Health literacy: communication strategies to improve patient comprehension of cardiovascular health

Accuracy and consistency of online large language model-based artificial intelligence chat platforms in answering patients' questions about heart failure

BACKGROUND

Heart failure (HF) is a prevalent condition associated with significant morbidity. Patients may have questions that they feel embarrassed to ask or will face delays awaiting responses from their healthcare providers which may impact their health behavior. We aimed to investigate the potential of large language model (LLM) based artificial intelligence (AI) chat platforms in complementing the delivery of patient-centered care.

METHODS

Using online patient forums and physician experience, we created 30 questions related to diagnosis, management and prognosis of HF. The questions were posed to two LLM-based AI chat platforms (OpenAI's ChatGPT-3.5 and Google's Bard). Each set of answers was evaluated by two HF experts, independently and blinded to each other, for accuracy (adequacy of content) and consistency of content.

RESULTS

ChatGPT provided mostly appropriate answers (27/30, 90%) and showed a high degree of consistency (93%). Bard provided a similar content in its answers and thus was evaluated only for adequacy (23/30, 77%). The two HF experts' grades were concordant in 83% and 67% of the questions for ChatGPT and Bard, respectively.

CONCLUSION

LLM-based AI chat platforms demonstrate potential in improving HF education and empowering patients, however, these platforms currently suffer from issues related to factual errors and difficulty with more contemporary recommendations. This inaccurate information may pose serious and life-threatening implications for patients that should be considered and addressed in future research.

Effectiveness of a health literacy intervention to improve diabetes outcomes in rural family medicine clinics: a randomized pragmatic trial

Background

Adults with diabetes mellitus (DM) living in rural areas often face limited access to medical and specialist care, minimal exposure to diabetes education, and transportation challenges. Rural residents also tend to be older, poorer, less educated, under-insured and have lower health literacy compared to their urban counterparts.

Aims

We tested the effectiveness of the American College of Physicians (ACP) diabetes health literacy intervention in rural community clinics to improve a range of diabetes-related patient outcomes and determine whether the intervention reduces disparities by health literacy.

Methods

We recruited 756 English-speaking adults with uncontrolled Type 2 DM from rural clinics in Arkansas. Trained health coaches reviewed the ACP Diabetes Guide and conducted counseling and action-planning monthly to participants randomized to the intervention. The enhanced usual care (EUC) arm received an American Diabetes Association workbook and was followed as usual. Interviews were conducted at baseline, 3 and 6 months, and clinical outcomes, including hemoglobin A1C and blood pressure values, were extracted from charts through 12 months post-baseline. Health literacy was measured at baseline using the Newest Vital Sign (NVS). Our primary outcome was A1C at 6 months, with other clinical values and self-reported diabetes-related knowledge, self-efficacy, distress, and self-care behaviors examined as secondary outcomes.

Results

Participants had a mean age of 55.8 (SD=11.7), 68% were female, two-thirds had an annual household income <$15,000, and 52% had limited health literacy. Overall, the intervention had little effect on outcomes at 6 and 12 months, including our primary outcome of A1C at 6 months (Intervention Least Squared Means (LSM) 8.28, 95% CI 8.11, 8.46; EUC LSM 8.44, 95% CI 8.26, 8.61). Diabetes knowledge was greater in those with adequate (LSM 9.46, 95% CI 9.25, 9.67) compared to those with limited health literacy (LSM 8.11, 95% CI 7.91, 8.23, p<0.001) at baseline. This disparity remained in the EUC arm after 6 months but disparities were mitigated in the intervention arm (interaction p<0.001).

Discussion

Our intensive intervention was well received, but insufficient to improve outcomes. Strategies may need to attend to other barriers faced by rural patients beyond health literacy to improve health behaviors and outcomes.

The effectiveness of visual-based interventions on health literacy in health care: a systematic review and meta-analysis

BACKGROUND

Limited Health Literacy (HL) is an obstacle to accessing and receiving optimal health care and negatively impacts patients' quality of life, thus making it an urgent issue in the health care system. Visual-based interventions are a promising strategy to improve HL through the use of visual aids and pictorial materials to explain health-related concepts. However, a comprehensive summary of the literature on the topic is still scarce.

METHODS

To fill this gap, we carried out a systematic review and meta-analysis with the aim to determine the effectiveness of visual-based interventions in improving comprehension of health related material in the clinical population. Independent studies evaluating the effectiveness of visual-based interventions on adults (> 18 years) and whose primary outcome was either health literacy (HL) or comprehension were eligible for the review. After a systematic literature search was carried out in five databases, 28 studies met the inclusion criteria and thus were included. Most of the studies were randomized controlled trials and they focused on HL and health knowledge as outcomes.

RESULTS

The review and meta-analysis showed that visual-based interventions were most effective in enhancing the comprehension of health-related material compared to traditional methods. According to meta-analytic results, videos are more effective than traditional methods (Z = 5.45, 95% CI [0.35, 0.75], p < 0.00001) and than the employment of written material (Z = 7.59, 95% CI [0.48, 0.82], p < 0.00001). Despite this, no significant difference was found between video and oral discussion (Z = 1.70, 95% CI [-0.46, 0.53], p = 0.09).

CONCLUSIONS

We conclude that visual-based interventions, particularly the ones using videos, are effective for improving HL and the comprehension of health-related material.

Health literacy in cancer care: A systematic review

PURPOSE

Health literacy (HL) is a set of knowledge and skills that enables individuals to interpret and act upon health information, which is essential for health equity. There is a growing body of evidence in the field of HL in cancer care but there is, to our knowledge, no systematic review that explores the association between sociodemographic factors and HL among patients with cancer. The aim of this study was therefore to conduct a systematic review of the existing literature that assesses HL levels and the relationship between HL and sociodemographic factors in an adult cancer population.

METHODS

This is a systematic review and its protocol was registered in PROSPERO (ID: CRD42021164071). The study was conducted in accordance with the PRISMA statement. The literature search, from December 2009 to September 2023, was made in six databases, AMED, CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science Core Collection.

RESULTS

Fifteen studies were included in the review. The included studies used nine different measurement tools for assessing HL. In the included studies between 11.9 % and 86 % had limited HL. We identified a relationship between limited HL and annual income, education level, ethnicity, living in rural areas and multiple comorbidities.

CONCLUSION

The results indicate that limited HL is prevalent in the cancer population and should be acknowledge in everyday practice to meet health equity. Our awareness about sociodemographic factors and its association with HL, may enhance adherence to cancer treatment and quality of life, and lower physical and emotional distress.

The effect of the COVID-19 pandemic on the provision of outpatient clinic services in East Jerusalem hospitals: patients' perspectives

Background

Due to the decreased availability, accessibility, and quality of services, the COVID-19 pandemic has an impact on the healthcare system. In the wake of the COVID-19 pandemic, patients' perceptions of healthcare have changed, and out-patient visits to clinics have decreased. As part of the COVID-19 outbreak in East Jerusalem, this study aims to assess how patients perceive the way that outpatient clinic services were delivered before and during COVID-19 outbreak.

Methodology

Convenience sampling and self-reported questionnaires were used in a cross-sectional study. Three hundred people from three significant outpatient clinic hospitals in East Jerusalem-Al-Makassed Hospital, Augusta Victoria Hospital, and Sant-Joseph Hospital- made up the sample. Multivariate tests, frequencies, and percentages were used in the statistical analysis.

Results

The results showed that the most of the participants (98.6%) had negative opinion when the current situation is compared with before the COVID-19 period in terms of accessibility, availability of resources, quality of care, attitudes and patient's preference. Finally, multivariate analysis indicated a significant relationship between participant opinion and education level and participants with educational levels of 12 study years or less had more positive opinions of the delivery of the healthcare system during the COVID-19 outbreak period than the group with more than 12 study years. Also, the multivariate analysis revealed a significant `relationship between participant opinion and the duration of the illness as those with years of illness and less had more negative opinion toward the delivery of the healthcare system than those with more than 3 years of illness.

Conclusion

This study found that when the current situation during the COVID-19 outbreak is compared to before the COVID-19 period in terms of accessibility, availability of resources, quality of care, attitudes, and patient preferences, the majority of the participants with chronic diseases or cancer had a negative opinion. Policymakers and health managers should enhance patient preferences and attitudes during the COVID-19 pandemic and other pandemics by increasing accessibility, availability of health resources, and the quality of healthcare.

Examination of health literacy and personal impact of epilepsy in patients with epilepsy

AIM

We conducted this study to examine the impact of health literacy on the personal impact of epilepsy in patients with epilepsy.

METHOD

We conducted this cross-sectional and correlational study with 125 individuals who were admitted to the neurology outpatient clinic of a university hospital in eastern Turkey, who met the research criteria, and who accepted to participate in the study. We collected the data by using the "Descriptive Information Form (DIF)", "The Personal Impact of Epilepsy Scale (PIES)", and "Health Literacy Scale (HLS)".

RESULTS

We found that the mean HLS total score of the participants was 104.84 ± 22.88. We also found the mean PIES total score to be 27.08 ± 18.56. Regression results using PIES as a dependent variable reported that the model created was statistically significant (F (21,83) = 11.398, p < 0.05). Among the variables included in the model, income status and HLS were negative (β = -0.209; β = -0.194; β = -0.364, respectively) predictors of the PIES total score. However, seizure status in the last year, number of drugs used, and seizure type were positive predictors of the PIES total score. We found that the variables included in the analysis explained 74% of the total PIES score.

CONCLUSION

In conclusion, the health literacy level (HLL) of the participants was sufficient or very good, and the effect of the disease on individuals with epilepsy was low. The effect of the disease on individuals with epilepsy decreased as the level of health literacy increased.

Hearts in their hands-Physicians' gestures embodying shared professional knowledge around the world

The biomedical approach to medical knowledge is widely accepted around the world. This article considers whether the incorporated aspects of physician-patient interaction have become similarly common across the globe by comparing the gestures that physicians use in their interactions with patients. Up to this point, there has been little research on physicians' use of gestures in health-care settings. We explore how-in four university hospitals in Turkey, the People's Republic of China, The Netherlands and Germany-physicians use gesture in their discussions with simulated patients about the condition of heart failure. Our analysis confirms the importance of gestures for organising both the personal interaction and the knowledge transfer between physician and patient. From the perspective of global comparison, it is notable that physicians in all four hospitals used similar gestures. This demonstrates the globality of biomedical knowledge in an embodied mode. Physicians used gestures for a range of purposes, including to convey the idea of an 'anatomical map' and for constructing visual models of (patho-)physiological processes. Since biomedical language is rife with metaphor, it was not surprising that we also identified an accompanying metaphorical gesture which has a similar form in the various locations that were part of the study.

Current Situations and Challenges in the Development of Health Information Literacy

Health information literacy (HIL) is a significant concept that has gradually become known to the broader public in recent years. Although the definitions of HIL and health literacy seem to overlap, as an independent subconcept, HIL still shows a unique influence on improvements in people's health and health education. Remarkable evidence indicates that online health information (OHI) can effectively enrich people's knowledge and encourage patients to actively join the medical process, which is also accompanied by the emergence of various assessment tools. Although the current assessment tools, to a certain extent, can help people identify their shortcomings and improve their HIL, many studies have indicated that the deficiencies of the scales induce incomplete or unreal results of their HIL. In addition, continuing research has revealed an increasing number of influencing factors that have great effects on HIL and even regulate the different trends in doctor-patient relationships. Simultaneously, most of the uncensored OHI broadcasts have also affected the improvement in HIL in various ways. Thus, this review aims to summarize the assessment tools, influencing factors and current situations and challenges related to HIL. Further studies are required to provide more trusted and deeper references for the development of HIL.

Vaccine Champions Training Program: Empowering Community Leaders to Advocate for COVID-19 Vaccines

Strong community engagement has been critical to support COVID-19 vaccine uptake in Australia and elsewhere. Community engagement builds trust, enables tailored information dissemination and shapes social norms. Engagement is particularly important in communities with greater vaccine hesitancy, lower health literacy and mistrust in authorities. Early in 2021, as a team of vaccine social scientists and clinicians, we developed a program to train and empower community, faith, industry and healthcare leaders to advocate for COVID-19 vaccines as “vaccine champions”. We partnered with the Victorian Department of Health to deliver 91 online Vaccine Champions sessions from March 2021 to June 2022. Over 80 people who received this training were supported by the Department of Health to become formal vaccine champions, independently delivering over 100 locally tailored information sessions. Our survey evaluation of 20 sessions delivered in 2022 found most participants (94%, 118/125) felt more confident to discuss safety and effectiveness of COVID-19 vaccines and find relevant information after attending a session. We also recorded >90% participant satisfaction with training content, format and presentation. Qualitative feedback from two group interviews highlighted the value of vaccine communication role plays and opportunities for discussion. In this brief report, we present an overview of the Vaccine Champions program, evaluation and next steps.

Healthcare-seeking behaviour, barriers to care and predictors of symptom improvement among patients with cardiovascular disease in northern Tanzania

BACKGROUND

Little is known about healthcare-seeking behaviour and barriers to care for cardiovascular disease (CVD) in sub-Saharan Africa.

METHODS

Emergency department patients in Tanzania with acute CVD were prospectively enrolled. Questionnaires were administered at enrollment and 30 d later.

RESULTS

Of 241 patients, 186 (77.2%) had visited another facility for the same illness episode (median symptom duration prior to presentation was 7 d) and 82 (34.0%) reported that they were initially unaware of the potential seriousness of their symptoms. Of the 208 (86.3%) patients completing follow-up, 16 (7.7%) had died, 38 (18.3%) had visited another facility for persistent symptoms, 99 (47.6%) felt they understood their diagnosis, 87 (41.8%) felt they understood their treatment and 11 (7.8%) could identify any of their medications. Predictors of 30 d survival with symptom improvement included medication compliance (p<0.001), understanding the diagnosis (p=0.007), understanding the treatment (p<0.001) and greater CVD knowledge (p=0.008).

CONCLUSIONS

Patients with CVD in Tanzania usually visit multiple facilities for the same illness episode, typically after prolonged delays. Only a minority understand their diagnosis and treatment, and such understanding is correlated with survival with symptom improvement. Patient-centred interventions are needed to improve the quality of cardiovascular care in Tanzania.

The Effect of Socio-Economic Status on Health Information Literacy among Urban Older Adults: Evidence from Western China

The present study aimed to observe the effect of socio-economic status on health information literacy and to identify whether there is a social gradient for health information literacy among urban older adults in Western China. This study employed a cross-sectional research design, and 812 urban participants aged 60 and older were enrolled in Western China. In the current study, only 16.7% of urban older adults reported having adequate health information literacy. Binary logistic regression analysis showed that socio-economic status factors including educational attainment, ethnicity, and financial strain were significantly and tightly associated with health information literacy. Additionally, other factors including suffering from chronic diseases, information-seeking activity, reading magazines and books, and watching television were also significantly linked to health information literacy. Consistent with existing studies, the findings indicate the health information literacy deficit and demonstrate the crucial impact of socio-economic status on health information literacy, which implies a social gradient in health information literacy. The importance of other factors related to health information literacy are discussed as well. The results suggest that reducing the health information literacy deficit and social gradient in health information literacy must be considered as an important priority when developing public health and health education strategies, programs, and actions among urban older adults in Western China.

'What the herbal medicine can do for me in a week, the orthodox does in a year': Perceived efficacy of local alternative therapies influences medication adherence in patients with atherosclerotic cardiovascular disease

Background

There is strong evidence that anti‐platelet therapy, ACE inhibitors, beta‐blockers and statins are cost‐effective in reducing subsequent cardiovascular disease (CVD) events in patients with atherosclerotic cardiovascular disease (ACVD). In some settings, only a low proportion of people have access to these medications, and even lower adhere to them. The current study explored and presents data on the causes of poor adherence to orthodox medication and motivations for alternative therapies in patients with established atherosclerotic cardiovascular disease (ACVD).

Methods

The study was conducted among city‐dwelling adults with ACVD in Accra – Ghana's capital city. Eighteen interviews were conducted with patients with established ACVD. A follow‐up focus group discussion was conducted with some of them. The protocol was approved by two ethics review committees based in Ghana and in the United Kingdom. All participants were interviewed after informed consent. Analysis was done with the Nvivo qualitative data analysis software.

Results

We identified motivations for use of alternatives to orthodox therapies. These cover the five dimensions of adherence: social and economic, health‐care system, condition‐related, therapy‐related, and patient‐related dimensions. Perceived inability of an orthodox medication to provide immediate benefit is an important motivator for use of alternative forms of medication.

Conclusions

A multiplicity of factors precipitate non‐adherence to orthodox therapies. Perceived efficacy and easy access to local alternative therapies such as herbal and faith‐based therapies are important motivators.

Health literacy and education level correlates of participation and outcome in a remotely delivered epilepsy self-management program

SIGNIFICANCE

Health literacy, the ability to understand necessary health information to make proper health decisions, has been linked to greater frequency of hospitalizations. However, there is limited literature on the associations between health literacy and outcomes in patients with epilepsy, and thus, this secondary analysis investigates the associations between health literacy and outcomes in patients with epilepsy enrolled in the self-management intervention "Self-management for people with epilepsy and a history of negative events" (SMART). We examined the associations between higher health literacy and higher education level and outcomes of the SMART trial.

METHODS

This is a secondary analysis of data from the SMART self-management intervention, where individuals were randomized to the SMART intervention or a 6-month waitlist (WL) control. Health literacy was assessed at baseline before randomization using the Rapid Estimate of Adult Literacy in Medicine (REALM-R). Education level was self-reported by participants at baseline. Pearson correlations between REALM-R scores and continuous demographic and clinical variables were conducted. Point-biserial Pearson correlations were computed for REALM-R and dichotomous variables. The effect of education on change in negative health events (NHEs) counts from baseline to six months was conducted using a linear regression. A logistic regression with health literacy and randomization arm as predictors and improvement in NHE (1 = improvement, 0 = no change or increased NHEs at 6 months) as the outcome was conducted.

RESULTS

Lower education and lower income were significantly correlated with lower health literacy (p < 0.001 and p = 0.03). Higher education level was associated with a greater improvement in 6-month seizure counts (r_s(105) = 0.29, p = 0.002), and a greater improvement in total 6-month NHEs (r_s(95) = 0.20, p = 0.045). Health literacy was not associated with change in NHEs or with study retention.

CONCLUSIONS

The SMART intervention appears effective for individuals regardless of health literacy competency. Nevertheless, individuals with higher levels of education have fewer epilepsy complications, and thus, those with limited education may still require additional support while participating in epilepsy self-management programs.

Diabetes mellitus literacy in a regional community of a developed country

BACKGROUND

Prevalence of diabetes mellitus (DM) is on the increase. Yet discrepancies exist in research reports regarding the level of knowledge of the disease in 'rural versus metropolitan communities', and 'developed versus developing countries'. This study examines the level of general knowledge of diabetes among adult community members of a regional city of Australia, whether it is comparable to reports from low-mid income countries.

METHODS

The study was designed to be a cross-sectional day-time-population survey. Major shopping centres were chosen for convenience sampling of community's daytime population. A total of 315 participants' (154 males and 161 females) responses were received. Data were analysed using SPSS - 20 software to identify differences between sub-groups of age stratifications, educational status, gender and the participants assumed knowledgee. The participant's average knowledge of diabetes symptoms and complications were also assessed.

RESULTS

The major finding is that the subgroup who claimed to know 'very little' showed equivalent knowledge levels with those who thought they had 'considerable knowledge'. The females know more about diabetes management than males (P < 0.004); level of knowledge increased with educational status (p < 0.01). These observations were comparable with reports from developing countries.

CONCLUSIONS

The limited knowledge of diabetes symptoms and complications in the population can be mitigating against early reporting of patients to diabetes clinics in the community. To ensure continuous decline in prevalence rates of diabetes and its complications, the ongoing efforts of diabetes awareness and educational programs need to be improved, particularly with regard to males and school children. (www.actabiomedica.it).

HPV Misconceptions Among College Students: The Role of Health Literacy

Human papillomavirus (HPV) is currently the most common sexually transmitted disease in the United States, with potentially serious health consequences, including cervical cancer. Young adults are particularly at risk of infection, but many remain unvaccinated. Low health literacy may contribute to poor knowledge of HPV and lack of vaccine uptake, and women living in the Southeastern United States are particularly at risk for lower vaccination rates and cervical cancer screening adherence. Three-hundred-sixty undergraduates at a Southeastern U.S. University completed measures of health literacy, sexual attitudes, and HPV knowledge in 2016. Less than half of both male and female participants had completed an HPV vaccine series, and there were no differences in health literacy scores between participants who had completed a vaccine series and those who had not. Forty subjects were familiar with HPV vaccines but not the virus itself. More than half of these individuals had received at least one dose of an HPV vaccine, highlighting a lack of knowledge regarding the purpose of this vaccine. While health literacy was not related to vaccination status, it was associated with greater knowledge of both HPV and available vaccines. Participants who were familiar with HPV had higher health literacy than participants who were not. College students hold serious misconceptions about HPV that may be redressed through public health education programs to increase health literacy and knowledge. Such public health interventions would potentially increase HPV vaccine uptake, leading to decreased cervical cancer incidence and mortality rates.

Risk Recall of Complications Associated with Vestibular Schwannoma Treatment

OBJECTIVE

To assess the risk recall of complications among patients who underwent different vestibular schwannoma (VS) treatments.

STUDY DESIGN

Patients with VS completed a voluntary and anonymous survey.

SETTING

Survey links were distributed via the Acoustic Neuroma Association (ANA) website, Facebook, and email list.

SUBJECTS AND METHODS

Surveys were distributed to ANA members from January to March 2017. Of the 3200 ANA members with a VS diagnosis at the time of survey distribution, 789 (25%) completed the survey.

RESULTS

Subjects reported the following incidence of posttreatment complications: imbalance (60%), hearing issues (51%), dry eyes (30%), headache (29%), and facial weakness (27%). Overall, 188 (25%) recalled remembering all the risks associated with their treatment. Among those in the surgical cohort (52%) who experienced balance issues, facial weakness, cerebrospinal fluid leak, meningitis, and stroke, 73%, 91%, 77%, 67%, and 33% claimed recall of these associated risks. Among those in the radiosurgery cohort (28%) who experienced balance issues, facial weakness, and hydrocephalus, 56%, 52%, and 60% recalled discussions of those risks. Patients with higher-level education (P = .026) and those who underwent surgery (P = .001) had a significantly higher risk recall ratio, while sex, age, and tumor size were not significant contributing factors.

CONCLUSION

Not all patients with VS who experienced treatment complications recalled remembering those risks being discussed with them. Patients with higher education and those who underwent surgery had a better recall of risks associated with different treatment modalities. The risk recall ratio of patients experiencing complications ranged 33% to 91%, suggesting an opportunity for decision-making and discussion improvement.

Rationale and development of a randomized pragmatic trial to improve diabetes outcomes in patient-centered medical homes serving rural patients

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

Enhancing communication skills for telehealth: development and implementation of a Teach-Back intervention for a national maternal and child health helpline in Australia

Background

Telehealth professionals require advanced communication skills, in part to compensate for lack of visual cues. Teach-Back is a best practice communication technique that has been recommended but not previously evaluated for consumer telehealth. We aimed to implement Teach-Back at a national maternal and child health telephone helpline. We describe the intervention and report telenurse experiences learning to use Teach-Back.

Methods

We identified barriers (time, knowledge, skills, beliefs) and enablers (self-reflection) to using Teach-Back, and developed a novel training program to address these, guided by the Theoretical Domains Framework. We engaged maternal and child health telenurses to participate in a “communication skills” study. The intervention had two key components: guided self-reflection and a Teach-Back skills workshop. For the duration of the 7-week study nurses completed brief online surveys following each call, reflecting on both the effectiveness of their communication and perceived caller understanding. At the end of each shift they reflected on what worked well. Teach-Back knowledge, skills, and beliefs were addressed in a 2-h workshop using videos, discussion, and role play. We explored nurses’ experiences of the intervention in focus groups and interviews; and analysed transcripts and comments from the self-reflection surveys using the Framework method. This study forms part of a larger evaluation conducted in 2016.

Results

In total 16 nurses participated: 15 were trained in Teach-Back, and 13 participated in focus groups or interviews. All engaged with both self-reflection and Teach-Back, although to differing extents. Those who reported acquiring Teach-Back skills easily limited themselves to one or two Teach-Back phrases. Nurses reported that actively self-reflecting (including on what they did well) was useful both for developing Teach-Back skills and analysing effectiveness of the techniques. Most wanted more opportunity to learn how their colleagues manage Teach-Back in different situations, and more visual reminders to use Teach-Back.

Conclusions

Our theory-informed intervention successfully enabled nurses to use Teach-Back. Guided self-reflection is a low-resource method aligned with nurse professional identity that can facilitate Teach-Back skills learning, and could also be applied to other advanced communication skills for telehealth. Listening to multiple workplace-specific examples of Teach-Back is recommended for future training.

Trial registration

ACTRN12616000623493 Registered 15 May 2016. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2956-6) contains supplementary material, which is available to authorized users.

Survey of risks and benefits communication strategies by research nurses

BACKGROUND

An ethical, informed consent process requires that potential participants understand the study, their rights, and the risks and benefits. Yet, despite strategies to improve communication, many participants still lack understanding of potential risks and benefits. Investigating attitudes and practices of research nurses can identify ways to improve the informed consent process.

RESEARCH QUESTION

What are the attitudes, practices, and preparedness of nurses involved in the informed consent process regarding communication of risks and benefits?

RESEARCH DESIGN

A survey was developed and administered online to a national purposive sample of 107 research nurses with experience obtaining informed consent for clinical trials. Survey responses stratified by selected work-related characteristics were analyzed.

ETHICAL CONSIDERATIONS

Participants were instructed they need not answer each question and could stop at any time. They consented by clicking "accept" on the email which linked to the survey. The study was approved by the Northeastern University Institutional Review Board, Boston, Massachusetts (NU-IRB Protocol #: 13-06-17).

FINDINGS

Most research nurses (87%) used a teach-back method to assess participant comprehension, while 72% relied on their intuition. About one-third did not feel prepared to communicate related statistics. About 20% did not feel prepared to tailor information, and half did not feel competent using supplemental materials to enhance risks and benefits comprehension. Only 70% had received training in the informed consent process which included in-person training (84%), case studies (69%), online courses (57%), feedback during practice sessions (54%), and simulation, such as role playing (49%) and viewing videos (45%). Perceived preparedness was significantly associated with greater informed consent experience and training.

CONCLUSION

Research nurses may have inadequate training to encourage, support, and reinforce communication of risks and benefits during the informed consent process. Relevant purposeful education and training should help to improve and standardize the ethical informed consent process.

Communication Between Health Workers and Ethnic Minorities in Vietnam

Background:

Vietnam has made notable progress in reducing maternal mortality rates during the past 2 decades, but this overall improvement conceals regional and ethnic inequalities. Ethnic minorities in Vietnam experience high rates of poverty and mortality, and they face communication and cultural barriers when accessing health services. Poor communication with health professionals combined with limited health literacy is concerning, particularly in the maternal health context, and may exacerbate existing inequalities.

Objective:

This study explores primary health care professionals' perceptions of the quality of their communication with ethnic minority women during and after pregnancy.

Methods:

Semi-structured interviews were conducted with 22 primary health care professionals in Dien Bien province. A thematic analysis was performed using a framework analysis method.

Key Results:

Health professionals had mostly positive perceptions about their communication with ethnic minority women. However, they generally perceived the effectiveness of their communication as being based on women's individual capacities to understand health information (both the language used and the content) and factors such as ethnic and cultural differences, rather than reflecting on the suitability of information and materials or on their own communication skills. This placed much of the burden of communication and understanding health information on ethnic minority women and their families.

Conclusions:

Health professionals perceived of communication as being mainly a one-way street for the provision of health information, and rarely acknowledged the interactive nature of communication. Patient-professional communication and health literacy in Dien Bien province may be improved through the introduction of patient-centered communication skills training that applies health literacy approaches at the health professional level. [Health Literacy Research and Practice. 2017;1(4):e163–e172.]

Plain Language Summary:

We looked at how primary health care professionals in Vietnam perceive their communication with ethnic minority women, particularly about pregnancy. Health professionals generally perceived the quality and effectiveness of their communication as being based on ethnic minority women's individual capacities and limitations. Applying a health literacy approach to communication skills training could improve patient-professional communication and health literacy.

Examination of an eHealth literacy scale and a health literacy scale in a population with moderate to high cardiovascular risk: Rasch analyses

INTRODUCTION

Electronic health (eHealth) strategies are evolving making it important to have valid scales to assess eHealth and health literacy. Item response theory methods, such as the Rasch measurement model, are increasingly used for the psychometric evaluation of scales. This paper aims to examine the internal construct validity of an eHealth and health literacy scale using Rasch analysis in a population with moderate to high cardiovascular disease risk.

METHODS

The first 397 participants of the CONNECT study completed the electronic health Literacy Scale (eHEALS) and the Health Literacy Questionnaire (HLQ). Overall Rasch model fit as well as five key psychometric properties were analysed: unidimensionality, response thresholds, targeting, differential item functioning and internal consistency.

RESULTS

The eHEALS had good overall model fit (χ2 = 54.8, p = 0.06), ordered response thresholds, reasonable targeting and good internal consistency (person separation index (PSI) 0.90). It did, however, appear to measure two constructs of eHealth literacy. The HLQ subscales (except subscale 5) did not fit the Rasch model (χ2: 18.18-60.60, p: 0.00-0.58) and had suboptimal targeting for most subscales. Subscales 6 to 9 displayed disordered thresholds indicating participants had difficulty distinguishing between response options. All subscales did, nonetheless, demonstrate moderate to good internal consistency (PSI: 0.62-0.82).

CONCLUSION

Rasch analyses demonstrated that the eHEALS has good measures of internal construct validity although it appears to capture different aspects of eHealth literacy (e.g. using eHealth and understanding eHealth). Whilst further studies are required to confirm this finding, it may be necessary for these constructs of the eHEALS to be scored separately. The nine HLQ subscales were shown to measure a single construct of health literacy. However, participants' scores may not represent their actual level of ability, as distinction between response categories was unclear for the last four subscales. Reducing the response categories of these subscales may improve the ability of the HLQ to distinguish between different levels of health literacy.

Impact of Health Literacy on Senior Citizen Engagement in Health Care IT Usage

Objective: Patient engagement in health care information technology (IT) is required for government reimbursement programs. This research surveyed one older adult group to determine their willingness to use health information from a variety of sources. Health literacy was also measured using the Newest Vital Sign (NVS) and eHealth Literacy Scale (eHEALS) tools. Method: Regression models determined engagement in health care IT usage and impact of literacy levels based on survey data collected from the group. Results: Although most participants have adequate literacy, they are not more likely to use health care IT than those with limited literacy scores. Knowledge of how to use the Internet to answer questions about health was statistically associated with IT usage. Discussion: Health care IT usage is important for healthy aging. The ability of older adults to understand information provided to them can impact population health including medication usage and other important factors.

Medication adherence among cardiac patients in Khartoum State, Sudan: a cross-sectional study

INTRODUCTION

Non-adherence to medication among cardiac patients is often the major risk factor for poor clinical outcomes, increased mortality rates and higher healthcare costs. The literature evaluating the prevalence of and reasons for non-adherence in resource-poor settings is extremely limited compared to resource-rich settings. There is a scarcity of data about medication adherence in Sudan hence this study was performed to identify prevalence, predictors and barriers of non-adherence to medication among cardiac patients in Khartoum State.

METHODS

A descriptive, cross-sectional survey was performed using a pre-tested, self-administered questionnaire on a sample of 433 randomly selected cardiac patients attending the largest three cardiac centres located in Khartoum State. Descriptive and multivariate logistic regression analyses were used for data analysis.

RESULTS

The response rate was 89.1%. The mean (± SD) number of chronic diseases among respondents was 2.3 ( ± 1.3) and that of medication use was 4.2 ( ± 1.9). The mean ( ± SD) duration of medication use among participants was 6.4 ( ± 5.4) years. Optimal adherence was defined as having a score of greater than six on the eight-item Morisky medication adherence scale. Using this cut-off point, 49% (95% CI: 43.9-54.1) of respondents had optimal adherence and 51% (95% CI: 45.9-56.1) had poor adherence. Respondents with a high level of education, low and middle income levels, and those taking five or more medications daily were found to be significantly more non-adherent to medication use than those with low to intermediate education levels (p < 0.001), those with high income levels (p < 0.001), and those taking one to four medications daily (p = 0.039). The top four barriers for poor medication adherence among the study participants were the high cost of drugs, polypharmacy and lack of pharmacist and physician communication with patients about their drug therapy.

CONCLUSIONS

The current findings highlight the need for urgent, multifaceted interventions, given the burden of cardiovascular diseases and the clinical and economic consequences of medication non-adherence. These interventions include affordable medications, easy-to-use medication regimens with fewer daily doses, ongoing communication between patients and healthcare providers, and improvement of the patient-provider partnership.

The Status of Health Literacy Research in Health Communication and Opportunities for Future Scholarship

While national concern is growing, the scholarly body of knowledge in health literacy is still relatively small in health communication literature. The field began to distinguish itself as an outgrowth of adult literacy that focused on patient understanding of health information. It grew out of medicine and public health science mostly, and still today the majority of research can be found in health professional journals. However, the links with health communication, particularly with provider-patient communication and with printed health information, have been established and documented over the last decade. This article is a conceptual review that highlights state-of-the-science literature that has made connections between health literacy and health communication. Evidence reveals the contribution that health literacy can have on the health communication body of knowledge. The article illuminates the gaps in research and possibilities for theory development and future studies.

eHealth Literacy: Predictors in a Population With Moderate-to-High Cardiovascular Risk

Background

Electronic health (eHealth) literacy is a growing area of research parallel to the ongoing development of eHealth interventions. There is, however, little and conflicting information regarding the factors that influence eHealth literacy, notably in chronic disease. We are similarly ill-informed about the relationship between eHealth and health literacy, 2 related yet distinct health-related literacies.

Objective

The aim of our study was to investigate the demographic, socioeconomic, technology use, and health literacy predictors of eHealth literacy in a population with moderate-to-high cardiovascular risk.

Methods

Demographic and socioeconomic data were collected from 453 participants of the CONNECT (Consumer Navigation of Electronic Cardiovascular Tools) study, which included age, gender, education, income, cardiovascular-related polypharmacy, private health care, main electronic device use, and time spent on the Internet. Participants also completed an eHealth Literacy Scale (eHEALS) and a Health Literacy Questionnaire (HLQ). Univariate analyses were performed to compare patient demographic and socioeconomic characteristics between the low (eHEALS<26) and high (eHEALS≥26) eHealth literacy groups. To then determine the predictors of low eHealth literacy, multiple-adjusted generalized estimating equation logistic regression model was used. This technique was also used to examine the correlation between eHealth literacy and health literacy for 4 predefined literacy themes: navigating resources, skills to use resources, usefulness for oneself, and critical evaluation.

Results

The univariate analysis showed that patients with lower eHealth literacy were older (68 years vs 66 years, P=.01), had lower level of education (P=.007), and spent less time on the Internet (P<.001). However, multiple-adjusted generalized estimating equation logistic regression model demonstrated that only the time spent on the Internet (P=.01) was associated with the level of eHealth literacy. Regarding the comparison between the eHEALS items and HLQ scales, a positive linear relationship was found for the themes “usefulness for oneself” (P=.049) and “critical evaluation” (P=.01).

Conclusions

This study shows the importance of evaluating patients’ familiarity with the Internet as reflected, in part, by the time spent on the Internet. It also shows the importance of specifically assessing eHealth literacy in conjunction with a health literacy assessment in order to assess patients’ navigational knowledge and skills using the Internet, specific to the use of eHealth applications.

A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities

The disparate effects of social determinants of health on cardiovascular health status and health care have been extensively documented by epidemiology. Yet, very little attention has been paid to how understanding and addressing social determinants of health might improve the quality of clinical interactions, especially by improving patients' adherence to recommended therapies. We present a case and suggested approach to illustrate how cardiovascular clinicians can use patient-centered approaches to identify and address social determinants of health barriers to adherence and reduce the impact of unconscious clinician biases. We propose that cardiovascular clinicians (1) recognize that patients may have different belief systems about illnesses' cause and treatment, which may influence their actions, and not assume they share one's experiences or explanatory model; (2) Endeavor to understand the individual patient before you; (3) based on that understanding, tailor your approach to that individual. We suggest a previously-developed mnemonic for an approach to RESPECT the patient: First, show Respect; then elicit patients' understandings of their illness by asking about their Explanatory model. Ask about the patient's Social context, share Power in the interaction, show Empathy, ask about Concerns or fears, and work to develop Trust by building the relationship over time. We provide additional clinical resources to support these efforts, including lay descriptions of cardiovascular conditions, challenges to adherence, and suggested strategies to address them.

Assessing the Mental Health Needs of Pregnant Adolescents: Health Literacy Frameworks to Guide Research and Practice

Background: Psychological distress negatively impacts fetal development and may result in complications such as preterm delivery, low infant birth weight, and poor maternal–infant attachment during the postpartum period. Female adolescents may be experiencing environmental and psychosocial stressors during the pre- and postnatal periods that may predispose them to psychological distress. Health literacy has been used to assess the needs of individuals who have chronic illnesses. Mental health literacy however has not been assessed as extensively, particularly among pregnant adolescents. Purpose: Analysis of 2 health literacy frameworks for assessment of relevancy for use among adolescents experiencing psychological distress. Methods: Systematic analyses of health literacy frameworks by Anthony Jorm and that of Paasche-Orlow and Wolf are provided in this article. Results: Paasche-Orlow and Wolf’s frameworks both provide useful approaches for assessing pregnant adolescent needs. A modified holistic health literacy conceptual model based on Paasche-Orlow and Wolf’s and Jorm’s framework is proposed. Implications for Practice: Assessing the mental health needs of pregnant adolescents requires a holistic approach. The modified conceptual model provides a basis for research and practice addressing health literacy and psychological distress among pregnant adolescents.

Understanding Health Literacy and its Impact on Delivering Care to Patients with Inflammatory Bowel Disease

Health literacy (HL) is the extent to which individuals have the capacity to obtain, process, and understand basic health information that is needed to make appropriate health decisions. As adults with inflammatory bowel disease engage in complex health decisions throughout their lives, attention is needed regarding the influence of HL on the lives of people with inflammatory bowel disease. About one-third of adults in the United States have limited HL. Limited HL is a potentially modifiable risk factor that has been associated with barriers to patient-provider communication and worse health outcomes for people with a range of chronic diseases. Gastroenterologists must recognize the role of HL in their practice. Limited HL can affect a patient's ability to understand the purpose of a screening test for colorectal cancer, understand the concept of an asymptomatic yet chronic disease, ask questions in an office visit and engage in shared decision making. Gastroenterologists must approach each patient as potentially having limited HL and use clear communication strategies in all encounters. Currently, there is a lack of training, education, and support for health care providers to meet the needs of patients with limited HL. More research is needed in inflammatory bowel disease to understand the impact of limited health literacy on health outcomes in this population and develop effective systems-based interventions to reduce the health literacy burden on patients.

Engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma

AIM

To present the methods and outcomes of stakeholder engagement in the development of interventions for children presenting to the emergency department (ED) for uncontrolled asthma.

METHODS

We engaged stakeholders (caregivers, physicians, nurses, administrators) from six EDs in a three-phase process to: define design requirements; prototype and refine; and evaluate.

RESULTS

Interviews among 28 stakeholders yielded themes regarding in-home asthma management practices and ED discharge experiences. Quantitative and qualitative evaluation showed strong preference for the new discharge tool over current tools.

CONCLUSION

Engaging end-users in contextual inquiry resulted in CAPE (CHICAGO Action Plan after ED discharge), a new stakeholder-balanced discharge tool, which is being tested in a multicenter comparative effectiveness trial.

Reprint of: Health literacy in Canada and the ophthalmology patient

Health literacy represents the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.(1) According to the 2003 International Adult Literacy and Life Skills Survey (IALSS), over 12 million (60%) adult Canadians lack the capacity to obtain, understand, and act on health information and services, as well as make appropriate health decisions on their own.(2,3) Of these 12 million Canadians, the elderly are the most health illiterate age group in Canada. What this suggests for Canadian physicians is that to improve the CanMEDS roles of communicator and health advocate,(4) physicians need to recognize health literacy as a modifiable contributor of poor health outcomes and work to remove literacy-related barriers.(5) This is particularly important for ophthalmologists who manage chronic illnesses in elderly patients.(2,6,7) The objective of this review is 2-fold. The first objective is to describe health literacy in Canada and provide a summary on the current state of health literacy research, both generally in medicine and specifically to Ophthalmology. The second objective is to propose a 3-step approach of evidence based techniques for managing low health literate patients in clinic.

Persistence with secondary prevention medications after acute myocardial infarction: Insights from the TRANSLATE-ACS study

BACKGROUND

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes.

METHODS

Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes.

RESULTS

Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence.

CONCLUSIONS

Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

Supporting Radiation Therapy Patients with Limited Health Literacy

Health literacy is one of the most important determinants of patient outcome. Literacy levels are influenced by factors such as formal education status, socioeconomic circumstances, age, language, cultural background, and employment status. Few health professionals are aware of health literacy issues, and even fewer can accurately address them. The purpose of this review article was to bring attention to the issue of health literacy, to provide information on how to identify patients at risk of limited health literacy, and to develop communication strategies designed to support cancer patients and their families. This article also aimed to develop and identify specific tools for radiation therapists and the radiation medical science community based on literature, evidence, and educational material from nursing and other allied professions. Health care organizations and professionals need to be aware of their duty to ensure that patients fully comprehend both the complex and simple information presented. Improving comprehension related to health choices leads to better decision making by the patient, improves patient outcomes, reduces hospitalization rates, and cuts health care costs.

Non-adherence to cardiovascular medications

Despite evidence-based interventions, coronary heart disease (CHD) remains a leading cause of global mortality. As therapies advance, patient non-adherence to established treatments is well recognized. Non-adherence is a powerful confounder of evidence-based practice and can affect daily patient management, resulting in inappropriate therapeutic escalation with greater costs and potential for harm. Moreover, it increases risk for adverse cardiac events, including mortality. Yet, non-adherence is complex, remains difficult to define, and provider ability to identify its presence accurately remains limited. Improved screening tools are needed to detect at-risk patients, enabling appropriate targeting of interventions. Given the rapidly expanding global population with CHD and emerging clinical and cost-benefits of adherence, addressing non-adherence to prescribed therapies is a top priority.

Asthma self management in adults: a review of current literature

Self management programs for chronic conditions, such as asthma, have an important place in healthcare delivery. When properly implemented, they can curb the impact of disease and reduce both the high personal costs for individuals and significant financial costs for health care systems. The purpose of this review was to establish an understanding of current published literature on asthma self management programs in adults and to identify any reported attributes or components which serve to either assist or obstruct the uptake of self management strategies. Electronic data sources including Scopus, Proquest 5000, CINAHL, PubMed and Web of Science were accessed and literature searches were conducted using the key terms: asthma, chronic disease, self management, morbidity, quality of life, health outcomes, patient education and best practice. Inclusion criteria for the search included journal articles relating to adults with asthma published in English in peer reviewed journals from 1995 to 2011. Exclusion criteria included research targeting children, parents of children or families; and articles examining Asthma and COPD (or any other co-morbidity). Sixty four articles were included in this review due to their relevance to the major components of asthma self management, as defined by the Australian Asthma Management Handbook. A major conclusion from this review was that the uptake of asthma self management strategies is poor despite global recommendations for over twenty years; and that a likely reason for this is that generic asthma self management advice does not engage the individual with asthma.

Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III

BACKGROUND

Occlusion of the left atrial appendage (LAA) is a promising approach to stroke prevention in atrial fibrillation (AF). However, evidence of its efficacy and safety to date is lacking. We herein describe the rationale and design of a definitive LAA occlusion trial in cardiac surgical patients with AF.

METHODS

We plan to randomize 4,700 patients with AF in whom on-pump cardiac surgical procedure is planned to undergo LAA occlusion or no LAA occlusion. The primary outcome is the first occurrence of stroke or systemic arterial embolism over a mean follow-up of four years. Other outcomes include total mortality, operative safety outcomes (chest tube output in the first post-operative 24 hours, rate of post-operative re-exploration for bleeding in the first 48 hours post-surgery and 30-day mortality), re-hospitalization for heart failure, major bleed, and myocardial infarction.

RESULTS

Left Atrial Appendage Occlusion Study (LAAOS) III is funded in a vanguard phase by the Canadian Institutes for Health Research (CIHR), the Canadian Network and Centre for Trials Internationally, and the McMaster University Surgical Associates. As of September 9, 2013, 162 patients have been recruited into the study.

CONCLUSIONS

LAAOS III will be the largest trial to explore the efficacy of LAA occlusion for stroke prevention. Its results will lead to a better understanding of stroke in AF and the safety and efficacy of surgical LAA occlusion.

Interdisciplinary medical social work: a working taxonomy

Findings from a year-long exploratory study aimed at describing universal functions of medical social work with interdisciplinary teams in acute care settings are reported here. A universal taxonomy of interdisciplinary social work skills and competencies was empirically identified through a participatory action research framework. Findings support previous conceptual descriptions of medical social work's overarching and historical role to help interdisciplinary teams in acute care to consider patients' home environment, knowledge, beliefs, culture, and resources during assessment, treatment, and discharge planning. The empirically determined taxonomy reported is intended to provide social workers a framework with which to articulate and evaluate their core competencies on interdisciplinary medical teams.

Examining the causal model linking health literacy to health outcomes of asthma patients

AIMS AND OBJECTIVES

To explore health literacy status in asthma patients and to examine the causal model linking health literacy to health outcome-related factors via mediator and moderator variables.

BACKGROUND

Understanding how low health literacy may influence health outcomes is important.

DESIGN

This is a cross-sectional survey study.

METHODS

A total of 326 asthma patients aged 20 years and older (average: 51 ± 18·3 years) were recruited by purposive sampling from pulmonary medicine outpatient departments at three medical centres and a regional teaching hospital in northern Taiwan. Data were collected via structured questionnaires, including measures of socio-demographic and disease characteristics; medical decision-making; asthma knowledge, attitudes and self-efficacy; healthcare experience and health outcome-related factors (metered-dose inhaler/dry-powder inhaler usage proficiency, medical use, self-management behaviour). Three hundred patients who met the inclusion criteria and completed the questionnaire survey were analysed.

RESULTS

Overall, 217 subjects (72·3%) had adequate functional health literacy, 42 (14%) had inadequate functional health literacy, and 41 (13·7%) had marginal functional health literacy. Subjects' average asthma knowledge, attitudes and self-efficacy scores were 7·23 ± 2·69, 51·46 ± 6·18 and 58·31 ± 8·10, respectively. Health literacy correlated positively with asthma knowledge (r = 0·605), attitudes (r = 0·192) and medical decision-making (r = 0·413).

CONCLUSIONS

Health literacy is positively associated with proficiency in metered-dose inhaler usage, asthma knowledge, attitudes and medical decision-making, but is not significantly associated with medical care use and self-management behaviour. Health literacy had an indirect effect on self-management behaviour through the mediation effect of asthma attitudes. No moderator was found for the effect of health literacy on health outcome-related factors.

RELEVANCE TO CLINICAL PRACTICE

Results of this study may help to develop adequate intervention strategies to improve the health outcomes of asthma patients.

The comprehensibility of health education programs: questionnaire development and results in patients with chronic musculoskeletal diseases

OBJECTIVE

The objective was to develop a comprehensive questionnaire for measuring the patient-perceived comprehensibility of health education programs (COHEP questionnaire). According to a conceptual model outlined in the article, comprehensibility is considered a context factor of patient health literacy.

METHODS

A questionnaire study was carried out on N=577 patients with chronic musculoskeletal diseases. During inpatient rehabilitation, patients participated in standardized, interactive group education programs conducted by clinic personnel. Factorial structure, unidimensionality, reliability, fit to the Rasch model, and construct validity were tested.

RESULTS

The COHEP consists of 30 items and 4 scales (comprehension-fostering behavior of program trainers, transferability to everyday life, comprehensibility of medical information, amount of information). All scales are reliable, unidimensional, and meet the requirements of the Rasch model. In addition, there are initial indications of validity. The descriptive results show that the overall rating of the comprehensibility of patient education programs in the German rehabilitation system is good, but that there are clear differences between centers.

CONCLUSION

The COHEP can be used to evaluate health education programs, since it measures an important proximal outcome.

PRACTICE IMPLICATIONS

An analysis of patient-perceived comprehensibility can help providers adapt education sessions better to the health literacy of patients.

Patients' and providers' perceptions of the impact of health literacy on communication in pulmonary rehabilitation

Chronic obstructive pulmonary disease (COPD) is the most prevalent form of chronic respiratory diseases worldwide. Pulmonary rehabilitation, including self-management education, highlights the importance of good patient-provider communication in establishing optimal care. There is a growing awareness of the potential impact of health literacy (HL) on the patients' access to and understanding of medical information. This study was designed to explore the patients' and health care professionals' (HCPs) perceptions of the role of HL in health communication. Semi-structured interviews and focus groups were conducted with 12 patients and 20 HCPs at a Pulmonary Rehabilitation Center in Metropolitan Toronto. Although the term health literacy was not familiar to many patients, the contribution of knowledge to patient well-being was consistently identified by patients and HCPs. Barriers to communication included provider time constraints and the use of medical jargon. For providers they also included patient characteristics, language, culture and awareness of health resources. Approaches that might improve communication incorporated family support, peer support, better print and visual teaching material and a trusting empathic patient-provider relationship. The findings provide an increased understanding of patients' and providers' perceptions of HL as a barrier to effective communication of medical information to patients with COPD as well as approaches that might improve this communication.

Health literacy practices and educational competencies for health professionals: a consensus study

Health care professionals often lack adequate knowledge about health literacy and the skills needed to address low health literacy among patients and their caregivers. Many promising practices for mitigating the effects of low health literacy are not used consistently. Improving health literacy training for health care professionals has received increasing emphasis in recent years. The development and evaluation of curricula for health professionals has been limited by the lack of agreed-upon educational competencies in this area. This study aimed to identify a set of health literacy educational competencies and target behaviors, or practices, relevant to the training of all health care professionals. The authors conducted a thorough literature review to identify a comprehensive list of potential health literacy competencies and practices, which they categorized into 1 or more educational domains (i.e., knowledge, skills, attitudes) or a practice domain. The authors stated each item in operationalized language following Bloom's Taxonomy. The authors then used a modified Delphi method to identify consensus among a group of 23 health professions education experts representing 11 fields in the health professions. Participants rated their level of agreement as to whether a competency or practice was both appropriate and important for all health professions students. A predetermined threshold of 70% agreement was used to define consensus. After 4 rounds of ratings and modifications, consensus agreement was reached on 62 out of 64 potential educational competencies (24 knowledge items, 27 skill items, and 11 attitude items), and 32 out of 33 potential practices. This study is the first known attempt to develop consensus on a list of health literacy practices and to translate recommended health literacy practices into an agreed-upon set of measurable educational competencies for health professionals. Further work is needed to prioritize the competencies and practices in terms of relative importance.

Coaching Older Adults and Carers to have their preferences Heard (COACH): A randomised controlled trial in an intermediate care setting (study protocol)

BACKGROUND

Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria.

AIMS

This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made.

METHOD

This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health-related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, 'red flags', end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician.

CONCLUSION

The costs and outcomes of the intervention are compared with usual care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).

Health disparities in later life: a simultaneous equations analysis of utilization

OBJECTIVE

This article examines health disparities between older Blacks/Whites by recognizing the importance of health services utilization. Although previous studies have examined health and utilization independently, this is among the first to (a) model its endogenous relation with utilization, and (b) use a continuous measure for health.

DATA

Household Component files from Medical Expenditures Panel Survey (MEPS) from 2004 and 2005, with 1,369 observations (1,169 for White and 200 for Black) between the ages of 61-69.

METHODS

The methods employed are two-equation modeling where Medicare eligibility functions as the identification criterion and also as an exogenous shock.

RESULTS

The results show older Blacks continue to remain in poorer health despite access to care and insurance status. The author shows underutilization accounts for some of this observed disparity and offers novel approaches to overcome this issue.

CONCLUSION

With the baby-boom cohort approaching retirement, this area of research is timely. This work is also practical because the Department of Health and Human Services has launched various projects examining health care issues for Americans. One major project, Healthy People 2010, provides a "framework for prevention for the Nation [and is] designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats" (http://www.healthypeople.gov/About/). Of the 28 areas, this article complements objectives relating to (a) disability and secondary conditions, and (b) access to quality health services. This article also supports Healthy People 2020, which sets a high priority on access to health care (one of 12 topic areas) and categorizes health disparities as part of the Leading Health Indicators Framework.