban hospitals within 6 weeks of injury or surgery. Participants completed a demographics survey, brief health literacy screen, and three PROMs: Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH); Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity v2.0 Short Form-7a (PROMIS-UE); and Numeric Rating Scale (NRS). Associations between social determinants of health (SDOH) factors (health literacy, income, education, and preferred language) and PROMs were assessed using multivariable linear regressions. Propensity score analyses to control for confounding and postmatching regressions were conducted.

RESULTS

Sixty-five patients participated in this study. In this sample, the mean age was 54 years, 65% were women, 26% had limited health literacy, 46% had public insurance, 18% completed at most a high school education, and 23% preferred a language other than English (PLOE). In multivariable analyses, limited health literacy and PLOE were associated with worse PROMIS-UE, and low income was associated with worse QuickDASH and NRS; associations between health literacy and QuickDASH and NRS were not statistically significant. Propensity score analyses indicated that all SDOH variables had confounding effects on associations between health literacy and PROMs. The postmatching regression analysis demonstrated that PLOE was associated with worse PROMIS-UE, and low income and PLOE with worse QuickDASH and NRS scores; limited health literacy was not significantly associated with any PROMs.

CONCLUSIONS

Low income and PLOE were significant predictors of worse PROM scores. After adjusting for other SDOH variables, limited health literacy was not significantly associated with PROM scores. These findings underscore the importance of recognizing and addressing the multiple interconnected SDOH aspects associated with PROM scores.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Health Literacy-Based Heart Failure Self-care (H2Lit) Application: Development and Usability Testing

The purpose of this study was to describe the development of a health literacy-focused heart failure self-care intervention (H2Lit Web-based app) and assess its usability using an online testing platform. We used an iterative approach, wherein participants evaluated more refined versions of H2Lit over four rounds of testing. Healthy participants were recruited for the earlier rounds of testing, and participants with heart failure were recruited for the final round. A total of 44 participants (10 participants with heart failure) were enrolled in the study. The participants had a mean age of 47.6 years, 57% were female, 70% identified as White, 70% were college-educated, and 34% had low health literacy. Using the System Usability Scale (score range of 0 to 100), the participants gave H2Lit a mean usability score of 74.1 in round 1, 54.3 in round 2, 85.3 in round 3, and 82.5 in round 4. H2Lit's usability score did not significantly differ between participants with adequate health literacy and those with low health literacy after controlling for age, sex, education level, and computer use duration. Further research is needed to determine the effect of the H2Lit intervention on heart failure self-care and heart failure-related outcomes.

Cardiomyopathy Prevalence and Pregnancy-Related Mortality: United States, 2010 to 2020

BACKGROUND

Cardiomyopathies, particularly peripartum cardiomyopathy (PPCM), significantly contribute to maternal morbidity in the United States.

OBJECTIVES

The authors estimated the prevalence and mortality of PPCM and other cardiomyopathies (OCMs) during pregnancy among women aged 15 to 55 years from 2010 to 2020 in the United States using a cross-sectional analysis of multiple data sets.

METHODS

We identified PPCM, OCM, and deliveries using International Classification of Diseases and diagnosis related group codes in the National Inpatient Sample. We calculated PPCM and OCM prevalence and adjusted prevalence ratios (aPRs) by select covariates. We identified pregnancy-related deaths from all cardiomyopathies combined and PPCM exclusively from 2015 to 2020 Pregnancy Mortality Surveillance System. We calculated pregnancy-related mortality ratios (PRMR) by select covariates.

RESULTS

The overall PPCM and OCM prevalence were 105.1 (95% CI: 101.8-108.3) and 76.1 (95% CI: 73.6-78.7) cases per 100,000 delivery hospitalizations, respectively. PPCM prevalence increased with advancing maternal age and decreasing neighborhood income and exhibited marked differences among Black and American Indian or Alaska Native women (aPR: 3.58 [95% CI: 3.36-3.82] and aPR: 1.96 [95% CI: 1.57-2.45], respectively). PPCM prevalence was higher among those with chronic hypertension and diabetes (aPR: 12.17 [95% CI: 11.51-12.88] and aPR: 6.25 [95% CI: 5.77-6.78], respectively). The overall cardiomyopathy and PPCM PRMR were 2.1 and 1.0 deaths per 100,000 live births, respectively. PRMR were highest among those aged ≥40 years and among American Indian and Black women (overall cardiomyopathy PRMR: 7.3, 6.0 deaths per 100,000 live births respectively).

CONCLUSIONS

Intensifying efforts to address cardiomyopathies and enhance cardiovascular health before, during, and following pregnancy may reduce the burden of maternal morbidity.

Perioperative inpatient falls for anterior cervical discectomy and fusion patients are on the rise: risk factors associated with this "never event"

BACKGROUND CONTEXT

Patients undergoing anterior cervical discectomy and fusion (ACDF) often have brief inpatient stays and may be at risk for inpatient falls (IPFs). Such IPFs should be preventable and have been termed a "never event" by the National Quality Forum, an affiliate of The Joint Commission. Despite increasing attention to IPF prevention, no studies have investigated the incidence, trends, and factors associated with IPFs among ACDF patients.

PURPOSE

To characterize the trends in the incidence of ACDF-related IPFs and their risk factors.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Adult patients who underwent inpatient ACDF between 2010 and Q3 2022 were abstracted from a large, national, multiinsurance administrative claims database.

OUTCOME MEASURES

Incidence, trends, and factors associated with IPFs.

METHODS

Adult patients who had undergone single or multilevel inpatient ACDF were identified by administrative coding. Exclusion criteria included: patients <18 years of age, those who underwent outpatient ACDF, concurrent posterior cervical procedures, thoracic or lumbar fusion, and those with trauma, neoplasm, or infection diagnosed within 90-days prior to surgery. The subset of patients who suffered an IPF were subsequently identified. The annual incidence of IPFs was analyzed over the study years and various risk factors were assessed for their correlation with IPFs by multivariable logistic regression. To determine the association between IPF and length of stay (LOS), patients with relative to without IPF were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI) and compared by multivariable logistic regression.

RESULTS

Of the 294,165 inpatient ACDF patients meeting inclusion criteria, IPFs were identified for 5,548 (1.9%). Between 2010 and Q3 2022, the annual incidence of IPFs increased from 309 (1.1%) to 515 (4.8%) for patients undergoing ACDF (p<.001). Independent predictors of an IPF were: hospital-acquired delirium (odds ratio [OR] 4.50), history of prior falls (OR 3.38), hospital-acquired psychosis (OR 3.17), alcohol use disorder (OR 2.68), cervical myelopathy (relative to radiculopathy) (OR 2.66), socioeconomically disadvantaged patients (OR 1.85), history of dementia (OR 1.77), underweight body mass index (BMI <18.5) (OR 1.67), multilevel ACDF (OR 1.43), history of prior cervical surgery (OR 1.41), male sex (OR 1.37), Medicaid insurance (OR 1.34), older age (OR 1.33), patients in the northeast United States (OR 1.15), and obese BMI >30 (OR 1.15) (p<.001 for all). Relative to patients without IPF, patients who suffered an IPF following ACDF demonstrated incrementally increasing odds of extended LOS (4-5 days [OR 2.63], 6 to 7 days [OR 3.85], 7+ days [OR 6.78]) (p<.001 for all).

CONCLUSION

In this robust national sample of patients undergoing inpatient ACDF, IPFs were identified for 1.9%, with an increasing annual incidence over the years. Among these patients, various factors were associated with their occurrence, many of which may be potentially modifiable. These findings have major clinical implications on care pathway optimization regarding early identification of high-risk patients undergoing ACDF and lays a foundation for the refinement of multidisciplinary fall prevention programs.

Linguistic difference in the effect of organized programs on socioeconomic inequalities in breast cancer screening: ecological study in Switzerland

OBJECTIVE

The objective of this study is to examine how the effect of organized mammography screening programs on breast cancer screening participation differ between socioeconomic strata and how this relationship may be modified by the context of linguistic differences. Switzerland, marked by its diverse linguistic landscape, reflects cultural variations alongside differences in public health strategies. The goal of this study was to assess potential socioeconomic differences in regional mammography screening programs effectiveness to improve breast cancer screening participation.

METHODS

Data on 14 173 women in the regionally adapted breast cancer screening age range was drawn from five cross-sectional waves of the nationally representative Swiss Health Interview Survey (1997-2017). Socioeconomic indicators included education, household income, and employment status. Poisson regression was used to estimate the adjusted prevalence ratios of up-to-date (last 2 years) mammography uptake. Inequality was assessed using relative index of inequality and the slope index of inequality.

RESULTS

Organized screening programs were generally effective and increased up-to-date mammography uptake by close to 20 percentage points in both regions. While in the Latin cantons, screening programs had no impact on socioeconomic inequalities in screening, it reduced inequalities for women with lower education in the German cantons. This modification effect of screening programs was not seen for income and employment-related inequalities and did not differ across linguistic regions.

CONCLUSIONS

Public health agencies should consider the different cultural reception of programs as addressing these differences could help ensure that breast cancer screening initiatives are not only effective, but also culturally equitable across different socioeconomic groups.

Income inequality and access to advanced immunotherapy for lung cancer: the case of Durvalumab in the Netherlands

BACKGROUND AND OBJECTIVES

With the introduction of immunotherapy with nonsmall cell lung cancer, prognosis of these patients has improved. However, socioeconomic differences in access to various immunotherapy treatments have been reported. In the Netherlands, such differences are not expected due to universal insurance coverage.

STUDY DESIGN AND SETTING

We investigated the existence of differential susceptibility by socioeconomic status (SES) of the effect of distance to treatment hospital on access to Durvalumab in patients with stage III nonsmall cell lung cancer who received chemoradiation, and the influence of differential mortality. We used data from the Netherlands Cancer Registry (n = 3774) from the period 2017-2021. First, we fitted Bayesian discrete failure time models and compared SES-by-distance-to-hospital interaction to a baseline model including age, distance, SES, and performance score. We then fitted a time to mortality model and used both models in a g-formula to simulate a scenario where mortality levels were equalized.

RESULTS

Our results showed that the high SES group received Durvalumab more often than the low SES group (hazard ratio = 1.26; 95% credible interval = [1.06, 1.53]), and even 4 km distance increase leads to less Durvalumab (hazard ratio = 0.93; 95% credible interval = [0.86, 0.99]). Bayes factor < 3 indicated inconclusive evidence for a SES by distance interaction effect, while g-formula results showed that differential mortality does not affect SES differences. Secondary analyses showed strong evidence that SES differences in using Durvalumab were constant over the years (Bayes factor > 17).

CONCLUSION

Overall, these results are significant for understanding how socioeconomic inequality affects proper care and can be vital for public policy.

The association between health literacy and cancer screening participation: A cross-sectional study across three organised screening programmes in Denmark

Objective

Health literacy may be related to non-participation in cancer screening, but there is limited understanding of its association with participation across all cancer screening programmes. This study aims to explore the associations between health literacy and advancing in participation in cancer screening programmes.

Methods

We conducted a cross-sectional study involving women aged 53-65 years residing in Denmark on 31 March 2018. Data utilised was from population registries and self-reported health literacy (HLS-EU-Q16) collected autumn 2017. Uni- and multivariate ordinal logistic regression models were employed to assess associations between health literacy levels and the likelihood of increased attendance in cancer screening programmes. Results were presented as odds ratios (ORs) with 95 % confidence intervals (CIs).

Results

Of the women included, 2668 (69.8 %) responded to the health literacy questionnaire. Among these, 53.3 % demonstrated adequate health literacy, 34.4 % had problematic, and 12.3 % inadequate. In total, 71.2 % attended three screening programmes, 20.1 % attended two, 6.2 % attended one, and 2.5 % attended none.There were no differences in the ORs for advancing in screening attendance when comparing problematic (OR = 1.18, 95 % CI: 0.97-1.42) or inadequate (OR = 0.96, 95 % CI: 0.74-1.26) health literacy levels with an adequate level.

Conclusions

Our study suggests that health literacy does not significantly influence cancer screening participation among the studied population in Denmark. Therefore, interventions aimed at increasing screening participation in this group should not only target health literacy but also focus on other aspects of non-participation.

Neighborhood-Level Socioeconomic Disadvantage and Adherence to Guidelines for the Evaluation of Patients With Incidentally Detected Pulmonary Nodules

BACKGROUND

The management of incidental pulmonary nodules is guided by recommendations set forth by the Fleischner Society. Although most pulmonary nodules are benign, timely and evidence-based follow-up can reduce morbidity and mortality. There are known socioeconomic disparities for engagement with recommended cancer screenings; however, it is unclear whether disparities exist for follow-up of incidentally detected pulmonary lesions.

RESEARCH QUESTION

Do patients residing in more socioeconomically deprived neighborhoods have reduced likelihood of adherence to guideline-recommended follow-up of incidentally detected pulmonary nodules?

STUDY DESIGN AND METHODS

We assembled a retrospective cohort of 32,965 patients within a large, regional integrated health care system with a defined membership who had a pulmonary nodule ≤ 30 mm identified on diagnostic CT scan between 2012 and 2016. Patients with prior history of malignancy were excluded. Participants were subsequently divided into quartiles using the Neighborhood Deprivation Index as a metric for socioeconomic status. Adherence was ascertained using International Classification of Diseases, Ninth Revision-coded or Current Prodecural Terminology-coded imaging or biopsy to determine if follow-up was performed within an interval specified by 2005 Fleischner Society guidelines (with a ± 33% margin of error) based on each patient's nodule characteristics. Negative binomial regression was performed to determine the association between neighborhood-level deprivation and adherence to guideline-concordant care, with and without adjustment for plausible confounders.

RESULTS

Only 49.6% of patients had follow-up imaging or other diagnostic procedure performed within the guideline-recommended time frame. There was a 3% reduction in adherence to follow-up for patients residing in the most socioeconomically deprived neighborhood quartile (relative risk [RR], 0.97; 95% CI, 0.94-1.0) compared with the least deprived quartile. Smoking status was also associated with worse adherence (previous tobacco use vs does not smoke: RR, 0.67; 95% CI, 0.65-0.69; active tobacco use vs does not smoke: RR, 0.73; 95% CI, 0.70-0.76). Multimorbidity, and congestive heart failure in particular, was associated with decreased adherence to guideline-recommended care (Charlson Comorbidity Index 3 vs 0: RR, 0.93; 95% CI, 0.89-0.97; history of congestive heart failure: RR, 0.93; 95% CI, 0.90-0.97).

INTERPRETATION

In the context of poor adherence overall, patients residing in the most socioeconomically deprived neighborhoods were shown to be less likely to receive care in concordance with Fleischner Society recommendations for management of incidental pulmonary nodules.

Benign Prostatic Hyperplasia Knowledge Deficits Among Male Urology Patients

OBJECTIVE

To measure patient knowledge about Benign prostatic hyperplasia (BPH) and identify factors associated with knowledge deficiencies among those newly presenting to our urology clinic.

METHODS

Adult men presenting as new patients to our institution's urology clinic, regardless of chief complaint, were invited to complete a 26-item multiple choice questionnaire to assess basic knowledge about BPH, related symptomatology, and treatment options prior to their initial consultation. Responses were correlated to demographic variables using Analysis of Variance (ANOVA) and multivariable linear modeling.

RESULTS

206 patients completed the questionnaire and had a mean age of 60.8 years. The majority were white (85.6%) and 28.9% were medicare/medicaid insured. The mean correct response rate was 62% (standard deviation of 22.9%) with the worst performing domain being BPH complications. Having a graduate or professional degree (P <.001) and self-referral were associated with significantly higher scores (P = .027).

CONCLUSION

There remain significant knowledge gaps about BPH among men seeking urologic care. Education tools for both patients and primary care physicians may help improve health literacy as well as health outcomes for patients with BPH.

Patient-centered evaluation of integrated care and health equity: evidence from county medical alliances in Henan province

BACKGROUND

Integrated care services have been initiated in China for several years, yet there remains a dearth of substantial evidence and research elucidating the service's efficacy, particularly in underdeveloped areas. This study aims to address this gap by evaluating the effectiveness of integrated care from the patients' perspective, thereby offering practical strategies to improve service effectiveness and promote health equity within county medical alliances.

METHODS

The Patient Perceptions of Integrated Care (PPIC) and European Quality of Life-5 Dimensions-5 Levels (EQ-5D-5 L) scales were employed to gather information on patients' perceptions of integrated care and their self-rated health status. A total of 1093 respondents from two pilot areas were selected for data collection. T-tests and one-way analysis of variance (ANOVA) were recruited, additionally, the study utilized multiple linear regression models to examine the specific impact of various factors on the effectiveness of integrated care services.

RESULTS

The average score for the effectiveness of integrated healthcare services from the patients' perspective was 67.72 (SD = 14.443, n = 1093). Statistical analysis revealed that as the respondents' age increased and their self-rated health declined, the PPIC scores showed an upward trend. Regression analysis found that factors such as age, education level, income, health status, and level of healthcare intervention significantly influenced PPIC scores. Overall, there is a trend where respondents with higher health needs tend to have higher perceptions of the service, while those with relatively higher socioeconomic status are more likely to provide lower ratings. Additionally, increasing the frequency and duration of healthcare interventions can improve respondents' evaluations of the services.

CONCLUSIONS

This study analyzes the effectiveness of integrated services in China's county-level medical alliance from the patients' perspective. It finds progress in resource integration and efficiency but identifies limitations in implementation, particularly in balancing equity. Socio-economic factors continue to affect the fairness of service utilization and patient satisfaction. Constraints in finance, human capital, and technology hinder the provision of more targeted services for vulnerable groups. To promote health equity, future services need to focus more on key populations and provide more targeted services, accelerate the integration of information technology, and expand service coverage to address the diverse needs of marginalized communities.

Oral health behaviours and metabolic syndrome: mediation effect of lifestyle habits

BACKGROUND

Recent studies have reported an association between toothbrushing frequency and systemic health. Plaque control, achieved through frequent brushing, is known to prevent dental caries and periodontal disease, potentially reducing the risk of systemic diseases. However, individuals with good oral health behaviours may also exhibit healthier lifestyle habits which could impact systemic health. In examining the relationship between oral health behaviours and systemic health, it is important to consider the influence of factors that mediate the relationship between them. This study conducted mediation analyses to evaluate the extent to which lifestyle habits and periodontal status mediate the relationship between oral health behaviours and systemic health.

METHODS

Health examinations, including dental assessments, were performed on 15,579 individuals at the Aichi Health Promotion Foundation. Of these, 12,540 participants aged 40-74 years were included in the analysis. Mediation analyses were conducted using the number of metabolic syndrome (MS) components as the outcome variable, oral health behaviours (regular dental visits, use of interdental brushes or dental floss, and toothbrushing frequency) as exposure variables, lifestyle habits (smoking, drinking, exercise, and eating habits) and periodontal status as mediators, and age and sex as covariates.

RESULTS

Regular dental visits showed significant total and indirect effects on MS, although no significant direct effect was observed. The use of interdental brushes or dental floss and toothbrushing frequency demonstrated significant total, direct and indirect effects on MS. Exercise habits, eating habits and periodontal status were significant mediators in the relationship between regular dental visits and MS. These mediators also significantly influenced the associations between both the use of interdental brushes or dental floss and toothbrushing frequency with MS.

CONCLUSION

The relationship between oral health behaviours and MS is mediated by lifestyle habits and periodontal status. Among the mediating variables tested in this study, the indirect effects of diet and exercise habits tended to be stronger than the indirect effect of periodontal disease. Oral health behaviours may influence systemic health through their impact on lifestyle habits.

Evaluating musculoskeletal imaging communication interventions using behavioural science: a scoping review using the COM-B model

OBJECTIVES

Clinicians and patients have been found to attribute musculoskeletal (MSK) pain to normal age-related changes seen on imaging, which can negatively impact patient outcomes and increase healthcare costs. While some studies have tested interventions to improve how MSK imaging findings are communicated, their impact has been limited. Applying a behavioural science framework has the potential to identify the rationale and target of these interventions to inform future intervention design-an analysis that has not yet been conducted. This study aims to identify the Behaviour Change Techniques (BCTs), the behavioural targets and the theoretical basis of interventions seeking to affect the communication of MSK imaging.

DESIGN

Scoping review using the Capability, Opportunity, Motivation - Behaviour (COM-B) model.

DATA SOURCES

Searches of MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 9 February 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that have developed or evaluated interventions which target the communication of MSK imaging findings. Interventions targeting both patients and clinicians were included. Experimental and quasi-experimental study designs were included, and studies that focused on serious or specific known causes of MSK pain were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent authors extracted study participant data and intervention details. A theory of behaviour called the COM-B model was used to map the BCTs and behavioural components targeted by studies.

RESULTS

We identified 11 studies from 2486 studies in our electronic search. 11 different BCTs were identified across 11 studies. The most common techniques were framing/reframing (nine studies), adding objects to the environment (eight studies), incompatible beliefs (seven studies) and avoidance/reducing exposure to cues for the behaviour (four studies). Only two studies (feasibility studies) used behavioural theory to guide their intervention design. While one study showed a large effect, most interventions had little to no impact on pain, disability, or fear over time.

CONCLUSION

This review highlighted a lack of studies targeting clinician knowledge and the provision of high-quality patient resources about the nature of MSK pain, even though the broader literature identifies both as enablers of effective health communication. Additionally, the absence of a theory-informed design likely resulted in attempts to reassure patients about normal age-related imaging findings without providing an alternate, more coherent explanation for symptoms. Future interventions should focus on enhancing clinician psychological capability (knowledge) as well as clinician and patient reflective motivation (beliefs) to enable more helpful explanations of MSK symptoms. The key challenge for future interventions will be achieving these aims in a way that is effective, consistent and practical.

TRIAL REGISTRATION DETAILS

Open Science Framework (https://doi.org/10.17605/OSF.IO/ECYS8).

Association of health literacy with cancer survival: a single-centre prospective cohort study

BACKGROUND AND PURPOSE

Health literacy is defined as the ability to find, understand and use health information for informed decision. The role of health literacy in treatment decisions and outcome remains largely unexplored. This study sought out to assess the effect of individual health literacy on overall survival (OS) in cancer patients in Ostrobothnia.

MATERIAL AND METHODS

The present study is a follow-up of a cross-sectional survey study performed during December 2021 and March 2022. The survey assessed socioeconomic factors, lifestyle factors and self-reported health literacy. The follow-up included data on recorded death, cause of death, performance status (PS), clinical frailty scale, Charlson comorbidity index and body mass index. The sample size for this study was 400 participants, and any participant with a malignancy was eligible for the study.

RESULTS

Low health literacy was associated with increased risk of death. The disparity remained after adjustments for age, sex, comorbidities, PS, stage and hazard ratios (HR) = 1.47 (1.01-2.14). After adjustments for lifestyle patterns, the disparity remained, HR = 1.49 (1.03-2.17). The difference diminished after adjustments for cancer types. The median OS was 3.6 months longer for those with medium-high health literacy than those with low health literacy.

INTERPRETATION

The results indicated health literacy having a direct, clinically significant, effect on OS, which is likely not explained by differences in cancer entity alone. Future studies should focus on assessing whether an intervention aiming to improve health literacy may improve overall cancer survival.

Assessment of readability of gynecologic cancer clinical trials literature at National Cancer Institute-designated Comprehensive Cancer Centers

OBJECTIVE

This study aimed to assess the readability of patient-facing gynecologic cancer clinical trial information on National Cancer Institute-Designated Comprehensive Cancer Center (NCI-CCCs) websites.

METHODS

This was a cross-sectional analysis of publicly accessible information pertaining to gynecologic cancer clinical trials on NCI-CCC's websites in September 2023. Clinical trial descriptions for endometrial, cervical, and ovarian cancers were assessed. Websites with limited to no descriptive information regarding their clinical trials were excluded. Readability was assessed using Readability Studio Professional Edition software for 5 readability metrics (FORCAST, Fry, Gunning Fog, Raygor Estimate, and SMOG).

RESULTS

Of 56 NCI-CCCs evaluated, 78% (n = 44) had information pertaining to gynecologic cancer clinical trials and gynecologic clinical trial descriptions for readability analysis. A total of 14% (n = 8) lacked clinical trial descriptions and linked to Clinicaltrials.gov and 7% (n = 4) only had information available through additional inquiry within the cancer center. The overall mean reading level across all NCI-CCCs was 15th-grade or collegiate-level reading. The specific readability metric analyses were as follows: FORCAST: 12.4 (range; 9.7-14.7), Fry: 17 (range; 13-17), Gunning Fog: 16.8 (range; 10-19), Raygor Estimate: 16 (range; 7-17), and SMOG: 16.5 (range; 11.4-19). Clinical trial information was stratified by the National Cancer Institute Geographic Management of Cancer Health Disparities Program, with no statistically significant differences in readability or complexity.

CONCLUSIONS

In this analysis of publicly available patient-facing information on NCI-CCC websites regarding gynecologic cancer clinical trials, the readability scores were above the high school level across the United States, which far exceeds the recommended readability metric of sixth grade by the National Institutes of Health. Opportunities exist to improve the readability of gynecologic cancer clinical trial online literature, which may facilitate patient access, participation, and understanding.

The Epidemiology and Survival Outcomes of Adult Conjunctival Malignancies in Germany: A Decade-Long Population-Based Analysis (2009-2019)

PURPOSE

This study aims to evaluate the epidemiological patterns, treatment strategies, and survival outcomes of conjunctival malignancies in Germany between 2009 and 2019.

METHODS

A total of 1,532 cases were analyzed, with the crude incidence rate calculated. The survival rates were investigated using life tables and Cox regression analysis.

RESULTS

The overall incidence rate was 1.7 per million. Incidence rates varied across age groups, peaking in the 75+ age group. Carcinomas (43%), melanomas (30%), and lymphomas (20%), were the most prevalent malignancies. Of the total cases with reported treatment, surgical intervention was undertaken in 64.5% of the patients. The 5-year overall survival rates were 90.4% for lymphomas, 73.8% for melanomas, and 72.9% for carcinomas. Age at diagnosis emerged as a significant prognostic factor in the Cox regression analysis.

CONCLUSIONS

This study provides the first population-based incidence data on conjunctival malignancies in Germany, noting a generally low incidence with survival rates comparable to other regions. The findings underscore the importance of consistent reporting and further research into risk factors for a deeper understanding of these malignancies. The study calls for improved reporting systems and further investigations into genetic factors and targeted prevention strategies for high-risk groups.

Influence of Home Language Use on the Association Between Parent Education and Child Adiposity in Latino Families

BACKGROUND

Parent education and language use are associated with child obesity, but the impact of their interaction is less known. This study assessed whether parent education was associated with child adiposity and if this association was moderated by home language use in Latino families.

METHODS

Participants (n = 415) were Latino families from the Long Beach area. Demographic data were obtained by self-report parent surveys, and children's body size was objectively assessed via bioelectric impedance. Independent t-tests and hierarchical linear regressions were performed on baseline data from a larger intervention study.

RESULTS

In the overall sample, parent education and child body mass index (BMI) percentile were not related (p = .050). However, stratification by home language use revealed that parent education was inversely associated with child BMI percentile among those whose primary home language was Spanish (p = .049), but not English/bilingual homes (p = .296). There were no significant associations with child percent body fat.

CONCLUSION

Higher education was associated with a lower BMI percentile only in Spanish-speaking homes. Research to understand how home language influences this relationship is warranted, particularly as it relates to a subset of education and health literacy. Significant results with BMI percentile but not percent body fat highlight the fact that these distinct markers of obesity are not interchangeable.

Socioeconomic status and adherence to COVID-19 preventative measures in Australia: A national cohort study

ISSUE ADDRESSED

The uptake of recommended preventative measures is a critical concern for protecting the public against COVID-19 outbreaks and future pandemics. However, it is unclear to what extent COVID-19 preventative measures were followed in Australia. This study aims to determine adherence level to COVID-19 preventative measures in 2021, and whether these were associated with socioeconomic status (SES).

STUDY DESIGN

This was a national cross-sectional study using data from the Household Income and Labour Dynamics in Australia (HILDA) survey.

METHODS

This study included 15 457 community-dwelling adults (18 years or older) who participated in the 2021 wave of HILDA survey. SES was assessed by the Socio-Economic Index For Areas (SEIFA) score, split into quintiles. Outcomes included self-reported adherence to COVID-19 preventative measures (mask wearing, keeping distance, staying home; sum score range 3-15) and COVID-19 status (yes/no). Linear and logistic regression were used accordingly to assess the association between SES and the sum score of adherence to COVID-19 measures, and COVID-19 vaccination status.

RESULTS

Adherence to COVID-19 preventative measures and uptake of COVID-19 vaccine in Australia in 2021 were moderate (between 60% and 70%). Regression models showed higher SES was associated with a slightly higher score of adherence (β = .08, 95% CI = .04-.12) and a higher likelihood of self-reporting receiving COVID-19 vaccination (OR 1.27, 95% CI = 1.23-1.31).

CONCLUSION

SES was positively associated with the level of adherence to COVID-19 preventative measures and the probability of receiving COVID-19 vaccine. The findings of this study highlight the potential benefits of considering SES, particularly its impact on equity and access, when designing an educational program or awareness campaign in times of crisis. SO WHAT?: The findings of this study highlight the importance of considering SES when designing an educational program or an awareness campaign in times of crisis.

Exploring Laypersons' Experiences With a Mobile Symptom Checker App as an Interface Between eHealth Literacy, Health Literacy, and Health-Related Behavior: Qualitative Interview Study

BACKGROUND

Symptom checkers aim to help users recognize medical symptoms and recommend actions. However, they are not yet reliable for self-triage or diagnostics. Health literacy plays a role in their use, but the process from symptom recognition to health care consultation remains unclear.

OBJECTIVE

This qualitative observatory study explored how laypersons use symptom checkers, focusing on the process of use, entry points and outcomes, and the role of health literacy. Laypersons are defined as individuals who are neither medical professionals nor developers of such apps. Three research questions were addressed: (1) How do such users describe the process of using symptom checkers? (2) What are entry points and possible outcomes of symptom checker app use? (3) How are health literacy and eHealth literacy expressed during the use of symptom checker apps?

METHODS

As part of the Ethical, Legal, and Social Implications of Symptom Checker Apps in Primary Health Care project, 15 laypersons (n=9, 60% female and n=6, 40% male; mean age 30.7, SD 13.6 years) were interviewed about their experiences with the symptom checker Ada. The interviews were analyzed using an integrative approach combining social positioning, agency, and the Rubicon model as a heuristic framework.

RESULTS

App use follows a cyclic process comprising 4 steps: motivation (influenced by biography and context), intention formation (assigning a purpose), intention implementation (recruiting resources), and evaluation (transforming interactions into health-related insights). Biographical, social, and contextual factors shape process initiation. Users use symptom checkers for 3 main purposes: understanding their condition, receiving recommendations for action, and documenting or communicating health-related information. Each purpose requires specific planning and integration into health-related behaviors drawing on personal, social, and technological resources. Evaluation depends on contextual factors, app outputs, and the outcomes of users' health-related actions. Users assess whether the app aligns with their expectations, condition severity, and previous experiences, with health literacy playing a critical role in validation processes.

CONCLUSIONS

Symptom checker use is a complex, cyclic process shaped by context, biography, and health literacy. Users are motivated by health concerns influenced by personal, social, and contextual factors, with trust and attitudes impacting initial engagement. Intention formation reflects a balance between user skills and context, where app outputs inform decisions but may not always lead to action, especially in ambiguous situations. Users rely on personal resources and social networks to integrate app use into health-related behaviors, highlighting the limitations of symptom checkers in providing social or empathetic support. Symptom checkers have the potential to serve as an interface between users and health care, but future development must address the complexity of their use to unlock this potential.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/34026.

Socioeconomic variations in the proportions of stroke attributable to reproductive profiles among postmenopausal women in China

BACKGROUND

This prospective study aimed to examine the individual and combined population attributable fractions (PAFs) of stroke and its subtypes associated with reproductive factors among Chinese postmenopausal women, highlighting variations across socioeconomic status (SES) stratas.

METHODS

Data were from 138,873 Chinese postmenopausal women enrolled in the China Kadoorie Biobank. Reproductive factors evaluated in this study included early age at menarche, early age at menopause, advanced age at first live birth, high parity, history of stillbirth, history of miscarriage or termination, and non-lactation. PAFs were calculated using hazard ratios, estimated using Cox proportional hazard regression, and prevalence of the seven reproductive factors. PAF for each reproductive risk factor and combined PAFs for all factors were estimated in total population and across SES classes.

RESULTS

Of the 138,873 included participants, 17,042 developed strokes during a median follow-up period of 8.9 years. Across SES classes, the greatest attributable fractions of total stroke cases were observed for high parity among low-SES women (PAF 17.2%, 95% confidence interval [CI] 13.7%, 20.6%), history of miscarriage or termination among medium-SES women (PAF 11.4%, 95% CI 8.2%, 14.5%), and no history of lactation among high-SES women (PAF 3.1%, 95% CI 1.7%, 4.9%). A multiplicatively estimated 20.5% (95% CI 20.4%, 20.5%) and 3.1% (95% CI 1.7%, 4.9%) of stroke cases were attributable to the seven reproductive risk factors in low-SES and high-SES women, respectively.

CONCLUSIONS

A large fraction of stroke cases among Chinese postmenopausal women were associated with reproductive factors. Targeted cardiovascular prevention strategies are warranted among women with different SES to mitigate risks associated with different reproductive profiles.

Association of Health Information Literacy and Health Outcomes Among Individuals with Type 2 Diabetes and Metabolic Syndrome

Objectives: Based on social cognitive theory, this study aims to explore the associated factors of and whether and how health information literacy was correlated to health behavior and glycemic control among individuals with type 2 diabetes and metabolic syndrome. Methods: Following convenient sampling, this cross-sectional, correlational study was conducted among 225 patients with type 2 diabetes and metabolic syndrome from an outpatient clinic in a suburban area of Beijing, China. Hierarchical multiple regression and mediation analysis were performed to explore the effect of health information literacy on self-management practice and hemoglobin A1c in this sample. The STROBE guidelines for cross-sectional studies were followed. Results: The findings showed incompetent health information literacy, inadequate self-management behavior, and suboptimal glycemic control in a sample of patients with type 2 diabetes and metabolic syndrome. Based on social cognitive theory, the results of regression analysis indicated that self-management attitude, health problem-solving, and chronic illness resources were correlated with self-management practice, and health problem-solving and health information evaluation were correlated with hemoglobin A1c. Mediation analysis revealed that self-management attitude, health problem-solving, and chronic disease resources fully mediated the effect of health information literacy on self-management practice. There was an indirect effect of health information literacy on hemoglobin A1c through health problem-solving. Conclusions: The findings demonstrated that health information literacy has significant indirect and direct effects on self-management behavior and glycemic control through self-management attitude, health problem-solving, and chronic disease resources in a sample of patients with type 2 diabetes and metabolic syndrome.

Factors influencing nutrition literacy in patients of colorectal cancer: a cross-sectional study

Background

Colorectal cancer (CRC) patients often experience varying degrees of malnutrition both pre-and post-treatment, highlighting the importance of their nutritional knowledge. However, studies on nutrition literacy (NL) in this population remain scarce. This study aims to evaluate the level of NL in colorectal cancer patients and identify key factors influencing NL.

Methods

A total of 245 colorectal cancer patients participated in this study. The questionnaire included five sections: sociodemographic information, the Chinese Version of the Nutrition Literacy Assessment Instrument (CHI-NLit), the Montreal Cognitive Assessment Scale (MoCA), and the Hospital Anxiety and Depression Scale (HADS). Both univariate and multivariate analyses were performed to examine sociodemographic determinants of NL. We used Pearson and Spearman correlation coefficients to assess relationships between NL, MoCA and HADS.

Results

The overall NL level among CRC patients was moderately low, with an average score of 19.224 ± 4.391-significantly below the normative neutrophil score of 21.5. Among the assessed dimensions, food groups received the lowest scores while food label calculation achieved the highest. Significant predictors influencing NL levels included age, years of education, family annual income, in review duration of illness, number of hospitalizations, memory and attention abilities and anxiety and depress symptoms.

Conclusion

This study provides a comprehensive examination of NL in CRC patients. The findings indicate a relatively low level of NL within this group. Younger age, higher income levels, and urban residency correlated positively with elevated NL. Factors such as illness duration, number of hospitalizations, cognitive function measured by relevant scales are also emerged as significant determinants impacting NL. To enrich the research on NL, it is essential to conduct further data collection. From a clinical perspective, this evidence-based framework enables the development of stratified nutritional intervention protocols, specifically targeting vulnerable subgroups (e.g., elderly patients, rural dwellers, and those with extended illness duration). Such precision approaches hold significant potential to optimize dietary adherence, mitigate treatment-related complications, and ultimately enhance long-term quality of life in cancer survivorship care.

Health literacy of primary caregivers of children with cerebral palsy in low- and middle-income countries: a systematic review

OBJECTIVE

We aimed to synthesise existing literature on the health literacy of primary caregivers (PCGs) of children with cerebral palsy (CP) in low- and middle-income countries (LMICs).

DESIGN

Systematic review informed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, CINAHL via EBSCO, Scopus and Web of Science were searched from inception to January 2024.

ELIGIBILITY CRITERIA

Original studies including observational or experimental data, examining health literacy and/or health literacy proxies using Optimising Health Literacy and Access domains as indicators (eg, education, social support, self-efficacy, health attitudes, reading and writing skills) in primary caregivers of children with CP in LMICs.

DATA EXTRACTION AND SYNTHESIS

Data from included studies were systematically recorded using an Excel template, with information extracted independently by two reviewers. We used the Study Quality Assessment Tool developed by the National Health, Lung, and Blood Institute.

RESULTS

The systematic review yielded 2734 articles, with 15 eligible for inclusion. None used health literacy (HL) measurement tools, and there was limited reporting on specific HL domains. Studies spanned 11 LMICs across 5 major regions. PCGs, predominantly mothers, exhibited varying levels of service awareness, service utilisation and social support. Literacy levels significantly impacted HL proficiency, exposing a notable research gap in LMICs.

CONCLUSIONS

This study presents the first comprehensive analysis of health literacy among PCGs of children with CP in LMICs. Findings reveal a striking absence of tailored health literacy literature, impacting current considerations of PCGs' understanding and management of their child's condition. Additionally, challenges in social support, healthcare navigation and low literacy levels further hinder effective caregiving in LMICs.

Health literacy in adults with a spinal cord injury or disorder: An updated and expanded systematic review

BACKGROUND

The importance of health literacy in personal health management is widely recognised in the general population, yet remains poorly understood in some patient groups, including people with spinal cord injury or disorder (SCI/D).

OBJECTIVES

The systematic review had two objectives: (1) to determine the health literacy levels of individuals with SCI/D, and (2) to identify facilitators and barriers to developing health literacy in this group.

METHODS

Seven databases (CINAHL, Embase, Emcare, ProQuest, PsycINFO, PubMed, and Web of Science) were searched from inception, with an updated search completed on January 21, 2025. Study quality was evaluated (QualSyst Checklist) and both quantitative and qualitative research narratively summarised by our research aims.

RESULTS

Seven quantitative studies and one qualitative study (N = 2471 participants) published from 2005 to 2022 were included. All demonstrated good methodological rigour. Most participants reported having sufficient health literacy. Those with higher health literacy were more likely to have higher education and socio-economic advantage, and to experience better physical and mental health outcomes. Evidence regarding the role of SCI/D variables in developing health literacy capacity was limited.

CONCLUSIONS

Health literacy remains an under-researched topic in the SCI/D literature. Further studies are needed to examine how health literacy can impact health behaviours and overall health for this group. This research would also benefit from focusing on personal experiences of health literacy development.

Performance of older adults in a digital change detection task: The role of heterogeneous education

The influence of education on traditional paper-and-pen cognitive assessments is widely reported. However, a minimal amount of evidence is available regarding the role of education in digital tasks. This study aimed to compare the performance of older adults with different educational attainment in a digital change detection task, as well as to relate their performance on the digital task and traditional paper-based tests. Participants (n = 180) were recruited in primary health care settings from a countryside city in the state of Sao Paulo-Brazil and were assigned to three different groups according to their educational background. Traditional paper-based neuropsychological instruments (i.e., ACE-R, Digit Span, Bells test) were used in addition to a digital change detection task. There was no difference in reaction time on the change detection task between the groups; however, participants with higher educational levels performed better than illiterates or lower education groups. The digital test was correlated to ACE-R total score as well as to its language domain. Our results suggested that the performance in the digital task was different for older adults with heterogeneous educational attainment. Technology is a promising pathway in cognitive assessment, and education should be considered in the interpretation of the results.

[Measuring health literacy: methods and tools for assessing general health literacy in adults]

The measurement of health literacy (HL) began in the 1990s with instruments that focused on a functional understanding of HL. Since then, the understanding of HL and the measurement of HL have evolved. This article reviews two particularly well-validated instruments for measuring comprehensive general health literacy: The Health Literacy Questionnaire (HLQ) and the HLS19-Q12 questionnaire.The HLQ consists of nine scales with a total of 44 items covering different HL aspects of coping with illness. The HLQ has been validated in numerous studies and translated into 47 languages. It has high content and criterion validity and is used, for example, in the WHO European Action Network on Health Literacy for Prevention and Control of Noncommunicable Diseases and in the European Joint Action on Cardiovascular Diseases and Diabetes (JACARDI). The nine scales can be used to create HL profiles of strengths and challenges.The HLS19-Q12 is a short questionnaire to measure general HL and is based on the HLS19-Q47. It consists of 12 items, has been validated in more than 20 countries, and has been translated into more than 30 languages. The HLS19-Q12 also has high content and criterion validity and is used in the Health Literacy Surveys of the WHO Action Network on Measuring Population and Organizational Health Literacy (M-POHL) and the European Joint Action Prevent Non-Communicable Diseases. Based on the 12 items, a total score is calculated that can be categorized into four levels of HL.In order to create a comparable database in the long run, it is recommended that these two instruments be used in studies, evaluations, and monitoring of HL.

Empirical design of population health strategies accounting for the distribution of population health risks

Recent discussions in epidemiology have emphasised the need to estimate the heterogeneous effects of risk factors across the distribution of health outcomes for better aetiological understanding of the determinants of population health. We propose using quantile regression-based decomposition to expand the empirical discussion on population health intervention strategies for health equity by incorporating population homogeneity/heterogeneity in the risk-outcome association. We theorised that the 'proportionate universalism' approach presumes population homogeneity in the risk-outcome association with varying risk intensities, which decomposition analysis shows as the 'covariates part' between groups. Conversely, the 'targeted approach' assumes population heterogeneity in the risk-outcome association across the outcome range, which the analysis identifies as the 'coefficients part'. Our demonstration, using a case of education-related disparity in dietary behaviours, exemplified that differences between education groups were mainly explained by the coefficients part. This finding suggests heterogeneity in their risk profiles, necessitating a 'targeted approach' across outcome quantiles to close the gap. The 'proportionate universalism' strategy could be partially applied to specific quantile segments where the covariates part remained significant as a supplementary intervention. However, simply increasing the magnitude of certain risk factors (e.g., income) showed conflicting directions between covariates and coefficients parts. Structural modifications of risk-outcome associations would therefore be more equitable. We also discuss the potential strengths and limitations of the analysis, suggesting that it may be complemented by data-driven methods using machine learning to identify discriminating risk factors for population health equity.

Patient at community clinics: Recommendations for advancing health literacy

OBJECTIVE

This study aimed to assess community clinics in enhancing health literacy among underserved patients. We focus on patient-provider communication at these clinics to understand how this communication may foster or hinder health literacy and how the organizational health literacy of clinics may be improved.

METHODS

We surveyed 303 patients at three community clinics to evaluate providers' communication behaviors related to health literacy. The city health department entered surveys into SurveyMonkey™ and analyzed them using Stata/SE™. The analysis included frequencies of all variables for all participants and by clinic. Qualitative methods were also used.

RESULTS

Community clinics are trusted care sources; however, around 13 % of patients reported rarely or never being encouraged to ask questions, 20 % reported providers spoke too fast, and 17 % reported that medical staff were not always informative. Patients needing an interpreter reported more communication problems than those not requiring one, making these results more salient.

CONCLUSIONS

Community clinics serving low-income patients can enhance personal and organizational health literacy by improving patient-provider communication such as active listening, encouraging patients to ask questions, and addressing language barriers.

PRACTICE IMPLICATIONS

Advancing health literacy impacts community and public health initiatives, improves health disparities, builds patient-provider trust, and improves health systems.

Psychosocial risks in metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly becoming more prevalent in the general population. MASLD is more common in persons with low socioeconomic status (SES), yet little is known about the psychosocial challenges associated with this disease, and clinical recommendations on how to approach psychosocial challenges are lacking.

AREAS COVERED

A PubMed search using the search terms MASLD, psychosocial risks, stigmatization, psychiatric comorbidities (i.e. depression, bipolar disorder, psychosis, attention deficit hyperactivity disorder, and substance abuse), SES, quality of life (QoL), over the past 20 years (2004-2024) was performed.

EXPERT OPINION

Persons with MASLD often experience psychosocial adversities that may be expressed as lower SES, high prevalence of depression, and reduced QoL. Knowledge gaps remain regarding the association between severe mental disorders (e.g. psychosis and bipolar disorders). Timely detection and treatment of MASLD in persons with psychosocial risks may require attention and cross-field collaboration. Studies on QoL in persons with MASLD differ in methodology which makes formal comparisons difficult. Psychosocial adversity may be a barrier to lifestyle modifications, which remain the cornerstone of MASLD management. Guidelines on how to address psychosocial adversities in a clinical setting are warranted to improve outcomes and decrease further multimorbidity.

Conceptualization of health literacy from the perspective of children and adolescents - a meta-ethnography

Existing models of health literacy have included a limited perspective of children and adolescents. We conducted a meta-ethnography to develop a child- and adolescent-centered conceptualization of health literacy. We dually screened 3564 abstracts, 205 full texts, assessed the 40 included studies' methodological limitations, and considered 25 data-rich studies in our synthesis. We assessed our confidence in each finding using GRADE-CERQual. Our model shows that health literacy development involves active information seeking (moderate confidence), passive information receiving (very low confidence), processing information (moderate confidence), and (not) taking action (moderate confidence). This process is embedded in a socio-cultural environment, educational system, healthcare system, internet/media, and living environment (very low to moderate confidence). Our model shows that children's and adolescents' health literacy is influenced by cognitive psychological (moderate confidence) and sociodemographic factors (moderate confidence). Social relationships play a crucial role (moderate confidence). Our model supports the development of evidence-based interventions and policies that promote youth and child well-being, laying the foundation for lifelong health literacy. This approach also provides a basis for future research to explore health literacy concepts that are grounded in young people's real-life contexts.Registration: Before writing this manuscript, we developed a study protocol and registered it on PROSPERO: CRD4202343090.

Health literacy disparities in Thai university students: exploring differences between health science and non-health science disciplines

BACKGROUND

Health literacy (HL) in Thailand remains a significant issue, with a large portion of the population demonstrating limited HL, and limited research exists on specific determinants among Thai university students. Some culture shapes health decision-making and HL disparities within this group, highlighting the need to evaluate HL comprehensively. This study aims to assess and compare HL levels among health science and non-health science students, and identify key predictors associated with HL.

METHODS

A cross-sectional study was conducted among 1,647 Thai university students, comprising 676 health science and 971 non-health science students, recruited through multi-stage stratified random sampling. Data were collected using validated questionnaires that measured sociodemographic characteristics, academic background, lifestyle behaviors, and HL levels across three sub-domains, including healthcare, disease prevention, and health promotion. Statistical analyses included univariable and multivariable regression models, with significance set at p-value < 0.05.

RESULTS

Health sciences students demonstrated significantly higher HL scores across all sub-domains compared to non-health sciences students. Limited HL was found in 12.6% for health science students, and 28.4% for non-health science students. Key predictors of overall HL included gender, income, faculty of study, and lifestyle-related health behaviors. Female students showed higher total HL (β = 1.41; 95% CI: 0.62, 2.21), as did those with higher income (β = 1.28; 95% CI: 0.76, 1.80). Students enrolled in health sciences programs had higher HL scores (β = 2.86; 95% CI: 2.07, 3.64). Lifestyle behaviors also correlated with HL, with non-smoking (β = -0.58; 95% CI: -1.03, -0.13), no alcohol consumption (β = -0.45, 95%CI: -0.89, -0.01), and regular physical activity (β = 0.35; 95% CI: 0.04, 0.66). Consumption of sweet foods/drinks was inversely related to HL scores (β = -0.87; 95% CI: -1.49, -0.26).

CONCLUSIONS

HL among Thai university students varies significantly by sociodemographic factors, academic background, and lifestyle behaviors. Health sciences students exhibited stronger HL skills, underscoring the importance of integrating health education into non-health sciences curricula. Targeted HL interventions are recommended for non-health sciences students, males, and individuals from lower-income backgrounds to enhance health decision-making and reduce HL disparities. These findings have implications for policy and practice, emphasizing the integration of HL modules into university curricula, health promotion campaigns, and the provision of accessible health services to foster an inclusive and health-literate student population.

Interventions Addressing Health Literacy in Cancer Care: A Systematic Review of Reviews

(1) Background: Interventions addressing the health literacy (HL) of people suffering from an illness such as cancer can improve the understanding of the illness and lead to better-adapted behaviors, regarding the participation in cancer screenings, adhering to the complex multimodal therapy, participating in cancer treatment, and self-managing everyday health. This study provides a review of systematic reviews that include intervention articles addressing the HL of patients, healthcare professionals, and/or organizations in cancer, to identify the factors related to their effectiveness, as well as the missing elements, in light of the recent developments in HL research and practice. (2) Methods: A literature search was performed in Embase, Pubmed, PsycINFO, and Science Direct. Existing published reviews of studies targeting the interventions in the oncology domain, and which explicitly mentioned HL as a factor/outcome, were included. (3) Results: One hundred and fifty-five studies were retrieved. Ten fit the criteria and were included in this review. (4) Conclusions: Most of the interventions addressing HL in people with cancer included the target patients' information and communication skills through education. To keep the full scope of the concept, as investigated in the recent literature, clinical applications of HL in patients with cancer should also consider organizational HL.

Exploring the Landscape of Social and Economic Factors in Critical Illness Survivorship: A Scoping Review

OBJECTIVES

To explore the breadth of social, demographic, and economic (SDE) factors reported in critical illness survivorship research, with a focus on how they impact survivorship outcomes.

DATA SOURCES

We obtained articles from Medline, Embase, PsycInfo, and CINAHL, as well as reference list reviews of included articles and relevant reviews captured by searches.

STUDY SELECTION

SDE factors were defined as any nonmedical factor that can influence outcomes. We included primary studies published in English that explored SDE factors as an independent variable or as an outcome in post-ICU survivorship of adults. Two authors independently assessed each study for inclusion in duplicate, and conflicts were resolved by consensus. Our searches returned 7151 records, of which 83 were included for data extraction and final review.

DATA EXTRACTION

We used a standardized data collection form to extract data, focusing on the characteristics of each study (i.e., year and country of publication), SDE factors explored, how the factors were measured, the impacts of SDE factors on post-ICU survivorship outcomes, and the impacts of ICU admission on SDE outcomes.

DATA SYNTHESIS

We summarized the relationships between SDE factors and ICU survivorship in table format and performed a narrative synthesis. We identified 16 unique SDE factors explored in the current literature. We found that generally, higher education, income, and socioeconomic status were associated with better outcomes post-ICU; while non-White race, public insurance status, and social vulnerability were associated with poorer outcomes.

CONCLUSIONS

Various SDE factors have been explored in the critical illness survivorship literature and many are associated with post-ICU outcomes with varying effect sizes. There remains a gap in understanding longitudinal outcomes, mechanisms of how SDE factors interact with outcomes, and of the complexity and interconnectedness of these factors, all of which will be instrumental in guiding interventions to improve post-ICU survivorship.

Improving the health literacy of persons with epilepsy

Improving health literacy can improve health. This essay reviews the resources available to help improve epilepsy health literacy, including websites, drug inserts/labels/information leaflets, patient educators, handouts, plain language, lay summaries, and other efforts to close the gaps between research and epilepsy health literacy.

Differences Between Black and White Caregivers in the Association Between Autism Diagnostic Process Satisfaction and Service Use

BACKGROUND

Black families of children with autism spectrum disorder have less access to high quality, culturally responsive care for their children.

METHOD

We assessed satisfaction and service utilization among fifty (29%) Black caregivers and 124 (71%) White caregivers of children with autism spectrum disorder. We also examined whether race moderated the association between satisfaction and service utilization.

RESULTS

We did not identify racial differences in satisfaction or service utilization. Race moderated the association between satisfaction and total service use, F(170) = 5.29, p =.02, therapy service use, F(163) = 3.59, p =.046, and community service use, F(169) = 4.76, p =.046. For Black families, there was a positive association between satisfaction and service use. There was no association between satisfaction and service use among White families.

DISCUSSION

Satisfaction may be particularly important among Black families, who have been mistreated by the healthcare system and frequently face discrimination. Our results suggest the importance of culturally responsive care for Black families.

Critical thinking about health and treatments in the United States: a cross-sectional assessment of parents and undergraduate college students

BACKGROUND

There is an urgent need to study and increase the public's ability to think critically about health and treatments. Unfortunately, we do not currently have a clear, in-depth understanding of critical thinking about health in the United States, especially its rates among parents and college students, two particularly important groups. This study assessed and characterized critical thinking about health with U. S. parents and college students. We also explored whether critical thinking about health varied as a function of sociodemographic determinants.

METHODS

Parents (N = 142) and college students (N = 145) in the U. S. completed an online test of critical thinking about health, and answered questions about their background.

RESULTS

Both parents and college students in the U. S. struggled to think critically about health and treatments based on various science literacy and evidence-based practice principles. Parents with higher educational attainment had lower critical thinking about health, and college students who reported a liberal political affiliation had higher critical thinking scores.

CONCLUSIONS

This investigation demonstrates a need to increase critical thinking about health among U. S. parents and college students so they can be empowered to make informed health choices.

Racial, socioeconomic, and payer status disparities in utilization of unicompartmental knee arthroplasty in the USA

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is a surgical treatment for knee osteoarthritis associated with lower morbidity compared with total knee arthroplasty (TKA) in patients with isolated unicompartmental knee arthritis. As disparities have been noted broadly in arthroplasty care, it follows that such disparities might be present in the utilization of UKA relative to TKA. This study therefore examined racial/ethnic, socioeconomic, and payer status differences in utilization of UKA.

METHODS

Patients who underwent UKA or TKA between 2016 and 2020 in the National Inpatient Sample were identified. Multivariable Poisson regression models adjusted for hospital geographic region and patient characteristics [age, sex, and Elixhauser Comorbidity Index (ECI)] were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on incidence rate ratio of UKA relative to TKA.

RESULTS

Of the 8472 UKA patients and 639,937 TKA patients identified between 2016 and 2020, 8027 (94.7%) UKA patients and 606,028 (94.7%) TKA patients met inclusion criteria. Patients who underwent UKA were significantly younger (63.5 ± 10.7 years) than patients who underwent TKA (66.8 ± 9.5 years; p < 0.001) and had significantly lower ECI scores (1.8 ± 1.5) than patients who underwent TKA (2.2 ± 1.6; p < 0.001). Black patients were less likely to undergo UKA relative to TKA compared with white patients [incidence rate ratio (IRR) 0.64, confidence interval (CI) 0.58-0.71, p < 0.001]. Compared with patients in income quartile 4, patients in income quartiles 1 and 2 underwent UKA at a lower relative rate (IRR 0.85, CI 0.79-0.90, p < 0.001 and IRR 0.87, CI 0.82-0.93, p < 0.001, respectively). Compared with patients with private insurance, patients with Medicare underwent UKA at a lower relative rate (IRR 0.83, CI 0.79-0.88, p < 0.001).

CONCLUSIONS

Black patients, lower-income patients, and Medicare-insured patients undergo UKA at a lower relative rate than white, higher-income, and privately insured patients, respectively. Further research may help elucidate reasons for these differences and identify targets for intervention.