Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen): a tool to screen adolescents for below-grade reading in health care settings

Subjective health literacy skills among Greek secondary school students: results from a national-wide survey

Health literacy is a significant element of education and is inextricably linked to children's and adolescents' growth and prosperity. It is critical to monitor students' health literacy on a nationwide scale and identify the factors that influence it in order to create policies that advance it. The purpose of this study was to determine the health literacy level of Greek secondary school students and to correlate it with possible determinants such as personal and family characteristics, social support and personal and/or family illness experiences. A representative sample of 2749 seventh-, ninth-, and tenth-grade students was involved. Results showed that a higher motivation to learn about health topics and having positive social interactions and support were strongly associated with a higher level of health literacy. Gender, high academic achievement, absence of learning disabilities, gender, preference for biology and informatics and primary source of health information were also found to influence the skills' level. In order to enhance health literacy, the Greek educational system should take measures to include health literacy skills development goals in their curricula.

Health literacy and adolescents' substance use behaviors and correlates: a scoping review

From 2011 to 2023, substance use increased by 23% worldwide. Given that substance use initiation is highest during adolescence, it is crucial to identify amenable correlates of substance use prevention [e.g. health literacy (HL)], which, if embedded in interventions, may improve uptake and outcomes. Hence, this study conducted a scoping review to answer the question: What is known from the existing literature about the relationship between HL and substance use correlates and behaviors in adolescents? Five electronic databases and the bibliography of review articles were searched and a total of 1770 records were identified. After removing duplicates and engaging in three levels of screening to identify studies that included adolescents ≤ 25 years old and assessed the relationship between general HL (vs. behavior/disease-specific health knowledge) and substance use behaviors and correlates, 16 studies were retained. Studies assessed alcohol-related (n = 11), tobacco-related (n = 12), electronic vapor product use-related (n = 4), cannabis-related (n = 1), and amphetamines/methamphetamines-related (n = 1) outcomes. Studies spanned Africa, Asia, Europe, and North and Central America. Most studies included substance use as an outcome and found an inverse relationship between HL and use. Few studies examined substance use correlates (e.g. risk perception). There were no longitudinal or intervention studies. This review highlighted that the topic of adolescent HL and its relationship with substance use remains inadequately researched. Notable gaps for future studies include intervention and longitudinal designs, expansion of outcomes (e.g. more studies on marijuana, prescription drug misuse, vaping, substance use-related correlates), and examining HL as a mediator or moderator of substance use and its correlates.

What Is Health Literacy Among Orthognathic Surgery Patients?

BACKGROUND

Health literacy of orthognathic surgery patients has not been thoroughly evaluated.

PURPOSE

The purpose of this study was to estimate health literacy and identify risk factors associated with inadequate health literacy in orthognathic surgery patients.

STUDY DESIGN, SETTING, SAMPLE

A cross-sectional study was implemented utilizing patients ages 14-80 years who presented for orthognathic surgery evaluation between September 2021 and December 2022. Subjects were excluded from the study if they did not complete the orthognathic surgery evaluation, were not between the ages of 14-80 years old, or did not complete the Brief Health Literacy Screening Tool (BRIEF) questionnaire during intake. Subjects who have not undergone orthognathic surgery but completed the initial evaluation for orthognathic surgery were included in the study.

PREDICTOR VARIABLES

The predictor variables were a set of risk factors for inadequate health literacy: age, sex, primary language, race, estimated household income, and diagnosis.

MAIN OUTCOME VARIABLE

The main outcome variable was health literacy assessed using the BRIEF questionnaire. During intake, subjects completed the BRIEF questionnaire consisting of four questions scored on an ordinal scale of 1-5. Inadequate health literacy was defined as a BRIEF score ≤16.

COVARIATES

Not applicable.

ANALYSES

Bivariate and multivariate analyses were performed. P < .05 was considered statistically significant.

RESULTS

Of 150 patients presenting for orthognathic surgery, fifteen percent of patients had inadequate health literacy via the BRIEF test. The mean age of those with adequate health literacy was 27.9 years (standard deviation, ±12.5) compared to 18.5 years (standard deviation, ±5.7) for those with inadequate health literacy (P = <.001). After adjusting for sex, language, race, estimated household income, and diagnosis via multivariate analysis, increasing age was associated with decreased odds of inadequate health literacy (adjusted odds ratio = 0.81; confidence interval, 0.72-0.92; P = <.001).

CONCLUSION AND RELEVANCE

In the complex process of orthognathic surgery, it is essential to identify patients with inadequate health literacy that may require additional health literacy interventions. Ultimately, 15% of orthognathic surgery subjects had inadequate health literacy, and younger patients were the most susceptible as the odds of inadequate health literacy decreased with increasing age.

The Intersection of Health Literacy and Public Health: A Machine Learning-Enhanced Bibliometric Investigation

In recent decades, health literacy has garnered increasing attention alongside a variety of public health topics. This study aims to explore trends in this area through a bibliometric analysis. A Random Forest Model was utilized to identify keywords and other metadata that predict average citations in the field. To supplement this machine learning analysis, we have also implemented a bibliometric review of the corpus. Our findings reveal significant positive coefficients for the keywords "COVID-19" and "Male", underscoring the influence of the pandemic and potential gender-related factors in the literature. On the other hand, the keyword "Female" showed a negative coefficient, hinting at possible disparities that warrant further investigation. Additionally, evolving themes such as COVID-19, mental health, and social media were discovered. A significant change was observed in the main publishing journals, while the major contributing authors remained the same. The results hint at the influence of the COVID-19 pandemic and a significant association between gender-related keywords on citation likelihood, as well as changing publication strategies, despite the fact that the main researchers remain those who have been studying health literacy since its creation.

Optimizing health literacy to facilitate reproductive health decision-making in adolescent and young adults with cancer

Despite being considered "standard of care" by many organizations, fertility and reproductive health communications and counseling practices remain inconsistent for adolescents and young adults (AYAs) newly diagnosed with cancer and during survivorship. One factor known to affect how information is provided and received in the medical setting is health literacy. Providers should consider health literacy to optimize reproductive health communication with AYAs as they cope with their diagnosis, understand what it means for their future, process information about treatment options, learn about their potential harmful effects on fertility, make quick decisions about fertility preservation, and navigate a future family planning course. Thus, the objectives of this manuscript are to (a) summarize literature on reproductive health literacy; (b) describe health literacy frameworks; (c) examine ways to assess health literacy; and (d) identify ways to enhance clinician-patient communication in the AYA oncofertility setting.

Pilot label comprehension study for an over-the-counter combined oral contraceptive pill in the United States

CONTEXT

A growing body of evidence supports over-the-counter access to oral contraceptives in the United States. An important consideration for over-the-counter approval is consumers' ability to understand key package label messages related to safety and effectiveness without clinician involvement. We developed a prototype over-the-counter Drug Facts Label for a combined oral contraceptive pill and conducted a pilot label comprehension study to evaluate consumer understanding of key messages for use.

METHODS

In November-December 2020, we conducted interviews with 163 adults and teens in the United States who were aged 12-49 years and identified as female or another gender but had a uterus and the ability to become pregnant. We developed 11 primary endpoints based on assessment of clinical risks that could occur if consumers fail to heed them, including messages about contraindications and directions for use; 11 secondary endpoints represented additional important information but with lower potential for clinical consequences if not understood. We evaluated endpoint comprehension by computing frequencies, percentages, and 2-sided Exact (Clopper-Pearson) 95% confidence intervals for observed proportions.

RESULTS

Ten of the 11 primary endpoints and 10 of the 11 secondary endpoints were each understood by ≥95% of participants. The remaining primary endpoint on use with prior blood clots was understood by 89% of participants. The remaining secondary endpoint on the product being designed for "people who have the ability to become pregnant" was understood by 83% of participants.

CONCLUSION

Participants understood the key label information required for safe and effective combined oral contraceptive use without clinician involvement.

Modeling the potential benefit of an over-the-counter progestin-only pill in preventing unintended pregnancies in the U.S

OBJECTIVES

To develop a model to estimate the possible impact of use of an over-the-counter (OTC) progestin-only pill (POP) on the number of unintended pregnancies in the United States.

STUDY DESIGN

Using typical use failure rates (7% for POPs), we compared the expected number of unintended pregnancies for two theoretical cohorts of 100,000 women: one which purchased and used an OTC POP exclusively for contraception, the other using contraceptive methods at proportions obtained from an actual-use clinical trial simulating OTC use of norgestrel 0.075 mg (including 35% using no method and only 19% using hormonal contraception or long-acting contraceptives). Sensitivity analyses were conducted using alternative model inputs such as different failure rates for OTC POPs and varied alternative contraceptive method mix.

RESULTS

An estimated 37,624 unintended pregnancies would occur annually if 100,000 women continued their usual contraceptive method as used at baseline in the actual use trial. This would be reduced by 81% to 7,000 pregnancies with the exclusive use of an OTC POP - a net reduction of 30,624 unintended pregnancies annually. While the number of unintended pregnancies prevented varied as the model parameters were modified (ranging from 1,461 to 34,124), a net benefit of OTC POP use was observed over a wide range of input values.

CONCLUSIONS

Using data from a real-world contraception user profile, our model suggests that use of an OTC POP could reduce the overall number of unintended pregnancies in the United States. This conclusion remains true across a wide range of modeled scenarios.

IMPLICATIONS

The estimates suggested by this model are supportive of an OTC switch for a POP.

Vergleich unterschiedlicher Instrumente zur Messung von Gesundheitskompetenz im Zusammenhang mit Lesekompetenz und kognitiven Fähigkeiten von Jugendlichen

Zusammenfassung. Instrumente zur Messung von Gesundheitskompetenz bei Jugendlichen basieren auf sehr heterogenen Definitionen und Konzepten. Zudem können sie grundsätzlich in subjektive (Selbsteinschätzungs–) und objektive (die Performanz messende) Verfahren unterteilt werden. In der vorliegenden Studie wurden 2 subjektive (eHEALS; Kurzform des HLS-EU-Q16) und ein objektives Messinstrument (Claim) von 471 Jugendlichen der 6. und 7. Klassenstufe (Durchschnittsalter 13.04 Jahre; 49 % Mädchen; 63 % Familiensprache Deutsch) bearbeitet und auf ihren wechselseitigen Zusammenhang, den Zusammenhang mit kognitiven und Lesefähigkeiten, sowie Unterschiede in Bezug auf Geschlecht und Familiensprache untersucht. Das objektive Verfahren korrelierte nicht mit den subjektiven Verfahren. Dies bestätigt die Annahme, dass sie aufgrund der Messperspektive unterschiedliche Indikatorenausprägungen von Gesundheitskompetenz erfassen. Korrelationen mit Lese- und kognitiven Fähigkeiten zeigten sich nur beim objektiven Instrument, wohingegen die Selbsteinschätzungsinstrumente diese Aspekte der Gesundheitskompetenz nicht abbilden. Unterschiede hinsichtlich des Geschlechts und der Familiensprache zeigten sich insbesondere beim objektiven Instrument, allerdings sind Antwortverzerrungen bei Selbsteinschätzungen möglich. Die spezifischen Vor- und Nachteile von subjektiven und objektiven Verfahren sollten bei der Instrumentenauswahl berücksichtigt werden.

Measuring health literacy: A systematic review and bibliometric analysis of instruments from 1993 to 2021

BACKGROUND

It has been about 30 years since the first health literacy instrument was developed. This study aimed to review all existing instruments to summarize the current knowledge on the development of existing measurement instruments and their possible translation and validation in other languages different from the original languages.

METHODS

The review was conducted using PubMed, Web of Science, Scopus, and Google Scholar on all published papers on health literacy instrument development and psychometric properties in English biomedical journals from 1993 to the end of 2021.

RESULTS

The findings were summarized and synthesized on several headings, including general instruments, condition specific health literacy instruments (disease & content), population- specific instruments, and electronic health. Overall, 4848 citations were retrieved. After removing duplicates (n = 2336) and non-related papers (n = 2175), 361 studies (162 papers introducing an instrument and 199 papers reporting translation and psychometric properties of an original instrument) were selected for the final review. The original instruments included 39 general health literacy instruments, 90 condition specific (disease or content) health literacy instruments, 22 population- specific instruments, and 11 electronic health literacy instruments. Almost all papers reported reliability and validity, and the findings indicated that most existing health literacy instruments benefit from some relatively good psychometric properties.

CONCLUSION

This review highlighted that there were more than enough instruments for measuring health literacy. In addition, we found that a number of instruments did not report psychometric properties sufficiently. However, evidence suggest that well developed instruments and those reported adequate measures of validation could be helpful if appropriately selected based on objectives of a given study. Perhaps an authorized institution such as World Health Organization should take responsibility and provide a clear guideline for measuring health literacy as appropriate.

The Role of Health Literacy in Health Behavior, Health Service Use, Health Outcomes, and Empowerment in Pediatric Patients with Chronic Disease: A Systematic Review

About 8% of all children and adolescents worldwide are affected by chronic diseases. Managing chronic conditions requires pediatric patients to be health literate. The purpose of this review is to examine the existing evidence on the links between health literacy and its outcomes proposed by the model by Sørensen et al. in chronically ill pediatric patients. Four electronic databases (PubMed, Scopus, CINAHL, PsycINFO) were searched to identify pertinent articles published up to November 2021. The search was conducted independently by two researchers and restricted to observational studies. Of 11,137 initial results, 11 articles met eligibility criteria. Overall, 6 studies identified a significant association between health literacy and one of the considered outcomes. Regarding health behavior, none of the studies on adherence found significant associations with health literacy. The results in terms of health service use were inconclusive. Regarding health outcomes, health literacy did not affect most physiological parameters, but it significantly improved health-related quality of life. Overall, evidence remains inconclusive but suggests that health literacy is associated with self-efficacy, health-related quality of life, and health service use in pediatric patients. Further research should be undertaken to strengthen the evidence.

Socio-Economic Determinants of Health Literacy in High School Students: A Cross-Sectional Study

Today, a person’s health literacy (HL) is perceived as a critical determinant for their health. It is well known that limited health literacy is associated with harmful health behaviours, the lower use of preventive services, problems in making use of healthcare resources and poor skills for the self-management of chronic disorders. This study analysed the level and factors associated with HL in high school students in southern Poland. The study is based on the data from a paper-and-pencil survey of high schools students in the Malopolska Voivodshop. The students were selected using a two-stage cluster random sampling procedure. The level of HL was assessed with the European Health Literacy Survey Questionnaire, consisting of 47 items. Univariate logistic and linear regression models were applied to analyse the association between general HL score and the main domain-specific indices. The respondents whose parents had attended University and came from more affluent families were less likely to demonstrate limited HL. There was a significant positive relationship between the self-assessment of the economic situation, size of accommodation, the level of expenditure on a mobile phone and receiving external support, the size of the book collection at home, and domain-specific HL sub-indices. In conclusion, among socio-demographic factors, the parents’ education is the only consistent predictor of the level of HL in high school students. Furthermore, most variables reflecting the economic status of the respondent’s family are significantly associated with the general HL score and its sub-indices.

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth

PURPOSE

Youths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization.

METHODS

Youths with special healthcare needs aged 12-18 years were recruited from a Medicaid accountable care organization (2012-2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness.

RESULTS

Among 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (β = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis.

CONCLUSIONS

HL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

A Study on the Reliability and Validity of the Korean Health Literacy Instrument for Late School-Aged Children

This study aimed to develop and validate the Korean Health Literacy Instrument, which measures Korean late school-aged children's understanding capacity. The construct's concepts were drawn from the literature review and interviews with school nurses and teachers. A survey was then conducted in 552 fifth and sixth graders in nine elementary schools, from 1 to 9 May 2014. The KR-20 coefficient for reliability, difficulty index, discrimination index, item-total correlation, and known group technique for validity were performed. An exploratory factor analysis was performed to test the construct validity of the instrument and its unidimensionality. The results reveal that a two-factor structure was appropriate for the Korean school-age health literacy tool (root mean square error of approximation = 0.06, Comparative Fit Index = 0.96, and Tucker-Lewis Index = 0.95). From the remaining 16 items, the internal consistency reliability coefficient of this instrument was 0.85, and the criterion-related validity was 0.62 (p < 0.001). The Korean health literacy instrument for late school-aged children was suitable for screening individuals who have limited health literacy. Based on the findings of this study, future studies must continue to conduct empirical investigations on the Korean health literacy instrument for late school-aged children.

Health Literacy Does Not Protect Against Underage Alcohol Use During the COVID-19 Pandemic

Limited health literacy (HL) and alcohol use increase teens' risk for preventable disease burden and adverse outcomes. In the current study, relationships between HL and alcohol use were explored in 39 secondary school students sheltering-at-home during the coronavirus disease 2019 pandemic. HL was assessed using the Newest Vital Sign. Alcohol use was assessed with questions from the Youth Risk Behavior Survey (YRBS). Most students (76.9%) had adequate HL. Males had higher HL than females. Many teens (42.9%) reported drinking and recent alcohol use (18.2%). Drunk driving and riding with someone under the influence were comparable to the YRBS. Lifetime and recent alcohol use and positive alcohol expectancies were comparable among teens with adequate and limited HL. More teens with adequate HL had negative expectancies. Only teens with adequate HL reported recent binge drinking (10.3%), drunk driving (10.5%), or riding with someone under the influence (17.9%). Adequate HL does not protect teens from alcohol use and misuse. [Journal of Psychosocial Nursing and Mental Health Services, 59(12), 13-21.].

"The Way you Interpret Health": Adolescent Definitions and Perceptions of Health Literacy

BACKGROUND

Adolescents are required to take increased responsibility for their health. Although health literacy is implicated in adults' health decision-making and health behaviors, little is known about adolescents' health literacy and its relationship to their health behaviors. Furthermore, adolescent health literacy research overlooks adolescent development-specific needs and skills. Therefore, we qualitatively explored adolescents' (1) definitions of health literacy, preventive health behaviors, and health risk behaviors; and (2) perception of the health literacy/health behavior relationship.

METHODS

Six semi-structured focus groups were conducted with adolescents (N = 37) who answered questions about their perceptions of health literacy, preventive health behaviors, and health risk behaviors. Focus groups were coded using thematic analysis. Themes representing adolescents' definitions of health literacy were secondarily coded for alignment with definitions in the literature.

RESULTS

Some of adolescents' health literacy definitions aligned with the adult health literacy literature. They considered health literacy a tool for informed decision-making, but acknowledged not always using these skills.

CONCLUSIONS

Adolescents' definitions of health literacy were multidimensional, going beyond numeracy and literacy skills. Developmental characteristics and adolescents' definition of health risk behaviors were related to use of health literacy skills. Opportunities for adolescents to develop and practice health literacy skills are discussed.

GeneLiFT: A novel test to facilitate rapid screening of genetic literacy in a diverse population undergoing genetic testing

With the broader introduction of genomic medicine in research and clinical care, an increasing number of persons are offered genetic testing. Many factors, including genetic literacy, may impact the utilization of genetic results by patients and their families. We developed a rapid, self-administered measure of genetic literacy, called Genetic Literacy Fast Test (GeneLiFT). We next evaluated the association of GeneLiFT scores with the comprehension of limitations of genomic medicine in participants undergoing genetic testing in the NIH-sponsored eMERGE III study at Columbia University Irving Medical Center, New York. All participants underwent genetic screening for variants in 74 actionable genes associated with adult-onset disorders. A diverse cohort of 724 participants completed the survey (60% women, 45% less than 40 years old, and 53% self-reported White non-Hispanic ancestry). The GeneLiFT was validated using known group differences based on education, health literacy, and numeracy, and with questions assessing genetic knowledge. GeneLiFT identified multiple standard genetics terms, that is, jargon, not recognized by more than 50% of participants (including actionability and pathogenicity). Low genetic literacy, identified in 210 participants (29%), was significantly associated with poor understanding of the limitations of genetic testing (p-values < 10-9 ). This association was independent of education, health literacy, and numeracy levels, highlighting the importance of directly measuring genetic literacy. Low genetic literacy was also associated with low satisfaction with the informed consent process. GeneLiFT is a practical tool for rapid assessment of genetic literacy in large studies or clinical care. GeneLiFT will allow future research to efficiently assess the role of genetic literacy on the clinical impact of genetic testing.

Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs?

OBJECTIVE

To explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities.

METHODS

HL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12-18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression.

RESULTS

Half of youth and over 80 percent of parents had adequate HL (REALM score ≥62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites.

CONCLUSION

Results suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC.

PRACTICAL IMPLICATIONS

Provider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.

Testing the Digital Health Literacy Instrument for Adolescents: Cognitive Interviews

Background

Despite the increasing number of youth seeking health information on the internet, few studies have been conducted to measure digital health literacy in this population. The digital health literacy instrument (DHLI) is defined as a scale that measures the ability to operate digital devices and read and write in web-based modes, and it assesses seven subconstructs: operational skills, navigation skills, information searching, evaluating reliability, determining relevance, adding self-generated content to a web-based app, and protecting privacy. Currently, there is no validation process of this instrument among adolescents.

Objective

This study aims to explore the usability and content validity of DHLI.

Methods

Upon the approval of institutional review board protocol, cognitive interviews were conducted. A total of 34 adolescents aged 10-18 years (n=17, 50% female) participated in individual cognitive interviews. Two rounds of concurrent cognitive interviews were conducted to assess the content validity of DHLI using the thinking aloud method and probing questions.

Results

Clarity related to unclear wording, undefined technical terms, vague terms, and difficult vocabularies was a major issue identified. Problems related to potentially inappropriate assumptions were also identified. In addition, concerns related to recall bias and socially sensitive phenomena were raised. No issues regarding response options or instrument instructions were noted.

Conclusions

The initial round of interviews provided a potential resolution to the problems identified with comprehension and communication, whereas the second round prompted improvement in content validity. Dual rounds of cognitive interviews provided substantial insights into survey interpretation when introduced to US adolescents. This study examined the validity of the DHLI and suggests revision points for assessing adolescent digital health literacy.

Patient-Reported Outcome Measures in Voice: An Updated Readability Analysis

PURPOSE

The purpose of this study was to investigate whether voice-related patient-reported outcome measures (PROMs) developed and validated since 2011 meet the recommendation by health literacy experts that such materials be written at a fifth-to-sixth grade reading level.

METHOD

A readability analysis of eight voice-related PROMs was conducted. Readability formulas utilized were the Coleman-Liau index, Flesch-Kincaid reading ease, FORCAST, simple measure of Gobbledygook index, and Gunning-Fog score.

RESULT

Three-fourths of the PROMs exceeded the recommended fifth- to sixth-grade reading level.

CONCLUSION

Although awareness of health literacy has grown, voice-related PROMs continue to be developed without full consideration of their reading grade level. Researchers should consider revising or developing PROMs with consideration to reading grade level as well as other features to enhance readability.

Health Literacy and Health Behavior Among Women in Ghazni, Afghanistan

Background: Health literacy is a determinant of health and assessed globally to inform the development of health interventions. However, little is known about health literacy in countries with one of the poorest health indicators worldwide, such as Afghanistan. Studies worldwide demonstrate that women play a key role in developing health literacy. Hence, this study's purpose is to explore health literacy of women in Afghanistan and the associated factors. Methods: From May to June 2017, we randomly recruited 7-10 women per day at the hospital in Ghazni, a representative province of Afghanistan. Two trained female interviewers interviewed 322 women (15-61 years old) orally in Dari or Pashto on a voluntary basis and assessed their health literacy using the HLS-EU-Q16, associated socio-demographics, and health behavior. Results: Health literacy of women (among educated and illiterates) is low even compared to other Asian countries. Health literacy is linked to age and education. We found mixed evidence of the relationship between health literacy and contextual factors, help-seeking, and health-related behavior. Conclusion: This study provides novel data on health literacy and astonishing insights into its association with health behavior of women in Afghanistan, thus contributing to health status. The study calls for recognition of health literacy as a public health challenge be addressed in Afghanistan and other low-income countries affected by crises.

Cultural Adaptation of Health Literacy Measures: Translation Validation of the Newest Vital Sign in Arabic-Speaking Parents of Children With Type 1 Diabetes in Kuwait

PURPOSE

The purpose of the study was to assess the feasibility of use and reliability of the Arabic version of the Newest Vital Sign (NVS-Ar) in parents of children with type 1 diabetes (T1D).

METHODS

The final translated version of NVS-Ar was administered to 175 adult caregivers of children with T1D who are native Arabic speakers. The association between NVS-Ar scores for the parents/legal guardians and A1C for their children was assessed. The internal consistency was evaluated by Cronbach's α, and reliability was assessed by test-retest method.

RESULTS

The median (interquartile range) score was 4.0 (3-5). The internal consistency of the NVS-Ar was moderate (α = .58). The intraclass correlation coefficient was .61. There was no correlation between NVS-Ar score and A1C (Spearman's ρ = .055; P = .62). Furthermore, there was significant inverse association between adequate health literacy and optimal glycemic control among the children, which remained evident even after adjusting for the duration of T1D, age, or education of the parents/guardians. However, it lost statistical significance after adjustment for treatment regimen.

CONCLUSION

Study findings indicate that the NVS is unlikely to be a predictive tool for functional health literacy in Arabic settings and that there is a need to properly translate and validate other tools such as the Test of Functional Health Literacy in Adults or, alternatively, to develop a reliable tool.

Using an educational intervention to assess and improve disease-specific knowledge and health literacy and numeracy in adolescents and young adults with haemophilia A and B

INTRODUCTION

Health literacy (HL) and health numeracy (HN) are underestimated barriers to treatment adherence in patients with haemophilia.

AIM

To test the ability of an educational intervention to improve knowledge, HL, HN, adherence and joint health in adolescent and young adult (AYA) males with haemophilia.

METHODS

We performed a longitudinal pilot study of 41 participants aged 12-21 years with haemophilia A or B during two clinic visits 6-12 months apart. The first visit included a comprehensive pre-intervention assessment: demographics, knowledge survey, Montreal Cognitive Assessment testing, 5-question tool to assess baseline HN, assessment of HL with the Rapid Estimate of Adolescent Literacy in Medicine tool, history of adherence and Haemophilia Joint Health Score (HJHS). An educational intervention using a visual aid explained basic pharmacokinetic (PK) concepts and personal teaching regarding haemophilia treatment regimens was used during this visit. The second visit included a post-intervention assessment: a reassessment of knowledge, HL, HN, HJHS, adherence to prescribed therapy and number of joint bleeds since the pre-intervention visit.

RESULTS

Forty-one males with haemophilia A or B were enrolled in the study. Of these, 33 completed the post-intervention assessment. Knowledge (p = .002) and HN (p = .05) were significantly improved post-intervention, although the HL, number of joint bleeds, adherence to prescribed therapy and HJHS were not.

CONCLUSIONS

Participants with low HL and/or HN may benefit from alternate methods of education such as audiovisual material. Education using audiovisual materials improved knowledge and HN in this study; however, this did not affect adherence to prescribed therapy.

A Medical Student Initiative to Enhance the Pediatric Hemodialysis Experience

Background:

Children and young adults receiving hemodialysis (HD) face unique challenges including frequent school absenteeism, psychosocial issues, and social isolation, placing them at risk for decreased academic achievement and health literacy.

Objective:

To address this, we implemented the Child and Adolescent Motivation and Enrichment Program (CHAMP) at Holtz Children's Hospital in Miami, FL. The objective of this study is to describe the organizational structure and program design of CHAMP and provide preliminary program opinions.

Methods:

Medical students served as longitudinal one-on-one mentors to patients receiving HD. Face-to-face intervention, books, board games, and electronic tablets were used to enhance patients' educational and recreational experience. We surveyed participating patients, medical students, and unit nurses regarding their opinions of CHAMP.

Key Results:

Patients responded to a series of questions on a Likert scale scored from 1 to 5 and reported the highest scores on questions pertaining to having fun with mentors (mean = 4.88), enjoying mentor visits (mean = 4.78), and learning during visits (mean = 3.88). Mentors reported the highest level of agreement (mean = 4.82) that CHAMP helped them gain empathy for patients with chronic and/or special health care needs. Nurses scored highly on the point that “overall, the program was useful and helped the patient” (mean = 6.86 of a possible 7).

Conclusion:

CHAMP is an academic and psychosocial enrichment program for children and adolescents receiving HD. The program is regarded highly by participating patients, medical students, and unit nurses. Patients report enjoying and learning from mentor sessions, whereas nurses report improved interactions with patients. Medical students who participate as mentors also gain important exposure to the field of pediatric nephrology. The program design as described herein positions CHAMP for replication at academic medical centers nationwide, allowing for optimization of the health and well-being of the pediatric HD population. [HLRP: Health Literacy Research and Practice. 2021;5(1):e60–e69.]

Plain Language Summary:

Pediatric patients undergoing hemodialysis (HD) are at risk for decreased academic achievement and health literacy. To address this, we implemented the Child and Adolescent Motivation and Enrichment Program, a longitudinal mentorship program pairing medical students as one-on-one mentors to patients undergoing HD. Preliminary results from this program demonstrate satisfaction and enjoyment by participating patients, medical students, and dialysis unit nurses.

Dimensionen der Gesundheitskompetenz von Viertklässler*innen

Hintergrund

Die Gesundheitskompetenz (GK) junger Menschen wird von Wissenschaft und Politik zunehmend als Ansatzpunkt für Gesundheitsförderung und Prävention anerkannt. Gerade die GK von Kindern wurde jedoch, insbesondere in Deutschland, bisher kaum erforscht. Diese Studie widmet sich dieser Forschungslücke, indem sie die GK von Viertklässler*innen in Nordrhein-Westfalen (NRW) untersucht.

Ziel der Arbeit (Fragestellung)

Die Fragestellung ist die explorative Beschreibung verschiedener Dimensionen der GK von Kindern unter Berücksichtigung sozioökonomischer Merkmale.

Material und Methoden

Es wurde eine schriftliche Klassenraumbefragung durchgeführt. Der Fragebogen, der speziell für 9‑ bis 10-Jährige entwickelt wurde, umfasst drei Dimensionen der GK: selbstberichtete allgemeine GK, funktionale GK (schriftsprachliche und numerische Fähigkeiten) und das Gesundheitswissen.

Ergebnisse

Es wurden 899 Schüler*innen an 32 Schulen befragt. Hierbei wurde eine hohe selbstberichtete GK ermittelt: die Befragten empfinden den Umgang mit Gesundheitsinformationen als einfach. Kinder mit niedrigem Wohlstand schneiden in allen Dimensionen der GK signifikant schlechter ab. Dies gilt mit Ausnahme der selbstberichteten GK auch für Kinder, die zuhause nicht nur Deutsch sprechen.

Schlussfolgerung

Diese Studie untersucht erstmals die GK von Viertklässler*innen in NRW. Wenngleich die selbstberichtete GK hoch ist, zeigt sich schon bei dieser jungen Altersgruppe ein sozialer Gradient hinsichtlich Wohlstand und Sprache. Die Forschungslage ist für das Kindesalter zwar noch lückenhaft und es besteht weiterhin Forschungsbedarf, die Ergebnisse deuten aber auf einen frühen Interventionsbedarf hin, um allen Kindern unabhängig von ihrer Herkunft zu ermöglichen, GK in dem Maß zu entwickeln, wie es der eigenen Gesundheit zuträglich ist.

Osteosarcoma Online Resources: A Quantitative Assessment of the Understandability and Readability of Web-based Patient Education Material (Preprint)

Background

Patients often turn to web-based resources following the diagnosis of osteosarcoma. To be fully understood by average American adults, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend web-based health information to be written at a 6th grade level or lower. Previous analyses of osteosarcoma resources have not measured whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT) is a validated measurement of understandability and actionability.

Objective

The purpose of this study was to evaluate web-based osteosarcoma resources using measures of readability, understandability, and actionability.

Methods

Using the search term “osteosarcoma,” two independent Google searches were performed on March 7, 2020 (by AGS), and March 11, 2020 (by TRG). The top 50 results were collected. Websites were included if they were directed at providing patient education on osteosarcoma. Readability was quantified using validated algorithms: Flesh-Kincaid Grade Ease (FKGE), Flesch-Kincaid Grade-Level (FKGL). A higher FKGE score indicates that the material is easier to read. All other readability scores represent the US school grade level. Two independent PEMAT assessments were performed with independent scores assigned for both understandability and actionability. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Statistical significance was defined as P≤.05.

Results

Two searches yielded 53 unique websites, of which 37 (70%) met the inclusion criteria. The mean FKGE and FKGL scores were 40.8 (SD 13.6) and 12.0 (SD 2.4), respectively. No website scored within the acceptable NIH or AHA recommended reading level. Only 4 (11%) and 1 (3%) website met the acceptable understandability and actionability threshold. Both understandability and actionability were positively correlated with FKGE (ρ=0.55, P<.001; ρ=0.60, P<.001), but were otherwise not significantly associated with other readability scores. There were no associations between readability (P=.15), understandability (P=.20), or actionability (P=.31) scores and Google rank.

Conclusions

Overall, web-based osteosarcoma patient educational materials scored poorly with respect to readability, understandability, and actionability. None of the web-based resources scored at the recommended reading level. Only 4 achieved the appropriate score to be considered understandable by the general public. Authors of patient resources should incorporate PEMAT and readability criteria to improve web-based resources to support patient understanding.

Group-Based Care in Adults and Adolescents With Hypertension and CKD: A Feasibility Study

Rationale & Objective

Group-based care provides an opportunity to increase patient access to providers without increasing physician time and is effective in the management of chronic diseases in the general population. This model of care has not been investigated in chronic kidney disease (CKD).

Study Design

Randomized controlled trial in adults (n = 50); observational study in adolescents (n = 10).

Setting & Participants

Adults and adolescents with CKD and hypertension in the Bronx, NY.

Intervention

Group-based care (monthly sessions over 6 months) versus usual care in adults. All adolescents received group-based care and were analyzed separately.

Outcomes

Participant attendance and satisfaction with group-based care were used to evaluate intervention feasibility. The primary clinical outcome was change in mean 24-hour ambulatory blood pressure. Secondary outcomes included physical activity, medication adherence, quality of life, and sodium intake as assessed by 24-hour urinary sodium excretion and food frequency questionnaires.

Results

Among adults randomly assigned to group-based care, attendance was high (77% of participants attended ≥3 sessions) and most reported higher satisfaction. Mean 24-hour ambulatory systolic blood pressure decreased by −4.2 (95% CI, −13.3 to 5.8) mm Hg in group-based care patients compared with usual care at 6 months but this was not statistically significant. Similarly, we did not detect significant differences in health-related behaviors (such as medication adherence, sodium intake, and physical activity) or quality-of-life measures between the 2 groups. Among the adolescents, attendance was very poor; self-reported satisfaction, although high, did not change from baseline compared with the 6-month follow-up.

Limitations

Small study size, missing data.

Conclusions

Group-based care is feasible and acceptable among adults with hypertension and CKD. However, a larger trial is needed to determine the effect on blood pressure and health-related behaviors. Patient participation may limit the effectiveness of group-based care models in adolescents.

Funding

National Institutes of Health R34 DK102174.

Trial registration

https://clinicaltrials.gov/show/NCT02467894.

FDA Initiative for Drug Facts Label for Over-the-Counter Naloxone

BACKGROUND

The opioid crisis highlights the need to increase access to naloxone, possibly through regulatory approval for over-the-counter sales. To address industry-perceived barriers to such access, the Food and Drug Administration (FDA) developed a model drug facts label for such sales to assess whether consumers understood the key statements for safe and effective use.

METHODS

In this label-comprehension study, we conducted individual structured interviews with 710 adults and adolescents, including 430 adults who use opioids and their family and friends. Eight primary end points were developed to assess user comprehension of each of the key steps in the label. Each of these end points included a prespecified target threshold ranging from 80 to 90% that was evaluated through a comparison of the lower boundary of the 95% exact confidence interval.

RESULTS

The results for performance on six primary end points met or exceeded thresholds, including the steps "Check for a suspected overdose" (threshold, 85%; point estimate [PE], 95.8%; 95% confidence interval [CI], 94.0 to 97.1) and "Give the first dose" (threshold, 85%; PE, 98.2%; 95% CI, 96.9 to 99.0). The lower boundaries for four other primary end points ranged from 88.8 to 94.0%. One exception was comprehension of "Call 911 immediately," but this instruction closely approximated the target of 90% (PE, 90.3%; 95% CI, 87.9 to 92.4). Another exception was comprehension of the composite step of "Check, give, and call 911 immediately" (threshold, 85%; PE, 81.1%; 95% CI, 78.0 to 83.9).

CONCLUSIONS

Consumers met thresholds for sufficient understanding of six of eight components of the instructions in the drug facts label for naloxone use and came close on two others. Overall, the FDA found that the model label was adequate for use in the development of a naloxone product intended for over-the-counter sales.

How Do Subjective Health Literacy Measures Work in Young Adults? Specifying "Online" or "Paper-Based" Forms Impacts Results

Purpose. There is no gold-standard health literacy measure. The Single Item Literacy Screener (SILS) and Subjective Literacy Screener (SLS) ask people to self-report ability to understand health information. They were developed in older adults, before common use of electronic health information. This study explored whether the SILS and SLS related to objective literacy, numeracy, and comprehension among young adults, and whether specifying "online" or "paper-based" wording affected these relationships. Methods. Eligible individuals (18-35 years of age, English-speaking, US residents) from an online survey company were randomized to 1) original measures; 2) measures adding "paper-based" to describe health information/forms; or 3) measures adding "online" to describe health information/forms. We examined how each measure related to e-Health Literacy (eHEALS), subjective numeracy (SNS), objective numeracy (ONS), and comprehension of a short passage. Results. A total of 848/1342 respondents correctly answered attention-checks and were analyzed. The validated SILS related to comprehension (P = 0.003), eHEALS (P = 0.04), and ONS (P < 0.001) but not SNS (P = 0.44). When adding "paper-based," SILS related to eHEALS (P < 0.001) and ONS (P = 0.003) but did not relate to comprehension (P = 0.25) or SNS (P = 0.35). When adding "online," SILS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P = 0.005), and SNS (P = 0.03). The validated SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P < 0.001), and SNS (P < 0.001). When adding "paper-based," the SLS only related to eHEALS (P = <0.001) and comprehension (P = 0.03) but did not relate to ONS (P = 0.13) or SNS (P = 0.33). When adding "online," the SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), and SNS (P = 0.03) but not ONS (P = 0.06). Conclusions. Young adults might interpret subjective health literacy measures differently when prompted to think about electronic or paper-based information. Researchers should consider clearer instructions or modified wording when using these measures in this population.

Systematic Review of Health Literacy in Childhood Cancer Patients, Survivors, and Their Caregivers

Objective

This systematic review examined the literature regarding health literacy among pediatric cancer patients, survivors, and their caregivers. Specific aims were to identify and summarize measures used, levels of and demographic correlates of health literacy, effects of health literacy interventions, and associations between health literacy and health outcomes.

Methods

The search strategy was executed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, ERIC, and the Cochrane Library. Of the 842 unique studies retrieved, 9 met the inclusion criteria and were included in the systematic review.

Results

Studies used a variety of validated and study-specific measures with no measure emerging as the standard. Levels of health literacy were typically assessed subjectively and across studies the majority of those sampled self-reported adequate health literacy. Few studies examined demographic correlates of health literacy, precluding the identification of consistent predictors. Health literacy intervention research for this population is in its infancy and only pilot projects were identified; effects could not be evaluated. No studies assessed the impact of health literacy on health outcomes.

Conclusions

Very few studies assessed health literacy in pediatric oncology. As treatment for childhood cancer becomes increasingly complex, and patients and caregivers are expected to have adequate understanding of health information, health literacy is a critical construct that should not be overlooked.

Health-Related Quality of Life and Health Literacy among Mexican American and Black American Youth in a Southern Border State

Among adults, health literacy and health-related quality of life are highly correlated constructs that are associated with tangible health outcomes. While the connection between these concepts and health outcomes among youth is still unclear, studying these factors among at-risk adolescent populations can provide researchers, policy-creators, and educators a quantifiable summary of the challenge they face in their efforts to reduce health disparities. The purpose of this study was to better understand the health of minority youth living in a Southern state near the US-Mexico border. Specifically, we sought to describe their health literacy and health-related quality of life, and identify how those concepts may be interrelated. Results indicated that our sample of primarily Mexican American and Black American youth living along the US-Mexico border may be struggling more than other known high-risk groups in terms of health literacy and health-related quality of life. Practical implications for families, schools, and border communities are discussed.

Functional health literacy among left-behind students in senior high schools in an ethnic minority area: A cross-sectional study

To verify the validity of functional health literacy scale and analyze what influences functional health literacy.Using convenience sampling method based on cross-sectional data to select 589 left-behind senior high-school students in an ethnic minority area, using the functional health literacy scale.The scale results were relatively strong, and the absolute fitness index, value-added fitness index, and simple fitness index reached the fitness standards. The overall functional health literacy score was (0.65 ± 0.12), which falls within the upper middle class. Gender(t = 2.40, P < .05), ethnicity (t = 4.28, P < .001), place of residence (t =  = 4.51, P < .001), mother's education level (F = 3.608, P < .05), self-assessment of grades for 1 year (F = 25.781, P < .001), and whether the participant liked the health education content (F = 9.416, P < .001) had impacts on overall functional health literacy.The study results show that relatively satisfactory reliability and validity and can be applied further analysis for improving students functional health literacy levels.

Measurement of Key Constructs in a Holistic Framework for Assessing Self-Management Effectiveness of Pediatric Asthma

The 2007 U.S. National Institutes of Health EPR-3 guidelines emphasize the importance creating a provider-patient partnership to enable patients/families to monitor and take control of their asthma, so that treatment can be adjusted as needed. However, major shortfalls continue to be reported in provider adherence to EPR-3 guidelines. For providers to be more engaged in asthma management, they need a comprehensive set of resources for measuring self-management effectiveness of asthma, which currently do not exist. In a previously published article in the Journal of Asthma and Allergy, the authors conducted a literature review, to develop a holistic framework for understanding self-management effectiveness of pediatric asthma. The essence of this framework, is that broad socioecological factors can influence self-agency (patient/family activation), to impact self-management effectiveness, in children with asthma. A component of socio-ecological factors of special relevance to providers, would be the quality of provider-patient/family communication on asthma management. Therefore, the framework encompasses three key constructs: (1) Provider-patient/family communication; (2) Patient/family activation; and (3) Self-management effectiveness. This paper conducts an integrative review of the literature, to identify existing, validated measures of the three key constructs, with a view to operationalizing the framework, and discussing its implications for asthma research and practice.

The impact of traditional literacy and education on health literacy in adolescents with asthma

Introduction: People with low health literacy have poorer self-management of chronic diseases like asthma. Studies of parent health literacy and education level on the management of children's chronic illnesses reveal inconclusive results. We hypothesized a correlation between parent and adolescent health literacy in teens with asthma. Methods: Sociodemographic data were obtained; health literacy was assessed on adolescents and parents with three instruments: Rapid Estimate of Adolescent/Adult Literacy in Medicine (REALM), Single Item Literacy Screener (SILS) and Newest Vital Sign (NVS). Agreement between scores was examined by calculating weighted kappa statistics and performing Bowkers test of symmetry. Results: In all, 243 adolescents and 203 parents completed health literacy assessments yielding 198 paired observations. 9th-12th graders, 60.6% female, 72.7% African-American (AA), mean age: 15.3 years (±0.9). Parent education ranged from < high school (19.1%) to college graduate (24.0%). Agreement between adolescent and parent scores was poor: REALM (κw = 0.26), SILS (κw = 0.12), and NVS (κw = 0.29) and disagreement did not significantly differ by race. Positive correlations of moderate strength (overall and between racial groups) were found between reading scores and both REALM and NVS scores, and between REALM and NVS scores. Due to the inverse relationship of SILS scores with health literacy level, SILS scores (overall and between racial groups) were weakly and negatively correlated with reading scores, REALM and NVS. Conclusion: Correlation between education level and traditional literacy suggests that these are contributing factors to the health literacy of adolescents with asthma. Correlation between adolescent and caregiver health literacy was not supported.

Assessing the link between modified 'Teach Back' method and improvement in knowledge of the medical regimen among youth with kidney transplants: The application of digital media

OBJECTIVE

The objective of this study was to facilitate functional health literacy (FHL) with a modified "Teach Back" method. A computer-based program was developed for adolescent and young adult kidney transplant recipients (KTR) to knowledgeably answer questions about their medical condition, medications, and create a simple synopsis of their personal health record with the help of the heath care provider (HCP).

METHODS

In a pre-post quasi-experimental design, 16 patients received the computer intervention in which they navigated questionnaires and brief informational video clips. Knowledge scores were assessed at baseline and 3 months. The binomial sign test was used to evaluate change in knowledge and purpose of medications.

RESULTS

Mean age was 17.3 ± 2.4 years and 94% were non-Caucasian. Seven of 16 patients were academically below grade level. Twelve of 16 patients improved their overall knowledge (P = 0.0002) and purpose of medications (P = 0.0017).

CONCLUSIONS

A Modified "Teach Back" during clinic visits was associated with improvements in FHL.

PRACTICE IMPLICATIONS

This modified 'teach back' program has the potential to improve FHL which could contribute to long-term preservation of kidney transplants.

Developing and trialling a school-based ovulatory-menstrual health literacy programme for adolescent girls: a quasi-experimental mixed-method protocol

INTRODUCTION

A review of international and Australian school-based resources suggests that teaching of the ovulatory-menstrual (OM) cycle is predominantly couched in biology. A whole-person framework that integrates spiritual, intellectual, social and emotional dimensions with the physical changes of the OM cycle is needed to facilitate adolescent OM health literacy. This paper describes the protocol for a study that aims to develop and trial an intervention for adolescent girls aged 13-16 years that enhances positive attitudes towards OM health coupled with developing skills to monitor and self-report OM health. These skills aim to foster acceptance of the OM cycle as a 'vital sign' and facilitate confident communication of common OM disturbances (namely, dysmenorrhoea, abnormal uterine bleeding and premenstrual syndrome), which are known to impact school and social activities.

METHODS AND ANALYSIS

Phase I will comprise a Delphi panel of women's health specialists, public health professionals and curriculum consultants and focus groups with adolescent girls, teachers and school healthcare professionals. This will inform the development of an intervention to facilitate OM health literacy. The Delphi panel will also inform the development of a valid and reliable questionnaire to evaluate OM health literacy. Phase II will trial the intervention with a convenience sample of at least 175 adolescent girls from one single-sex school. The mixed-method evaluation of the intervention will include a pre-intervention and post-intervention questionnaire. One-on-one interviews with teachers and school healthcare professionals will expand the understanding of the barriers, enablers and suitability of implementation of the intervention in a school-based setting. Finally, focus groups with purposively selected trial participants will further refine the intervention.

ETHICS AND DISSEMINATION

The study findings will be disseminated through local community seminars, conferences, peer-review articles and media channels where appropriate. The Curtin University of Human Research Ethics Committee has approved this study (approval HRE2018-0101). This project is registered with the 'Australian and New Zealand Clinical Trials Registry'.

TRIAL REGISTRATION NUMBER

ACTRN12619000031167; Pre-results.

QuikLitE, a Framework for Quick Literacy Evaluation in Medicine: Development and Validation

Background

A plethora of health literacy instruments was developed over the decades. They usually start with experts curating passages of text or word lists, followed by psychometric validation and revision based on test results obtained from a sample population. This process is costly and it is difficult to customize for new usage scenarios.

Objective

This study aimed to develop and evaluate a framework for dynamically creating test instruments that can provide a focused assessment of patients’ health literacy.

Methods

A health literacy framework and scoring method were extended from the vocabulary knowledge test to accommodate a wide range of item difficulties and various degrees of uncertainty in the participant’s answer. Web-based tests from Amazon Mechanical Turk users were used to assess reliability and validity.

Results

Parallel forms of our tests showed high reliability (correlation=.78; 95% CI 0.69-0.85). Validity measured as correlation with an electronic health record comprehension instrument was higher (.47-.61 among 3 groups) than 2 existing tools (Short Assessment of Health Literacy-English, .38-.43; Short Test of Functional Health Literacy in Adults, .34-.46). Our framework is able to distinguish higher literacy levels that are often not measured by other instruments. It is also flexible, allowing customizations to the test the designer’s focus on a particular interest in a subject matter or domain. The framework is among the fastest health literacy instrument to administer.

Conclusions

We proposed a valid and highly reliable framework to dynamically create health literacy instruments, alleviating the need to repeat a time-consuming process when a new use scenario arises. This framework can be customized to a specific need on demand and can measure skills beyond the basic level.

Sexual and reproductive health literacy of school adolescents in Lao PDR

RATIONALE

Adolescent pregnancy in Lao PDR is the highest in Southeast Asia. It leads to negative health and social consequences in young people. It is anticipated that this problem is partly caused by limited sexual and reproductive health literacy (SRHL), leading to poor sexual and reproductive health (SRH) decisions. Based on the concept of health literacy, SRHL goes beyond knowledge and behavior and is the self-perceived ability of an individual to access the needed information, understand the information, appraise and apply the information into informed decision making for a good way to contribute to sexual and reproductive health. It is not only knowing (knowledge) and doing (behavior), but it is the process of individual's thought on an SRH problem before taking an action. The aim of this study was to measure SRHL among school-going adolescents aged 15-19 and to determine factors associated with SRHL.

METHOD

We conducted a cross-sectional study in rural and urban areas of Lao PDR in 2017. Respondents completed a self-administered questionnaire with five parts: socio-demographic, personal health, SRH knowledge and behavior, SRHL, and functional literacy. We calculated the SRHL score based on the HL-EU index and used descriptive statistics to determine the score and levels. Then we used bivariate statistics and multiple linear regression to identify factors associated with SRHL in these adolescents.

RESULT

Among 461 respondents, 65.5% had inadequate SRHL. Scores were positively and significantly associated with several factors, including: school location (β: 3.218; p<0.001), knowledge on SRH and attending SR class in school (p:0.010-p<0.001), and functional literacy on condoms, which reflected how respondents understood the use of condoms (β: 0.871; p<0.001).

CONCLUSION

Because most school adolescents had inadequate SRHL, comprehensive sexual education and enabling information as well as service access for adolescents are essential to ensure that adolescents can access, understand, appraise and apply good SRH knowledge in decision-making to benefit their own health.

How Well Do Children Understand the Vocabulary of Sleep?

BACKGROUND

Sleep surveys, such as the Pediatric Daytime Sleepiness Scale (PDSS), are used to determine a variety of concerns associated with sleep, including excessive daytime sleepiness (hypersomnolence), bedtime sleep behaviors, night awakenings, sleep duration, and sleep-disordered breathing. However, the literacy ability of the patient may not be adequate to ensure comprehension of questions and provision of accurate responses.

OBJECTIVE

To assess children's understanding of the sleep-associated vocabulary included in the PDSS.

METHODS

A cross-sectional, open-response survey was developed for use with students age 4 to 12 years. Prior to completing the instrument, each student was asked the meaning of six key sleep-related words used in the PDSS: drowsy, sleepy, alert, awakened, tired, and awake. The parents/caregivers were requested to record their child's definitions of these key words exactly as stated. Identification of words for "suitable" definitions was undertaken through consultation of three online dictionaries. This enabled the qualitative process associated with open-response surveys to be followed: identification of common themes, chunking of information, and criteria for coding responses. The final sample consisted of word definitions from 325 students (152 boys and 173 girls) from a school enrollment of 727 (45%).

KEY RESULTS

A high percentage of children provided "suitable" responses for the words sleepy (84%) and tired (75%). The percentage of "suitable" responses for the words drowsy and awakened gradually increased across the age groups. The words alert and awake were challenging for the children to define, with the sleep-associated definition for alert only being provided by 31% of children overall and awake only being provided by 48% overall. In total, 57% of children were able to provide suitable definitions for at least four words.

CONCLUSIONS

Our findings suggest that the results of many sleep surveys using these terms may not yield results that accurately reflect a child's actual state of daytime sleepiness and sleep/wake behaviors. Prior to administering a sleep survey, physicians need to clearly explain the meanings of sleep-associated words used in the survey and thus gain a more accurate reflection of a child's sleep and daytime behaviors. [HLRP: Health Literacy Research and Practice. 2019;3(1):e53-e69.].

PLAIN LANGUAGE SUMMARY

Sleep surveys are used to identify problems with sleep. Children with poor health literacy due to age may not understand the questions and may not provide adequate answers. Children's understanding of sleep-associated vocabulary was assessed using six words: drowsy, sleepy, alert, awakened, tired, and awake. Many of these words were found to be difficult for the children to define.

Electronically Verified Use of Internet-Based, Multimedia Decision Aids by Adolescents With Type 1 Diabetes and Their Caregivers

Decision aids (DAs) are central to shared decision making (SDM) interventions, yet little is known about patients' actual DA use. Adequate utilization of DAs could optimize SDM effectiveness. Electronic DAs enable more objective tracking and analysis of actual DA utilization than do paper DAs. This report is part of an ongoing randomized controlled SDM trial enrolling adolescents with type 1 diabetes and their caregivers (n = 153) who were considering use of an insulin pump or continuous glucose monitor. Extensive stakeholder engagement guided creation of two online DAs. After completing baseline measures, 133 dyads were randomized to SDM (access to the pertinent DA) or Usual Care (clinic routines for preparing candidates for adopting these devices). Utilization data showed that 80% of caregivers and 66% of youths logged into a DA at least once; youths and caregivers, respectively, dedicated a mean of 44.7 and 55.0 minutes to website use and viewed 72.2% and 77.4% of the DA content. Median total duration from enrollment to last DA logout was 48.2 days for adolescents and 45.6 days for caregivers. Bivariate comparisons showed that non-Hispanic, Caucasian females from households with higher socioeconomic status were significantly more likely to login to the assigned DA at least once. Hierarchical multiple regression showed that adolescent males with lower levels of health literacy demonstrated fewer DA logins (F = 2.59; P < 0.009), but identified no significant predictors of adolescents' or caregiver' duration of DA use or proportion of DA content viewed. Future SDM trials should seek to promote DA use, especially by non-White adolescents, perhaps with direct assistance with the initial DA login. Trials employing electronic DAs should routinely report and analyze utilization data.

Quality of health literacy instruments used in children and adolescents: a systematic review

OBJECTIVE

Improving health literacy at an early age is crucial to personal health and development. Although health literacy in children and adolescents has gained momentum in the past decade, it remains an under-researched area, particularly health literacy measurement. This study aimed to examine the quality of health literacy instruments used in children and adolescents and to identify the best instrument for field use.

DESIGN

Systematic review.

SETTING

A wide range of settings including schools, clinics and communities.

PARTICIPANTS

Children and/or adolescents aged 6-24 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Measurement properties (reliability, validity and responsiveness) and other important characteristics (eg, health topics, components or scoring systems) of health literacy instruments.

RESULTS

There were 29 health literacy instruments identified from the screening process. When measuring health literacy in children and adolescents, researchers mainly focus on the functional domain (basic skills in reading and writing) and consider participant characteristics of developmental change (of cognitive ability), dependency (on parents) and demographic patterns (eg, racial/ethnic backgrounds), less on differential epidemiology (of health and illness). The methodological quality of included studies as assessed via measurement properties varied from poor to excellent. More than half (62.9%) of measurement properties were unknown, due to either poor methodological quality of included studies or a lack of reporting or assessment. The 8-item Health Literacy Assessment Tool (HLAT-8) showed best evidence on construct validity, and the Health Literacy Measure for Adolescents showed best evidence on reliability.

CONCLUSIONS

More rigorous and high-quality studies are needed to fill the knowledge gap in measurement properties of health literacy instruments. Although it is challenging to draw a robust conclusion about which instrument is the most reliable and the most valid, this review provides important evidence that supports the use of the HLAT-8 to measure childhood and adolescent health literacy in future school-based research.

Navigating the Health Care System: An Adolescent Health Literacy Unit for High Schools

BACKGROUND

Currently, no intervention concerning transition of health care responsibilities from parents to teens exists for adolescents in the general population. The purpose of this intervention was to evaluate teacher satisfaction and student knowledge gain of a health unit developed for adolescents on becoming their own health care advocates.

METHODS

Throughout the 2014-2015 school year, 13 health and career technical education teachers in 11 Delaware high schools taught the unit to 948 students in 2 90-minute classes in 35 classrooms. Assessments included teacher reflections and student pre- and posttests to measure knowledge transfer and gain and gather feedback.

RESULTS

Teacher and student feedback indicated the materials were appropriate and useful in teaching students to navigate the health care system. Student knowledge increased from pretest (64%) to posttest (82%), (p < .001). The educational background of the teacher did not influence this outcome. Students reported they will know what to do better at their next doctor's appointment because of this unit and indicated support for peers to learn this information.

CONCLUSIONS

The unit resulted in content knowledge increase for students. It was consistently effective throughout all schools regardless of social and demographic characteristics, teacher type, or experience teaching the unit.

The Use of the Newest Vital Sign Health Literacy Instrument in Adolescents With Sickle Cell Disease

The purpose of this article is to discuss the use of the Newest Vital Sign (NVS) health literacy instrument in adolescents with sickle cell disease. The NVS evaluates both literacy and numeracy (the ability to understand and work with numbers) as well as the ability to locate and apply information. It is important to validate the NVS for use in adolescents, as the only currently validated instrument, the Rapid Estimate of Adolescent Literacy in Medicine–Teen (REALM-Teen), does not measure numeracy or the ability to locate or apply information. This cross-sectional, descriptive, exploratory correlational study included appraisal of data from completion of the REALM-Teen and NVS instruments by a convenience sample of 75 adolescents with sickle cell disease. The mean age of this study sample was 14.7 years ( SD = 2.2). The mean grade level of participants was 8.7 ( SD = 2.2). Internal consistency for the NVS in this population was acceptable (α = .63). Criterion validity was based on correlations between raw scores on the NVS and raw scores on the REALM-Teen. There was a significant moderate, positive correlation between NVS and REALM-Teen scores ( r = .38, p < .01), demonstrating good criterion validity. Preliminary evidence for reliability and validity of the NVS in this population was established.