Gender differences in the impact of health literacy on hospital readmission among older heart failure patients: A prospective cohort study

Barriers and Facilitators to Implementing a Nurse-Led Information System for Older Adult Patients' Post-Discharge Self-Care: An Exploratory Sequential Mixed-Methods Study

AIM

To explore determinants impacting an Electronic Health Record-based information system implementation and their association with implementation fidelity based on the Theoretical Domains Framework (TDF) from nurses' perspectives.

DESIGN

Exploratory sequential mixed-method design.

METHODS

In stage one, semi-structured interviews with 53 purposively selected nurses informed the exploration of TDF domains influencing the implementation of the information system with directed content analysis. In stage two, a cross-sectional survey, informed by the qualitative findings, was conducted among 482 nurses to identify the most relevant and relatively important TDF domains by running generalised linear regression models.

RESULTS

The qualitative interviews generated 13 TDF domains that were identified as major influencing factors, including technology characteristics, knowledge, attitudes, role agreement, self-efficacy, goal-setting, information circulation, and communication among nurses. Quantitative findings showed that 70% of nurses used and printed the written form through the information system, and only 34% offered verbal education consistently. Regression analysis identified nine domains that were relevant and important factors for implementation fidelity, including knowledge, skills, role identity, beliefs in consequences, beliefs in capabilities, intentions, goals, memory and decision processes, and environmental context.

CONCLUSION

Our findings confirmed previous evidence on determinants of implementing digital health technologies, including knowledge, competencies, perceived effectiveness, role agreement, intentions, decision processes, and environmental context. Additionally, we highlighted the importance of goal-setting for successful implementation.

IMPACT

This study investigated the relatively important associated factors that can impact the successful implementation of the nurse-led information system for post-acute care based on nurses' perspectives. These results can guide nurse practitioners in implementing similar initiatives and support evidence-based decision-making. Researchers can also further investigate the relationships between the identified determinants.

REPORTING METHOD

Journal Article Reporting Standards for Mixed Methods Research.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Relationship Between Perceived Social Support and Physical Frailty Among Older Patients with Coronary Artery Disease: A Dual Mediation Model

Background: Physical frailty is common among older patients with coronary artery disease (CAD) and is influenced by perceived social support, health literacy, and a sedentary lifestyle. This study examined the dual mediating roles of health literacy and a sedentary lifestyle in the relationship between perceived social support and physical frailty in older patients with CAD. Methods: This cross-sectional study included data collected from 182 older patients with CAD at a general hospital in Korea between June 2022 and January 2023. Participants completed self-reported questionnaires measuring the main variables and demographic information. Clinical data were obtained from electronic medical records. Results: The mediation hypothesis was tested using a dual mediation model with the PROCESS macro (Model 6) and 95% bias-corrected bootstrap confidence intervals. Perceived social support indirectly influenced physical frailty through three pathways: health literacy alone, sedentary lifestyle alone, and a sequential process in which health literacy influenced sedentary lifestyle and ultimately physical frailty. Conclusions: This study identified a strong mediating effect of health literacy and a sedentary lifestyle on the relationship between perceived social support and physical frailty. A built environment of perceived social support among older patients with CAD improves health literacy, modifies sedentary lifestyles, and helps prevent physical frailty. Thus, healthcare professionals should evaluate the perceived social support, health literacy, and sedentary lifestyle of older patients when developing physical frailty prevention programs.

Validity of patient-reported information: agreement rate between patient reports and registry data

BACKGROUND

The accuracy of patient-reported clinical information, including cancer stage, is not well understood. This study aims to evaluate the agreement between patient-reported survey data and clinical information recorded in hospital-based cancer registries (HBCR).

METHODS

A total of 730 patients from 166 hospitals in Japan were randomly selected and informed that their survey responses would be validated against HBCR data. Demographic details, including age, sex, cancer stage, and cancer site, were recorded and compared with clinical data from the HBCR. Agreement rates between patients' self-reported demographic and clinical data and the corresponding HBCR records were analyzed. Logistic regression analysis was conducted to identify factors associated with accurate reporting of cancer stage information.

RESULTS

Agreement rates for age, sex, and cancer site were 99.4%, 99.8%, and over 90% across all cancer sites, respectively. The agreement rate for cancer stage reporting was 49.9%. Patients with stage IV cancer had the highest agreement rate at 68.4%. Patients under 75 years of age and those with specific cancer types demonstrated higher odds of reporting data consistent with HBCR records.

CONCLUSIONS

For cancer stage data, relying on more credible sources, such as cancer registries, is recommended over patient-reported information to ensure accuracy.

Influence of Health Literacy on Physical Activity and Sedentary Behaviors in Older Patients with Coronary Artery Disease

BACKGROUND

Coronary artery disease is a chronic condition that requires continuous adherence to healthy behaviors. Adhering to physical activity and reducing prolonged sedentary behavior are important for the physical health of older patients with coronary artery disease (CAD). Health literacy is increasingly recognized as a key factor in secondary prevention for these patients. However, evidence regarding the associations among health literacy, physical activity, and sedentary behaviors for secondary prevention in older patients with coronary artery disease remains limited.

OBJECTIVES

This study aimed to identify the prevalence of limited health literacy and the influence of health literacy on physical activity and sedentary behaviors in older patients with CAD.

METHODS

This study was a descriptive cross-sectional study conducted from May to December 2022 in South Korea. A total of 186 patients aged 65 and older diagnosed with coronary artery disease participated. Data on health literacy, physical activity, and sedentary behaviors were collected through self-reported questionnaires and electronic medical records.

RESULTS

The prevalence of limited health literacy in older patients was 66.7%. Hierarchical linear regression revealed that health literacy was a significant determinant of physical activity (β = -0.50, P < .001) and sedentary behaviors (β = 0.58, P < .001) after adjusting for confounding variables.

CONCLUSIONS

Our main findings showed that health literacy can facilitate improvements in physical activity and sedentary behaviors. Health literacy can facilitate health decisions for secondary prevention in older patients with CAD. Thus, healthcare professionals should assess patient health literacy and illness severity when designing secondary prevention programs.

[Chronic Heart Failure: Focus on Differences Between Men and Women]

This review focuses on the sex-related differences of patients in etiological factors, clinical picture, and objective laboratory and instrumental signs of heart failure. The authors performed an analysis of the effectiveness of drug and non-drug treatments depending on the gender of patients with low and preserved left ventricular ejection fraction, which should improve the quality of medical care and outcomes in patients with heart failure.

Effect of health literacy on hospital readmission among patients with heart failure: A protocol for systematic review and meta-analysis

BACKGROUND

Patients with heart failure have a high rate of health literacy deficiency, and their hospital readmission is a great burden. Whether health literacy affects hospital readmission remains controversial.

OBJECTIVE

To investigate the impact of health literacy on hospital readmission among heart failure patients.

METHOD

Relevant keywords were used to search for Chinese and English literature from Web of Science, PubMed, Cochrane Library, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, Digital Journal of Wanfang Data, and Chinese BioMedical Literature Database. Newcastle-Ottawa Scale was used to assess the quality of the studies. Statistical analysis was performed using Stata 15.0, the fixed effect model was used to calculate the pooled effect estimate, and Begg's and Egger's tests were applied to assess the presence of publication bias.

RESULTS

Nine studies, involving 4093 heart failure patients, were included in this study. The overall rate of inadequate health literacy was 40.3%. Among these articles, 6 were included in the meta-analysis to calculate the pooled effect. The results indicated that, when compared with patients with adequate health literacy, those with inadequate health literacy had a relative risk of hospital readmission of 1.01, which increased to 1.14 after adjusting for follow-up time, the result was not significant (P = .09).

CONCLUSIONS

About 2 out of 5 heart failure patients had inadequate health literacy, and there was no statistical association between health literacy and hospital readmission among these patients. This finding should be carefully considered and confirmed in further studies.

Association between health literacy and Framingham risk score

High health literacy (HL) plays a critical role in preventing or delaying the onset of cardiovascular diseases (CVDs) and can improve disease management and control. The present study aims to determine the association between HL and non-laboratory-based (office-based) Framingham 10-year risk score of CVD. This cross-sectional study was conducted on 648 people aged 30-65 in the health centers of Jahrom. The Health Literacy Instrument for Adults (HELIA) was used to assess HL. The non-laboratory-based Framingham risk score (FRS) was utilized to determine the 10-year risk of CVDs. Risk factors such as age, gender, diabetes, current smoking status, systolic blood pressure (SBP), hypertension (HTN) treatment, and body mass index (BMI) were applied in the non-laboratory-based model. The average age of the subjects was 44.7 ± 10.5 years, among which 49.2% were males. The prevalence of diabetes, HTN, and smoking equaled 8.5%, 15.7%, and 10%, respectively. In addition, the average BMI was 26.1 ± 3.6 kg/m2. Based on the non-laboratory-based Framingham 10-year risk score of CVD, 72.5%, 13.9%, and 13.6% of the subjects were in the low, moderate, and high risk groups, respectively. Based on the HL grouping, the levels of insufficient, borderline, sufficient, and excellent HL were 19.3%, 26.4%, 34.6%, and 19.7%, respectively. A significant association was observed between 10-year CVD risk and HL grouping. In addition, a negative correlation was reported at the individual level between HL and non-laboratory-based FRS among the whole population (r = - 0.39, p < 0.001), men (r = - 0.32, p < 0.001), and women (r = - 0.42, p < 0.001). A higher HL score is associated with a lower risk of CVD. In addition, the adjusted logistic regression analysis showed that there was a strong association between elevated CVD risk (≥ 10%) and HL (OR 6.1, 95% CI 2.9-12.6) among inadequate HL participants compared with excellent HL individuals. Thus, designing and implementing training programs to increase HL, especially among those who are at risk of CVDs, should be regarded as an important issue for the prevention of such diseases.

Factors associated with poor health literacy in older adults: A systematic review

OBJECTIVES

To identify factors associated with poor health literacy in older adults.

METHODS

A systematic literature review was conducted, employing the descriptors "Aged" and "Health Literacy".

PROSPERO - CRD

42022350140.

RESULTS

Out of 23,500 articles screened, 176 were selected. Several factors associated with poor health literacy in older adults were identified, such as sociodemographic (e.g., advanced age, low educational level, non-white population, and others), social (e.g., poor family/social support, loneliness, social isolation, few social activities, and others), economic (e.g., lower income and/or lower socioeconomic status) and health aspects (e.g., poor health, chronic conditions, mental health challenges, hospitalizations, frailty, physical inactivity, cognitive impairment, and others).

CONCLUSIONS

The factors associated with poor health literacy in older adults identified in this review could contribute to future research, support interventions to improve health literacy, and assist professionals in planning educational activities and public policies.

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

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

One-year trajectories of self-care behaviours and unplanned hospital readmissions among patients with heart failure: A prospective longitudinal study

AIM AND OBJECTIVES

This study aimed to identify the associations between longitudinal trajectories of self-care behaviours and unplanned hospital readmissions in patients with heart failure.

BACKGROUND

Adherence to self-care behaviours is crucial to prevent hospital readmissions; however, self-care behaviours remain unsatisfactory among patients with heart failure. Studies of long-term trajectories of self-care behaviours and their influence on hospital readmissions are limited in this population.

DESIGN

A prospective, longitudinal observational study.

METHODS

Among 137 participants with heart failure (mean age 67.36 years, 62% men), we analysed the 1-year follow-up data to determine the association between 1-year trajectories of self-care behaviours and hospital readmissions using Kaplan-Meier analysis and multivariable Cox regression, adjusted for confounding variables.

RESULTS

Self-care behaviour trajectories of heart failure patients were classified as 'high-stable' (58.4%) or 'low-sustained' (41.6%). The cumulative rate of readmissions for the low-sustained class was higher than that of the high-stable class for all periods. Factors influencing readmissions included anaemia, cognitive function, frailty and self-care behaviours trajectories. The low-sustained class had a 2.77 times higher risk of readmissions within 1 year than that in the high-stable class.

CONCLUSIONS

Longitudinal self-care behaviours pattern trajectories of heart failure patients were stratified as high-stable and low-sustained. Routine follow-up assessment of patients' self-care behavioural patterns, including anaemia and frailty, and cognitive function can minimise unplanned hospital readmissions.

RELEVANCE TO CLINICAL PRACTICE

Identification of trajectory patterns of self-care behaviours over time and provision of timely and individualised care can reduce readmissions for heart failure patients. Healthcare professionals should recognise the significance of developing tailored strategies incorporating longitudinal self-care behavioural patterns in heart failure patients.

REPORTING METHOD

The study has been reported in accordance with the STROBE checklist (Appendix S1).

PATIENT OR PUBLIC CONTRIBUTION

Patients have completed a self-reported questionnaire after providing informed consent.

Health Literacy and Serious or Persistent Mental Illness: A Mixed Methods Study

BACKGROUND

Health literacy is increasingly recognized as a major determinant of health; however, our insights into the health literacy strengths and needs of adults living with serious or persistent mental illness remain limited by a notable lack of research in this area. Improving our understanding is important because people in this group are especially vulnerable to numerous negative health outcomes, many preventable.

OBJECTIVE

To assess the health literacy strengths and needs of people living with serious or persistent mental illness in terms of their ability to acquire, understand, and use information about their illness and the health services they require.

METHODS

A cross-sectional convergent mixed methods design guided by the Ophelia Access and Equity Framework. People diagnosed with serious or persistent mental illness were offered participation. Quantitative and qualitative data was collected using questionnaires (Health Literacy Questionnaire [HLQ], World Health Organization [WHO-5]) and semi-structured interviews. Hierarchical cluster analysis identified and grouped participants with similar health literacy scores into mutually exclusive groups, for the development of clinical vignettes.

KEY RESULTS

Participants struggled most with the appraisal of health information (HLQ mean 2.72, standard deviation [SD] .63 [scale 1-4]) and navigating what they often perceived to be a confusing health care system (HLQ mean 3.29, SD .79 [scale 1-5]). On the other hand, most participants reported positive experiences with their health care providers (HLQ mean 3.19, SD .62 [scale 1-4]) and generally felt understood and supported. The cluster analysis suggests we should not assume people living with serious or persistent mental illness have homogeneous HL strengths and needs, meaning a one-size-fits-all solution for improving health literacy in this diverse group will likely not be a successful strategy. It will be important to explore solutions that embrace patient-centered care approaches.

CONCLUSIONS

This study is one of only a handful assessing the health literacy strengths and needs of people living with serious or persistent mental illness. By collecting both quantitative and qualitative data, then analyzing the results using sophisticated cluster analysis methods, the authors were able to develop clinical vignettes per the Ophelia Framework that offer results in a practical way that can be readily understood and acted upon by stakeholders. We found that the HLQ is a measure of HL that is acceptable to mental health clients, and our findings provide preliminary data on the use of this instrument in the mental health population. [HLRP: Health Literacy Research and Practice. 2023;7(1):e2-e13.] Plain Language Summary: This study explored the health literacy strengths and needs of people living with serious or persistent mental illness. The results showed a mix of strengths and needs among our participants, though several consistent themes emerged. Most of our participants felt understood and supported by their health care providers, but many often struggle with judging the quality of health information and finding their way through the health care system.

Health literacy and quality of life of patients with coronary heart disease in Tibet, China: The mediating role of self-efficacy and self-management

BACKGROUND

The disease burden of coronary heart disease patients in Tibet, China, ranks high in the country. Due to the local culture and environment, patients with coronary heart disease have increased risk factors for the disease, and their survival is worrisome.

OBJECTIVES

The purpose of this study was to determine the relationship between health literacy and quality of life for patients with coronary heart disease in Tibet, China, and to explore the mediating roles of self-efficacy and self-management.

METHODS

A cross-sectional study was conducted from August 2020 to July 2021 in Tibet. A total of 258 patients with coronary heart disease in Tibet participated. Self-reported questionnaires were used to assess health literacy, self-efficacy, self-management, and quality of life. Pearson correlation analysis and the SPSS PROCESS macro were used to analyze the data.

RESULTS

The mean total score for the health literacy of patients with coronary heart disease in Tibet was 3.59 ± 0.80 points, showing the existence of a limited level of literacy. The quality of life was of an average level, with scores of 57.20 ± 21.70 points and 63.63 ± 20.66 points for physical and mental status, respectively. Self-efficacy and self-management mediated the relationship between health literacy and quality of life.

CONCLUSIONS

Self-efficacy and self-management mediate the relationship between health literacy and quality of life. Targeted interventions for health literacy, self-efficacy, and self-management skills are important to improve the quality of life of Tibetan patients with coronary heart disease.

Gender differences in factors associated with the health literacy of hospitalized older patients with chronic diseases: A cross-sectional study

Background

To identify gender differences in factors associated with the health literacy of hospitalized older patients with chronic diseases.

Methods

A total of 471 hospitalized older patients with chronic diseases in four hospitals were investigated from May 2019 to June 2020. The self-developed demographic information questionnaire, the "Health Literacy Scale for Patients with Chronic Diseases" and the "Self-Efficacy for Managing Chronic Diseases 6-item Scale" were applied in this study. Multiple linear regression was used to assess the factors influencing health literacy among older patients with chronic diseases by gender.

Results

The factors influencing health literacy differed by gender. Male health literacy was related to education background, number of children, monthly income, duration of chronic disease and chronic disease self-efficacy. For females, health literacy was associated with age, education background, monthly income, duration of chronic disease and chronic disease treatment.

Conclusion

Healthcare providers should focus on the above-mentioned factors that could help identify those with low health literacy differ base on gender. Gender-specific strategies should be developed to improve the health literacy of older patients with chronic diseases and strengthen their chronic disease management.

Impact of health literacy in patients with cardiovascular diseases: A systematic review and meta-analysis

OBJECTIVE

To clarify the impacts of health literacy on mortality, readmission, and quality of life (QOL) in the secondary or tertiary prevention of cardiovascular diseases (CVD) through a meta-analysis.

METHODS

Six electronic databases were searched on June 11, 2020. Observational studies involving patients with CVD, health literacy as an exposure factor and mortality, readmission, or QOL as outcomes were included in this study. Two researchers screened the retrieved articles and extracted data independently. The meta-analysis calculated the pooled relative risk of mortality and readmission. We also assessed the body of evidence based on Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Following screening of 1616 studies, 16 observational studies were included. The mean rate of low health literacy was 32.8%. All studies focusing on QOL showed significant impacts of health literacy. Pooled relative risk was 1.621 (95% confidence interval: 1.089-2.412) for mortality and 1.184 (95% confidence interval: 1.035-1.355) for readmission, indicating significant effects of health literacy. GRADE assessment showed "LOW" certainty for each outcome.

CONCLUSION

Low health literacy was significantly associated with increased mortality and hospital readmission and decreased QOL in patients with CVD.

PRACTICE IMPLICATIONS

Considering low health literacy in clinical practice is very important to improve prognosis of CVD patients.

Scoping review: Influence of cisgender male and female genders on health literacy of the elderly people

This scoping review mapped out the relevant literature, identified gaps and made suggestions on the influence of cisgender on the health literacy (HL) of the elderly people. This scoping review was guided by the PRISMA-ScR checklist. The databases Wiley Online Library™ and Elsevier™ were searched for academic articles published in the English language between February 2011 and February 2021 that met a pre-set criteria of content. The process of selection of sources of evidence based on screening and eligibility of evidence reduced the initially identified 153 sources of evidence in the searched databases to 14 sources of evidence. The content of these 14 sources of evidence was mapped out on a charting table where data was summarised and synthesised individually and collectively by the authors. Repetitive and irrelevant data were deleted. Identified gaps include the lack of extensive exploration of male and female genders alone as a determinant of HL, how gender may be utilised to encourage elderly men and women to apply HL, how different sociocultural and sociodemographic backgrounds of elderly men and women would require separate academic research, the scarcity of social sciences based research and qualitative research methodologies on the subject as well as the use of mixed-methodologies and longitudinal studies. Future research directions were suggested and limitations of this scoping review are addressed in the discussion.

Health Literacy in Patients’ Clinical Records of Hospital Settings: A Systematic Review

Introduction

Health literacy (HL) can be defined as the individual's ability to understand and process health information. A low level of HL can be viewed as a stronger predictor of a person's health status than age, education level, and race. Although HL is an important determinant of health, it is often underestimated. This systematic review investigates the evidence on HL assessment in hospital settings.

Methods

PubMed Medline, CINAHL, Scopus, Web of Science and Educational Resources Information Centre databases were searched, with the date last searched being 16 March 2020. The PRISMA guidelines were applied, and the protocol of the study was registered with PROSPERO (CRD42021236029). The quality of the included studies was appraised using the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Results

Five studies reported HL assessments in hospital patients’ clinical records. Four main strategies were used to implement HL routine assessment in hospitals: multidisciplinary teams, stakeholders, training, and monitoring. Different performance measures were used to monitor the feasibility of incorporating HL assessment into electronic health records (EHRs).

Conclusion

This review examined how inpatients’ HL is recorded in hospital settings. HL is poorly measured in a hospital setting. These results guide hospital leadership in involving nurses in HL assessment implementation in hospitals and support nurses in creating a specific performance measure dashboard to monitor effective HL assessments in hospitals.

Psychometric Validation of the Korean Version of the Heart Failure-Specific Health Literacy Scale

BACKGROUND AND PURPOSE

The goals of heart failure (HF) management include lowering adverse outcomes through optimal self-care. Health literacy has a significant role in ensuring optimal and effective HF self-care. Unfortunately, the proportion of low health literacy in HF patients is higher than those with other chronic diseases as well as the general population. Thus, healthcare providers need to screen HF patients. The HF-Specific Health Literacy Scale is a specific questionnaire to screen the health literacy in HF patients; however, the Korean version has not yet been validated. The study aimed to investigate the reliability and validity of the Korean version of the HF-Specific Health Literacy Scale.

METHODS

We adopted a cross-sectional study design with 386 outpatients with chronic HF from a tertiary care hospital in Cheonan, South Korea. Data were collected from April to December 2020.

RESULTS

The exploratory factor analysis revealed a three-factor (functional, communicative, and critical health literacy) 12-item structure of the scale. The result of the confirmatory factor analysis confirmed a good statistical fit for the data. The Korean version of the tool demonstrated satisfactory convergent and discriminant validity. The criterion validity analysis revealed significant correlation with general health literacy and knowledge about HF. The Korean version of the tool for 12 items had adequate overall internal consistency.

IMPLICATIONS FOR PRACTICE

The Korean version of the HF-Specific tool can be easily utilized for assessing health literacy level for HF patient education. Moreover, the tool can help healthcare providers develop strategies for promoting HF patients' health literacy.