Misperceptions of Medical Understanding in Low-Literacy Patients: Implications for Cancer Prevention

Background

Patients with limited literacy skills often have difficulty understanding medical information, are less likely to undergo cancer screening, and present with cancer at later stages than patients with better literacy skills. Since primary care physicians are responsible for performing or initiating the majority of cancer screening in the United States, they need to be able to not only identify patients who might not understand medical information but also communicate effectively with them about cancer prevention and screening.

Methods

To determine whether family medicine residents could identify patients who might have difficulty understanding medical information because of limited literacy, we measured the literacy skills of patients in a university-based family medicine clinic using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). After the patients completed their office visits with a physician, we asked family medicine residents to rate the patients’ ability to understand medical information.

Results

Among 140 patients who met with 18 family medicine resident physicians, 24% had limited literacy skills based on testing with the S-TOFHLA. Residents identified only about half of these patients as having poor or below average understanding of medical information.

Conclusions

In many cases, family medicine residents are unable to identify patients who, based on assessment of their literacy skills, are likely to have difficulty understanding medical information. When working with residents, medical educators should promote the habit of taking poor literacy into account when communicating with patients.

Nutrition in Chronic Disease Management in the Elderly

Older Americans experience chronic disease at rates well above other segments of our society. Rates of health services use are also 2 to 3 times that of younger age groups. The most rapidly growing segments of America's aging population are also its most nutritionally vulnerable-women, minorities, and those 85 years of age and older. The routine incorporation of nutrition screening and intervention into chronic disease management protocols will lower healthcare services usage, decrease healthcare costs, help relieve the burden of human suffering experienced by older Americans with chronic disease, and improve quality of life for our nation's elders.

Use of theory in low-literacy intervention research from 1980 to 2009

OBJECTIVE

To examine whether theories and/or models are used in interventions geared towards improving health-related outcomes for individuals with limited literacy skills.

METHODS

Intervention studies (n=52) published between 1980 and 2009 that met inclusion criteria were reviewed to assess the topic addressed, type of theory and/or model used, and the extent of theory use.

RESULTS

Twenty-one (40.4%) interventions were based on a theory or model. Most of those 21 interventions were either "informed by" (n=15, 71.4%) or "applied" (n=4, 19.1%) theory whereas 2 (9.5%) "tested" theory.

CONCLUSIONS

Most low-literacy intervention research is not based on any educational, behavioral, or social science theory or model.

Digging deeper: quality of patient-provider communication across Hispanic subgroups

Background

Recent research suggests that ethnic subgroup designation plays an important role in health-related disparities among Hispanics. Our objective was to examine the influence of Hispanics' self-reported ethnic subgroup designation on perceptions of their health care providers' communication behaviors.

Methods

Cross-sectional analysis of the 2005 Medical Expenditure Panel Survey (MEPS). Participants included non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged ≥18 years, reporting visiting a health care provider within the past 12 months. Six (n = 6) items were used to capture respondents' perceptions of their health care providers' communication behaviors.

Results

After controlling for socio-demographic covariates, compared to Other Hispanics (reference group), very few differences in perceptions of health care providers communication emerged across ethnic subgroups. Puerto Ricans were more likely to report that their health care provider "always" showed respect for what they had to say (OR = 2.16, 95% CI 1.16-4.03). Both Puerto Ricans (OR = 2.28, 95% CI 1.06-4.92) and Mexicans (OR = 1.88, 95% CI 1.02-3.46) were more likely to indicate that their health care provider "always" spent enough time with them as compared to Other Hispanics.

Conclusions

We observed very few differences among Hispanics respondents in their perceived quality of interactions with health care providers as a function of their ethnic subgroup designation. While our findings somewhat contradict previous research, they do suggest that other underlying factors may influence the quality of perceived interactions with health care providers.

Are patient-administered attention deficit hyperactivity disorder scales suitable for adults?

OBJECTIVE

This primary purpose of this study was to examine cognitive complexity and readability of patient-administered ADHD scales. The secondary purpose was to estimate variation in readability of individual ADHD scale items.

METHOD

Using comprehensive search strategies, we identified eight English-language ADHD scales for inclusion in our study. A complete copy of each ADHD scale was obtained from the most current publication. Cognitive complexity of individual ADHD scale items were assessed using three techniques (number of items, number of words, and linguistic problems), while readability was calculated using the Flesch-Kinkaid formula.

RESULTS

Total number of ADHD scale items ranged from 6 to 66. The ADHD scale items averaged from a low of 4.4+/-2.9 to a high of 18.7+/-4.4 words. Most individual ADHD scale items had between 1 to 3 linguistic problems. Although readability of ADHD scales ranged from approximately 5th to 8th grade, there was notable variation in readability across individual statements and questions.

CONCLUSION

Formatting characteristics, including linguistic problems and high readability, may interfere with patients' ability to accurately complete ADHD scales.

Relationship between health literacy and health-related quality of life among Tennesseans

The purpose of this study was to examine the relationship between health literacy and health-related quality of life (HRQOL) in a sample of English-speaking Tennesseans attending a university-based family medicine residency clinic. We measured the health literacy skills of patients (n = 249) using the Rapid Estimate of Adult Literacy in Medicine (REALM), dividing patients' scores into limited (< or = 8th-grade level) and adequate (> or = 9th-grade) literacy skill levels. We measured HRQOL using four items developed and validated by the Centers for Disease Control and Prevention (CDC). Scores on the REALM indicated that 28.5 percent of patients had limited and 71.5 percent had adequate health literacy skills. There was a significant correlation between patients' health literacy skills and self-reported general health (rho = 0.249, P < 0.01). Patients with limited health literacy skills had a higher median number of physically unhealthy days (P = 0.05) and activity limitation days (P = 0.05) compared with patients with adequate health literacy skills. Based on this study, patients' health literacy skills are associated with several components of HRQOL.

The medical dialogue: disentangling differences between Hispanic and non-Hispanic whites

BACKGROUND

Patients' race and ethnicity play an important role in quality of and access to healthcare in the United States.

OBJECTIVES

To examine the influence of ethnicity--Hispanic whites vs. non-Hispanic whites--on respondents' self-reported interactions with healthcare providers. To understand, among Hispanic whites, how demographic and socioeconomic characteristics impact their interactions with healthcare providers.

DESIGN

Cross-sectional analysis of the 2002 Medical Expenditure Panel Survey, a nationally representative survey on medical care conducted by the Agency for Healthcare Research and Quality.

PARTICIPANTS

Civilian, noninstitutionalized U.S. population aged > or = 18 years who reported visiting a healthcare provider within the past 12 months prior to data collection.

RESULTS

After controlling for several demographic and socioeconomic covariates, compared to non-Hispanic whites (reference group), Hispanic whites who had visited a doctor's office or clinic in the past 12 months were more likely to report that their healthcare provider "always" listened to them [odds ratio (OR) = 1.36, 95% confidence interval (CI) 1.21-1.53], explained things so that they understood (OR = 1.25, 95% CI 1.10-1.41), showed respect for what they had to say (OR = 1.52, 95% CI 1.35-1.72), and spent enough time with them (OR = 1.22, 95% CI 1.08-1.38). However, Hispanics were less likely to indicate that their health care provider "always" gave them control over treatment options (OR = 0.83, 95% CI 0.72-0.95) as compared to non-Hispanics. Within the Hispanic population exclusively, age, place of residence, census region, health insurance status, and presence of a usual source of care influenced self-reported interactions with healthcare providers.

CONCLUSION

Hispanic white respondents were more likely to report that some aspects of provider-patient interactions were indicative of high quality, whereas those related to decision-making autonomy were not. These somewhat paradoxical results should be examined more fully in future research.

Can Screening Items Identify Surgery Patients at Risk of Limited Health Literacy?

BACKGROUND

Health literacy skills (HLS) have been shown to have a major impact on patient outcomes. To identify patients with limited or marginal HLS, the accuracy of three established screening items were examined.

MATERIALS AND METHODS

We studied English-speaking adults (>or=21 years) attending a university-based vascular surgery clinic. Structured interviews were conducted to assess sociodemographic characteristics, screening items, and HLS. Area under the receiver operating characteristic (AUROC) curves were plotted to assess the discriminatory capacity of each screening item in detecting patients with limited/marginal HLS.

RESULTS

One hundred patients agreed to enter the study and met inclusion criteria. The mean age was 62.0 +/- 12.9; 65 were female; 96 were Caucasian; and 32 had not completed high school. The three screening items were effective in detecting patients with limited (n=18) or marginal (n=21) HLS. "How often do you have someone (like a family member, friend, or hospital worker) help you read hospital materials?" (AUROC of 0.83; 95% confidence interval [CI]=0.73, 0.92), "How often do you have problems learning about your medical condition because of difficulty understanding written information?" (AUROC of 0.77; 95% CI=0.67, 0.86), and "How confident are you filling out medical forms by yourself?" (AUROC of 0.76; 95% CI=0.66, 0.86) were effective in detecting those with limited/marginal HLS skills.

CONCLUSIONS

Our findings provide further evidence of the clinical usefulness of these screening items for detecting inadequate HLS in this patient population. Surgeons should consider administering these easy screening items to identify patients at greatest risk of limited or marginal HLS.

Brief report: screening items to identify patients with limited health literacy skills

BACKGROUND

Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians.

OBJECTIVE

To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills.

METHODS

We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard.

RESULTS

The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P<.01) and also a greater AUROC than questions based on demographic characteristics.

CONCLUSIONS

One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Suitability of written supplemental materials available on the Internet for nonprescription medications

PURPOSE

The suitability, readability, and cultural appropriateness of written supplemental materials available on the Internet for nonprescription medications were examined.

METHODS

We videotaped 48 hours of television programming, recording a total of 152 advertisements highlighting 37 unique nonprescription medications. The supplemental materials corresponding to each advertised medication were downloaded and printed in their entirety from each product-specific Web site. These materials were assessed using the Suitability Assessment of Materials (SAM) instrument. Total SAM scores were grouped as follows: not suitable (0-39%), adequate (40-69%), and superior (70-100%). The Fry readability formula was used to determine the reading grade level for the materials assessed with the SAM instrument.

RESULTS

The mean +/- S.D. SAM score of all materials was 54.9% +/- 0.1% (range, 38-76%). Materials for the majority of drugs (86.5%, n = 32) were rated adequate. Materials for four drugs (10.8%) were rated superior, and the material for one drug was not suitable. While the total SAM scores were adequate for most of the materials evaluated, the majority of materials scored particularly poorly for their reading level (the materials for 81.1% of drugs were not suitable). The materials for 40.9% of drugs used uncommon words.

CONCLUSION

Evaluation of the suitability, readability, and cultural appropriateness of written supplemental materials for nonprescription medications available on manufacturer-sponsored Web sites and intended for consumers or patients revealed that SAM scores were adequate for most of the materials; however, many scored poorly in the areas of reading level and used uncommon words.

Literacy, medical care, and health status in Tennessee

Based on the most recent information, Tennessee is facing an enormous problem with literacy and health outcomes. As a result, the healthcare industry is vulnerable because of patients' inability to understand and follow a plan of treatment. This in part has resulted in poor healthcare and increased costs in providing care. By implementing strategies such as those outlined in Table 1, strides can be made in improving the healthcare provided to Tennesseans and reducing costs associated.

Unique issues in assessing work function among individuals with psychiatric disabilities

With the admission of people who experience psychiatric disabilities in the state-federal vocational rehabilitation system and the Social Security disability rolls in the 1960s, assessment of their capacity to work has been a major concern. Given the rising rates of claims for psychiatric disability in both the public and the private sectors, and the disappointing employment outcomes of people with psychiatric disabilities compared to those with other disabilities, there have been numerous initiatives to accurately assess their employment potential. Historically, such assessment within the Social Security Administration has relied upon evaluation of a person's medical impairment, but numerous studies suggest a weak relationship between measures of psychiatric diagnosis or symptoms and work outcome. Efforts have been undertaken to identify valid and reliable methods of assessing the ability of people with psychiatric disabilities to work. The authors review (a) methods of assessing work function for this population, and (b) the literature on predictors of work functioning and the nature of psychiatric disability, and suggest implications for disability determination policies and for future research.

Assessing readiness for change among persons with severe mental illness

Studies focusing on the readiness of persons to change have burgeoned in recent years. Assessing readiness for change is viewed as important for interventions aimed at promoting health behaviors, such as smoking cessation and substance abuse programs. This study is the first to examine readiness for change, as conceived by Prochaska and his colleagues, among a sample of persons with severe mental illness who were about to participate in a vocational rehabilitation program. We examined the reliability, validity, and other psychometric properties of the Change Assessment Scale and its ability to predict attrition and actual change.

The IAPSRS toolkit: development, utility, and relation to other performance measurement systems. Members of the IAPSRS Research Committee. International Association of Psychological Rehabilitation Services

The current climate of economic constraint in community-based mental health services has all but required psychosocial rehabilitation (PSR) programs to demonstrate their effectiveness by adopting outcome assessment systems. Agencies of disparate size and varying degrees of sophistication are now responding to mandates to systematically monitor program outcomes. In doing so, however, PSR practitioners and administrators are faced with a bewildering array of competing measures, some of which are impractical, costly, or irrelevant for capturing the outcomes of PSR services (Blankertz & Cook, 1998). To acquaint readers with issues in performance measurement in PSR, this article describes a newly developed outcome measurement system created to document the achievements of service recipients in PSR programs and to monitor progress towards recovery. We discuss principles and logistical issues in performance measurement which are important to PSR agencies and which the Toolkit has been designed to address. Results of the pilot testing of the PSR Toolkit are presented to demonstrate the feasibility of its use, logistical problems in implementation, psychometric properties of the measures, and the Toolkit's sensitivity to change. We discuss next steps in the development of the Toolkit.

The residential needs and preferences of persons with serious mental illness: a comparison of consumers and family members

This study reports on a systematic statewide effort to determine the residential needs and preferences of two important groups: primary consumers of mental health services and family members of consumers. Two comparable surveys regarding the residential needs of consumers were conducted. In all, 314 consumers and 459 family members participated in the survey. A comparison of the preferences of family members and consumers suggests that family members more often prefer congregate living situations and more staff support than do consumers. Consumers more often express a desire to reside by themselves without staff and without other persons who are mentally ill. While the direct comparison of preferences from these two constituencies has limitations, these data do suggest significant variability in needs and preferences voiced by consumers and their family members; discrepancies that need to be addressed by mental health policymakers and planners.

Effectiveness of technical assistance in the development of psychiatric rehabilitation programs

Most mental health programs need technical assistance to develop effective psychiatric rehabilitation programs. This article discusses how psychiatric rehabilitation was introduced into three community mental health programs and describes the elements of a psychiatric rehabilitation program and the phases of a technical assistance process. A case study illustrates how technical assistance consultants can be trained to develop psychiatric rehabilitation programs. Barriers and facilitators to the technical assistance are discussed in the context of several other technical assistance studies.

Characteristics of mental health case management: results of a national survey

In the last several years, state mental health authorities throughout the United States have assigned a high priority to the funding, development, and operation of case management programs. Although the concept of case management has been in existence for over a decade, there is still confusion regarding the definition of case management and the identification of alternative case management approaches. Recognizing this confusion, the Center for Psychiatric Rehabilitation undertook a comprehensive study to determine the state of case management practice today. This article reports on the results of a national survey of case management programs and describes the characteristics of the programs themselves, the case managers, the clients they serve, and the systems within which they operate. Implications of these findings for a definition of case management are discussed.

A consumer-constructed scale to measure empowerment among users of mental health services

OBJECTIVE

A scale to measure the personal construct of empowerment as defined by consumers of mental health services was developed and field tested.

METHODS

After extensive development, pilot testing, and analyses, a 28-item scale to measure empowerment was tested on 271 members of six self-help programs in six states. Factor analyses were used to identify the underlying dimensions of empowerment. To establish the scale's reliability and validity, responses were factor analyzed, and other analyses were conducted.

RESULTS

Analyses revealed five factors: self-efficacy-self-esteem, power-powerlessness, community activism, righteous anger, and optimism-control over the future. Empowerment was related to quality of life and income but not to the demographic variables of age, gender, ethnicity, marital status, education level, or employment status. Empowerment was inversely related to use of traditional mental health services and positively related to community activism.

CONCLUSIONS

The findings set a framework for a clearer understanding of the imprecise and overused concept of empowerment. The scale demonstrated adequate internal consistency and some evidence for validity. Further testing must be done to establish whether it has discriminant validity and is sensitive to change.

Prediction of vocational outcome based on clinical and demographic indicators among vocationally ready clients

This study examined the clinical and demographic correlates of work skills and vocational outcome for persons with psychiatric disabilities. The same clinical, demographic, work skills, and vocational outcome instruments were administered to 275 persons working toward their vocational goals at three psychosocial rehabilitation centers. Data regarding vocational outcomes were collected quarterly over a period of 3 1/4 years. Using multivariate statistical techniques, clinical and demographic variables that predict work skills and future vocational outcomes were identified. The implications of the findings for program administrators, system planners, and researchers are discussed.

Relationships between psychiatric symptomatology, work skills, and future vocational performance

OBJECTIVE

Experts do not agree on what, if any, relationships exist between diagnosis, symptomatology, work skills, and the future vocational performance of persons with severe mental illness. The objective of this study was to longitudinally examine such relationships, using a sample of clients who were attending psychosocial rehabilitation programs.

METHODS

Subjects were 275 clients of three psychosocial rehabilitation programs who had expressed a vocational goal. They were assessed at intake into the study and then quarterly until they left the rehabilitation program. The variables examined included symptoms, measured by the Brief Psychiatric Rating Scale; diagnosis; work skills, measured by the Griffiths Work Behavior Scale; and vocational status at end-point.

RESULTS

Among subjects remaining in the study for one year, both symptomatology and work skills improved significantly. Moderately significant negative correlations were found between symptoms and work skills; subjects who became employed had lower symptom scores and higher work skills than persons who never became employed.

CONCLUSIONS

Although a moderate relationship was found between symptomatology and work skills, symptoms should not be considered a proxy measure for vocational functioning among persons with severe mental illness. Participation in psychosocial rehabilitation programs appeared to have a salutary effect on symptoms and work skills.

Comparison of outcomes for clients seeking and assigned to supported housing services

As part of state-supported interventions to reduce risk of rehospitalization, seriously disabled psychiatric patients who had been involuntarily hospitalized twice in the previous three years were assigned to receive supported housing services in an Oregon community. Compared with 22 voluntary clients in the same supported housing program, the 21 involuntary (assigned) clients rated higher on risk factors such as history of suicide attempts, self-neglect, homelessness, and medication noncompliance, The involuntary clients showed a much higher utilization of supported housing services and case management, psychiatric, and shelter services during the nine months after entry into the program, and they had a higher one-year rehospitalization rate. However, they used substantially fewer inpatient days in the six months after entry in the program than in the six months before.

A supported education program for young adults with long-term mental illness

Fifty-two young adults with severe psychiatric disabilities were selected to participate in a university-based supported education program aimed at helping them develop the skills to choose and implement a career plan. Thirty-five of the subjects completed the four-semester program. After the intervention, 42 percent of the students were competitively employed or enrolled in an educational program, compared with 19 percent before the intervention. The number of hospitalizations experienced by the subjects in the first year of the program decreased significantly, and the subjects' self-esteem increased significantly. The results indicate that rehabilitation services on a university campus may be a viable adjunct to more traditional rehabilitation services for persons with psychiatric disabilities.

Rehabilitation outcome of long-term hospital patients left behind by deinstitutionalization

In 1979 a Massachusetts state hospital initiated a plan to transfer 54 long-term residents of two wards to the community through a series of increasingly independent working and living arrangements. This study assesses the patients' residential and vocational status and living skills over a five-year period beginning in February 1979. The patients demonstrated a significant increase in living independence, but only eight were able to live continuously in the community after their discharge, and 24 never left the hospital. Overall, vocational status did not improve, and living skills improved only slightly. Living skills and vocational status were predictive of living independence. The authors identify several steps that the mental health field should take to promote success among chronic patients, deinstitutionalized or not.

The mental health needs of the severely physically disabled

Severely physically disabled individuals, advocates for the disabled, and rehabilitation and mental health professionals were surveyed to determine their perceptions of the need for services for 12 mental health problems encountered by persons with physical disability and the kinds of services needed. All groups surveyed agreed that vocational, social-interpersonal, personal-emotional, self-concept, and marital-family problems were in greatest need of services, but their perceptions of the extent of service need for each of the 12 problems differed significantly. The groups unanimously perceived rehabilitation counseling as the most needed service but differed significantly in their perception of the extent of service need for other services that were also highly rated, such as family, group, and individual therapy; peer counseling; respite care; and social skills training. The groups unanimously agreed that services designed to treat major mental illness were the least needed.

Training mental health workers in psychiatric rehabilitation

Staff members from nine mental health agencies were trained in psychiatric rehabilitation technology. The trainers then received intensive followup to assist them in implementing the technology in their own agencies. Evaluation of the impact of the "training of trainers" strategy suggested that mental health workers were able to acquire and apply the skills of psychiatric rehabilitation. The training strategy also appeared to be effective in helping the agencies adopt the philosophy, principles, and skills of psychiatric rehabilitation.