Lung cancer screening: assessment of health literacy and readability of online educational resources

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

The Readability, Actionability, and Accessibility of Hemorrhoid-Focused Online Patient Education Materials: Are We Adequately Addressing Patient Concerns?

BACKGROUND

Hemorrhoidal disease is highly prevalent in the United States and frequently queried online. Unfortunately, health education web pages often lack reliable information.

OBJECTIVE

To evaluate whether online hemorrhoid education materials in English and Spanish meet national recommendations for readability, actionability, and accessibility and provide critical clinical guidance on when to seek medical care.

DESIGN

Using 3 search engines (Bing, Google, and Yahoo), we selected the top 30 results for formal medical and colloquial English and Spanish search terms regarding hemorrhoids. We assessed readability using validated scoring systems for readability in English and Spanish to report median reading levels and assessed health literacy performance on a 6-point checklist in 3 categories: accessibility, actionability, and critical clinical guidance.

SETTINGS

University of California Los Angeles.

MAIN OUTCOME MEASURES

Readability and health literacy performance.

RESULTS

After removing duplicates, 90 to 95 web pages generated from formal English, Spanish, and colloquial English terms remained. There was minimal overlap of results from the formal and colloquial English searches. Median reading levels were first-year university for formal and colloquial English web pages and 11th grade for Spanish web pages. Regarding health literacy, 43.2%, 48.4%, and 18.2% of formal English, Spanish, and colloquial English websites, respectively, had minimal health literacy performance. Health literacy performance criteria that were met least often were printability and providing specific, actionable goals for patients to implement.

LIMITATIONS

Our study represents searches completed at 1 point in time using specific terms. Colloquial search terms were generated via a survey with convenience sampling and may not be representative of all possible searches used by patients seeking information on hemorrhoidal disease.

CONCLUSIONS

Most English and Spanish hemorrhoid-focused web pages failed to provide appropriate patient education, as they exceeded the recommended sixth-grade reading level, lacked actionable recommendations, were not accessible, and failed to provide critical clinical guidance. Online resources are essential for patients of all health literacy levels; improvement is critical to reducing health care disparities. See Video Abstract .

LA LEGIBILIDAD, VIABILIDAD Y ACCESIBILIDAD DE LOS MATERIALES EDUCATIVOS EN LNEA CENTRADOS EN LAS HEMORROIDES PARA PACIENTES ESTAMOS ABORDANDO ADECUADAMENTE LAS INQUIETUDES DE LOS PACIENTES

ANTECEDENTES:La enfermedad hemorroidal es muy prevalente en los Estados Unidos y se busca con frecuencia información en línea. Desafortunadamente, las páginas web de educación para la salud a menudo carecen de información confiable.OBJETIVO:Evaluar si los materiales educativos en línea sobre hemorroides en inglés y español cumplen con las recomendaciones nacionales de legibilidad, viabilidad y accesibilidad, y brindan orientación clínica crítica sobre cuándo buscar atención médica.DISEÑO:Utilizando tres motores de búsqueda (Bing, Google, Yahoo), seleccionamos los 30 resultados principales de términos de búsqueda médicos formales y coloquiales en inglés y español relacionados con hemorroides. Evaluamos la legibilidad utilizando sistemas de puntuación validados para la legibilidad en inglés y español para informar los niveles de lectura promedio y evaluamos el desempeño en alfabetización en salud en una lista de verificación de seis puntos en tres categorías: accesibilidad, viabilidad y orientación clínica crítica.ESCENARIO:Universidad de California en Los Ángeles.PRINCIPALES MEDIDAS DE RESULTADOS:Legibilidad y desempeño en alfabetización en salud.RESULTADOS:Después de eliminar los duplicados, quedaron entre 90 y 95 páginas web generadas a partir de términos en inglés formal, español e inglés coloquial. Hubo una superposición mínima de resultados de las búsquedas en inglés formal y coloquial. Los niveles de lectura promedio fueron de primer año de universidad para las páginas web en inglés formal y coloquial, y de undécimo grado para las páginas web en español. El 43,2 %, el 48,4 % y el 18,2 % de los sitios web en inglés formal, español e inglés coloquial, respectivamente, tuvieron un desempeño mínimo en alfabetización en salud. Los criterios de desempeño en alfabetización en salud que se cumplieron con menos frecuencia fueron la posibilidad de imprimir y proporcionar objetivos específicos y viables para que los pacientes los implementen.LIMITACIONES:Nuestro estudio representa búsquedas completadas en un momento dado utilizando términos específicos. Los términos de búsqueda coloquiales se generaron a través de una encuesta con muestreo por conveniencia y pueden no ser representativos de todas las búsquedas posibles utilizadas por los pacientes que buscan información sobre la enfermedad hemorroidal.CONCLUSIONES:La mayoría de las páginas web en inglés y español sobre hemorroides no proporcionaron una educación adecuada para los pacientes, ya que excedían el nivel de lectura recomendado para sexto grado, carecían de recomendaciones prácticas, no eran accesibles y no brindaban orientación clínica crítica. Los recursos en línea son esenciales para los pacientes de todos los niveles de alfabetización en salud; es fundamental mejorarlos para reducir las disparidades en la atención médica. (Traducción-Dr. Felipe Bellolio ).

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

BACKGROUND AND PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

INTERPRETATION

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

Improving lung cancer decision-making using a conversation tool (iDECIDE): a stepped wedge pragmatic clinical trial

Lung cancer is a leading cause of cancer-related mortality. However, few treatment decision-making resources exist. In this study, we evaluate a low literacy lung cancer treatment conversation tool to enhance shared decision-making (SDM). The Improving Decision-Making Encounters in Lung Cancer (iDECIDE) pragmatic, stepped-wedge cluster randomized trial evaluates the effectiveness of a conversation tool for patients with lung cancer. Our primary outcome is SDM, a multifaceted outcome consisting of decisional conflict (DCS), decision self-efficacy (DSES), satisfaction with communication (COMRADE), and assessment of lung cancer knowledge. SDM is assessed 2 weeks, 3 months, and 6 months after patients' treatment decision-making encounter. Each measure within the primary outcome will be assessed separately. We began recruiting patients in 2022 from four health care centers and will conduct outcome assessments at four timepoints over 6 months. We aim to recruit 230 patients by 2025. We seek to address the gaps in NSCLC decision-making support using an innovative trial design to determine whether our conversation tool improves SDM and other patient-centered outcomes.Clinical Trial Registration: NCT05407168 (clinicaltrials.gov).

Hospital-to-Home Transitions for Lung Cancer Patients-A Qualitative Study of Healthcare Professionals' Experiences

AIMS AND OBJECTIVES

To explore the professional practice of transferring patients with lung cancer from hospitals to their homes through the experiences of healthcare professionals (HCPs) working in hospitals.

BACKGROUND

Hospital-to-home transitions are particularly challenging for vulnerable patients, including lung cancer patients, and could threaten patient safety. There is a need to improve coordination between specialised and community care and to develop knowledge on the practice of transferring patients with lung cancer.

DESIGN

A descriptive qualitative design was used. Consolidated criteria for reporting qualitative research (COREQ) were followed for reporting.

METHODS

Six focus group interviews with nurses and two focus group interviews with physicians at pulmonary medicine units in two hospitals in Norway were conducted. Qualitative content analysis was used to analyse the focus group interviews.

RESULTS

Patients' vulnerability and gratitude motivated HCPs to ensure that patients experienced the best hospital-to-home transition. The following obstacles made it challenging to plan for a good hospital-to-home transition and to transfer the responsibility for the patient to the municipality: lack of time and routines to attend to the patient's individual needs, lack of established standards for patient information, absence of resources and predictability, and inadequate communication tools for collaborating with the primary healthcare services.

CONCLUSION

The healthcare system does not provide hospital units and HCPs with adequate resources to accommodate the individual needs of lung cancer patients in hospital-to-home transitions. HCPs compensate with supplementary initiatives to secure patient safety, but the additional responsibility and tasks leave them overworked.

RELEVANCE TO CLINICAL PRACTICE

The study provides knowledge on lung cancer patients' needs in hospital-to-home transitions and how HCPs try to ensure patient safety by compensating for the healthcare system's deficiencies.

PUBLIC CONTRIBUTION

A reference group comprising one patient representative from the Norwegian Cancer Society and five HCPs with varied relevant backgrounds contributed to the overall design, recruited participants, and provided feedback on the interview guide.

"I Saw it Incidentally but Frequently": Exploring the Effects of Online Health Information Scanning on Lung Cancer Screening Behaviors Among Chinese Smokers

In China, lung cancer is the most common cancer with high mortality. While prior research suggests that health information scanning influences cancer screening within the general population, a deeper exploration of the underlying mechanisms is imperative. This study specifically targets smokers, aiming to investigate whether online health information scanning can effectively encourage lung cancer screening and elucidate the mechanisms driving this association. Data were extracted from a Chinese national survey conducted between January and September 2023, exclusively involving current smokers (N = 992). A moderated mediation model was employed to examine a cognitive-affective sequential chain of mediation through risk perceptions and cancer worry. Results showed that 99.1% of Chinese smokers reported online health information scanning, which possessed significant influence. Online health information scanning was positively associated with effective lung cancer screening among smokers directly (OR = 1.927, p < .01) and indirectly (OR = .065, p < .001). The perceived threat of smoking and cancer worry served as the cognitive and affective mediating mechanisms. Furthermore, a moderating effect of eHealth literacy was observed (OR = 6.292, p < .05). Smokers with higher eHealth literacy are more inclined to undergo effective lung cancer screening. Based on these findings, public health sectors should leverage online platforms to disseminate tailored cancer screening education and implement initiatives to enhance public eHealth literacy.

Addressing knowledge and attitude barriers to lung cancer screening: Development and evaluation of web-based decision aid

OBJECTIVE

Low-dose computed tomography screening reduces lung cancer and overall mortality, but the participation rate remains low. The objective of this study was to develop a decision aid (DA) that addresses the overabundance of healthcare options and barriers to participation in lung cancer screening (LCS) among the general population aged 40-79 years in Korea.

MATERIALS AND METHODS

The DA was developed by following the International Patient Decision Aid Standards process. To evaluate the DA, participants aged 40-79 years were purposively sampled from four districts of the Seoul metropolitan area, with 25 individuals from each decade of the age range. Participants used the DA for LCS, and pre-post comparison was conducted. The primary outcome was a change in intention to undergo LCS after completing the DA. The secondary outcomes were changes in knowledge and attitude about LCS, decisional conflict, and the perceived usefulness of the DA.

RESULTS

The DA prototype contained lung cancer risk assessment and decision-making components that addressed knowledge, risks, benefits, costs, and personal values. In a pilot study of 100 participants (mean age 59.0 [SD 11.1] years, 80 % male, 25 % of whom had undergone LCS), knowledge about LCS increased (mean [SD] score [out of 100] before vs. after: 68.3 [13.4] vs. 73.6 [18.0], p < 0.001). A positive change in attitude was observed (p = 0.004), but the intention to screen remained consistent (70 % before vs. 72 % after; p = 0.650). Eighty-eight participants reported the lowest level of conflict in decision-making, and most reported that the DA was useful (mean [SD] score 78.8 [9.0] out of 100). 72 % reported that the DA facilitated self-decision-making, but 27 % felt the DA recommended LCS.

CONCLUSIONS

This study highlights the potential of a well-designed DA to enhance knowledge and attitudes about LCS, but those improvements did not translate to a significant change in screening intentions.

A study protocol for a mixed-method environmental scan of contextual factors that influence lung cancer screening adherence

BACKGROUND

The efficacy of lung cancer screening (LCS) to reduce lung cancer specific mortality is heavily dependent on adherence to recommended screening guidelines, with real-world adherence rates reported to be drastically lower than rates described in clinical trials. There is a dearth in the literature on reminder processes and clinical workflows used to address adherence and robust data is needed to fully understand which clinical set-ups, processes, and context enhance and increase continued LCS participation. This paper describes a protocol for an environmental scan of adherence and reminder processes that are currently used in LCS programs across the United States.

METHODS

This study will triangulate data using a 3-step explanatory sequential mixed methods design to describe mechanisms of current adherence and reminder systems within academic and community LCS programs to pinpoint clinic or system barrier and facilitator combinations that contribute to increased adherence. In step 1, surveys from a nationally representative sample of LCS programs will yield quantitative data about program structure, volume, and tracking/reminder processes and messages. After completion of the survey, interested LCS program personnel will be invited to participate in an in-depth interview (step 2) to explore current processes and interventions used for adherence at the participant and program level. Finally, in step 3, triangulation of quantitative and qualitative data will be completed through qualitative comparative analysis to identify combinations of components that affect higher or lower adherence.

DISCUSSION

This research advances the state of the science by filling a gap in knowledge about LCS program characteristics and processes associated with better adherence which can inform the development and implementation of interventions that are scalable and sustainable across a wide variety of clinical practice settings.

The Use of Podcasts as Patient Preparation for Hospital Visits-An Interview Study Exploring Patients' Experiences

INTRODUCTION

Podcasts have emerged as a promising tool in patient preparation for hospital visits. However, the nuanced experiences of patients who engage with this medium remain underexplored.

OBJECTIVES

This study explored patients' experiences of receiving information by way of podcasts prior to their hospital visits.

METHODS

Semi-structured interviews were conducted with patients with suspected chronic obstructive pulmonary disease (COPD), lung cancer, or sleep apnea. The method of data analysis chosen was thematic analysis.

RESULTS

Based on data from 24 interviews, five key themes were identified: technical challenges in utilization of podcasts; individual preferences for information prior to hospital visits; building trust and reducing anxiety through podcasts; the role of podcasts as an accessible and convenient source of information; and enhancement of engagement and empowerment through podcasts. Additionally, the study highlighted the critical importance of tailoring podcasts' content to individual preferences to optimize the delivery of healthcare information.

CONCLUSIONS

Podcasts can serve as a meaningful supplement to traditional information sources for patients. However, it is important to recognize that not all patients may be able to engage with this medium effectively due to technical challenges or personal preferences.

Evaluating Efficiency and Adherence in Asian Lung Cancer Screening: Comparing Self-paid and Clinical Study Approaches in Taiwan

RATIONALE AND OBJECTIVES

This study aimed to assess how different screening methods, specifically self-paid screening versus participation in clinical studies, affect screening efficiency and adherence in a real-world Asian lung cancer screening population.

MATERIALS AND METHODS

This study collected 4166 participants from our hospital imaging database who underwent baseline low-dose computed tomography (LDCT) between January 2014 and August 2021. Adherence status was determined by counting CT scans, with one check indicating non-adherence and two or more checks indicating adherence. The primary objective was to investigate adherence to LDCT follow-up schedules among individuals with baseline pure ground-glass nodules (GGNs) based on different screening settings and to evaluate adherence status and CT follow-up clinical profiles.

RESULTS

Of the 4166 participants in the study, 3619 in the self-paid group and 547 in the clinical study group were men, with an average follow-up period of 4.5 years. Significant differences were observed in the proportions of Lung-RADS 4 lesions, subsolid nodules, and pure GGN lesions between the self-paid and clinical trial groups. A significant difference was found in adherence rates between the self-paid screening group (60.5%) and the clinical study group (84.8%) (p < 0.001). Adherence status rates significantly increased with larger GGN sizes across categories (p < 0.001). Multivariate logistic regression revealed that age (odds ratio [OR], 1.025; p = 0.012), smoking habits (OR, 1.744; p = 0.036), and clinical study screening type (OR, 3.097; p < 0.001) significantly influenced the adherence status.

CONCLUSION

The disparities in Asian lung cancer screening emphasize the need for increased efficacy, public awareness, and culturally sensitive approaches to mitigate overdiagnosis and enhance adherence among self-paying groups.

Development of Podcasts in a Hospital Setting: A User-Centered Approach

Patient information plays a pivotal role in preparing individuals for hospital visits and empowering them to actively participate in decision-making processes regarding their healthcare. However, many patients face challenges related to reading comprehension. In response, podcasts have become a popular, user-friendly medium for sharing essential and easily understandable information in an engaging format.The aim of the present project was to use a user-centered approach to develop podcasts providing patient information prior to hospital visits. We aimed to describe the steps of the development in detail with the purpose of inspiring podcast development in the future.In Phase 1 we conducted interviews with patients and focus groups with clinicians based on the "empathy map" method, with the purpose of exploring patients' needs on which to subsequently build the podcasts' content and format. In Phase 2 we produced and refined the podcasts on the basis of feedback from clinician- and patients representatives.Our results indicated the importance of clear and concise language, personalization of communication, and content alignment with patients' needs. Our project resulted in a description of each step of the development that can be used as inspiration for others who wish to take a user-centered approach to podcast development.

Promoting Lung Cancer Screen Decision-Making and Early Detection Behaviors: A Systematic Review and Meta-analysis

BACKGROUND

Promoting lung cancer screening (LCS) is complex. Previous studies have overlooked that LCS behaviors are stage based and thus did not identify the characteristics of LCS interventions at different screening stages.

OBJECTIVE

The aims of this study were to explore the characteristics and efficacy of interventions in promoting LCS decision making and behaviors and to evaluate these interventions.

METHODS

We conducted a study search from the inception of each bibliographic database to April 8, 2023. The precaution adoption process model was used to synthesize and classify the evidence. The RE-AIM framework was used to evaluate the effectiveness of LCS programs. Heterogeneity tests and meta-analysis were performed using RevMan 5.4 software.

RESULTS

We included 31 studies that covered 4 LCS topics: knowledge of lung cancer, knowledge of LCS, value clarification exercises, and LCS supportive resources. Patient decision aids outperformed educational materials in improving knowledge and decision outcomes with a significant reduction in decision conflict (standardized mean difference, 0.81; 95% confidence interval, -1.15 to -0.47; P < .001). Completion rates of LCS ranged from 3.6% to 98.8%. Interventions that included screening resources outperformed interventions that used patient decision aids alone in improving LCS completion. The proportions of reported RE-AIM indicators were highest for reach (69.59%), followed by adoption (43.87%), effectiveness (36.13%), implementation (33.33%), and maintenance (9.68%).

CONCLUSION

Evidence from 31 studies identified intervention characteristics and effectiveness of LCS interventions based on different stages of decision making.

IMPLICATIONS FOR PRACTICE

It is crucial to develop targeted and systematic interventions based on the characteristics of each stage of LCS to maximize intervention effectiveness and reduce the burden of lung cancer.

Social and Biological Determinants in Lung Cancer Disparity

Lung cancer remains a leading cause of death in the United States and globally, despite progress in treatment and screening efforts. While mortality rates have decreased in recent years, long-term survival of patients with lung cancer continues to be a challenge. Notably, African American (AA) men experience significant disparities in lung cancer compared to European Americans (EA) in terms of incidence, treatment, and survival. Previous studies have explored factors such as smoking patterns and complex social determinants, including socioeconomic status, personal beliefs, and systemic racism, indicating their role in these disparities. In addition to social factors, emerging evidence points to variations in tumor biology, immunity, and comorbid conditions contributing to racial disparities in this disease. This review emphasizes differences in smoking patterns, screening, and early detection and the intricate interplay of social, biological, and environmental conditions that make African Americans more susceptible to developing lung cancer and experiencing poorer outcomes.

Evaluation of the usability, content, readability and cultural appropriateness of online alcohol and other drugs resources for Aboriginal and Torres Strait Islander Peoples in New South Wales, Australia

OBJECTIVES

This study aimed to analyse the usability, content, readability and cultural appropriateness of alcohol and other drugs (AODs) resources for Aboriginal and Torres Strait Islander Peoples in New South Wales (NSW), Australia.

OUTCOME MEASURES

The content of 30 AOD resources for Aboriginal and Torres Strait Islander Peoples was analysed according to the following criteria: general characteristics; elements of graphical design and written communication; thoroughness and content; readability (Flesch-Kincaid grade level (FKGL), Gunning Fog index (Fog), Simplified Measure of Gobbledygook and Flesch Reading Ease); and cultural appropriateness.

RESULTS

Most resources displayed good usability, depicted by the use of headings and subheadings (n=27), superior writing style (n=19), relevant visuals (n=19) and use of colour support (n=30). However, some resources used at least one professional jargon (n=13), and many did not provide any peer-reviewed references (n=22). During content analysis, 12 resources were categorised into the alcohol group and 18 resources in the other drugs group. Impact of alcohol during pregnancy and breast feeding (n=12) was the most common included topics in the resources related to alcohol, while the physical impact of drugs (n=15) was the most discussed topics among the other drugs group. Based on the FKGL readability score, 83% of resources met the recommended reading grade level of 6-8 by NSW Health. Many resources (n=21) met at least half of the cultural appropriateness elements of interest. However, less than one-third were developed in collaboration with the local community (n=9), used local terms (n=5), targeted the local community (n=3), included an Aboriginal voice (n=2) and addressed the underlying cause (n=1).

CONCLUSIONS

Many AOD resources are developed specifically for Aboriginal and Torres Strait Islander Peoples, but their usability, content and readability differed, and they were not culturally appropriate for all communities. Development of a standardised protocol for resource development is suggested.

Impact of U.S. Preventive Services Task Force lung cancer screening update on drivers of disparities in screening eligibility

BACKGROUND

In 2021, the U.S. Preventive Services Task Force (USPSTF) updated its recommendation to expand lung cancer screening (LCS) eligibility and mitigate disparities. Although this increased the number of non-White individuals who are eligible for LCS, the update's impact on drivers of disparities is less clear. This analysis focuses on racial disparities among Black individuals because members of this group disproportionately share late-stage lung cancer diagnoses, despite typically having a lower intensity smoking history compared to non-Hispanic White individuals.

METHODS

We used data from the National Health Interview Survey to examine the impact of the 2021 eligibility criteria on racial disparities by factors such as education, poverty, employment history, and insurance status. We also examined preventive care use and reasons for delaying medical care.

RESULTS

When comparing Black individuals and non-Hispanic White individuals, our analyses show significant differences in who would be eligible for LCS: Those who do not have a high school diploma (28.7% vs. 17.0%, p = 0.002), are in poverty (26.2% vs. 14.9%, p < 0.001), and have not worked in the past 12 months (66.5% vs. 53.9%, p = 0.009). Further, our analyses also show that more Black individuals delayed medical care due to not having transportation (11.1% vs. 3.6%, p < 0.001) compared to non-Hispanic White individuals.

CONCLUSIONS

Our results suggest that despite increasing the number of Black individuals who are eligible for LCS, the 2021 USPSTF recommendation highlights ongoing socioeconomic disparities that need to be addressed to ensure equitable access.

Lung Cancer Screening

Lung cancer is a leading cause of cancer death in the United States and globally with the majority of lung cancer cases attributable to cigarette smoking. Given the high societal and personal cost of a diagnosis of lung cancer including that most cases of lung cancer when diagnosed are found at a late stage, work over the past 40 years has aimed to detect lung cancer earlier when curative treatment is possible. Screening trials using chest radiography and sputum failed to show a reduction in lung cancer mortality however multiple studies using low dose CT have shown the ability to detect lung cancer early and a survival benefit to those screened. This review will discuss the history of lung cancer screening, current recommendations and screening guidelines, and implementation and components of a lung cancer screening program.

Primary Care Physician Perceptions of Shared Decision Making in Lung Cancer Screening

The Centers for Medicare and Medicaid Services (CMS) supports lung cancer screening (LCS) with annual low-dose computed tomography (LDCT) for patients who undergo shared decision-making (SDM) about LCS. Unfortunately, SDM and LCS rates are low in primary care, and, as a result, the potential benefits of LCS are not being realized. The research team interviewed 16 primary care physicians in a large urban medical center (7 in Family and Community Medicine and 9 in Internal Medicine) on their views of SDM and LCS. Interview audio-recordings were transcribed. Coders analyzed the interview transcripts independently using direct content analysis to identify major themes and subthemes. Results of interview analyses show that physicians were aware of LCS but believed that they and their patients would benefit from receiving more information about screening guidelines. Physicians knew about SDM and felt that SDM performance could help to identify issues that are important to patients and may affect their receptivity to LCS. However, many physicians expressed concerns about the time required for SDM and completing SDM about LCS when other issues need to be addressed. They also acknowledged the challenge of engaging patients, especially those with low health literacy, in SDM. In practice, some physicians reported instead of engaging eligible patients in SDM, they simply encourage them to screen. Importantly, most physicians said that they would like to receive training in SDM. Findings from this study indicate that primary care physicians support the dissemination of information about LCS and understand the importance of SDM. Physicians also feel that performing SDM in routine care is challenging but are receptive to additional training in SDM. Health systems should take steps to support SDM and LCS performance in primary care.

Lung Disease in Central Appalachia: It's More than Coal Dust that Drives Disparities

The population living in Central Appalachia is disproportionately impacted by lung disease. This is driven, in part, by occupational hazards and environmental exposures. However, it is more than coal dust that is driving the ongoing disparity of lung disease in the region. This review describes how the decline of the coal mine industry and subsequent rise of unemployment, poverty, and educational disparities have increased risk for worse pulmonary health outcomes in the region. Additional challenges related to healthcare access, substance use, cultural characteristics, and social capital are highlighted in their relation to pulmonary health within Central Appalachia. Lastly, the review describes strategies that hold promise to reduce regional health disparities. Several healthcare and community-centered initiatives are highlighted as successful examples of collaborative efforts working towards improving pulmonary health outcomes in the region. However, significant challenges related to social, economic, and environmental factors remain. Addressing these social determinants of health must be a paramount concern for healthcare, community and political leaders seeking to impact change and improve the health and well-being of this vulnerable population.

Readability Assessment of HPV Vaccination and Cervical Cancer Information: A Systematic Scoping Review

It is important to provide information on HPV vaccination and on early detection and early treatment for cervical cancer. Readability is a key aspect in the success of cancer communication using written health information. We reviewed studies assessing the readability of information on HPV vaccination and cervical cancer. We conducted a systematic literature search in June 2021 using four online databases (Medline, CINAHL, PsycArticles, and PsycINFO). Studies that assessed the readability level of online and offline information regarding HPV vaccination and cervical cancer were included in the review. Twelve articles were deemed fit for study inclusion. Our results showed that most of the materials assessed were difficult to read and higher than eighth-grade reading level. Few of the materials assessed were at the recommended grade 5-6 level or below. Readability assessments of HPV vaccination and cervical cancer information are scarce. Additional studies on the readability of information regarding HPV vaccination and cervical cancer are recommended. Health professionals should develop health information on HPV vaccination and cervical cancer that is easy to read.

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

OBJECTIVES

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

METHODS

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

KEY FINDINGS

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

CONCLUSIONS

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

Disparities in Lung Cancer Screening: A Review

Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.

Lung cancer screening eligibility and use with low-dose computed tomography: Results from the 2018 Behavioral Risk Factor Surveillance System cross-sectional survey

BACKGROUND

In randomized controlled trials, lung cancer screening with low-dose chest computed tomography (LCS) has been reported to reduce lung cancer mortality. Although initial studies suggested that only approximately 5% of eligible patients have undergone LCS, recent studies have indicated that use of LCS may be increasing nationwide. The objective of the current study was to estimate recent LCS use using cross-sectional survey data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey.

METHODS

The BRFSS is a nationally representative, cross-sectional telephone survey of adults in the United States (response rate of approximately 50%). The 2018 BRFSS survey included questions regarding LCS eligibility and use in 8 states. The primary outcome was the percentage of participants (aged 55-79 years with a smoking history of >30 pack-years) who reported undergoing LCS. Logistic regression analyses evaluated the association between LCS use and sociodemographic characteristics, adjusted for potential confounders and accounting for complex survey design elements.

RESULTS

A total of 26,910 participants were included, 9.9% of whom were eligible for LCS (95% CI, 8.8%-10.6%). Of the eligible patients, 19.2% reported undergoing LCS (95% CI, 14.0%-24.4%). Approximately 16.4% of current smokers were eligible for LCS (95% CI, 14.2%-18.6%). In our multiple variable analyses of eligible patients, age, sex, marital status, current smoking status, and race were not found to be associated with statistically significant differences in reported LCS (P > .05). Retired patients, patients with personal physicians, and patients who did not complete a high school education were more likely to report receiving LCS (P < .05).

CONCLUSIONS

Compared with previously published studies, the results of the current study suggested that LCS use is increasing. However, LCS use remains low (19%) among eligible participants.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Delving deeper into disparity: The impact of health literacy on the surgical care of breast cancer patients

BACKGROUND

Breast surgical oncology is a unique field that involves complex cancer management and longstanding patient interactions with the healthcare system, making it potentially challenging for patients with low health literacy. The purpose of this review is to summarize the current knowledge regarding health literacy in breast cancer and identify future directions for research and potential intervention in breast surgical oncology.

DATA SOURCES

A search of relevant literature querying PubMed and Science Direct was performed and included the following keywords: health literacy, breast cancer, breast surgical oncology, surgery, outcomes, prevention, screening, healthcare utilization, chronic disease.

CONCLUSIONS

Limited health literacy may detrimentally affect understanding and outcomes in breast surgical oncology. Identifying ways providers can improve patient understanding and utilization of health information is important, and surgeons may have a pivotal role. Further studies addressing health literacy in breast surgical oncology is needed in order to better optimize care of patients.

The Difficulty of German Information Booklets on Psoriasis and Psoriatic Arthritis: Automated Readability and Vocabulary Analysis

Background

Information-seeking Psoriasis or Psoriatic Arthritis patients are confronted with numerous educational materials when looking through the internet. Literature suggests that only 17.0-21.4% (Psoriasis, Psoriatic Arthritis) of patients have a good level of knowledge about psoriasis treatment and self-management. A study from 1994 found that English Psoriasis/Psoriatic Arthritis brochures required a reading level between grades 8-12 to be understandable, which was confirmed in a follow-up study 20 years later. As readability of written health-related text material should not exceed the sixth-grade level, Psoriasis/Psoriatic Arthritis material seems to be ill-suited to its target audience. However, no data is available on the readability levels of Psoriasis/Psoriatic Arthritis brochures for German-speaking patients, and both the volume and their scope are unclear.

Objective

This study aimed to analyze freely available educational materials for Psoriasis/Psoriatic Arthritis patients written in German, quantifying their difficulty by assessing both the readability and the vocabulary used in the collected brochures.

Methods

Data collection was conducted manually via an internet search engine for Psoriasis/Psoriatic Arthritis–specific material, published as PDF documents. Next, raw text was extracted, and a computer-based readability and vocabulary analysis was performed on each brochure. For the readability analysis, we applied the Flesch Reading Ease (FRE) metric adapted for the German language, and the fourth Vienna formula (WSTF). To assess the laymen-friendliness of the vocabulary, the computation of an expert level was conducted using a specifically trained Support Vector Machine classifier. A two-sided, two-sample Wilcoxon test was applied to test whether the difficulty of brochures of pair-wise topic groups was different from each other.

Results

In total, n=68 brochures were included for readability assessment, of which 71% (48/68) were published by pharmaceutical companies, 22% (15/68) by nonprofit organizations, and 7% (5/68) by public institutions. The collection was separated into four topic groups: basic information on Psoriasis/Psoriatic Arthritis (G1/G2), lifestyle, and behavior with Psoriasis/Psoriatic Arthritis (G3/G4), medication and therapy guidance (G5), and other topics (G6). On average, readability levels were comparatively low, with FRE=31.58 and WSTF=11.84. However, two-thirds of the educational materials (69%; 47/68) achieved a vocabulary score ≦4 (ie, easy, very easy) and were, therefore, suitable for a lay audience. Statistically significant differences between brochure groups G1 and G3 for FRE (P=.001), WSTF (P=.003), and vocabulary measure (L) (P=.01) exist, as do statistically significant differences for G2 and G4 in terms of FRE (P=.03), WSTF (P=.03) and L (P=.03).

Conclusions

Online Psoriasis/Psoriatic Arthritis patient education materials in German require, on average, a college or university education level. As a result, patients face barriers to understanding the available material, even though the vocabulary used seems appropriate. For this reason, publishers of Psoriasis/Psoriatic Arthritis brochures should carefully revise their educational materials to provide easier and more comprehensible information for patients with lower health literacy levels.

Evaluation of the Informational Content and Readability of US Lung Cancer Screening Program Websites

IMPORTANCE

The internet is an important source of medical information for many patients and may have a key role in the education of patients about lung cancer screening (LCS). Although most LCS programs in the United States have informational websites, the accuracy, completeness, and readability of these websites have not previously been studied.

OBJECTIVE

To evaluate the informational content and readability of US LCS program websites.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed US LCS program websites identified on September 15, 2018. A standardized checklist was used to assess key informational content of each website, and text was analyzed for reading level, word count, and reading time. Links to US websites of national advocacy organizations with LCS program content were tabulated. All functional LCS program websites in Google internet search engine results using the search terms lung cancer screening, low-dose CT screening, and lung screening were included in the analysis.

MAIN OUTCOMES AND MEASURES

Radiologists used a standardized checklist to evaluate content, and readability was assessed with validated scales. Website word count, reading time, and number of links to outside LCS informational websites were assessed.

RESULTS

A total of 257 LCS websites were included in the analysis. The word count ranged from 73 to 4410 (median, 571; interquartile range, 328-909). The reading time ranged from 0.3 to 19.6 minutes (median, 2.5; interquartile range, 1.5-4.0). The median reading level of all websites was grade 10 (interquartile range, 9-11). Only 26% (n = 66) of websites had at least 1 web link to a national website with additional information on LCS. There was wide variability regarding reported eligibility age criteria, with ages 55 to 77 years most frequently cited (42% [n = 108]). Only 56% (n = 143) of websites mentioned smoking cessation. The subject of patient cost was mentioned on 75% (n = 192) of websites. Although major LCS benefits, such as detection of lung cancer, were discussed by most (93% [n = 239]) websites, less than half of the websites (45% [n = 115]) made any mention of possible risks associated with screening.

CONCLUSIONS AND RELEVANCE

There appears to be marked variability in the informational content of US LCS program websites, and the reading level of most websites is above that recommended by the American Medical Association and the National Institutes of Health. Efforts to improve website content and readability may be warranted.

Barriers, Facilitators, and Suggested Interventions for Lung Cancer Screening Among a Rural Screening-Eligible Population

Introduction: Rural areas are disproportionally affected by lung cancer late-stage incidence and mortality. Lung cancer screening (LCS) is recommended to find lung cancer early and reduce mortality, yet uptake is low. The purpose of this study was to elucidate the barriers to, facilitators of, and suggested interventions for increasing LCS among a rural screening-eligible population using a mixed methods concurrent embedded design study. Methods: Qualitative and quantitative data were collected from rural-residing adults who met the eligibility criteria for LCS but who were not up-to-date with LCS recommendations. Study participants (n = 23) took part in 1 of 5 focus groups and completed a survey. Focus group discussions were recorded, transcribed, and coded through a mixed deductive and inductive approach. Survey data were used to enhance and clarify focus group results; these data were integrated in the design and during analysis, in accordance with the mixed methods concurrent embedded design approach. Results: Several key barriers to LCS were identified, including an overall lack of knowledge about LCS, not receiving information or recommendation from a health care provider, and lack of transportation. Key facilitators were receiving a provider recommendation and high motivation to know the screening results. Participants suggested that LCS uptake could be increased by addressing provider understanding and recommendation of LCS and conducting community outreach to promote LCS awareness and access. Conclusion: The results suggest that the rural screening-eligible population is generally receptive to LCS. Patient-level factors important to getting this population screened include knowledge, transportation, motivation to know their screening results, and receiving information or recommendation from a provider. Addressing these factors may be important to increase rural LCS uptake.

Educational Attainment and Quality of Life among Older Adults before a Lung Cancer Diagnosis

Background: Demographic and contextual factors are associated with quality of life (QoL) in older adults and prediagnosis QoL among older adults has important implications for supportive care in older cancer patients. Objective: To examine whether lower educational attainment is associated with poorer QoL among community dwelling older adults just before their diagnosis of lung cancer in a nationally representative sample. Design: This study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) dataset, which provides cancer registry data linked with survey data for Medicare Advantage enrollees. Subjects: Adults 65 years and older at time of diagnosis with first or only primary lung cancer and with at least one survey before their cancer diagnosis. Measurements: Level of education attained was categorized as less than high school (<HS) or at least a high school diploma (≥HS). QoL was calculated based on individual subscale scores from the 36-item Short Form Health Survey (SF-36) until 2006 (Veteran's RAND 12-Item Survey [VR-12] after 2006). Demographic covariates as well as number of comorbidities were adjusted for in multivariable models. Results: Higher education was positively associated with prediagnosis mental and physical QoL. Other factors associated with lower QoL were Medicaid status and number of comorbidities. Conclusions: Particular attention should focus on identifying and addressing QoL needs among vulnerable older adults to bolster QoL to mitigate its potential impact on prognosis following a lung cancer diagnosis.

Readability and Understandability Analysis of Online Materials Related to Abdominal Aortic Aneurysm Repair

Background:

Patients commonly use online materials as a source of health information. Since poor health literacy has been shown to correlate with negative outcomes, it is recommended that patient-directed materials be written at a sixth-grade reading level. This study evaluates the readability and understandability of commonly accessed online materials pertaining to both endovascular and open repair of abdominal aortic aneurysm.

Methods:

Searches for “endovascular repair abdominal aortic aneurysm” and “open repair abdominal aortic aneurysm” were performed on both Google and Bing, and the top 10 websites from each search engine were identified. Relevant websites (total N = 28, endovascular n = 15, open n = 15, and 2 redundant sites) with patient-directed content were analyzed. Readability was assessed using 9 established methods, and understandability was assessed using the Patient Education Materials Assessment Tool scoring system.

Results:

The average reading grade level for all sites was 12.8. Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 to 15.6. Open-repair websites had a grade-level average of 12.1 with a range from 9.9 to 14.1. Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of −0.551 ( P = .003). No website was written at or below the recommended sixth-grade reading level.

Conclusions:

Patient-directed online health information pertaining to open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level. Increasing complexity of health literature correlates with poor understandability. Modifications such as shorter sentences, fewer words with more than 6 letters, and increasing usage of clear visual aids can increase readability and understandability.

Automatic Evaluation of Cancer Treatment Texts for Gist Inferences and Comprehension

Background. It is difficult to write about cancer for laypeople such that everyone understands. One common approach to readability is the Flesch-Kincaid Grade Level (FKGL). However, FKGL has been shown to be less effective than emerging discourse technologies in predicting readability. Objective. Guided by fuzzy-trace theory, we used the discourse technology Coh-Metrix to create a Gist Inference Score (GIS) and applied it to texts from the National Cancer Institute website written for patients and health care providers. We tested the prediction that patient cancer texts with higher GIS scores are likely to be better understood than others. Design. In study 1, all 244 cancer texts were systematically subjected to an automated Coh-Metrix analysis. In study 2, 9 of those patient texts (3 each at high, medium, and low GIS) were systematically converted to fill-the-blanks (Cloze) tests in which readers had to supply the missing words. Participants (162) received 3 texts, 1 at each GIS level. Measures. GIS was measured as the mean of 7 Coh-Metrix variables, and comprehension was measured through a Cloze procedure. Results. Although texts for patients scored lower on FKGL than those for providers, they also scored lower on GIS, suggesting difficulties for readers. In study 2, participants scored higher on the Cloze task for high GIS texts than for low- or medium-GIS texts. High-GIS texts seemed to better lend themselves to correct responses using different words. Limitations. GIS is limited to text and cannot assess inferences made from images. The systematic Cloze procedure worked well in aggregate but does not make fine-grained distinctions. Conclusions. GIS appears to be a useful, theoretically motivated supplement to FKGL for use in research and clinical practice.