Information needs and preferences of low and high literacy consumers for decisions about colorectal cancer screening: utilizing a linguistic model

How well do we measure the impact of bowel dysfunction on health-related quality of life after rectal cancer surgery?

BACKGROUND

Rectal cancer surgery risks causing bowel dysfunction, which has an important impact on health-related quality of life. The validity of generic tools used to measure health-related quality of life after bowel dysfunction is unclear. This study aims to determine the content validity of health-related quality-of-life measurement tools in rectal cancer.

METHODS

This was a qualitative single-center study in which adult patients who underwent rectal cancer surgery with sphincter preservation from July 2017 to October 2020 were recruited. Patients were excluded if they developed local metastasis, required a permanent stoma, or had surgery <1 year since recruitment. Telephone-based semi-structured interviews were conducted. Bowel dysfunction was measured using the Low Anterior Resection Syndrome score. Content analysis was achieved using the International Classification of Functioning framework.

RESULTS

Recurrent bowel dysfunction-related concepts included "Mental functions," "Defecation functions," "Emotional functions," "Recreation and leisure," "Intimate relationships," and "Remunerative employment." A mean of 7.5 recurrent bowel dysfunction-related concepts were identified within the health-related quality of life instruments analyzed. The European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30 (n = 11) and the 36-Item Short Form Health Survey (n = 9) covered the greatest number of recurrent bowel dysfunction-related concepts. Concepts such as "Mental functions," "Urination functions," "Sexual functions," "Driving," and "Mobility" were not covered by any instrument.

CONCLUSION

The content of traditional health-related quality-of-life instruments is missing important areas that represent the impact of bowel dysfunction after rectal cancer surgery on health-related quality of life. These findings could help improve patient-centered care in rectal cancer surgery.

'You are making it sound like you are talking to a child': exploring community sentiment on developing and disseminating tailored sexual health education resources for migrants

Health communication is a critical component of public health, which includes health education resources. Resource effectiveness is improved where health literacy demands, including the cultural appropriateness of resources, match the intended audience. International guidelines support the tailoring of resources for migrants from culturally and linguistically diverse backgrounds (CaLD). Five focus groups (n = 18) and interviews (n = 9) with people from CaLD migrant backgrounds explored community perspectives on sexual health resources developed by a state department of health, specifically clarity, comprehensiveness, cultural appropriateness and strategies for dissemination. We identified three major thematic areas relating to simplicity, cultural norms and beliefs and dissemination. Participants recommended resource delivery in different formats as part of a broader intervention. Generally, sexual health information was deemed appropriate and easily understood. However, the resources used simplified language that participants reported was vague and inaccurate at times, potentially contributing to misinformation and reinforcing stigma relating both to the status of being a migrant and sexual health. Findings suggest the need for more nuanced health resource development beyond translation and language simplification. Resources developed in different formats, including different health literacy demands, using approaches that engage the target group in design and dissemination and contextualized within a comprehensive health promotion project, are likely to be more effective.

Understanding the Impact of Bowel Dysfunction on Quality of Life After Rectal Cancer Surgery From the Patient's Perspective

BACKGROUND

Bowel dysfunction is an important consequence of rectal cancer surgery' and the specific quality-of-life domains that are affected remain unclear and unaddressed by generic surveys.

OBJECTIVE

This study aimed to identify quality-of-life domains most affected by rectal cancer surgery.

DESIGN

Qualitative content analysis.

SETTINGS

Semistructured interviews conducted by telephone with patients recruited from a single university-affiliated colorectal referral center.

PATIENTS

Adult patients were included if they underwent rectal cancer surgery with sphincter preservation from July 2017 to July 2020. Patients were excluded if their surgery was <1 year since the recruitment date, received a permanent stoma, or developed recurrence or metastasis.

MAIN OUTCOME MEASURES

Bowel dysfunction was evaluated via the low anterior resection syndrome score. Interview transcripts were coded by 2 independent reviewers and evaluated for concordance. Qualitative content analysis was used to identify themes, and their frequency of occurrence was quantified (percent total number of interviews).

RESULTS

A total of 54 patient interviews were conducted. Analysis revealed 5 quality-of-life-related themes impacted by bowel dysfunction: experiencing psychological and emotional stress, challenging roles and relationships within society, encountering physical limitations, restricting leisure and recreational activities, and learning self-empowerment and adapting to change. Patients with minor and major bowel dysfunction were more likely to report disruption to their social activities and their role as a sexual partner versus those with no bowel dysfunction. Patients with major bowel dysfunction were more likely to report effects on sleep versus those with no and minor bowel dysfunction.

LIMITATIONS

Single center, self-reported, and observer bias.

CONCLUSION

The impact of bowel dysfunction on quality of life includes a wide range of themes that extend beyond traditional measures. These results may help better inform patients in the preoperative setting and serve as a basis for the development of a more patient-centered quality-of-life survey.

COMPRENDER EL IMPACTO DE LA DISFUNCIN INTESTINAL EN LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE RECTO DESDE LA PERSPECTIVA DEL PACIENTE

ANTECEDENTES:La disfunción intestinal es una consecuencia importante de la cirugía del cáncer de recto y los dominios específicos de la calidad de vida que se ven afectados siguen sin estar claros y sin abordarse en las encuestas genéricas.OBJETIVO:Identificar los dominios de calidad de vida más afectados por la cirugía del cáncer de recto.DISEÑO:Análisis cualitativo de contenido.ÁMBITOS:Entrevistas semiestructuradas realizadas por teléfono con pacientes reclutados de un único centro de referencia colorrectal afiliado a una universidad.PACIENTES:Pacientes adultos intervenidos de cáncer de recto con preservación de esfínter del 07/2017 al 07/2020. Los pacientes fueron excluidos si su cirugía fue <1 año desde la fecha de reclutamiento, recibieron un estoma permanente o desarrollaron recurrencia o metástasis.PRINCIPALES MEDIDAS DE RESULTADO:La disfunción intestinal se evaluó a través de la puntuación del síndrome de resección anterior baja. Dos revisores independientes codificaron las transcripciones de las entrevistas y evaluaron su concordancia. Se utilizó el análisis de contenido cualitativo para identificar los temas, cuantificando su frecuencia de aparición (porcentaje del número total de entrevistas).RESULTADOS:Se realizaron un total de 54 entrevistas a pacientes. El análisis reveló cinco temas relacionados con la calidad de vida afectados por la disfunción intestinal: experimentar estrés psicológico y emocional, roles y relaciones desafiantes dentro de la sociedad, encontrar limitaciones físicas, restringir actividades recreativas y de ocio, y autoempoderamiento y adaptación al cambio. Los pacientes con disfunción intestinal menor y mayor tenían más probabilidades de informar la interrupción de las actividades sociales y el papel como pareja sexual en comparación con aquellos sin disfunción intestinal. Los pacientes con disfunción intestinal importante tenían más probabilidades de informar efectos sobre el sueño en comparación con aquellos sin disfunción intestinal o con disfunción intestinal menor.LIMITACIONES:Sesgo de un solo centro, autoinformado y observador.CONCLUSIÓN:El impacto de la disfunción intestinal en la calidad de vida incluye una amplia gama de temas que se extienden más allá de las medidas tradicionales. Estos resultados pueden ayudar a informar mejor a los pacientes en el entorno preoperatorio y servir como base para el desarrollo de una encuesta de calidad de vida más centrada en el paciente. (Traducción-Dr. Yesenia Rojas-Khalil ).

Evaluation of a New Performance-Based Health Literacy Measurement Tool for Individuals With Chronic Airways Disease

BACKGROUND

Low health literacy is a global challenge. Health literacy is positively correlated with chronic airways disease desirable outcomes. Despite the importance of health literacy in disease management, current health literacy measurement tools are suboptimal. As part of a multi-stage project to develop a performance-based, disease-specific Vancouver Airways Health Literacy Tool (VAHLT) for individuals with chronic airways disease, this study assessed the relationships between the VAHLT scores and characteristics of patients with chronic airways disease. The primary aim of the study was to provide preliminary evidence of construct validity of the VAHLT.

METHODS

A cross-sectional study design was applied. Study subjects were recruited from 6 specialty care clinics to complete the VAHLT measurement tool. Demographic and clinical data, including quality of life and disease control, were collected via validated questionnaires. The study subjects also completed a spirometry test. Inferential analysis was conducted by using mean difference testing and correlational methods.

RESULTS

A total of 320 subjects were recruited, and, after imputing missing data, 315 were ultimately analyzed. The subjects were predominantly women (61%), white (83%), had a post-high-school education (74%), and a mean ± SD age of 65.2 ± 13.2 y. Age was significantly negatively correlated with the VAHLT scores (P = .004); the subjects with a post-high school education had significantly higher VAHLT scores than those with a high school education or less (P < .001). No significant sex or ethnicity related differences in VAHLT scores were observed. For clinical outcomes, no significant differences were found between the VAHLT scores and disease severity or measures of quality of life and asthma control.

CONCLUSIONS

We report a chronic airways disease-specific health literacy measurement tool developed with the involvement of patients and professionals. Age and education were highly correlated with health literacy, which emphasizes the importance of addressing these factors in health literacy interventions among patients with chronic airways disease.

"A whole new perspective on how the body fits together"-An evaluation of a cadaver laboratory experience for high school students

The Center for Anatomy and Physiology Education has hosted interactive human cadaver laboratory tours for local high schools (ages 14-18) and undergraduate university students since 2014 to expose students to healthcare careers. Students receive information on the history of body donation and healthcare careers and observe human anatomy on prosections and with isolated organs. The goal of this study was to evaluate students' perceptions of the anatomy laboratory tours and their impact on students' interests in healthcare careers. Students completed pre- and post-tour questionnaires. Responses were analyzed using thematic analysis and linguistic inquiry. Of the 261 students who completed pre-tour questionnaires, 204 (78%) completed the post-tour questionnaire. Before the tour, students anticipated learning about human anatomy and expected to only see but not touch a cadaver. Most students expressed excitement and/or nervousness. A few students viewed the laboratory tour as an opportunity to test if they could see themselves in a healthcare career. After the tour, most students indicated that the tour either met or exceeded their expectations. Students found the laboratory tour to be educational and interesting and were surprised by the opportunity to interact with the donor. Numerous students expressed an increased interest in healthcare careers after the tour. Overall, students perceived the tour as an engaging experience that improved their anatomical knowledge and reinforced/increased their interest in healthcare careers. Academic institutions can positively impact local students by implementing an anatomy tour, sharing access to their in-house human cadaver laboratory, and recruiting instructors to share their anatomy expertise.

Information Needs of People With Limited Health Literacy Regarding a New "Opt-Out" Organ Donation System: A Qualitative Study in the Netherlands

Background: In the Netherlands, new legislation on organ donation was implemented, based on a “opt-out” consent system, which means that all adults are presumed to consent for organ donation, unless they actively register their decision not to donate. A public information campaign preceded the law change. In the Netherlands, 29% of the population has limited health literacy (LHL). The aim of the study was to gain insight in the information needs of Dutch citizens with LHL regarding organ donation and the new legislation, as well as in their preferred information channels.

Methods: A qualitative study was performed; 30 people participated in four focus groups and six individual interviews. Transcripts were coded, interviews were thematically analysed.

Results: People with LHL need specific information to make an informed decision on organ donation. Relevant topics: 1) choice options, 2) eligibility, 3) role of partner and/or family, 4) impact on quality of care, and 5) process of organ donation. Information should be easy to understand.

Conclusion: Current standard materials are too difficult and abstract. People with LHL require personal support to tailor general information to their personal situation, and practical help to actually register their choice. Suggestions on how to improve information is provided.

The impact of bowel dysfunction on health-related quality of life after rectal cancer surgery: a systematic review

BACKGROUND

Symptoms of bowel dysfunction after sphincter-preserving rectal cancer surgery have an important impact on health-related quality of life (HRQOL), but that relationship is complex. A better understanding of this relationship allows for better informed shared decision-making about surgery. Our objective was to perform a systematic review to determine which HRQOL domains are most affected by postoperative bowel dysfunction.

METHODS

A systematic review of the CINAHL, Cochrane Library, Embase, Medline, PsycInfo, PubMed, Web of Science, and Scopus databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies that evaluated bowel function after sphincter-preserving rectal cancer surgery and assessed HRQOL using a validated instrument. The quality of HRQOL analysis was assessed using an 11-item checklist. The main outcome was the impact bowel dysfunction had on global and domain specific quality-of-life indices. The impact was evaluated for clinical relevance using the Minimum Clinical Important Difference (MCID) for each specific HRQOL instrument.

RESULTS

Out of 952 unique citations, 103 studies were full-text reviews. Eighteen studies met the inclusion criteria (4 prospective cohorts and 9 cross-sectional studies). Of the 15 studies with long-term follow-up, the time to assessment after surgery ranged from 1.2 to 14.6 years. The low anterior resection syndrome score and European Organization for Research and Treatment core quality-of-life questionnaire (EORTC QLQ-C30) were the most commonly used instruments. Medium and large magnitudes in MCID were seen for global health, social functioning, emotional functioning, fatigue, diarrhea, and financial difficulties. Among included studies, the most consistently reported functional domains affected by bowel function were social functioning and emotional functioning.

CONCLUSIONS

Following sphincter-preserving rectal cancer surgery, poor bowel function mainly affects the social and emotional functional domains of HRQOL, which in turn impact global scores. This finding can help inform patients about expected changes in HRQOL after rectal cancer surgery and facilitate individualized treatment decisions.

Implementation of an animated medication information tool in community pharmacies, with a special focus on patients with limited health literacy

OBJECTIVES

The animated medication information tool 'Watchyourmeds' provides information in an accessible manner through animated videos and therefore appears to be especially suitable for people with limited health literacy. This study aimed to assess the implementation of this animated medication information tool in Dutch community pharmacies, with a special focus on patients with limited health literacy.

METHODS

A cross-sectional survey based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was sent to approximately 75% of the ±1900 community pharmacies in the Netherlands through email newsletters of pharmacy networks.

KEY FINDINGS

140 pharmacists (⁓10%) completed the survey and 125 of them (89%) indicated that they offered the animated medication information tool to their patients. 108 pharmacists indicated that the tool was offered to all patients, not only to patients with limited health literacy. The distribution method was primarily passive (patients were given a leaflet and were not explicitly pointed to or informed about the tool). Two frequently cited motivations for offering the tool were that it complemented other sources of information and that the health insurer provided a financial incentive. The main reasons patients refused to use the tool were that they had no access to or no affinity for the required technology.

CONCLUSIONS

This study demonstrated that the tool is used in community pharmacies and that it is offered to all patients, regardless of their presumed health literacy level. A more active method of offering the tool may be warranted to better reach patients with limited health literacy.

Effects by educational attainment of a mammography screening patient decision aid for women aged 75 years and older

BACKGROUND

To help inform screening decisions, a mammography screening decision aid (DA) for women aged 75 years and older was tested in a cluster randomized clinical trial of 546 women. DA use increased women's knowledge of the benefits and harms of mammography and lowered screening rates. In the current study, the objective was to examine whether participants' views of the DA and/or its effects differed by educational attainment.

METHODS

A secondary analysis was conducted of 283 women who received the DA before a personal care provider (PCP) visit during the trial to examine the acceptability of the DA and its effects on knowledge of the benefits and harms of mammography, screening intentions, and receipt of screening by educational attainment. Adjusted analyses accounted for clustering by PCP.

RESULTS

Of the 283 participants, 43% had a college education or less. Regardless of educational attainment, 87.2% found the DA helpful. Women with lower educational attainment were less likely to understand all of the DA's content (46.3% vs 67.5%; P < .001), had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; P < .001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P = .01). Receipt of screening did not differ by educational attainment.

CONCLUSIONS

A mammography DA for women aged 75 years and older was helpful to women regardless of their educational attainment; however, those with a college degree or greater understood the DA and, possibly as a result, lowered their screening intentions. Future studies need to examine how to better support informed decision making around mammography screening in older women with lower educational attainment.

LAY SUMMARY

The authors examined data from a previous study to learn the effects of a mammography decision aid (DA) for women aged 75 years and older according to their level of education. Overall, women found the DA helpful, but women with lower educational attainment found it harder to understand the benefits and harms of mammography screening and were less likely to lower their screening intentions than women with a college degree. The findings suggest that women aged 75 years and older who have lower educational attainment may need an even lower literacy DA and/or more support from health care professionals.

Health literacy and cancer screening behaviors among community-dwelling female adults in Taiwan

This study was designed to explore the association among health literacy and cancer screening behaviors in Taiwanese females. A total of 353 community-dwelling females were recruited in this cross-sectional study from February to October 2015. Demographic, socioeconomic and personal behavior variables including physical activity, community activity, smoking, alcohol consumption, and betel nut chewing were recorded. Health literacy was evaluated using the Mandarin version of the European Health Literacy Survey Questionnaire. Data on screening behaviors for cervical, breast and colorectal cancers were confirmed by the Taiwanese National eHealth Database. Most respondents with inadequate or problematic general health literacy had no or irregular screening behaviors for cervical, breast and colorectal cancers. In multivariable regression analysis, women with inadequate health literacy were at a greater risk (Odds ratio = 5.71; 95% CI: 1.40-23.26) of having no previous Pap smear screening or >3 years screening interval regardless of education level. However, this association was not detected for breast or colorectal cancer. Women with inadequate health literacy were more likely to have irregular cervical cancer screening, however no associations among health literacy and breast or colorectal cancer were detected. The impact of health literacy on cancer screening behavior warrants further attention and research.

Health Literacy, Language, and Cancer-Related Needs in the First 6 Months After a Breast Cancer Diagnosis

PURPOSE

Low health literacy (HL) and language negatively affect cancer screening and prevention behaviors; less is known about how they affect the patient's experience during cancer treatment. This study explores associations among HL, spoken language, and dimensions of cancer-related needs within 6 months of receiving a breast cancer diagnosis.

METHODS

Women speaking English, Spanish, or Haitian Creole, enrolled in a patient navigation study at diagnosis, completed a survey in their primary spoken language at baseline and 6 months to characterize their cancer-related needs. HL was measured using the Brief Health Literacy Screening Tool. Outcomes included the Cancer Needs Distress Inventory (CaNDI; n = 38 items) and the Communication and Attitudinal Self-Efficacy scale (CASE-Cancer) for cancer (n = 12 items). Linear regressions measured the impact of HL and language on total CaNDI and CASE-Cancer scale for cancer scores and subscales, adjusted for demographics.

RESULTS

At baseline, 262 women participated and 228 (87%) followed up at 6 months. Of these, 38% had adequate HL, 33% had marginal HL, and 29% had inadequate HL. Women with inadequate or marginal HL had higher median baseline CaNDI scores (P = .02) and lower self-efficacy scores (P = .008), relative to those with adequate HL. Haitian-Creole speakers had significantly lower CANDI scores at baseline (P = .03). Adjusting for demographics, differences in CaNDI scores at baseline remained significant for those with lower HL and Haitian-Creole speakers. At 6 months, differences in self-efficacy persisted for Haitian-Creole speakers.

CONCLUSION

Findings suggest that interventions oriented to mitigating HL and language barriers might reduce distress at the time of diagnosis and improve self-efficacy over the course of treatment.

Evaluation of an Australian Health Literacy Program Delivered in Adult Education Settings

Background:

Adult education targeting health literacy (HL) may bring added value in the form of improved health.

Objective:

This study evaluated the effects of a HL program as part of an adult education curriculum for adults with low literacy and numeracy.

Methods:

This was a partial-cluster randomized controlled trial among 308 adults enrolled in basic education programs in Australia. Of the 308 participants, 141 (46%) were randomized to either the standard program (language, literacy, and numeracy [LLN]), or the HL intervention (LLN with embedded health content); the remainder (n = 167) were allocated to standard intervention programs by the education provider at the class level. The main outcomes were functional HL, self-reported confidence, patient activation, generic HL (ie, HLQ, health knowledge, and self-reported health behavior). Data were collected at baseline, immediately after, and at 6 months post-intervention.

Key Results:

Of the 308 participants, 71% had limited literacy and 60% spoke a language other than English at home. Both interventions benefited participants, with improvements from baseline to immediate follow up on individual-level functional HL (e.g., reading a thermometer; HL group 18.4% vs. standard group 7.2%; p = .001), confidence (HL group 0.34 vs. standard group 0.06; p = .014) and health literacy questionnaire (HLQ) subscales. At 6 months, improvements in confidence (p < .001) and some HLQ measures were retained. A consistent pattern of increased improvement in the HL program was observed compared to the standard program, although only some measures reached statistical significance: reading a food label (HL group 6.03/10 correct vs. standard group 5.49/10 correct; p = .022); confidence (p = .008); ability to actively manage health (HLQ) (p = .017), and health knowledge at 6 months (HL group 68% vs. standard group 60% correct, p = .052). HL participants reported being more likely to share course information and rated the program more useful to understand their health.

Conclusions:

Improving language, literacy, and numeracy generally has potential public health benefits that are retained at 6 months. Integrating health content adds further value to adult basic learning, is feasible, and potentially scalable. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S42–S57.]

Plain Language Summary:

We compared the effect of an adult education-based health literacy (HL) program versus a standard language, literacy, and numeracy program on students' HL skills and psychosocial outcomes. Although students in both trial arms improved their skills, students in the HL program had better outcomes with higher HL, greater confidence, and higher health knowledge scores at 6 months.

Health Literacy Influences Men's Active and Passive Cancer Information Seeking

Background:

For cancer prevention information to be effective, it must be accessible to its target populations. Prevalence of inadequate health literacy (HL) is high, but there is a dearth of information on the impact of HL on men's cancer information seeking.

Objective:

We investigated (1) men's cancer information seeking behaviors, (2) the effect of HL on men's cancer information seeking behavior, and (3) men's preferences for cancer information, considering their HL level. From a national perspective, we investigated men's information seeking behavior from the Irish Cancer Society (ICS), the largest provider of cancer information in Ireland.

Methods:

Men from adult literacy classes and men's groups were invited to complete a questionnaire. General and ICS-specific cancer information seeking behavior was investigated. Univariate and multivariate logistic regression models were conducted with “ever” seeking cancer information from any source, and actively seeking and passively acquiring ICS information as dependent variables.

Key Results:

Overall, 259 men completed the questionnaire and 44% had inadequate HL. About one-half of responders reported “ever” actively looking for cancer information. In the study group, 19% actively sought and 67% passively acquired ICS-specific information. In multivariate analysis, the odds of actively seeking (2.93; 95% CI [1.05, 8.15]) or passively acquiring (4.7; 95% CI [1.99, 11.05]) ICS-specific cancer information was significantly higher among those with adequate versus inadequate HL, respectively. HL was not significantly associated with odds of “ever” cancer information seeking in multivariate analysis (odds ratio 1.81; 95% CI [0.90, 3.63]). Men want information about cancer prevention. Suggested future cancer information sources differed by HL levels. General practitioners and the Internet were the preferred source for men with inadequate (53.3%) and adequate HL (57%), respectively.

Conclusions:

Men both passively acquire and actively seek cancer prevention information. Multimodal dissemination of cancer prevention information is necessary to reach a wide cross-section of men, including those with inadequate HL. This could potentially lower men's cancer burden and reduce gender inequalities in cancer mortality. [HLRP: Health Literacy Research and Practice. 2019;3(3):e147–e160.]

Plain Language Summary:

Most men get cancer prevention information by coming across it passively in their daily lives, instead of actively looking for this information. Men with low health literacy are less likely to obtain cancer information both passively and actively. Men want this information. Organizations need to make this information available in many places and formats (e.g., Internet, doctor, television, sports clubs).

User-testing an interactive option grid decision aid for prostate cancer screening: lessons to improve usability

OBJECTIVE

To user-test a web-based, interactive Option Grid decision aid 'prostate-specific antigen (PSA) test: yes or no?' to determine its usability, acceptability and feasibility with men of high and low health literacy.

DESIGN

A semi-structured interview study.

SETTING

Interviews were conducted at a senior centre, academic hospital or college library in New Hampshire and Vermont.

PARTICIPANTS

Individuals over 45 years of age with no history of prostate cancer who voluntarily contacted study authors after viewing local invitations were eligible for inclusion. Twenty interviews were conducted: 10 participants had not completed a college degree, of which eight had low health literacy, and 10 participants had high health literacy.

INTERVENTION

An interactive, web-based Option Grid patient decision aid for considering whether or not to have a PSA test.

RESULTS

Users with lower health literacy levels were able to understand the content in the tool but were not able to navigate the Option Grid independent of assistance. The tool was used independently by men with high health literacy. In terms of acceptability, the flow of questions and answers embedded in the tool did not seem intuitive to some users who preferred seeing more risk information related to age and family history. Users envisioned that the tool could be feasibly implemented in clinical workflows.

CONCLUSION

Men in our sample with limited health literacy had difficulty navigating the Option Grid, thus suggesting that the tool was not appropriately designed to be usable by all audiences. The information provided in the tool is acceptable, but users preferred to view personalised risk information. Some participants could envision using this tool prior to an encounter in order to facilitate a better dialogue with their clinician.

ETHICS APPROVAL

The study received ethical approval from the Dartmouth College Committee for the Protection of Human Subjects (STUDY00030116).

The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis

OBJECTIVE

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

METHODS

Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies.

RESULTS

We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level.

CONCLUSION

Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers.

PRACTICAL IMPLICATIONS

The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.

Development and validation of the Health Visual Information Preference Scale

OBJECTIVE

Patients are likely to have individual preferences for learning about health, which may influence their comprehension and utilization of health information. Some patients may prefer visual health information, which can make complex health information easier to understand. Aligning health information presentation with preferences may increase understanding and improve health outcomes, yet no scale measures preferences for visual health information.

DESIGN

Two studies examined the psychometric properties of the Health Visual Information Preference Scale (Health VIPS), a new measure designed to assess preferences for visual health information.

METHODS

In Study 1, 103 undergraduate students and 97 patients undergoing colorectal and gynaecological oncology surgery completed the Health VIPS. Exploratory factor analyses (EFA) were conducted for both samples. Internal consistency, test-retest reliability, and validity were assessed in the student sample. In Study 2, 196 outpatients completed the Health VIPS. Confirmatory factor analysis (CFA) was performed on this sample, in addition to measures of reliability and validity.

RESULTS

In Study 1, EFA analysis suggested a two-factor structure. The Health VIPS demonstrated good internal consistency in both the student sample (α = .70-.80) and patient sample (α = .80), and good test-retest reliability in the student sample (r = .63, p < .001). Convergent validity and discriminant validity were also established. In Study 2, the CFA confirmed a two-factor structure is the best model fit for the Health VIPS. The Health VIPS also demonstrated discriminant and convergent validity. Scale item means in all samples were positively skewed, suggesting a general preference for visual health information.

CONCLUSIONS

Initial evidence suggests the Health VIPS has good psychometric properties. This scale could identify patients who would benefit from additional visual aids when receiving health information. Statement of contribution What is already known on this subject? Poor comprehension of health information can lead to misunderstandings of illness and treatment, and potentially non-adherence. It is likely that patients have distinct preferences for how they would choose to receive health information, including information format. Visual health information is becoming more widely used to communicate information about health and illness to patients, although there is no measure to identify those who prefer this information format to standard written health materials. What does this study add? This study describes the first scale to assess preferences for visual health information. This scale could identify patients who would benefit from supplementary visual information in consultations.

Questionnaire Validation of Colorectal Cancer Literacy Scale among Thai People in Northeastern Thailand

Background: Colorectal cancer is an important public health problem worldwide. Although progress in screening and treatment has considerably improved the prognosis in the developed world, in developing countries colorectal cancer mortality rate remains relatively high. Colorectal cancer screening literacy is an important initial step in overcoming this problem. Development of a validated assessment instrument is therefore important for implementation of appropriate health education programs to facilitate early detection. Objectives: This study focused on generation and validation of a colorectal cancer screening literacy scale for Thai people in northeastern Thailand. Methods: This methodological study was carried out in two phases: (1) literature reviews and semi-structured interviews were used to select items, then the content and face validity were checked; and (2) a confirmatory factor analysis (CFA) was conducted to test construct validity and reliability. A self-administered questionnaire was used to collect data from Thai people aged 50- 65 in June 2017. Results: For the total of 400 participants who responded (response rate 100 %), the age ranged from 50 to 65 years old (mean = 57.3, SD = 4.616). The colorectal cancer screening literacy scale was designed to include 6 domains and it was shown to have good internal consistency, and CFA demonstrated the model to fit data adequately (Chi-squared/degree of freedom = 1.079, p = 0.061, CFI = 1.00, GFI = 0.93, AGFI = 0.91, RMSEA = 0.014 and SRMR = 0.036). The final version of its, consisting of 57 items across the 6 domains covering key aspects of colorectal cancer screening literacy, demonstrated good psychometric properties for this population. Conclusions: Use of the colorectal cancer screening literacy scale in Thai people could lead to improved educational programs for optimizing colorectal cancer screening.

Use of Two Self-referral Reminders and a Theory-Based Leaflet to Increase the Uptake of Flexible Sigmoidoscopy in the English Bowel Scope Screening Program: Results From a Randomized Controlled Trial in London

Background

We previously initiated a randomized controlled trial to test the effectiveness of two self-referral reminders and a theory-based leaflet (sent 12 and 24 months after the initial invitation) to increase participation within the English Bowel Scope Screening program.

Purpose

This study reports the results following the second reminder.

Methods

Men and women included in the initial sample (n = 1,383) were re-assessed for eligibility 24 months after their invitation (12 months after the first reminder) and excluded if they had attended screening, moved away, or died. Eligible adults received the same treatment they were allocated 12 months previous, that is, no reminder ("control"), or a self-referral reminder with either the standard information booklet ("Reminder and Standard Information Booklet") or theory-based leaflet designed using the Behavior Change Wheel ("Reminder and Theory-Based Leaflet"). The primary outcome was the proportion screened within each group 12 weeks after the second reminder.

Results

In total, 1,218 (88.1%) individuals were eligible. Additional uptake following the second reminder was 0.4% (2/460), 4.8% (19/399), and 7.9% (29/366) in the control, Reminder and Standard Information Booklet, and Reminder and Theory-Based Leaflet groups, respectively. When combined with the first reminder, the overall uptake for each group was 0.7% (3/461), 14.5% (67/461), and 21.5% (99/461). Overall uptake was significantly higher in the Reminder and Standard Information Booklet and Reminder and Theory-Based Leaflet groups than in the control (odds ratio [OR] = 26.1, 95% confidence interval [CI] = 8.1-84.0, p < .001 and OR = 46.9, 95% CI = 14.7-149.9, p < .001, respectively), and significantly higher in the Reminder and Theory-Based Leaflet group than in the Reminder and Standard Information Booklet group (OR = 1.8, 95% CI = 1.3-2.6, p < .001).

Conclusion

A second reminder increased uptake among former nonparticipants. The added value of the theory-based leaflet highlights a potential benefit to reviewing the current information booklet.

Trials Registry Number

ISRCTN44293755.

A Linguistic Analysis of Health Literacy Demands of Chronic Kidney Disease Patient Education Materials

Background:

Instruments to assess the quality and comprehensibility of printed patient education materials may lack proper consideration of how readers derive meaning from text. The Evaluative Linguistic Framework (ELF) considers how factors that influence readers' expectations about health care texts also affect their ability to understand them. The ELF has demonstrated value in improving the quality of patient materials about medication, consent, and self-reported questionnaires, but has not yet been used to evaluate a corpus of patient education materials about chronic disease self-management.

Objective:

This study sought to apply the ELF to examine specific elements of printed self-management patient education materials for chronic kidney disease (CKD) not captured by other tools.

Methods:

From a previously published systematic review, we identified 14 patient education materials (eight self-management, six diet and nutrition) for people with CKD. We used the ELF to identify the different ways the text could be structured, its intended purpose, the relationship established between reader and writer, presence of signposting, its complexity and technicality of language, and factual content.

Key Results:

Our analysis identified nine possible structural units, of which “introducing the problem” and “instructing the reader to self-manage” were common to all materials. However, there was no consistency or common sequence to these units of text. The intended readership and aims of the author(s) were not always clear; many materials made assumptions about what the reader knew, the language was often complex and dense, and the meta-discourse was sometimes distracting.

Conclusions:

Our analysis suggests CKD document developers can benefit from a theoretically grounded linguistic tool that focuses on the intended audience and their specific needs. The ELF identified structural units of text, aligned with rhetorical elements that can be uniformly applied for developing self-management education materials for CKD, and provided checks for language complexity. Further work can determine its usefulness for other (e.g., electronic) formats and other chronic diseases. [HLRP: Health Literacy Research and Practice. 2018;2(1):e1–e14.]

Plain Language Summary:

Helping patients make meaning from information about their condition is a key goal of health care organizations. We analyzed chronic kidney disease patient education materials on self-management using the Evaluative Linguistic Framework. The purpose and intended audience were frequently unclear. We identified nine structural units of text that may assist information providers to plan and structure content.

Informing Public Perceptions About Climate Change: A 'Mental Models' Approach

As the specter of climate change looms on the horizon, people will face complex decisions about whether to support climate change policies and how to cope with climate change impacts on their lives. Without some grasp of the relevant science, they may find it hard to make informed decisions. Climate experts therefore face the ethical need to effectively communicate to non-expert audiences. Unfortunately, climate experts may inadvertently violate the maxims of effective communication, which require sharing communications that are truthful, brief, relevant, clear, and tested for effectiveness. Here, we discuss the 'mental models' approach towards developing communications, which aims to help experts to meet the maxims of effective communications, and to better inform the judgments and decisions of non-expert audiences.

Men's information-seeking behavior regarding cancer risk and screening: A meta-narrative systematic review

OBJECTIVE

Preventive strategies are known to reduce cancer risk and incidence and improve prognosis. Men seldom seek medical information about cancer prevention and risk reduction. The aim of this meta-narrative systematic review was to critically appraise evidence from qualitative, quantitative, and mixed-methods studies that explored men's information-seeking behaviors in relation to cancer prevention and risk reduction.

METHODS

MEDLINE, CINAHL Plus with Full Text, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, Education Full Text, and ERIC were systematically searched for studies published in English between January 1, 2006 and May 30, 2016. A total of 4117 titles were identified; of which, 31 studies were included (21 qualitative studies, 9 quantitative studies, and 1 mixed-methods study). The methodological quality of the studies was appraised by using different tools.

RESULTS

Most studies focused on screening for prostate (n = 18) and colorectal cancer (n = 7). Most men were passive information-gatherers rather than active information-seekers. Key sources of information included the Internet for active information-seekers and health care professionals for passive information-gatherers. Barriers to information-seeking included information overload, embarrassment, and fear. Low literacy and health literacy levels were addressed in 3 studies and were identified as impediments to active information-seeking. Facilitators to information-seeking included family support, media, celebrity endorsements, and targeted information.

CONCLUSIONS

Men's information-seeking behavior regarding cancer risk reduction, prevention, and screening is influenced by several factors. This necessitates targeted interventions aimed at raising awareness of cancer prevention and screening, while accounting for men's informational needs, preferred learning strategies, and literacy levels.

Reducing the socioeconomic gradient in uptake of the NHS bowel cancer screening Programme using a simplified supplementary information leaflet: a cluster-randomised trial

BACKGROUND

Uptake of colorectal cancer screening is low in the English NHS Bowel Cancer Screening Programme (BCSP). Participation in screening is strongly associated with socioeconomic status. The aim of this study was to determine whether a supplementary leaflet providing the 'gist' of guaiac-based Faecal Occult Blood test (gFOBt) screening for colorectal cancer could reduce the socioeconomic status (SES) gradient in uptake in the English NHS BCSP.

METHODS

The trial was integrated within routine BCSP operations in November 2012. Using a cluster randomised controlled design all adults aged 59-74 years who were being routinely invited to complete the gFOBt were randomised based on day of invitation. The Index of Multiple Deprivation was used to create SES quintiles. The control group received the standard information booklet ('SI'). The intervention group received the SI booklet and the Gist leaflet ('SI + Gist') which had been designed to help people with lower literacy engage with the invitation. Blinding of hubs was not possible and invited subjects were not made aware of a comparator condition. The primary outcome was the gradient in uptake across IMD quintiles.

RESULTS

In November 2012, 163,525 individuals were allocated to either the 'SI' intervention (n = 79,104) or the 'SI + Gist' group (n = 84,421). Overall uptake was similar between the intervention and control groups (SI: 57.3% and SI + Gist: 57.6%; OR = 1.02, 95% CI: 0.92-1.13, p = 0.77). Uptake was 42.0% (SI) vs. 43.0% (SI + Gist) in the most deprived quintile and 65.6% vs. 65.8% in the least deprived quintile (interaction p = 0.48). The SES gradient in uptake was similar between the study groups within age, gender, hub and screening round sub-groups.

CONCLUSIONS

Providing supplementary simplified information in addition to the standard information booklet did not reduce the SES gradient in uptake in the NHS BCSP. The effectiveness of the Gist leaflet when used alone should be explored in future research.

TRIAL REGISTRATION

ISRCTN74121020 , registered: 17/20/2012.

Defining Research: The Effect of Linguistic Choices on the Intentions to Participate in Clinical Research

Significant barriers to participant recruitment for clinical research (CR) are related to effective communication, and nurse coordinators are entrusted with being knowledge brokers between investigators and prospective participants. This prospective cohort study sought to identify linguistic choices that could inform and facilitate recruitment efforts. Healthy adults ( N = 204) were invited to join an online survey to assess the likelihood of participation in CR based on short and extended definitions of CR. Five short definitions included clinical trial, clinical study, health-related research study, community participatory study, and quality improvement study. The likelihood of participation in CR was the lowest for clinical trial and the highest for health-related research study. However, when only an extended definition was provided, those differences were not observed. A linguistic change from trial to study could lead to positive attitude toward CR and improvements in recruitment. However, ethical implications of linguistic choices should be considered.

Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials

Background

Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.

Objective

To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.

Design

Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.

Methods

Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.

Results

The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.

Limitations

In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.

Conclusions

Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.

Future work

Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.

Trial registration

Current Controlled Trials ISRCTN74121020.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

Using the Evaluative Linguistic Framework for Questionnaires to Assess Comprehensibility of Self-Report Health Questionnaires

BACKGROUND

The Evaluative Linguistic Framework (ELF) was developed to judge the quality of health care texts for patients, based on systemic functional linguistic theory. This approach considers key variables such as context and structure, known to be important for communication.

OBJECTIVE

Our objective was to adapt the ELF to evaluate the quality of self-report questionnaires.

METHODS

We reviewed the Health Literacy Questionnaire using the ELF. On the basis of these data, we drafted the preliminary version of the Evaluative Linguistic Framework for Questionnaires (ELF-Q) and applied it to English- and French-language versions of two arthritis self-report questionnaires and to Spanish, Dutch, and Turkish versions of an arthritis questionnaire.

RESULTS

The developed ELF-Q was found to be effective for evaluating questionnaires in English and in four other languages. It contains nine items with new descriptions and assessment probes. These include overall organizational or generic structure of the questionnaire, metadiscourse (or text about the text), headings, rhetorical elements (function of each "move" or stage of the text in relation to the reader), the writer-reader relationship, technicality of vocabulary, lexical density (proportion of content words in the text), format, and overall judgment. We added assessment responses on a two- or three-point Likert scale to complement the assessment probes and make the intent and meaning of the probes fully explicit for the questionnaire developer or assessor.

CONCLUSIONS

The ELF-Q is a framework practical to use for the development or assessment of any type of self-report questionnaire. Its application can identify features of a self-report questionnaire that could be improved to optimize its comprehensibility.

Evaluation of an Australian health literacy training program for socially disadvantaged adults attending basic education classes: study protocol for a cluster randomised controlled trial

BACKGROUND

People with low literacy and low health literacy have poorer health outcomes. Literacy and health literacy are distinct but overlapping constructs that impact wellbeing. Interventions that target both could improve health outcomes.

METHODS/DESIGN

This is a cluster randomised controlled trial with a qualitative component. Participants are 300 adults enrolled in basic language, literacy and numeracy programs at adult education colleges across New South Wales, Australia. Each adult education institute (regional administrative centre) contributes (at least) two classes matched for student demographics, which may be at the same or different campuses. Classes (clusters) are randomly allocated to receive either the health literacy intervention (an 18-week program with health knowledge and skills embedded in language, literacy, and numeracy training (LLN)), or the standard Language Literacy and Numeracy (LLN) program (usual LLN classes, specifically excluding health content). The primary outcome is functional health literacy skills - knowing how to use a thermometer, and read and interpret food and medicine labels. The secondary outcomes are self-reported confidence, more advanced health literacy skills; shared decision making skills, patient activation, health knowledge and self-reported health behaviour. Data is collected at baseline, and immediately and 6 months post intervention. A sample of participating teachers, students, and community health workers will be interviewed in-depth about their experiences with the program to better understand implementation issues and to strengthen the potential for scaling up the program.

DISCUSSION

Outcomes will provide evidence regarding real-world implementation of a health literacy training program with health worker involvement in an Australian adult education setting. The evaluation trial will provide insight into translating and scaling up health literacy education for vulnerable populations with low literacy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000213448 .

The McMaster Optimal Aging Portal: Usability Evaluation of a Unique Evidence-Based Health Information Website

Background

Increasingly, older adults and their informal caregivers are using the Internet to search for health-related information. There is a proliferation of health information online, but the quality of this information varies, often based on exaggerated or dramatic findings, and not easily comprehended by consumers. The McMaster Optimal Aging Portal (Portal) was developed to provide Internet users with high-quality evidence about aging and address some of these current limitations of health information posted online. The Portal includes content for health professionals coming from three best-in-class resources (MacPLUS, Health Evidence, and Health Systems Evidence) and four types of content specifically prepared for the general public (Evidence Summaries, Web Resource Ratings, Blog Posts, and Twitter messages).

Objective

Our objectives were to share the findings of the usability evaluation of the Portal with particular focus on the content features for the general public and to inform designers of health information websites and online resources for older adults about key usability themes.

Methods

Data analysis included task performance during usability testing and qualitative content analyses of both the usability sessions and interviews to identify core themes.

Results

A total of 37 participants took part in 33 usability testing sessions and 21 focused interviews. Qualitative analysis revealed common themes regarding the Portal’s strengths and challenges to usability. The strengths of the website were related to credibility, applicability, browsing function, design, and accessibility. The usability challenges included reluctance to register, process of registering, searching, terminology, and technical features.

Conclusions

The study reinforced the importance of including end users during the development of this unique, dynamic, evidence-based health information website. The feedback was applied to iteratively improve website usability. Our findings can be applied by designers of health-related websites.

Views of People With High and Low Levels of Health Literacy About a Digital Intervention to Promote Physical Activity for Diabetes: A Qualitative Study in Five Countries

Background

Low health literacy is associated with poor health-related knowledge, illness self-management, health service use, health, and survival, and thus addressing issues related to low health literacy has been highlighted as a pressing international priority.

Objective

To explore views of a digital health promotion intervention designed to be accessible to people with lower levels of health literacy, in particular examining reactions to the interactive and audiovisual elements of the intervention.

Methods

Qualitative think-aloud interviews were carried out with 65 adults with type 2 diabetes in the UK, Ireland, USA, Germany, and Austria, with purposive sampling to ensure representation of people with lower levels of health literacy. Inductive thematic analysis was used to identify common themes. We then systematically compared views in subgroups based on country, health literacy level, age, gender, and time since diagnosis.

Results

Most participants from the chosen countries expressed positive views of most elements and features of the intervention. Some interactive and audiovisual elements required modification to increase their usability and perceived credibility and relevance. There were some differences in views based on age and gender, but very few differences relating to health literacy level or time since diagnosis.

Conclusions

In general, participants found the intervention content and format accessible, appropriate, engaging, and motivating. Digital interventions can and should be designed to be accessible and engaging for people with a wide range of health literacy levels.

The Effect of Chronological Age on the Acceptance of Internet-Based Hearing Health Care

PURPOSE

The purpose of this article is to offer design considerations in developing Internet-based hearing health care for older adults by analyzing and discussing the relationship between chronological age, computer skills, and the acceptance of Internet-based hearing health care.

METHOD

This article reports baseline data from a training study measuring the acceptance of Internet-based hearing health care. Participants (n = 26; 20 men, 6 women) were aged 55–95 years. All passed a cognitive screen and failed a hearing screen. Participants completed the Patient- Technology Acceptance questionnaire (Or, 2008). Computer literacy was measured using the Northstar Digital Literacy Assessment (Cytron-Hysom, Hadley, Vanek, Graif, & Asp, 2012).

RESULTS

Computer literacy was negatively correlated with increasing age. Additional negative relationships were seen between computer literacy and computer anxiety and between computer literacy and computer self-efficacy. Finally, there was a negative relationship between computer self-efficacy and computer anxiety.

CONCLUSION

These results suggest computer literacy is lower in adults of advanced age than in those who are a few years younger. Indirect relationships were observed between age and computer self-efficacy and between age and computer anxiety. Consideration should be given to addressing discrepancies in self-efficacy and computer literacy in older adults to increase the likelihood of acceptance of Internet-based hearing health care.

The Influence of Health Literacy and Patient Activation on Patient Information Seeking and Sharing

This study provided an assessment of how patients looked for information to prepare for a clinical appointment and whether they shared those findings with their provider. A cross-sectional survey allowed insight into patient attitudes, motivations, and behavior in clinical real time. At two hospital-based clinics, 243 patients completed surveys before and after clinical appointments. Younger patients with higher communicative and critical health literacy prepared for clinical appointments with information searches. The predicted association of health literacy and patient activation with information sharing was not supported. This study shows that patients with higher patient activation perceived that their providers responded more positively to patient-obtained medical information. The role of critical health literacy may show that individuals choosing to seek information are considering not just their ability to conduct the search but also their ability to synthesize and critically analyze the results of the information search. An implication for providers is to become skilled in directly asking or passively surveying what outside information sources the patient has engaged with, no matter if the patient does or does not introduce the information.

Effects of Health Literacy and Social Capital on Health Information Behavior

This study aimed to examine whether social capital (bonding and bridging social capital) attenuate the effect of low functional health literacy on health information resources, efficacy, and behaviors. In-person interviews were conducted with 1,000 residents in Seoul, Korea, in 2011. The authors found that respondents' functional health literacy had positive effects on the scope of health information sources and health information self-efficacy but not health information-seeking intention. Respondents' social capital had positive effects on the scope of health information sources, health information efficacy, and health information-seeking intention. The authors found (a) a significant moderation effect of bridging social capital on the relation between health literacy and health information self-efficacy and (b) a moderation effect of bonding social capital on the relation between health literacy and health information-seeking intention.

Informed choice in bowel cancer screening: a qualitative study to explore how adults with lower education use decision aids

BACKGROUND

Offering informed choice in screening is increasingly advocated, but little is known about how evidence-based information about the benefits and harms of screening influences understanding and participation in screening.

OBJECTIVE

We aimed to explore how a bowel cancer screening decision aid influenced decision making and screening behaviour among adults with lower education and literacy.

METHODS

Twenty-one men and women aged 55-64 years with lower education levels were interviewed about using a decision aid to make their screening decision. Participants were purposively selected to include those who had and had not made an informed choice.

RESULTS

Understanding the purpose of the decision aid was an important factor in whether participants made an informed choice about screening. Participants varied in how they understood and integrated quantitative risk information about the benefits and harms of screening into their decision making; some read it carefully and used it to justify their screening decision, whereas others dismissed it because they were sceptical of it or lacked confidence in their own numeracy ability. Participants' prior knowledge and beliefs about screening influenced how they made sense of the information.

DISCUSSION AND CONCLUSIONS

Participants valued information that offered them a choice in a non-directive way, but were concerned that it would deter people from screening. Healthcare providers need to be aware that people respond to screening information in diverse ways involving a range of literacy skills and cognitive processes.

Factors Associated with Informed Decisions and Participation in Bowel Cancer Screening among Adults with Lower Education and Literacy

Background. Making informed decisions about cancer screening involves understanding the benefits and harms in conjunction with personal values. There is little research examining factors associated with informed decision making or participation in screening in the context of a decision aid trial. Objectives. To identify factors associated with informed choice and participation in fecal occult blood testing (FOBT) among lower education populations. Design. Randomized controlled trial of an FOBT decision aid conducted between July and November 2008. Setting. Socioeconomically disadvantaged areas in New South Wales, Australia. Participants. Included 572 adults aged 55 to 64 years with lower education. Measurements. Sociodemographic variables, perceived health literacy, and involvement preferences in decision making were examined to identify predictors of informed choice (knowledge, attitudes, and behavior). Results. Multivariate analysis identified independent predictors of making an informed choice as having higher education (relative risk [RR], 1.49; 95% confidence interval [CI], 1.13–1.95; P = 0.001), receiving the decision aid (RR, 2.88; 95% CI, 1.87–4.44; P < 0.001), and being male (RR, 1.48; 95% CI, 1.11–1.97; P = 0.009). Participants with no confidence in completing forms and poorer self-reported health were less likely to make an informed choice (RR, 0.74; 95% CI, 0.53–1.03; P = 0.05 and RR, 0.57; 95% CI, 0.36–0.89; P = 0.007, respectively). Independent predictors of completing the FOBT were positive screening attitudes, receiving the standard information, preference for making the decision alone, and knowing that screening may lead to false-positive/negative results. Limitations. We did not objectively measure health literacy. Conclusions. Participants with the lowest levels of education had greater difficulties making an informed choice about participation in bowel screening. Alternative methods are needed to support informed decision making among lower education populations.

The development and testing of a brief ('gist-based') supplementary colorectal cancer screening information leaflet

OBJECTIVE

To design and user-test a 'gist-based' colorectal cancer screening information leaflet, which promotes comprehension of the screening offer.

METHODS

Twenty-eight individuals approaching screening age were recruited from organisations in deprived areas of England. Using a between-subjects design, we tested iterations of a newly-designed gist-based information leaflet. Participants read the leaflet and answered 8 'true' or 'false' comprehension statements. For the leaflet to be considered fit-for-purpose, all statements had to be answered correctly by at least 80% of participants in each round. Alterations were made if this threshold was not met and additional rounds of testing were undertaken.

RESULTS

At round 1, answers to 2/8 statements did not meet the threshold. After changes, answers in round 2 did not reach the threshold for 1/8 statements. In round 3, all answers were adequate and the leaflet was deemed fit-for-purpose. Qualitative data offered solutions such as language and layout changes which led to improved comprehension of the leaflet.

CONCLUSION

User-testing substantially improved the design and subsequent comprehensibility of a theory-driven gist-based colorectal cancer screening information leaflet.

PRACTICAL IMPLICATIONS

This leaflet will be evaluated as part of a large national randomised controlled trial designed to reduce socioeconomic inequalities in colorectal cancer screening participation.

Addressing health literacy in patient decision aids

Background

Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:

1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and

2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.

Methods

We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.

Results

Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.

Conclusion

Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

How do people interpret information about colorectal cancer screening: observations from a think-aloud study

Background

The English NHS Bowel Cancer Screening Programme biennially invites individuals aged 60–74 to participate in screening. The booklet, ‘Bowel Cancer Screening: The Facts' accompanies this invitation. Its primary aim is to inform potential participants about the aims, advantages and disadvantages of colorectal cancer screening.

Objective

To provide detailed commentary on how individuals process the information contained within ‘The Facts’ booklet.

Design, setting and participants

This study comprised of 18 interviews with individuals aged 45–60 and used a ‘think‐aloud’ paradigm in which participants read aloud the booklet. Participant utterances (verbal statements made in response to researcher‐led prompts) were transcribed and analysed using a combination of content and thematic analysis.

Results

A total of 776 coded utterances were analysed (mean = 43.1 per person; range = 8–95). While overall comprehension was satisfactory, several problem areas were identified such as the use of complex unfamiliar terminology and the presentation of numerical information. Specific sections such as colonoscopy risk information evoked negative emotional responses. Participants made several suggestions for ways in which comprehension might be improved.

Conclusion

Public perceptions of the NHS Bowel Cancer Screening Programme information materials indicated that specific aspects of the booklet were difficult to process. These materials may be an appropriate target to improve public understanding of the aims, benefits and disadvantages of colorectal cancer screening. These findings will contribute to a broader NIHR‐funded project that aims to design a supplementary ‘gist‐based’ information leaflet suitable for low literacy populations.

Insights into the concept and measurement of health literacy from a study of shared decision-making in a low literacy population

This article explores the concept and measurement of health literacy in the context of shared health decision-making. It draws upon a series of qualitative and quantitative studies undertaken in the development and evaluation of a bowel cancer screening decision aid for low literacy populations. The findings indicate that different types of health literacy (functional, interactive and critical) are required in decision-making and present a set of instruments to assess and discriminate between higher level health literacy skills required for engagement in decision-making. It concludes that greater sophistication in both the definition and measurement of health literacy in research is needed.

Access to information and expectations of treatment decisions for prostate cancer patients--results of a European survey

We surveyed patients in France, Germany, Italy, Spain and Poland to examine information requirements and expectations of patients with prostate cancer. Patients were identified via their healthcare teams or via existing databases and interviewed by telephone, or in face-to-face interviews (Italy). Survey questions were either multiple choice or rank-based, and additional information was available to assist patient comprehension. Overall, 80% of patients received information about prostate cancer at diagnosis and 76% rated their physician as the most useful information source. However, around a third of French and German patients did not receive any information about their condition at diagnosis, compared with 8%, 12% and 10% of Spanish, Italian and Polish patients, respectively. Most patients rated the information they received as 'very informative', but there were regional variations, with German patients being the least satisfied with the quality of information received. Despite receiving the least amount of information at diagnosis, more patients from France and Germany preferred to be involved in treatment decisions than patients from Spain, Italy and Poland. Results from this survey highlight important gaps in information provision for patients with prostate cancer in terms of information supplied and patient expectations regarding treatment decisions.

A theoretical framework for measuring knowledge in screening decision aid trials

OBJECTIVE

To describe a theoretical framework for assessing knowledge about the possible outcomes of participating in bowel cancer screening for the faecal occult blood test.

METHODS

The content of the knowledge measure was based on the UK General Medical Council's screening guidelines and a theory-based approach to assessing gist knowledge (Fuzzy Trace Theory). It comprised conceptual and numeric questions to assess knowledge of the underlying construct (e.g. false positive concept) and the approximate numbers affected (e.g. likelihood of a false positive). The measure was used in a randomised controlled trial involving 530 adults with low education, to compare the impact of a bowel screening decision aid with a screening information booklet developed for the Australian Government National Bowel Cancer Screening Program.

RESULTS

The numeric knowledge scale was particularly responsive to the effects of the decision aid; at follow-up decision aid participants' numeric knowledge was significantly greater than the controls (P<0.001). This contrasts with the conceptual knowledge scale which improved significantly in both groups from baseline to follow-up (P<0.001).

CONCLUSION

Our theory-based knowledge measure was responsive to change in conceptual knowledge and to the effect on numeric knowledge of a decision aid.

PRACTICE IMPLICATIONS

This theoretical framework has the potential to guide the development of knowledge measures in other screening settings.

Colorectal cancer screening behavior and willingness

The outpatient-based study by Deng et al [World J Gastroenterol 2011 July 14; 17(26): 3133-3139] on the factors that may influence the colorectal cancer (CRC) screening feasibility, encouraged our curiosity. Establishing a simple method for quickly assessing the educational level of patients and modulating a questionnaire for each type of patient, may be an effective protocol to increase the people participation, mainly in countries where sufficient medical resources and financial support are lacking. In fact, the knowledge directly affects the feasibility when screening is offered. Patient educational level influences the understanding of the knowledge and the screening method. This factor may affect patient’s priority level on the study participation, the understanding of questions, and the motivation to complete the questionnaire and, consequently, the screening success. Recent studies have found a relationship between high educational level and CRC screening participation, and emphasized the questionnaire ineffectiveness in the illiterate people. Although the questionnaire is an excellent method for this kind of evaluation, physician’s contribution could be the most important factor associated with the screening method. Thus, further studies should be conducted to explore the compliance of patients with low educational level and to look for the best solutions for their enrollment.

Community desires for an online health information strategy

OBJECTIVE

To determine whether the community's attitudes to components of a community eHealth strategy differ across three different socioeconomic groups.

DESIGN

A survey questionnaire was designed and implemented across three different communities.

PARTICIPANTS AND SETTING

Paper-based surveys were left in community organisations and local health practices in a low socioeconomic community on the outskirts of Ipswich, Queensland (n = 262), a mid-high socioeconomic community in the western suburbs of Brisbane (n = 256) and at a local university (n = 200).

MAIN OUTCOME MEASURES

Ascribed importance and comfort with proposed components of a community eHealth strategy.

RESULTS

A community-oriented health website was perceived as useful in getting access to relevant health information. Those who were most comfortable with accessing online health information were those who were: experienced, had home internet access and were frequent internet users. The most important types of health information for the website were: information about the treatment of conditions, how to manage a chronic illness, how to stay healthy and patient clinical pathways. The low socioeconomic community had different information priorities – all categories were considered more important, particularly information about how the public system operates, local health support groups, and the roles of health professionals.

CONCLUSIONS

Different communities have different information demands but there is a strong demand for information which empowers community members to take control of their own health and become active participants in their health care. Tools such as a community health portal and patient clinical pathways should become more available.

Investing in deliberation: a definition and classification of decision support interventions for people facing difficult health decisions

This article provides an analysis of 'decision aids', interventions to support patients facing tough decisions. Interest has increased since the concept of shared decision making has become widely considered to be a means of achieving desirable clinical outcomes. We consider the aims of these interventions and examine assumptions about their use. We propose three categories, interventions that are used in face-to-face encounters, those designed for use outside clinical encounters and those which are mediated, using telephone or other communication media. We propose the following definition: decision support interventions help people think about choices they face; they describe where and why choice exists; they provide information about options, including, where reasonable, the option of taking no action. These interventions help people to deliberate, independently or in collaboration with others, about options, by considering relevantattributes; they support people to forecast how they might feel about short, intermediate and long-term outcomes which have relevant consequences, in ways which help the process of constructing preferences and eventual decision making, appropriate to their individual situation. Although quality standards have been published for these interventions, we are also cautious about premature closure and consider that the need for short versions for use inside clinical encounters and long versions for external use requires further research. More work is also needed on the use of narrative formats and the translation of theory into practical designs. The interest in decision support interventions for patients heralds a transformation in clinical practice although many important areas remain unresolved.

A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial

OBJECTIVE

To determine whether a decision aid designed for adults with low education and literacy can support informed choice and involvement in decisions about screening for bowel cancer.

DESIGN

Randomised controlled trial.

SETTING

Areas in New South Wales, Australia identified as socioeconomically disadvantaged (low education attainment, high unemployment, and unskilled occupations).

PARTICIPANTS

572 adults aged between 55 and 64 with low educational attainment, eligible for bowel cancer screening.

INTERVENTION

Patient decision aid comprising a paper based interactive booklet (with and without a question prompt list) and a DVD, presenting quantitative risk information on the possible outcomes of screening using faecal occult blood testing compared with no testing. The control group received standard information developed for the Australian national bowel screening programme. All materials and a faecal occult blood test kit were posted directly to people's homes.

MAIN OUTCOME MEASURES

Informed choice (adequate knowledge and consistency between attitudes and screening behaviour) and preferences for involvement in screening decisions.

RESULTS

Participants who received the decision aid showed higher levels of knowledge than the controls; the mean score (maximum score 12) for the decision aid group was 6.50 (95% confidence interval 6.15 to 6.84) and for the control group was 4.10 (3.85 to 4.36; P<0.001). Attitudes towards screening were less positive in the decision aid group, with 51% of the participants expressing favourable attitudes compared with 65% of participants in the control group (14% difference, 95% confidence interval 5% to 23%; P=0.002). The participation rate for screening was reduced in the decision aid group: completion of faecal occult blood testing was 59% v 75% in the control group (16% difference, 8% to 24%; P=0.001). The decision aid increased the proportion of participants who made an informed choice, from 12% in the control group to 34% in the decision aid group (22% difference, 15% to 29%; P<0.001). More participants in the decision aid group had no decisional conflict about the screening decision compared with the controls (51% v 38%; P=0.02). The groups did not differ for general anxiety or worry about bowel cancer.

CONCLUSIONS

Tailored decision support information can be effective in supporting informed choices and greater involvement in decisions about faecal occult blood testing among adults with low levels of education, without increasing anxiety or worry about developing bowel cancer. Using a decision aid to make an informed choice may, however, lead to lower uptake of screening. Trial registration ClinicalTrials.gov NCT00765869 and Australian New Zealand Clinical Trials Registry 12608000011381.