Health literacy for people living with HIV/Aids: an integrative review

Health literacy & Chagas disease knowledge: A cross-sectional study in Southern Loja Province, Ecuador

Objective

Health literacy is associated with many patient outcomes. This study sought to determine the association between a person's level of health literacy and their knowledge about Chagas disease.

Methods

A cross-sectional survey was conducted with people living in two counties in rural Loja Province, Ecuador who attended a mobile health clinic. The communities in which the study was conducted are at high risk of Chagas disease and have limited access to both health care and educational resources. The Spanish version of Short Assessment for Health Literacy measured health literacy. The Chagas Disease Knowledge questionnaire measured knowledge of Chagas disease. T-tests and correlational analysis were used to assess associations.

Results

Overall 85 people participated in this study. A majority of the respondents were female (64.1%), and a plurality were married (40.7%) and had education less than secondary (40.7%). The average age of the sample was 44.31 ± 18.85. Health literacy levels and Chagas disease knowledge in the communities were low. About half of people had inadequate health literacy. No association between health literacy and Chagas knowledge was found.

Conclusion

Health literacy levels and Chagas disease knowledge were not found to be correlated. Explanations for the lack of association may include common causes of inadequate investment in Chagas disease education as well as neglect of health systems in rural Ecuador. Efforts to improve both health literacy and Chagas disease knowledge in poorer, rural areas of Ecuador are needed.

Innovation

This is the first study to assess relationships between health literacy and knowledge of Chagas disease in an uninfected population. For novel conditions, relationships between health literacy and disease knowledge should be investigated before communication campaigns are adapted.

"It was unusual but amazing": demand creation for PrEP among adolescents' men who have sex with men (MSM) and transgender women (TGW) in Brazil

This study aimed to analyze the challenges in demand creation for participation in an HIV pre-exposure prophylaxis (PrEP) project in two Brazilian capitals. This qualitative study was conducted with men who have sex with men and transgender women aged 15 to 19 years who lived in two Brazilian state capitals. For this analysis, 27 semi-structured interviews carried out from 2019 to 2020 were evaluated by reflexive thematic content analysis. For participants, PrEP demand creation was essential for their interaction, mediation, bonding, and attachment and proved effective for PrEP acceptability and adherence. Adolescents' narratives showed that the strategies promoted HIV combination prevention, opened up opportunities for recruitment meetings, helped to negotiate with and convince individuals to use PrEP, strengthened peer education, and evoked a feeling of "being with" and "walking together" despite the challenges. Face-to-face or online interactions using social technologies played a crucial role in recruiting adolescents for the project, expanding knowledge on PrEP and other combination prevention strategies and access to health services and self-care.

Comprehensive Knowledge of HIV and AIDS and Related Factors in Angolans Aged between 15 and 49 Years

A comprehensive knowledge of HIV and AIDS among men and women in Africa is reportedly low. To the best of our knowledge, no studies using any definition of comprehensive knowledge of HIV and AIDS have been conducted in Angola. To address this gap, we aimed to describe the comprehensive knowledge held by individuals aged between 15 and 49 years regarding HIV and AIDS and some associated factors, using the most recent Angolan demographic and health survey (DHS). Using an observational, cross-sectional design, we analyzed data collected from 19,785 individuals aged between 15 and 49 years for the 2016 DHS in Angola. We conducted a logistic regression analysis of descriptive and complex samples to examine the data and to unravel possible factors associated with having a comprehensive knowledge of HIV and AIDS. Almost half of the respondents (47.7%) had a general comprehensive knowledge of HIV and AIDS. Individuals who watched television (adjusted odds ratio [aOR]: 2.40; 95% CI: 2.11, 2.72) or read newspapers and magazines (aOR: 1.99; 95% CI: 1.72, 2.30) more than once a week had higher odds of having a comprehensive knowledge of HIV and AIDS compared to those who did not. Similarly, having completed primary education and above (aOR: 1.83; 95% CI: 1.67, 2.00) or living in urban areas (aOR: 1.51; 95% CI: 1.34, 1.71) increased the likelihood of individuals having a comprehensive knowledge of HIV and AIDS compared to their counterparts. These results reflect inequalities that require further attention at either a research or a political level. Nevertheless, we consider that these results can assist decision-makers in advocating for continuous investment in HIV health literacy and in adapting global solutions to local Angolan contexts.

Levels of health literacy among people living with HIV in outpatient care: a cross-sectional study from Denmark

BACKGROUND

Low health literacy (HL) among people living with HIV (PLWHIV) encounter more disease related complications, more difficulty understanding health-related information and low adherence. Considering that, the HL levels among PLWHIV needs to be further investigated. The objective of this study was to investigate the levels of HL and patient involvement among PLWHIV in an outpatient clinic in Denmark. A second objective was to examine differences in HL levels across socio-demographic characteristics.

METHODS

In 2019, a population of 682 PLWHIV from a Danish outpatient hospital clinic were enrolled in cross-sectional study. Patients who had a digital postbox received an electronic questionnaire including following domains; health literacy, patient involvement, and socio-demographic status. Health literacy was measured using the Health Literacy Questionnaire (HLQ) through scores on three subscales: social support for health (HLQ4), engaging with healthcare providers (HLQ6), and understanding health information (HLQ9). An unpaired t-test was used to investigate mean differences in the HLQ scores across socio-demographic variables.

RESULTS

A total of 338 (55%) patients responded to the questionnaire. The included participants demonstrated high levels of HLQ4 (mean = 4.2) and HLQ6 (mean = 4.2), but lower for HLQ9 (mean = 2.9). In total 70-80% reported being involved in decisions about their health. We found a positive association between high level of HL (HLQ9) and living with a partner and higher levels of HL (HLQ4, HLQ6, and HLQ9) and employment.

CONCLUSION

PLWHIV in a Danish out-patient care population were found to have high levels of HL despite differences in demographic characteristics. Further research is needed to examine the levels of HL among non-responders to develop HL approaches and strategies to meet the needs of individuals with different HL skills.

Exploring communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia

BACKGROUND

The World Health Organization has promoted a shift towards the test-and-treat-all strategy to accelerate the elimination of HIV/AIDS. Zambia was one of the early African countries to adopt this strategy as the policy change was officially announced on national television by the republican president on 15th August 2017. This study explored the communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia.

METHODS

A qualitative case study design was employed with a purposeful sample of policy makers, international partners, National AIDS Council representatives, health facility managers, and frontline health providers in selected tertiary, secondary and primary health facilities in the Lusaka District, Zambia. Thematic data analysis was performed using NVivo 12 Pro software.

RESULTS

In total, 22 key informant interviews and 3 focus group discussions were conducted. The government relied on formal and informal channels to communicate the test-and-treat-all policy change to health providers. Whilst HIV policy changes were reflected in the National HIV/AIDS Strategic Framework, there was little awareness of this policy by the frontline providers. The use of informal communication channels such as verbal and text instructions affected health providers' implementation of the test-and-treat-all. Electronic and print media were ineffective in communicating the test-and-treat-all policy change to some sections of the public. Top-down stakeholder engagement, limited health worker training, and poor financing negatively affected the implementation of the test-and-treat-all policy change. Acceptability of the test-and-treat-all policy change was shaped by positive provider perceptions of its benefits, limited sense of policy ownership, and resistance by the non-treatment-ready patients. Furthermore, unintended consequences of the test-and-treat-all policy change on human resources for health and facility infrastructure were reported.

CONCLUSION

Effective test-and-treat-all policy change communication is vital for successful policy implementation as it enhances interpretation and adoption among health providers and patients. There is a need to enhance collaboration among policy makers, implementers and the public to develop and apply communication strategies that facilitate the adoption of the test-and-treat-all policy changes to sustain gains in the fight against HIV/AIDS.

Sexually Transmitted Infections and Health Literacy: A Community-Based Preventive Program

BACKGROUND

Sexually transmitted infections (STIs) are a public health problem with a high risk of morbidity and community transmissibility. Evidence points to their continuous increase. This study describes the design, development, and implementation of a community-based STI prevention program for community healthcare users.

METHODS

Based on the Health Planning Process design method, a structured, community-based intervention program on STI counseling and detection was conducted in a primary health care unit in Lisbon. Two data collection instruments were applied in the diagnosis of the situation, namely the Health Literacy Survey Portugal (ILS-PT) and the STD Attitude Scale, to 47 patients who attended the health consultation on STI counseling and detection in a primary care unit in Lisbon. Two interventions were implemented, the health education session and the provision of an educational poster. In the evaluation of the project, the acceptance and satisfaction of the patients with the implemented interventions were considered as outcome indicators. A descriptive statistical analysis of the data was performed.

RESULTS

The participants shows considerably low levels of health literacy and high-risk behaviors for acquiring STIs. After an intervention, a high percentage of the participants point out the project as exciting and valuable and reveal having acquired knowledge that allowed them to improve their health. Furthermore, the patients were very satisfied with the implemented health education session and the educational poster.

CONCLUSION

This project revealed the urgent and important need to implement community intervention projects to prevent STIs and promote health literacy among the most vulnerable groups.

The relationship between acceptance of illness and quality of life among men who have sex with men living with human immunodeficiency virus: A cross-sectional study

Objectives

To explore the relationship between acceptance of illness and quality of life (QOL), and factors associated with acceptance of illness among men who have sex with men (MSM) living with human immunodeficiency virus (HIV).

Methods

Three hundred and one MSM were recruited from an HIV clinic between August and December 2018. The battery of measurements consisted of the Acceptance of Illness Scale, World Health Organization Quality of Life Questionnaire for HIV brief version, HIV Cognitive Appraisal Scale and a self-designed questionnaire used to collect general information. Pearson correlation test was used to examine the relationship between acceptance of illness and QOL. Univariate and multivariate ordinal logistic regression analyses were used to examine whether the general data (demographic and HIV-related clinical data) and HIV cognitive appraisal were associated with acceptance of illness levels.

Results

Descriptive analysis showed the acceptance level among MSM living with HIV was moderate (Mean = 26.29, SD = 5.28). Those with a better acceptance of illness had a better QOL (r = 0.69, P < 0.01). In the multivariate ordinal logistic regression model, education level, threat appraisals (OR:1.09; 95%CI [1.06–1.13]), and controllability appraisals (OR: 0.82; 95%CI [0.71–0.94]) were significantly associated with acceptance of illness.

Conclusions

Results showed acceptance level was moderate and had a positive correlation with QOL. High level of education, low threat appraisals and high controllability appraisals were related to high illness acceptance. This finding highlights the importance of focusing on HIV-infected MSM with low education and on their perceptions of threat and controllability about HIV-related issues when designing interventions to promote illness acceptance in this vulnerable population.

Assessing the Relationship Between HIV Quality of Care and Treatment Literacy on ART Adherence and Viral Suppression Among Female Sex Workers Living in the Dominican Republic

This study assessed the relationship between the quality of HIV care and treatment literacy on antiretroviral therapy (ART) adherence and viral suppression among female sex workers (FSWs) living with HIV (n = 211) in Santo Domingo, Dominican Republic. Multivariable logistic regression results indicate better patient-provider communication (AOR 1.04; 95% CI 1.01-1.07) and respectful treatment (AOR 2.17; 95% CI 1.09-4.32) increase the odds of viral suppression, while higher costs reduce both the odds of ART adherence (AOR 0.57, 95% CI 0.34- 0.95) and being virally suppressed (AOR 0.59, 95% CI 0.41-0.85). Greater treatment literacy was associated with an increased odds of ART adherence (AOR 4.15 for understanding of viral load; 95% CI 1.50-11.52) and viral suppression (AOR 2.75 for understanding of CD4 count; 95% CI 1.31-5.80). Findings support investments in treatment education, effective and respectful patient-provider communication, dignified care, and cost-support for associated HIV care costs to facilitate FSWs' pathway towards viral suppression.

Development and evaluation of a booklet to promote ealthy lifestyle in people with HIV

OBJECTIVE

To develop and evaluate an educational primer to promote healthy lifestyles in people with HIV.

METHODS

Study of technological development in three stages: Development of the booklet, with bibliographical review, illustrations, layout, diagramming, adopting as reference the trans-theoretical model of behavior change; Analysis of content and appearance by 22 judges; Semantic analysis by 22 people with HIV. The proportion of positive evaluations of the items was measured, considering a percentage equal to or greater than 85%.

RESULTS

My motivational booklet for change! Practices for promoting a healthy lifestyle" had six areas: Body weight control; Healthy eating; Exercise practice; Smoking, alcohol and other drugs; Stress control; and Drug treatment. Most of the items evaluated agreed with an overall average of 92.4% by the judges and 98.9% by the target audience.

CONCLUSION

The booklet had evidence of adequate validity to be used by people with HIV.

Health functional literacy and adherence to antiretroviral therapy in people living with HIV

OBJECTIVE

To verify the relationship between adherence to antiretroviral therapy and Functional Health Literacy.

METHODS

Cross-sectional study, carried out in the Specialized Care Service in 2019, using questionnaires about adherence to treatment and Functional Health literacy people living with human immunodeficiency virus. The LFS questionnaire has questions about numerical and text interpretation skills and the adherence questionnaire addresses how to use antiretrovirals. Viral load was verified by analysis of medical records. Associations between variables were analyzed using the Chi-square test.

RESULTS

78 patients were interviewed and a significant association between the variables to treatment adherence and Functional Literacy in Health was observed. The association between adherence to therapy and viral load levels was also significant.

CONCLUSIONS

The data found show a significant association between the variables, ie, the lower the functional health literacy, the greater the difficulty to adhere to treatment.

An Analytical Comparison of Knowledge, Attitudes, and Practices Regarding HIV/AIDS Among Medical and Non-Medical Students in Iran

Background and Objectives

Young people are the main group at risk of HIV/AIDS due to factors such as curiosity, peer pressure, lack of knowledge and skills, unsafe sexual behaviors, and drug abuse. The present study was conducted to compare the knowledge, attitudes, and practices regarding HIV/AIDS among medical and non-medical students in Iran.

Methods

This cross-sectional descriptive-analytical study was conducted on a population consisting of the students of Shahid Beheshti University (SBU) and Shahid Beheshti University of Medical Sciences (SBMU). A total of 303 students were randomly selected from the two universities. Data were collected using a researcher-made HIV/AIDS knowledge, attitude, and practice questionnaire. Data were then analyzed using the independent t-test, Mann–Whitney’s U-test, the ANOVA, and the Kruskal–Wallis test in SPSS-18. P<0.05 was set as the level of significance for all the tests.

Findings

The frequencies of marital status, education, smoking, alcohol and psychotropic substance use, employment status, and source of information differed significantly between the medical and non-medical students. There was a significant difference between the two groups regarding knowledge (P<0.001) and practice (P=0.019) regarding HIV/AIDS. Meanwhile, there was no significant difference between the two groups in terms of their attitude toward HIV/AIDS (P=0.503). The results of the ANOVA revealed a significant correlation between marital status and practice (P=0.022), education and attitude (P=0.004), and smoking and knowledge (P=0.008) among the medical students. Meanwhile, there was no significant difference between the demographic variables and knowledge, attitudes and practices regarding HIV/AIDS among the non-medical students (P>0.005).

Conclusion

The present findings showed that designing and developing appropriate educational programs, offered through group media, scientific seminars, courses, lectures, and group discussions, can be effective in enhancing the students’ knowledge and changing their attitudes and should be incorporated into healthcare programs.

Predictors of adherence to antiretroviral therapy among PLHIV

Adherence to antiretroviral therapy (ART) is of paramount importance to achieve the optimum control of viral load and progression of disease among people living with HIV (PLHIV). An overview of systematic reviews to summarize the factors influencing adherence to ART was not found in the literature; hence, the systematic review of systematic reviews was conducted to provide global view of factors influencing adherence to ART. Systematic reviews ever published till May 2018 were searched and retrieved between May 2015 and May 2018 from Cochrane and PubMed databases. Among 88 studies initially chosen based on inclusion and exclusion criteria, 22 were selected for further analysis. Qualitative analysis of included reviews was made through narrative synthesis approach. Results of the study show that among the 60 factors enlisted, 5 were most highly significant, 7 were highly significant, 19 were moderately significant, and 29 were emerged as significant factors. Substance abuse, financial constraints, social support, HIV stigma, and depressive symptoms were the most highly significant factors influencing the adherence, whereas age, employment status, long distance, side effects of drugs, pill burden, education, and mental health were regarded as highly significant factors influencing ART. Fatigue, away from home, being too busy in other things, simply forgot, and beliefs about the necessity of ART emerged as significant factors. The study concludes that findings from the overview give global insight into the factors determining adherence to ART which would further influence the innovations, program, and policy-making to mitigate the problem of nonadherence.

Management of nursing care in HIV/AIDS from a palliative and hospital perspective

OBJECTIVES

To understand the meaning attributed by the nurse to the management of nursing care to the person hospitalized due to clinical complications caused by AIDS; to analyze actions related to palliative care; and to construct a theoretical matrix regarding the management of nursing care.

METHOD

Qualitative, exploratory research, guided by the Grounded Theory. Seven nurses and ten nursing technicians were interviewed between May and September 2015, in a university hospital, located in Rio de Janeiro State, Brazil.

RESULTS

Five categories that covered the profile of the hospitalized person, palliative care, intervening conditions for care management, the need for professional qualification, and other aspects to better organize and manage care, including conflict management arose.

FINAL CONSIDERATIONS

The theoretical matrix values the quality of life, the need to understand the flow of care to avoid readmissions and not adherence to medications, requiring new research in the area, such as implementation.

Iranian Female Methadone Patients and the Perceived Educational Needs Related to Human Immunodeficiency Virus

Background

Iranian female methadone patients are at risk of human immunodeficiency virus (HIV) due to involvement in high-risk sexual behaviours and/or needle sharing. The present study aimed to explore the perceived educational needs related to HIV among a group of Iranian female methadone patients.

Methods

The research design was qualitative and the participants were sampled purposively. Semi-structured interviews were conducted with 34 women and 19 clinicians in Sari, Mashhad, and Tehran, Iran. Then, qualitative content analysis was implemented.

Findings

The emergence of three major themes and six minor themes was revealed. Women expressed a need to increase their knowledge including women-specific pathophysiology and disease progression and the modes of the virus transmission and prevention. Women also expressed a need to enhance their knowledge and skills related to the physical management of the virus including self-care and reproductive health. Other themes included perceived psychosocial needs including removing stigma and access to resources in the community.

Conclusion

Women reported a wide range of educational needs from basic knowledge to advanced skills. The findings can be used in designing women-specific educational programs related to HIV in Iran. Larger studies are suggested with gender-mixed samples in the Persian context.

Chinese health literacy scale for tuberculosis patients: a study on development and psychometric testing

BACKGROUND

The role of health literacy on tuberculosis patients has not been evaluated in China, in part because few special health literacy measurements exist.

METHODS

A three-step design process was used: (1) Scale construction: Based on the model of revised Bloom's taxonomy, the item-pool was drafted from a literature review, focus group discussion, and in-depth interviews. In addition, a Delphi survey was used in order to select items for inclusion in the scales; (2) Pilot study: Acceptability and clarity were tested with 60 tuberculosis patients; and (3) Psychometric testing: Validity analysis includes content validity, construct validity, and discriminative validity. The Cronbach's alpha coefficient, split-half reliability, and test-retest method were used to assess reliability. Finally, a receiver operating characteristic analysis was conducted to generate a cut-off point.

RESULTS

The final scale had 29 items with four domains. The item level Content Validity Index ranged from 0.70 to 1.0, and the scale level Content Validity Index was 0.95. The mean score among the lowest 27% group was significantly lower than that those of the highest 27% group (p < 0.01), which supports adequate discriminant validity. Explanatory factor analysis produced a clear four-factor construct, explaining 47.254% of the total variance. Factor 1 and Factor 2 were consistent with read and memorize TB-related words; Factor 3 was associated with understand the meaning of the health education leaflets and examine if TB patients can apply the correct approach to correct context; Factor 4 was related to the ability of TB patient to calculate and identify what unspecified assumptions are included in known conditions. The confirmatory factory analysis results confirmed that a four-factor model was an acceptable fit to the data, with a goodness-of-fit index = 0.930, adjusted goodness of fit index = 0.970, root mean square error of approximation = 0.069, and χ2/df = 2.153. The scale had good internal consistency and test-retest reliability. Additionally, the receiver operating characteristic analysis indicated that the cut-off point for the instrument was set at 45 and 35.

CONCLUSIONS

The Chinese Health Literacy scale for Tuberculosis has good reliability and validity, and it could be used for measuring the health literacy of Chinese patients with tuberculosis.

Health literacy and knowledge related to tuberculosis among outpatients at a referral hospital in Lima, Peru

BACKGROUND

Tuberculosis (TB) case detection in Peru relies on passive case finding. This strategy relies on the assumption that the community is aware that a persistent cough or contact with a TB patient is an indication to seek formal health care. This study evaluated health literacy and TB knowledge among outpatients at Hospital Cayetano Heredia in Lima, Peru.

METHODS

A cross-sectional survey was performed between June and August 2017. Data on sociodemographic factors, TB knowledge, and health literacy were collected, and bivariate and multivariate logistic regressions were performed to study the associations between variables.

RESULTS

The analysis included 272 participants; 57.7% knew someone who had TB and 9% had TB in the past. A 2-week cough was reported as a TB symptom by 66 (24%) participants. High TB knowledge was found among 149 (54.8%) participants and high health literacy was found among 193 (71.0%) participants. Health literacy and TB knowledge were not significantly associated (OR=0.9; 95% CI 0.5-1.5). After controlling for sex, age, district, education, health insurance, frequency of hospital visits, and previous TB diagnosis, high TB knowledge was associated with knowing someone with TB (aOR=2.7; 95% CI 1.6-4.7) and inversely associated with being a public transport driver (aOR=0.2; 95% CI 0.05-0.9). Not living in poverty was the single factor associated with high health literacy (aOR=3.8; 95% CI 1.6-8.9).

CONCLUSION

Although TB knowledge was fair, 30% did not know that cough is a symptom of TB and >70% did not know being in contact with a TB patient is a risk factor for TB. Tailoring educational strategies to at-risk groups may enhance passive case detection especially among transport workers and TB contacts in Lima, Peru.

Community health worker interventions to promote psychosocial outcomes among people living with HIV-A systematic review

Background

Community health worker (CHW) interventions are a successful strategy to promote health among HIV-negative and persons living with HIV (PLWH). Psychosocial factors are critical dimensions of HIV/AIDS care contributing to prognosis of the disease, yet it is unclear how CHW interventions improve psychosocial outcomes in PLWH. The purpose of this study was to critically appraise the types, scope, and nature of CHW interventions designed to address psychosocial outcomes in PLWH.

Methods

We performed database searches—PubMed, EMBASE, CINAHL, and Cochrane—to identify randomized controlled trials published in English before April 2017. Fourteen articles met the eligibility criteria.

Results

Half of the studies were conducted in the United States. Social cognitive theory was used more than once in nine theory-guided studies. CHW interventions were largely focused on reducing depression (n = 6) or stigma related to HIV (n = 4), or promoting quality of life (n = 4), social support (n = 4), and self-efficacy (n = 4). Didactic methods and role-playing were used to train CHWs. CHWs played multiple roles in delivering intervention, including a counselor and a supporter (n = 10), educator (n = 5), or a navigator (n = 3). CHW intervention fidelity was assessed in 4 studies. Five studies found positive changes in six psychosocial outcomes including quality of life (2 of 4) and self-efficacy (2 of 4). CHW interventions had no effect on social support in 2 of 4 studies, and stigma in 3 of 4 studies. None of the CHW interventions were successful in reducing depressive symptoms among PLWH.

Conclusions

Evidence partially supported the use of CHWs in promoting psychosocial outcomes in PLWH. Future CHW intervention should be expanded in scope to address key psychosocial determinants of HIV/AIDS outcomes such as health literacy. Further, fidelity measures should be incorporated into intervention delivery.

Understanding Health Literacy for People Living With HIV: Locations of Learning

Health literacy, including people's abilities to access, process, and comprehend health-related information, has become an important component in the management of complex and chronic diseases such as HIV infection. Clinical measures of health literacy that focus on patients' abilities to follow plans of care ignore the multidimensionality of health literacy. Our thematic analysis of 28 focus groups from a qualitative, multisite, multinational study exploring information practices of people living with HIV (PLWH) demonstrated the importance of location as a dimension of health literacy. Clinical care and conceptual/virtual locations (media/Internet and research studies) were used by PLWH to learn about HIV and how to live successfully with HIV. Nonclinical spaces where PLWH could safely discuss issues such as disclosure and life problems were noted. Expanding clinical perspectives of health literacy to include location, assessing the what and where of learning, and trusted purveyors of knowledge could help providers improve patient engagement in care.