Limited literacy and psychiatric disorders among users of an urban safety-net hospital's mental health outpatient clinic

Patient Experiences Completing Patient Reported Outcome Measures in Behavioral Health Within a Health Safety-Net Setting

Measurement based care (MBC), a practice that uses patient reported outcome measures (PROMs), is not widely used in behavioral health settings and little is known about the patient experience with MBC in safety-net settings. This study aimed to understand patient experiences completing PROMs on paper when presenting to an outpatient, behavioral health setting within a public safety-net hospital. Semi-structured interviews were conducted with 22 participants in English and Spanish. Participants were 42 years old (SD = 12.7), mostly white (36.4%) and Black (31.8%). Thematic analysis was used to analyze findings. Overall, participants were engaged with PROMs and described them as helpful for themselves and their clinicians. Participants also expressed themes focused on PROMs user-friendliness, including formatting, time to complete measures, and participant characteristics such as attention and literacy. These findings are important to consider to ensure equitable access to MBC when implemented in behavioral health in the health safety-net setting.

Performing an Organizational Health Literacy Assessment in a Shelter Serving People with Mental Illness

BACKGROUND

Health literacy research and practice are constantly evolving. Recent inquiry has highlighted the burdensome literacy demands faced by people with serious mental illness (SMI). Systems, organizational operations, and structures can play a role in decreasing literacy demand, thereby reducing unnecessary challenges for people with SMI. Brief Description of Activity: An organizational health literacy assessment was conducted to explore literacy demands in one mental health shelter and revealed best practice action steps for improving the literacy environment.

IMPLEMENTATION

The assessment included an exploration of the shelter environment using The Health Literacy Environment Activity Packet, First Impressions & Walking Interview, and a commonly used shelter document using the Simple Measure of Gobbledygook (SMOG), Suitability Assessment of Materials (SAM), and Centers for Disease Control and Prevention (CDC) Index.

RESULTS

The literacy demands of the shelter environment and a frequently used document exceeded the literacy skills of people with SMI. Environment assessment revealed environmental facilitators (e.g., welcoming atmosphere) and barriers (e.g., unclear signage). Document assessment also revealed facilitating factors and barriers. SMOG scores ranged from 11.25 to 11.80 (median: 11.38), meaning 11th to 12th grade-level reading skills are required to understand, use, and take action on the document's content. A SAM score of 50% (adequate) and a CDC Index score of 42.1 (revise and improve) reveal materials contain both facilitating factors (e.g., chunked sections) and barriers (e.g., jargon, mismatched graphics) to use.

LESSONS LEARNED

The mismatch between system demands and the literacy skills of people with SMI is more profound than that of the general United States population. Organizational health literacy assessments are achievable and useful for both immediate and long-term action aimed at understanding and improving the organizational health literacy of mental health spaces. Further work is needed to explore the role of behavioral health services in addressing the institutional and programmatic literacy demands that inhibit treatment and recovery. [HLRP: Health Literacy Research and Practice. 2022;6(3):e167-e174.] Plain Language Summary: An organizational health literacy assessment reveals how system demands can be changed to better serve intended users. Engaging in mental health, recovery, and treatment services requires complex literacy skills. Generally, the U.S. adult population does not have the skills to meet such demands, and this is especially true among public mental health service users.

Health literacy of people living with mental illness or substance use disorders: A systematic review

AIM

Health literacy is one's ability to use cognitive and social skills to access, understand and appraise health information. Despite poor health outcomes of people living with mental illness there is limited research assessing their health literacy. This systematic review aims to synthesise research on health literacy rates, conceptualizations, and outcomes of people living with mental illness, including substance use disorders. This will provide insights into how health literacy might be targeted to reduce these health inequities.

METHODS

A search of published literature in multiple databases up until February 2019 was conducted. One reviewer screened the titles, abstracts and keywords of identified publications and the eligibility of all full-text publications were assessed for inclusion along with a second reviewer. Both reviewers independently rated the quality of the included studies.

RESULTS

Fourteen studies were included in the review. Rates and measures of health literacy varied. Low health literacy and health literacy weaknesses were identified. There is a lack of research on the relationship between health literacy and other outcomes, particularly health service engagement.

CONCLUSION

The review highlights the high rates of low health literacy within this population compared with general populations. Most studies used a functional health literacy measure, despite its limitations, with only a few using multidimensional measures. Overall, there is limited research examining the impact that this populations health literacy has on their recovery and how it affects them over time. The review emphasizes the importance of practitioners assessing and targeting health literacy needs when working with this population.

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

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

Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness

OBJECTIVE

Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education.

METHODS

This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends.

RESULTS

Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%.

CONCLUSIONS

Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.

Prevalence and Predictors of Limited Literacy in Public Mental Health Care

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and "other" race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

La littératie en santé chez les personnes présentant des troubles mentaux graves

Le Plan d’action 2015-2020 en santé mentale du Québec vise, chez les personnes présentant des troubles mentaux graves, le développement d’une autonomie optimale dans la société et l’utilisation adéquate des services de santé. Néanmoins, à ce jour, un manque de données est rapporté au Québec, sur la capacité des personnes présentant des troubles mentaux à accéder, à comprendre et à utiliser l’information relative à la santé, ce qui correspond au concept de littératie en santé (LS). Une étude descriptive quantitative a été menée pour décrire la LS chez les personnes présentant des troubles mentaux graves et demeurant dans la communauté de Dolbeau-Mistassini, au Saguenay–Lac-Saint-Jean (Québec). Les données ont été collectées à l’aide de trois questionnaires autorapportés, incluant le Questionnaire sur la littératie en santé (QLS). Ce questionnaire permet de décrire la LS à partir de 9 dimensions, afin de soulever les besoins individuels, organisationnels et sociaux en lien avec la LS des personnes ciblées. Les résultats obtenus auprès des participants (n = 30) ont montré que la LS était plus faible dans la dimension « Comprendre l’information relative à la santé ». Les résultats de cette étude mettent en évidence la nécessité d’adapter les interventions éducatives chez cette population. Cette adaptation pourrait permettre à cette population de mieux intégrer le contenu de l’enseignement reçu, tout en privilégiant l’accompagnement d’un proche lors de la rencontre avec un professionnel de la santé.

Major anxiety disorders in Iran: prevalence, sociodemographic correlates and service utilization

BACKGROUND

It has been shown in the past two decades that anxiety disorders are the most common mental disorders in general population across the world. This study sought to assess the prevalence of major anxiety disorders, their sociodemographic correlates and mental health service utilization as part of the Iranian Mental Health Survey (IranMHS).

METHODS

A national household face-to-face survey was carried out on a representative sample of Iranian adults from January to June 2011 using Composite International Diagnostic Interview (CIDI 2.1). A total of 7886 subjects between 15 and 64 years who can understand Persian language were included. The 12-month prevalence of anxiety disorders according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), their socio-demographic correlates, health service use and days out of role were measured in this study.

RESULTS

The 12-month prevalence of anxiety disorders (not including specific phobias) was 15.6%. The prevalence was 12.0% in males and 19.4% in females. The three most prevalent anxiety disorders were generalized anxiety disorder (5.2%), obsessive-compulsive disorder (5.1%) and social phobia (3.2%), respectively. Factors found to be significantly associated with anxiety disorders were: female gender (OR = 1.16, 95% CI: 1.09-1.23), middle (OR = 1.23, 95%CI: 1.01-1.50) or low (OR = 1.66, 95%CI: 1.31-2.10) socioeconomic status, unemployment (OR = 1.98, 95%CI: 1.49-2.62), and urban residence (OR = 1.31, 95%CI: 1.10-1.57). Comorbidity with non-anxiety disorders significantly increased service utilization. In all subgroups, service utilization was higher among females while the number of days out of role was higher among males.

CONCLUSIONS

Anxiety disorders are common conditions with a higher prevalence among the female gender, unemployed individuals, and people with low socioeconomic conditions living in urban areas. Comorbidity of anxiety disorders with other psychological disorders aggravates the disability and significantly increases the number of days out of role.

Is Health Literacy Associated With Depressive Symptoms Among Korean Adults? Implications for Mental Health Nursing

OBJECTIVE

This study investigated whether health literacy is associated with depressive symptoms among Korean adults, when adjusting for relevant risk factors for depression.

METHODS

Data were collected from a sample of 585 community-dwelling Korean adults living in Seoul and Kwangju, South Korea, using a quota sampling strategy. A cross-sectional, multivariate regression analysis was used to investigate the association between health literacy and depressive symptoms.

RESULTS

When controlled for covariates, a lower level of health literacy was significantly associated with a higher level of depressive symptoms.

CONCLUSION

Health literacy may play an important role in preventing and treating depression. Future research is needed to determine if improving health literacy, through health promotion interventions, can enhance community-dwelling Korean adults' understanding of depressive symptoms and relevant treatment options.

Associations Between Gender and Obesity Among Adults with Mental Illnesses in a Community Health Screening Study

The prevalence of obesity and its associations with gender, clinical factors, and medical co-morbidities were examined among 457 adults attending public mental health programs in 4 U.S. states. BMI was measured directly and other information was gathered by interview. Over half (59%, n = 270) were obese including 18% (n = 83) who were morbidly obese. In hierarchical ordinary least squares regression analysis controlling for demographic, psychiatric, medical, smoking, and health insurance statuses, women were significantly more likely to be obese than men. Obesity also was more likely among those who were younger and not high school graduates, those with diabetes or hypertension, and those who did not smoke tobacco. Interaction effects were found between gender and diabetes, hypertension, tobacco smoking, education, race, and age. The high prevalence of obesity among women, coupled with interactions between gender and other factors, suggest that targeted approaches are needed to promote optimal physical health in this population.

Health Literacy as a Social Determinant of Health in Asian American Immigrants: Findings from a Population-Based Survey in California

BACKGROUND

Asian American immigrants have a lower level of health literacy than non-Latino whites, but their level of health literacy and its impact on health outcomes may differ among subgroups.

OBJECTIVE

We investigated the level of health literacy across five subgroups of Asian American immigrants and explored the association between health literacy and self-rated health status and symptoms of depression.

DESIGN

We utilized a cross-sectional survey research design and a population-based sampling strategy using the 2007 California Health Interview Survey (CHIS).

PARTICIPANTS

We sampled 30,615 non-Latino whites and 3,053 Asian American immigrants (1,058 Chinese, 598 Koreans, 534 Filipinos, 416 South Asians, and 447 Vietnamese).

MAIN MEASURES

We used two questions as proxy measures to assess the level of health literacy in non-Latino whites and in both aggregated and disaggregated Asian American immigrant groups. We then investigated the effect of health literacy on two main health outcomes: self-rated health status and depression symptoms.

KEY RESULTS

The level of health literacy varied across the five subgroups of Asian American immigrants. Chinese, Korean, and Vietnamese groups had the lowest levels of health literacy, while Filipinos showed the highest level. Health literacy was positively correlated with health status in Chinese and Korean immigrants, and negatively correlated with depression symptoms in Korean and South Asian immigrants.

CONCLUSION

We found heterogeneity in health literacy among Asian American immigrants and found that health literacy had varying associations with health outcomes. The aggregated Asian American immigrant group results may mask the true health disparities that each Asian American immigrant group faces. Koreans were the only group found to have a significant association between the proxy for health literacy and both health outcomes. Further research is needed to better understand the causes of heterogeneity and to investigate health literacy as a critical determinant of immigrant health.

Gender Differences in Health Literacy Among Korean Adults: Do Women Have a Higher Level of Health Literacy Than Men?

The role of gender in determining the level of health literacy in Korean adults is unclear. This study aimed to investigate the level of health literacy in Korean adults and identify factors associated with health literacy by gender. This study employed a cross-sectional survey design with a convenient sample of 585 community-dwelling Korean adults age19 years and older. Health literacy was measured by using eight items selected from Chew et al.'s 16-question self-reported health literacy measure. In accordance with Andersen's health behavior model, predisposing, enabling, and need factors were included in the multiple regression model. Women indicated a higher level of health literacy than men in understanding medical forms, directions on medication bottles, and written information offered by health care providers. Additionally, for Korean women, a higher level of health literacy was associated with attaining a higher education level and having a consistent place to receive care. Unmarried men and men who had higher self-rated health reported a higher level of health literacy compared with their counterparts. Lower level of depression and higher monthly income were significantly linked to a higher level of health literacy in both men and women. This study has established the importance of gender differences in health literacy and suggests gender-specific intervention may be warranted to reduce the existing gap in health literacy in both Korean men and women. Future research should replicate this study to confirm whether or not our finding is an international phenomenon.

Cardiovascular health literacy and treatment adherence in persons with serious mental illness

Persons with serious mental illnesses have shorter life spans than the general population, and their earlier death is often related to cardiovascular disease. This study examined health literacy and cardiovascular medication adherence in a sample of 98 participants with serious mental illness. Sixty-two percent of the participants had adequate health literacy as measured by the Test of Functional Health Literacy in Adults. The association between health literacy and medication adherence was not significant after controlling for education. There was a significant association between health literacy and education level, health literacy and site, and health literacy and the sodium intake subscale of the Hill-Bone adherence scale.

Perceived human rights violation in persons with mental illness: role of education

BACKGROUND

People with mental illness are vulnerable to human rights violations and people with illiteracy and mental illness are at a double disadvantage.

OBJECTIVE

To determine the role of education in ascertaining human rights needs of people with mental illness.

METHODOLOGY

This was a descriptive study carried out among randomly selected (N = 100) recovered psychiatric patients with mental illness in the past based on the Clinical Global Impression-Improvement scale at a tertiary care centre. Data were collected through face-to-face interview using structured needs assessment questionnaire comprising two sections related to family and community domains. Data were analysed and interpreted using descriptive and inferential statistics.

FINDINGS

Our findings revealed that human rights needs in the physical needs dimension--i.e., access to electricity (χ2 = 5.523, p < .019) and safe drinking water facilities (χ2 = 9.665, p < .022)--were rated higher in illiterates than in literates. The human rights needs in emotional dimension - i.e. feeling separated from their families because of their illness (χ2 = 13.118, p < .004), afraid of family members (χ2 = 13.388, p < .004) and called filthy nicknames (χ2 = 17.759, p < .000) - were rated higher in literates than in illiterates. The human rights needs in the religious needs dimension - i.e. allowed to go to temple, church, mosque etc. (χ2 = 12.000, p < .007) - and in the social needs dimension - i.e. friendliness with family members -were rated higher in illiterates than in literates (χ2 = 9.661, p < .022).

CONCLUSION

Empowering people with mental illness by providing adequate opportunity to pursue education will play an important role in fulfilling the obligation of the United Nations Convention on the Rights of Persons with Disabilities.

Evaluating the impact of California's full service partnership program using a multidimensional measure of outcomes

This study evaluates the impact of California's full-service partnership (FSP) program using a multidimensional measure of outcomes. The FSP program is a key part of California's 2005 Mental Health Services Act. Secondary data were collected from the Consumer Perception Survey, the Client and Service Information System, and the Data Collection and Reporting System, all data systems which are maintained by the California Department of Mental Health. The analytic sample contained 39,681 observations of which 588 were FSP participants (seven repeated cross-sections from May 2005 to May 2008). We performed instrumental variables (IV) limited information maximum likelihood and IV Tobit analyses. The marginal monthly improvement in outcomes of services for FSP participants was approximately 3.5 % higher than those receiving usual care with the outcomes of the average individual in the program improving by 33.4 %. This shows that the FSP program is causally effective in improving outcomes among the seriously mentally ill.

Response to a Relational Agent by Hospital Patients with Depressive Symptoms

Depression affects approximately 15% of the US population, and is recognized as an important risk factor for poor outcomes among patients with various illnesses. Automated health education and behavior change programs have the potential to help address many of the shortcomings in health care. However, the role of these systems in the care of patients with depression has been insufficiently examined. In the current study, we sought to evaluate how hospitalized medical patients would respond to a computer animated conversational agent that has been developed to provide information in an empathic fashion about a patient's hospital discharge plan. In particular, we sought to examine how patients who have a high level of depressive symptoms respond to this system. Therapeutic alliance-the trust and belief that a patient and provider have in working together to achieve a desired therapeutic outcome- was used as the primary outcome measure, since it has been shown to be important in predicting outcomes across a wide range of health problems, including depression. In an evaluation of 139 hospital patients who interacted with the agent at the time of discharge, all patients, regardless of depressive symptoms, rated the agent very high on measures of satisfaction and ease of use, and most preferred receiving their discharge information from the agent compared to their doctors or nurses in the hospital. In addition, we found that patients with symptoms indicative of major depression rated the agent significantly higher on therapeutic alliance compared to patients who did not have major depressive symptoms. We conclude that empathic agents represent a promising technology for patient assessment, education and counseling for those most in need of comfort and caring in the inpatient setting.