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Davis TC, Arnold CL, Bennett CL, Wolf MS, Reynolds C, Liu D, Rademaker A. Strategies to improve repeat fecal occult blood testing cancer screening. Cancer Epidemiol Biomarkers Prev 2014; 23:134-43. [PMID: 24192009 PMCID: PMC3894742 DOI: 10.1158/1055-9965.epi-13-0795] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND A comparative effectiveness intervention by this team improved initial fecal occult blood testing (FOBT) rates from 3% to 53% among community clinic patients. The purpose of this study was to evaluate the effectiveness and costs associated with a literacy-informed intervention on repeat FOBT testing. METHODS Between 2008 and 2011, a three-arm quasi-experiential comparative effectiveness evaluation was conducted in eight community clinics in Louisiana. Clinics were randomly assigned to receive: enhanced care, a screening recommendation, and FOBT kit annually; a brief educational intervention where patients additionally received a literacy appropriate pamphlet and simplified FOBT instructions; or nurse support where a nurse manager provided the education and followed up with phone support. In year 2, all materials were mailed. The study consisted of 461 patients, ages 50 to 85 years, with a negative initial FOBT. RESULTS Repeat FOBT rates were 38% enhanced care, 33% education, and 59% with nurse support (P = 0.017). After adjusting for age, race, gender, and literacy, patients receiving nurse support were 1.46 times more likely to complete repeat FOBT screening than those receiving education [95% confidence interval (CI), 1.14-1.06; P = 0.002] and 1.45 times more likely than those in enhanced care but this was not significant (95% CI, 0.93-2.26; P = 0.10). The incremental cost per additional person screened was $2,450 for nurse over enhanced care. CONCLUSION A mailed pamphlet and FOBT with simplified instructions did not improve annual screening. IMPACT Telephone outreach by a nurse manager was effective in improving rates of repeat FOBT, yet this may be too costly for community clinics.
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Wolf MS, Seligman H, Davis TC, Fleming DA, Curtis LM, Pandit AU, Parker RM, Schillinger D, Dewalt DA. Clinic-based versus outsourced implementation of a diabetes health literacy intervention. J Gen Intern Med 2014; 29:59-67. [PMID: 24002623 PMCID: PMC3889968 DOI: 10.1007/s11606-013-2582-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 06/14/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. METHODS A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. RESULTS Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (β = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (β = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (β = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. CONCLUSION An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.
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Serper M, McCarthy DM, Patzer RE, King JP, Bailey SC, Smith SG, Parker RM, Davis TC, Ladner DP, Wolf MS. What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use. PATIENT EDUCATION AND COUNSELING 2013; 93:306-311. [PMID: 23890725 PMCID: PMC4041129 DOI: 10.1016/j.pec.2013.06.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 06/20/2013] [Accepted: 06/29/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE We examined patient beliefs about provider awareness of medication use, patient-reported prevalence and nature of provider counseling about medications, and the impact of health literacy on these outcomes. METHODS Structured interviews were conducted at academic general internal medicine clinics and federally qualified health centers with 500 adult patients. Interviewer-administered surveys assessed patients' beliefs, self-reported prevalence and nature of provider counseling for new prescriptions, and medication review. RESULTS Most patients believed their physician was aware of all their prescription and over the counter medications, and all medications prescribed by other doctors; while a minority reported disclosing over the counter and supplement use. Among those receiving new prescriptions (n=190): 51.3% reported physician medication review, 77.4% reported receiving instructions on use from physicians and 43.3% from pharmacists. Side effects were discussed 42.9% of the time by physicians and 25.8% by pharmacists. Significant differences in outcomes were observed by health literacy, age, and clinic type. CONCLUSIONS There is a sizable gap between what patients believe physicians know about their medication regimen and what they report to the physician. PRACTICE IMPLICATIONS Discordance between patient beliefs and physician knowledge of medication regimens could negatively impact patient safety and healthcare quality.
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Bailey SC, Shrank WH, Parker RM, Davis TC, Wolf MS. Medication label improvement: An issue at the intersection of health literacy and patient safety. ACTA ACUST UNITED AC 2013. [DOI: 10.1179/cih.2009.2.3.294] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Sarfaty M, Doroshenk M, Hotz J, Brooks D, Hayashi S, Davis TC, Joseph D, Stevens D, Weaver DL, Potter MB, Wender R. Strategies for expanding colorectal cancer screening at community health centers. CA Cancer J Clin 2013; 63:221-31. [PMID: 23818334 DOI: 10.3322/caac.21191] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work.
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Lyles CR, Wolf MS, Schillinger D, Davis TC, Dewalt D, Dahlke AR, Curtis L, Seligman HK. Food insecurity in relation to changes in hemoglobin A1c, self-efficacy, and fruit/vegetable intake during a diabetes educational intervention. Diabetes Care 2013; 36:1448-53. [PMID: 23275354 PMCID: PMC3661820 DOI: 10.2337/dc12-1961] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Food insecurity is hypothesized to make diabetes self-management more difficult. We conducted a longitudinal assessment of food insecurity with several diabetes self-care measures. RESEARCH DESIGN AND METHODS We conducted a secondary, observational analysis of 665 low-income patients with diabetes, all of whom received self-management support as part of a larger diabetes educational intervention. We analyzed baseline food insecurity (measured by the U.S. Department of Agriculture Food Security module) in relation to changes in hemoglobin A1c (HbA1c) as well as self-reported diabetes self-efficacy and daily fruit and vegetable intake. We examined longitudinal differences using generalized estimating equation linear regression models, controlling for time, age, sex, race, income, and intervention arm. RESULTS Overall, 57% of the sample had an income <$15,000. Participants who were food insecure (33%) were younger, had less income, and were more likely to be unemployed compared with participants who were food secure. At baseline, those who were food insecure had higher mean HbA1c values (8.4% vs. 8.0%) and lower self-efficacy and fruit and vegetable intake than those who were food secure (all P < 0.05). Compared with food-secure individuals, participants who were food insecure had significantly greater improvements in HbA1c over time (0.38% decrease compared with 0.01% decrease; P value for interaction <0.05) as well as in self-efficacy (P value for interaction <0.01). There was no significant difference in HbA1c by food security status at follow-up. CONCLUSIONS Participants experiencing food insecurity had poorer diabetes-related measures at baseline but made significant improvements in HbA1c and self-efficacy. Low-income patients who were food insecure may be particularly receptive to diabetes self-management support, even if interventions are not explicitly structured to address finances or food security challenges.
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Sarfaty M, Doroshenk M, Hotz J, Brooks D, Hayashi S, Davis TC, Joseph D, Stevens D, Weaver DL, Potter MB, Wender R. Strategies for expanding colorectal cancer screening at community health centers. CA Cancer J Clin 2013. [PMID: 23681679 DOI: 10.1002/caac.21191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work. CA Cancer J Clin 2013. © 2013 American Cancer Society, Inc.
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Davis TC, Rademaker A, Bailey SC, Platt D, Esparza J, Wolf MS, Arnold CL. Contrasts in rural and urban barriers to colorectal cancer screening. Am J Health Behav 2013; 37:289-98. [PMID: 23985175 DOI: 10.5993/ajhb.37.3.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To contrast barriers to colon cancer (CRC) screening and Fecal Occult Blood Test (FOBT) completion between rural and urban safety-net patients. METHODS Interviews were administered to 972 patients who were not up-to-date with screening. RESULTS Rural patients were more likely to believe it was helpful to find CRC early (89.7% vs 66.1%, p < .0001), yet were less likely to have received a screening recommendation (36.4% vs. 45.8%, p = .03) or FOBT information (14.5% vs 32.3%, p < .0001) or to have completed an FOBT (22.0% vs 45.8%, p < .0001). CONCLUSIONS Interventions are needed to increase screening recommendation, education and completion, particularly in rural areas.
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McCarthy DM, Davis TC, King JP, Mullen RJ, Bailey SC, Serper M, Jacobson KL, Parker RM, Wolf MS. Take-Wait-Stop: a patient-centered strategy for writing PRN medication instructions. JOURNAL OF HEALTH COMMUNICATION 2013; 18 Suppl 1:40-48. [PMID: 24093344 PMCID: PMC3814925 DOI: 10.1080/10810730.2013.825675] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Recent studies have linked patient misunderstanding of label instructions for as needed (PRN) medications to dosing errors. This study conducted a preliminary field test of patient-centered PRN label instructions. Patients participated in a hypothetical dosing experiment and were randomized to a patient-centered label (referred to as "Take-Wait-Stop") or standard label. Participants were asked to demonstrate dosing the medicine over 24 hours. Three types of independent dosing errors were measured: (a) taking more than two pills at one time, (b) exceeding the maximum daily dose, and (c) waiting fewer than 4 hours between doses. Generalized linear models were used to assess the association between label type, health literacy, and sociodemographic characteristics. Participants' mean age was 39.8 years, 62.1% were female, 43.7% were White, and 72.4% had adequate literacy. Of participants, 31.8% who were shown the standard label demonstrated taking in excess of 6 pills in 24 hours compared with only 14.0% of participants who were shown the Take-Wait-Stop label (p = .05). Overall, only 1 person demonstrated he would take more than 2 pills in a single dose. Of the standard label group, 20.5% demonstrated dosing intervals of fewer than 4 hours compared with 23.3% of the Take-Wait-Stop label group (p=.75). In a multivariate model, participants who were exposed to the standard label were 2.5 times more likely to exceed the recommended maximum daily dose (95% CI [1.05, 7.70], p=.03). The Take-Wait-Stop label was beneficial in preventing participants from exceeding the maximum dose in 24 hours, although it did not significantly reduce other dosing errors.
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Lenahan JL, McCarthy DM, Davis TC, Curtis LM, Serper M, Wolf MS. A drug by any other name: patients' ability to identify medication regimens and its association with adherence and health outcomes. JOURNAL OF HEALTH COMMUNICATION 2013; 18 Suppl 1:31-39. [PMID: 24093343 PMCID: PMC3815114 DOI: 10.1080/10810730.2013.825671] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Understanding and organizing medication regimens can be challenging, and many patients struggle to properly dose prescribed medicine, potentially leading to less effective treatment or even harm. Generic prescriptions are increasingly common and may change in appearance, adding further complexity. The authors aimed to investigate familiarity with the drug regimen among a cohort of patients with diagnosed hypertension. Specifically, they determined the prevalence of patients' knowledge of their prescribed drug names and dosages compared to those who relied only on physical characteristics (size, shape, color) of their medications. The relationship between patients' identification strategies, self-reported adherence, and health outcomes (blood pressure control, hospitalization) were investigated. Patients who were dependent on the visual identification of their prescription medicine reported worse adherence. In addition, they had significantly lower rates of blood pressure control and greater risk of hospitalization. The ability to identify prescribed medicines by name may be helpful for screening and responding to patients at greater risk of making medication errors or being less engaged with their regimen for adherence purposes.
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Wolf MS, King J, Jacobson K, Di Francesco L, Bailey SC, Mullen R, McCarthy D, Serper M, Davis TC, Parker RM. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med 2012; 27:1587-93. [PMID: 22638604 PMCID: PMC3509295 DOI: 10.1007/s11606-012-2096-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 02/07/2012] [Accepted: 03/14/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is increasing concern over the risk of consumer unintentional misuse of non-prescription (a.k.a. 'over-the-counter') medications containing acetaminophen, which could lead to acute liver failure. OBJECTIVE To determine the prevalence of potential misuse and overdose of over-the-counter medications containing acetaminophen, either alone or in combination. DESIGN Cross-sectional, structured interviews with literacy assessment. SETTING One academic and one community-based general internal medicine practice in Chicago, IL, and one academic general internal medicine practice and a public hospital clinic in Atlanta, GA. PATIENTS Five hundred adults seeking primary care, ages 18-80. MEASUREMENT Demonstration of how and when patients would take over-the-counter medications containing acetaminophen, alone or in combination with one another, over a 24-hour period. RESULTS Overall, 23.8 % of participants demonstrated they would overdose on a single over-the-counter acetaminophen product by exceeding a dose of four grams in a 24-hour period; 5.2 % made serious errors by dosing out more than six grams. In addition, 45.6 % of adults demonstrated they would overdose by 'double-dipping' with two acetaminophen-containing products. In multivariable analyses, limited literacy (Relative Risk Ratio (RR) 1.65, 95 % Confidence Interval (CI) 1.03-2.66) and heavy acetaminophen use in the past six months (RR 1.70, 95 % CI 1.10-2.64) were independently associated with overdosing over-the-counter products. CONCLUSION Misunderstanding of the active ingredient and proper instructions for over-the-counter medications containing acetaminophen is common. The potential for errors and adverse events associated with unintentional misuse of these products is substantial, particularly among heavy users of acetaminophen and those with limited literacy.
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Davis TC, Arnold CL, Rademaker A, Bailey SC, Platt DJ, Reynolds C, Esparza J, Liu D, Wolf MS. Differences in barriers to mammography between rural and urban women. J Womens Health (Larchmt) 2012; 21:748-55. [PMID: 22519704 DOI: 10.1089/jwh.2011.3397] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies have examined differences between rural and urban women in mammography barriers, knowledge, and experiences. Exploring differences can help inform tailored interventions. METHODS Women, aged ≥40, who had not been screened in the past 2 years were recruited from eight federally qualified health centers across Louisiana. They were given a structured interview assessing mammography knowledge, beliefs, barriers, experiences, and literacy. RESULTS Of the 1189 patients who participated, 65.0% were African American, 61.6% were rural, and 44.0% had low literacy. Contrary to guidelines, most believed mammography should be done annually (74.3%) before age 40 (70.5%). Compared to urban women, rural participants were more likely to believe mammography will find small breast lumps early (34.4% vs. 6.5%, p<0.0001) and strongly disagree that mammography is embarrassing (14.6% vs. 8.4%, p=0.0002) or that they are afraid of finding something wrong (21.2% vs.12.3%, p=0.007). Rural women were more likely to report a physician recommendation for mammography (84.3% vs. 76.5%, p=0.006), but they were less likely to have received education (57.2% vs. 63.6%, p=0.06) or to have ever had a mammogram (74.8% vs. 78.1%, p=0.007). In multivariate analyses controlling for race, literacy, and age, all rural/urban differences remained significant, except for receipt of a mammogram. CONCLUSIONS Most participants were unclear about when they should begin mammography. Rural participants reported stronger positive beliefs, higher self-efficacy, fewer barriers, and having a physician recommendation for mammography but were less likely to receive education or screening.
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Davis TC, Seligman HK, Dewalt DA, Platt DJ, Reynolds C, Timm DF, Arnold CL. Diabetes Implementation of a Self-management Program in Resource Poor and Rural Community Clinics. J Prim Care Community Health 2012; 3:239-42. [PMID: 23804167 DOI: 10.1177/2150131911435673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate the implementation of a brief diabetes self-management support intervention designed for resource-poor community clinics. METHODS The authors conducted a pilot study among patients with type 2 diabetes in 3 community clinics. The intervention consisted of research assistants introducing and reviewing a diabetes self-management guide, helping patients set an achievable behavioral action plan, and following up with 2 telephone sessions. The primary outcome was patients' success setting and achieving behavioral goals. RESULTS All participants set an action plan (N = 247); most focused on physical activity or diet (97%). The initial session took an average of 15 minutes. At 2 to 4 weeks, 200 participants were contacted; 68% recalled their action plan; and 84% of these achieved it. At 6 to 9 weeks, approximately half of those who completed the first call were reached for the second call. Of those who remained in the intervention, 79% recalled their action plan, and 80% of these achieved it. At the end of the study, 62% of those initially enrolled reported behavior change. Most participants who did not complete the intervention could not be reached for telephone follow-up. CONCLUSIONS Although only about a third of patients remained engaged through the 2 follow-up calls, most of those who did reported they had achieved their action plan. This pilot study provides insight into initiating brief diabetes self-management strategies in resource-poor community clinics. Although telephone follow-up was challenging, using the self-management guide and action plan framework, particularly during the initial clinic visit, helped focus patients on behavior change.
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Davis TC, Arnold CL, Rademaker AW, Platt DJ, Esparza J, Liu D, Wolf MS. FOBT completion in FQHCs: impact of physician recommendation, FOBT information, or receipt of the FOBT kit. J Rural Health 2012; 28:306-11. [PMID: 22757955 DOI: 10.1111/j.1748-0361.2011.00402.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine the effect of common components of primary care-based colorectal cancer (CRC) screening interventions on fecal occult blood test (FOBT) completion within rural and urban community clinics, including: (1) physician's spoken recommendation, (2) providing information or education about FOBTs, and (3) physician providing the FOBT kit; to determine the relative effect of these interventions; and to compare the effect of each intervention between rural and urban clinics. METHODS We conducted structured interviews with patients aged 50 years and over receiving care at community clinics that were noncompliant with CRC screening. Self-report of ever receiving a physician's recommendation for screening, FOBT information or education, physician providing an FOBT kit, and FOBT completion were collected. FINDINGS Participants included 849 screening-eligible adults; 77% were female and 68% were African American. The median age was 57; 33% lacked a high school diploma and 51% had low literacy. In multivariable analysis, all services were predictive of rural participants completing screening (physician recommendation: P = .002; FOBT education: P = .001; physician giving FOBT kit: P < .0001). In urban clinics, only physician giving the kit predicted FOBT completion (P < .0001). Compared to urban patients, rural patients showed a stronger relationship between FOBT completion and receiving a physician recommendation (risk ratio [RR]: 5.3 vs. 2.1; P = .0001), receiving information or education on FOBTs (RR: 3.8 vs 1.9; P = .0002), or receiving an FOBT kit from their physician (RR: 22.3 vs. 10.1; P = .035). CONCLUSIONS Participants who receive an FOBT kit from their physician are more likely to complete screening.
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Arnold CL, Rademaker A, Bailey SC, Esparza JM, Reynolds C, Liu D, Platt D, Davis TC. Literacy barriers to colorectal cancer screening in community clinics. JOURNAL OF HEALTH COMMUNICATION 2012; 17 Suppl 3:252-64. [PMID: 23030574 PMCID: PMC3748808 DOI: 10.1080/10810730.2012.713441] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
This article examines the relationship between literacy and colorectal cancer (CRC) screening knowledge, beliefs, and experiences, with a focus on fecal occult blood tests (FOBTs). Participants were 975 patients in 8 Louisiana federally qualified health centers. Participants were 50 years of age or older and not up to date with CRC screening; approximately half (52%) had low literacy (less than a 9th-grade level). Participants with low literacy were less likely than were those with adequate literacy to be aware of advertisements promoting CRC screening (58.7% vs. 76.3%, p < .0001) or to believe it was very helpful to find CRC early (74.5% vs. 91.9%, p < .0001). The majority of participants had positive beliefs about the benefits of CRC screening using FOBTs. Participants with low literacy had more perceived barriers to FOBT completion and were more likely to strongly agree or agree that FOBTs would be confusing, embarrassing, or a lot of trouble; however, none of these remained significant in multivariate analyses controlling for relevant covariates. Confidence in being able to obtain an FOBT kit was high among those with low and adequate literacy (89.8% vs. 93.1%, respectively, p = .20); yet multivariate analyses revealed a significant difference in regard to literacy (p = .04) with low-literacy participants indicating less confidence. There was no significant difference by literacy in ever receiving a physician recommendation for CRC screening (38.4% low vs. 39.0% adequate, p = .79); however, multivariate analyses revealed significant differences in FOBT completion by literacy (p = .036). Overall, findings suggest that literacy is a factor in patients' CRC knowledge, beliefs, and confidence in obtaining a FOBT.
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Luebbe MK, Patterson JM, Jenkins KH, Buttrey EK, Davis TC, Clark BE, McCollum FT, Cole NA, MacDonald JC. Wet distillers grains plus solubles concentration in steam-flaked-corn-based diets: Effects on feedlot cattle performance, carcass characteristics, nutrient digestibility, and ruminal fermentation characteristics. J Anim Sci 2011; 90:1589-602. [PMID: 22147473 DOI: 10.2527/jas.2011-4567] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Two experiments were conducted to determine the effects of wet distillers grain plus solubles (WDG; <15% sorghum grain) concentration in steam-flaked corn (SFC) diets on feedlot performance, carcass characteristics, ruminal fermentation, and diet digestibility. In Exp. 1, six hundred crossbred steers (364 ± 35 kg of BW) were used in a randomized complete block design with 8 replications/treatment. Dietary treatments consisted of a dry-rolled corn (DRC) control diet without WDG, a SFC control without WDG, and SFC with 4 WDG concentrations (15, 30, 45, 60% DM basis) replacing SFC, cottonseed meal, urea, and yellow grease. Final BW, ADG, G:F, HCW, and 12th-rib fat depth were greater (P ≤ 0.05) for SFC compared with DRC. Dry matter intake tended (P = 0.06) to be greater for DRC compared with SFC. Final BW, ADG, G:F, HCW, 12th-rib fat depth, and marbling score decreased linearly (P < 0.01) with increasing WDG concentration. In Exp. 2, six ruminally and duodenally cannulated crossbred steers (481 ± 18 kg of BW) were used in a 6 × 6 Latin square design using the same diets as Exp. 1. Ruminal, postruminal, and total tract OM and NDF digestibility were not different (P > 0.14) for DRC compared with SFC. Ruminal and total tract starch digestibility were greater (P < 0.01) for SFC compared with DRC. Dry matter and OM intake were not different (P ≥ 0.43) among WDG treatments. Ruminal and total tract OM digestibility decreased linearly (P < 0.01) with increasing WDG concentration. Intake, ruminal digestibility, and total tract digestibility of NDF increased linearly (P < 0.01) with increasing WDG concentration. Starch intake decreased linearly (P < 0.01) with increasing WDG concentration. Ruminal starch digestibility increased (P = 0.01) with increasing concentration of WDG. Total tract starch digestibility decreased quadratically (P < 0.01) with increasing concentration of WDG. Feeding SFC improved steer performance compared with DRC. The concentration of WDG and corn processing method influences nutrient digestibility and ruminal fermentation. The addition of WDG in SFC-based diets appears to negatively affect animal performance by diluting the energy density of the diet.
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Kakkilaya V, Groome LJ, Platt D, Kurepa D, Pramanik A, Caldito G, Conrad L, Bocchini JA, Davis TC. Use of a visual aid to improve counseling at the threshold of viability. Pediatrics 2011; 128:e1511-9. [PMID: 22106080 DOI: 10.1542/peds.2011-0597] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To pilot-test a visual aid developed to help counsel pregnant women. METHODS After agreeing to participate, pregnant women at >28 weeks of gestation were assigned randomly to counseling with or without a visual aid. The visual aid contained pictures, graphics, and short messages about delivery room resuscitation, chances of survival, anticipated neonatal course, and long-term neurodevelopmental disabilities. A neonatal fellow performed counseling with a standardized script for an anticipated delivery at 23 weeks of gestation. In precounseling and postcounseling sessions, women were given a structured interview to assess their knowledge of chances of survival and disability and attitudes toward resuscitation. RESULTS Of the 89 women who participated, 76% were black and 59% read below a 9th-grade level. Compared with the no-visual aid group, women in the visual aid group recalled more disabilities and predicted longer neonatal stays (P = .01). For both groups, mothers' perceptions of the chances of survival were lower after counseling; the decrease was greater in the visual aid group (P = .03). The majority of women in each group opted for resuscitation, which was not affected by counseling. In multivariate analyses, use of the visual aid was a significant independent factor in explaining before/after differences in survival chances and recall of a long NICU stay and number of disabilities; higher literacy levels also were significant for recalling the number of disabilities. CONCLUSIONS Use of a visual aid improved mothers' knowledge and showed promise as a decision aid for counseling at the threshold of viability.
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King JP, Davis TC, Bailey SC, Jacobson KL, Hedlund LA, Di Francesco L, Parker RM, Wolf MS. Developing consumer-centered, nonprescription drug labeling a study in acetaminophen. Am J Prev Med 2011; 40:593-8. [PMID: 21565649 DOI: 10.1016/j.amepre.2011.02.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 02/11/2011] [Accepted: 02/14/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the U.S., acetaminophen overdose has surpassed viral hepatitis as the leading cause of acute liver failure, and misuse contributes to more than 30,000 hospitalizations annually. Half to two thirds of acetaminophen overdoses are unintentional, suggesting the root cause is likely poor understanding of medication labeling or failure to recognize the consequences of exceeding the recommended maximum daily dosage. PURPOSE Elicit subject feedback about active ingredient and dosing information on over-the-counter (OTC) acetaminophen and elicit feedback on proposed plain-language text and icons. METHODS Six focus groups, preceded by individual interviews, were conducted in April 2010 among 45 adults in two cities from two clinics and an adult basic education center. The individual interviews evaluated knowledge of OTC pain relievers, attention to product label information and literacy level while the group discussion elicited preference for label messages and icons. Analyses were conducted from April to June 2010. RESULTS Forty-four percent read at or below the 6th-grade level. Individual interviews revealed that <50% of participants routinely examine product label information. Only 31% know acetaminophen is in Tylenol®. The groups achieved consensus on a preferred icon for acetaminophen, desired explicit statement of potential liver damage in the warning against simultaneous use of acetaminophen products, and indicated preference for an icon and wording for maximum dose. CONCLUSIONS With the high prevalence of OTC use, a consumer-centered approach to developing icons and messages to promote awareness and safe use of acetaminophen could benefit consumers.
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Wolf MS, Curtis LM, Waite K, Bailey SC, Hedlund LA, Davis TC, Shrank WH, Parker RM, Wood AJJ. Helping patients simplify and safely use complex prescription regimens. ACTA ACUST UNITED AC 2011; 171:300-5. [PMID: 21357804 DOI: 10.1001/archinternmed.2011.39] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is considerable variability in the manner in which prescriptions are written by physicians and transcribed by pharmacists, resulting in patient misunderstanding of label instructions. A universal medication schedule was recently proposed for standardizing prescribing practices to 4 daily time intervals, thereby helping patients simplify and safely use complex prescription regimens. We investigated whether patients consolidate their medications or whether there is evidence of unnecessary regimen complexity that would support standardization. METHODS Structured interviews were conducted with 464 adults (age range, 55-74 years) who were receiving care either at an academic general medicine practice or at 1 of 3 federally qualified health centers in Chicago, Illinois. Participants were given a hypothetical, 7-drug medication regimen and asked to demonstrate how and when they would take all of the medications in a 24-hour period. The regimen could be consolidated into 4 dosing episodes per day. The primary outcome was the number of times per day that individuals would take medication. Root causes for patients complicating the regimen (>4 times a day) were examined. RESULTS Participants on average identified 6 times (SD, 1.8 times; range, 3-14 times) in 24 hours to take the 7 drugs. One-third of the participants (29.3%) dosed their medications 7 or more times per day, while only 14.9% organized the regimen into 4 or fewer times a day. In multivariable analysis, low literacy was an independent predictor of more times per day for dosing the regimen (β = 0.67; 95% confidence interval, 0.12-1.22; P = .02). Instructions for 2 of the drugs were identical, yet 31.0% of the participants did not take these medications at the same time. Another set of drugs had similar instructions, with the primary exception of 1 drug having the added instruction to take "with food and water." Half of the participants (49.5%) took these medications at different times. When the medications had variable expressions of the same dose frequency (eg, "every 12 hours" vs "twice daily"), 79.0% of the participants did not consolidate the medications. CONCLUSIONS Many patients, especially those with limited literacy, do not consolidate prescription regimens in the most efficient manner, which could impede adherence. Standardized instructions proposed with the universal medication schedule and other task-centered strategies could potentially help patients routinely organize and take medication regimens.
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Seligman HK, Davis TC, Schillinger D, Wolf MS. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved 2011; 21:1227-33. [PMID: 21099074 DOI: 10.1353/hpu.2010.0921] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
More than 14% of the American population is food insecure, or at risk of going hungry because of an inability to afford food. Food-insecure (FI) adults often reduce food intake or substitute inexpensive, energy-dense carbohydrates for healthier foods. We hypothesized these behaviors would predispose FI adults with diabetes to hypoglycemia and impaired diabetes self-management. We therefore assessed whether food insecurity was associated with multiple indicators of diabetes self-management (self-efficacy, medication- and glucose-monitoring adherence, hypoglycemia, or glycemic control) among 40 low-income adults with diabetes. Mean self-efficacy score was lower among FI than food-secure (FS) participants (34.4 vs. 41.2, p=.02). Food-insecure participants reported poorer adherence to blood glucose monitoring (RR=3.5, p=.008) and more hypoglycemia-related emergency department visits (RR=2.2, p=.007). Mean hemoglobin A1c was 9.2% among FI and 7.7% among FS participants (p=.08). Food insecurity is a barrier to diabetes self-management and a risk factor for clinically significant hypoglycemia.
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Wolf MS, Davis TC, Curtis LM, Webb JA, Bailey SC, Shrank WH, Lindquist L, Ruo B, Bocchini MV, Parker RM, Wood AJJ. Effect of standardized, patient-centered label instructions to improve comprehension of prescription drug use. Med Care 2011; 49:96-100. [PMID: 21150800 PMCID: PMC3845798 DOI: 10.1097/mlr.0b013e3181f38174] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of standardized, patient-centered label (PCL) instructions to improve comprehension of prescription drug use compared with typical instructions. METHODS A total of 500 adult patients recruited from 2 academic and 2 community primary care clinics in Chicago, IL and Shreveport, LA were assigned to receive as follows: (1) standard prescription instructions written as times per day (once, twice 3 times per day) (usual care), (2) PCL instructions that specify explicit timing with standard intervals (morning, noon, evening, bedtime) (PCL), or (3) PCL instructions with a graphic aid to visually depict dose and timing of the medication (PCL + Graphic). The outcome was correct interpretation of label instructions. RESULTS Instructions with the PCL format were more likely to be correctly interpreted compared with standard instructions (adjusted relative risk [RR]: 1.33, 95% confidence interval [CI]: 1.25-1.41). Inclusion of the graphic aid (PCL + Graphic) decreased rates of correct interpretation compared with PCL instructions alone (RR: 0.93; 95% CI: 0.89-0.97). Patients with low literacy were better able to interpret PCL instructions (low literacy: RR: 1.39; 95% CI: 1.14-1.68; P = 0.001). CONCLUSION The PCL approach could improve patients' understanding and use of their medication regimen.
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Cameron KA, Ross EL, Clayman ML, Bergeron AR, Federman AD, Bailey SC, Davis TC, Wolf MS. Measuring patients' self-efficacy in understanding and using prescription medication. PATIENT EDUCATION AND COUNSELING 2010; 80:372-6. [PMID: 20650594 PMCID: PMC3184839 DOI: 10.1016/j.pec.2010.06.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 06/22/2010] [Accepted: 06/23/2010] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To create a brief assessment tool, the Medication Understanding and Use Self-Efficacy Scale (MUSE). METHODS An existing scale (Communication and Attitudinal Self-Efficacy Scale) was modified, augmented, and piloted among 267 primary care patients in Chicago, New York City, and Shreveport, LA. Participant sociodemographics, literacy, current medication use, understanding medication instructions, and medication self-efficacy were measured. RESULTS Using principal components analysis, two scales emerged: taking medication and learning about medication; these two factors accounted for 55% of the total variance of understanding medication instructions. Performance on the MUSE differed by literacy level; multivariate analysis detected no interaction between literacy level and MUSE score. Regression analysis, adjusted for age, education, literacy level and number of current prescription medications indicated that participants' MUSE scores predicted patient understanding of common medication instructions (beta=0.07, 95% CI 0.001-0.14, p=0.04). CONCLUSION The MUSE is a valid and reliable tool measuring self-efficacy of understanding and using prescription medication. This scale differs from existing medication-specific self-efficacy scales as it addresses both learning about one's medications and adherence to the prescribed regimen. PRACTICE IMPLICATIONS The MUSE is an effective and brief research tool that can be utilized among participants with varying literacy levels.
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Osborn CY, Davis TC, Bailey SC, Wolf MS. Health literacy in the context of HIV treatment: introducing the Brief Estimate of Health Knowledge and Action (BEHKA)-HIV version. AIDS Behav 2010; 14:181-8. [PMID: 19023653 DOI: 10.1007/s10461-008-9484-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 10/14/2008] [Indexed: 11/25/2022]
Abstract
A brief, 8-item assessment of HIV treatment knowledge and action was developed and evaluated. Patients with HIV were interviewed in 2001 at infectious disease clinics in Shreveport, LA and Chicago, IL. Analyses on demographics, self-reported medication adherence, and responses to the Rapid Estimate of Adult Literacy in Medicine (REALM) and new, Brief Estimate of Health Knowledge and Action-HIV version (BEHKA-HIV) were performed in 2007. The BEHKA-HIV demonstrated high internal consistency, and construct validity. Lower scores on the BEHKA-HIV were independently associated with poorer rates of HIV medication adherence, scores 4-5 out of 8, AOR 2.6 (95% CI 1.9-3.6), and scores 0-3, AOR 11.4 (95% CI 8.2-15.9), as were the lowest scores on the REALM, AOR 3.3 (95% CI 1.3-8.7). The BEHKA-HIV is a psychometrically sound tool for assessing health knowledge and action regarding HIV treatment, and predicting non-adherence to HIV medications.
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Persell SD, Bailey SC, Tang J, Davis TC, Wolf MS. Medication reconciliation and hypertension control. Am J Med 2010; 123:182.e9-182.e15. [PMID: 20103029 DOI: 10.1016/j.amjmed.2009.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 06/13/2009] [Accepted: 06/18/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Discrepancies between the medical record and patient medication list are common. The relationship of discrepancies to chronic disease control has not been established. METHODS To determine the frequency and type of antihypertensive medication discrepancies between patient-named antihypertensive medications and the medical record, we performed a cross-sectional study of 315 adults with medically treated hypertension from 6 safety-net clinics in 3 states. We determined the association between medication discrepancies and uncontrolled blood pressure (> or =140/90 mm Hg or > or =130/80 mm Hg if diabetes) using multivariate logistic regression models. RESULTS Discrepancies were present for 75.2% of patients; 25.7% of patients could not provide the name of any antihypertensive medication they took; 49.5% could name 1 or more antihypertensive medications but had discrepancies between patient-reported antihypertensive medications and those listed in the medical record. Both patients who were unable to name any of their antihypertensive medications and patients with discrepancies between patient-named medications and the medical record were significantly more likely to have uncontrolled blood pressure than patients who named the same medications as the medical record in adjusted analyses, adjusted risk ratios 1.66 (95% confidence interval, 1.31-2.10) and 1.51 (95% confidence interval, 1.11-2.07), respectively. Twelve percent of patients reporting medications took antihypertensive medication that altered potassium metabolism that was not in their medical record. CONCLUSIONS Among patients at safety-net clinics, inability to name one's antihypertensive medications and discrepancies between patient-reported medications and the medical record were very common. Both were strongly associated with inadequate hypertension control. Performing medication reconciliation at the point of care may be an important way to identify patients at high risk for inadequate disease control or safety problems.
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Wolf MS, Davis TC, Bass PF, Curtis LM, Lindquist LA, Webb JA, Bocchini MV, Bailey SC, Parker RM. Improving prescription drug warnings to promote patient comprehension. ARCHIVES OF INTERNAL MEDICINE 2010; 170:50-6. [PMID: 20065199 PMCID: PMC3845799 DOI: 10.1001/archinternmed.2009.454] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prior studies have documented a high prevalence of patients who misunderstand prescription drug warning labels, placing them at risk for medication error. We evaluated whether the use of "enhanced print" drug warnings could improve patient comprehension beyond a current standard. METHODS An evaluation of enhanced print warning labels was conducted at 2 academic and 2 community health primary care clinics in Chicago, Illinois, and Shreveport, Louisiana. In total, 500 adult patients were consecutively recruited and assigned to receive (1) current standard drug warning labels on prescription containers (standard), (2) drug warnings with text rewritten in plain language (simplified text), or (3) plain language and icons developed with patient feedback (simplified text + icon). The primary outcome was correct interpretation of 9 drug warning labels as determined by a blinded panel review of patients' verbatim responses. RESULTS Overall rates of correct interpretation of drug warnings varied among standard, simplified text, and simplified text + icon labels (80.3%, 90.6%, and 92.1%, respectively; P < .001). Warnings with simplified text and simplified text + icons were more likely to be correctly interpreted compared with standard labels (simplified text - adjusted odds ratio [AOR] = 2.64; 95% confidence interval [CI], 2.00-3.49; simplified text + icons - AOR = 3.26; 95% CI, 2.46-4.32). Patients' ability to correctly interpret labels was not significantly different with the inclusion of icons (simplified text + icons - AOR = 1.23; 95% CI, 0.90-1.67; P = .20). Low literacy was also an independent predictor of misinterpretation (AOR, 0.65; 95% CI, 0.44-0.94). Patients with marginal and low literacy were better able to correctly interpret warning labels with simplified text + icons compared with labels with simplified text only (marginal literacy - AOR = 2.59; 95% CI, 1.24-5.44; P = .01; low literacy - AOR = 3.22; 95% CI, 1.39-7.50; P = .006). CONCLUSIONS Simple, explicit language on warning labels can increase patient understanding; the addition of appropriate icons is particularly useful for adults with lower literacy skills. Evidence-based standards are needed to promote patient-centered prescription labeling practices.
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Berkman ND, Davis TC, McCormack L. Health literacy: what is it? JOURNAL OF HEALTH COMMUNICATION 2010; 15 Suppl 2:9-19. [PMID: 20845189 DOI: 10.1080/10810730.2010.499985] [Citation(s) in RCA: 478] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The concept of health literacy evolved from a history of defining, redefining, and quantifying the functional literacy needs of the adult population. Along with these changes has come the recognition that sophisticated literacy skills are increasingly needed to function in society and that low literacy may have an effect on health and health care. We present a brief history of literacy in the United States, followed by a discussion of the origins and conceptualization of health literacy. Increased attention to this important issue suggests the need to review existing definitions of the term "health literacy," because despite the growing interest in this field, one question that persists is, "What is health literacy?"
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DeWalt DA, Davis TC, Wallace AS, Seligman HK, Bryant-Shilliday B, Arnold CL, Freburger J, Schillinger D. Goal setting in diabetes self-management: taking the baby steps to success. PATIENT EDUCATION AND COUNSELING 2009; 77:218-23. [PMID: 19359123 PMCID: PMC4286314 DOI: 10.1016/j.pec.2009.03.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 02/03/2009] [Accepted: 03/02/2009] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals. METHODS We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study. RESULTS We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide. CONCLUSIONS A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals. PRACTICE IMPLICATIONS Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.
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Bailey SC, Pandit AU, Yin S, Federman A, Davis TC, Parker RM, Wolf MS. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med 2009; 41:715-721. [PMID: 19882395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Our objective was to determine the level of adult understanding of dosage instructions for a liquid medication commonly prescribed for children. METHODS Structured interviews were conducted with 373 adults waiting for an appointment at family medicine clinics serving low-income populations in Shreveport, La; Chicago; and Jackson, Mich, from July 2003-August 2004. Subjects were asked to read a prescription label for amoxicillin and explain how they would take the medication. Correct interpretation was determined by a panel of blinded physician reviewers who coded subjects' verbatim responses. Qualitative methods were used to determine the nature of incorrect responses. RESULTS Twenty-eight percent of subjects misunderstood medication instructions. The prevalence of misinterpreting instructions among subjects with adequate, marginal, and low literacy was 18%, 34%, and 43%, respectively. Common causes for misunderstanding included problems with dosage measurement (28%; ie, tablespoon instead of teaspoon) and frequency of use (33%; ie, every 3 hours instead of every 6-8 hours). In an adjusted analysis that excluded literacy, African Americans were more likely to misunderstand instructions than Caucasians (adjusted odds ratio [AOR] 1.63, 95% confidence interval [CI]=1.02-2.61). When literacy was included in the model, the effect of race on misunderstanding was reduced and nonsignificant. Inadequate and marginal literacy remained independent predictors of misunderstanding (inadequate--AOR 2.90, 95% CI= 1.41-6.00; marginal--AOR 2.20, 95% CI=1.19-3.97). CONCLUSIONS Misinterpretation of pediatric liquid medication instructions is common. Limited literacy is a significant risk factor for misunderstanding and could contribute to racial disparities. Instructions should be written in a concise manner and standardized to ensure comprehension.
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Wolf MS, Wilson EA, Rapp DN, Waite KR, Bocchini MV, Davis TC, Rudd ARE. Literacy and learning in health care. Pediatrics 2009; 124 Suppl 3:S275-81. [PMID: 19861481 PMCID: PMC4131737 DOI: 10.1542/peds.2009-1162c] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The relationship between literacy and health outcomes are well documented in adult medicine, yet specific causal pathways are not entirely clear. Despite an incomplete understanding of the problem, numerous interventions have already been implemented with variable success. Many of those who proposed earlier strategies assumed the problem to originate from reading difficulties only. Given the timely need for more effective interventions, it is of increasing importance to reconsider the meaning of health literacy to advance our conceptual understanding of the problem and how best to respond. One potentially effective approach might involve recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. Here we review the current health literacy definition and literature and draw on relevant research from the fields of education, cognitive science, and psychology. In this framework, a research agenda is proposed that considers an individual's "health-learning capacity," which refers to the broad constellation of cognitive and psychosocial skills from which patients or family members must draw to effectively promote, protect, and manage their own or a child's health. This new, related concept will lead, ideally, to more effective ways of thinking about health literacy interventions, including the design of health-education materials, instructional strategies, and the delivery of health care services to support patients and families across the life span.
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Wallace AS, Seligman HK, Davis TC, Schillinger D, Arnold CL, Bryant-Shilliday B, Freburger JK, DeWalt DA. Literacy-appropriate educational materials and brief counseling improve diabetes self-management. PATIENT EDUCATION AND COUNSELING 2009; 75:328-33. [PMID: 19167857 PMCID: PMC3773938 DOI: 10.1016/j.pec.2008.12.017] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 12/05/2008] [Accepted: 12/17/2008] [Indexed: 05/21/2023]
Abstract
OBJECTIVE In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care. METHODS We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients' activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up. RESULTS Statistically significant (p<or=0.001) and clinically important (effect sizes=0.29-0.42) improvements were observed in participants' activation, self-efficacy, diabetes-related distress, self-reported behaviors, and knowledge. Improvements were similar across literacy levels. Spanish speakers experienced both greater improvement in diabetes-related distress and less improvement in self-efficacy levels than English speakers. CONCLUSION A diabetes self-management support package combining literacy-appropriate patient education materials with brief counseling suitable for use in primary care resulted in important short-term health-related psychological and behavioral changes across literacy levels. PRACTICE IMPLICATIONS Coupling literacy-appropriate education materials with brief counseling in primary care settings may be an effective and efficient strategy for imparting skills necessary for diabetes self-management.
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Pandit AU, Tang JW, Bailey SC, Davis TC, Bocchini MV, Persell SD, Federman AD, Wolf MS. Education, literacy, and health: Mediating effects on hypertension knowledge and control. PATIENT EDUCATION AND COUNSELING 2009; 75:381-385. [PMID: 19442477 DOI: 10.1016/j.pec.2009.04.006] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 04/03/2009] [Accepted: 04/19/2009] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To determine whether literacy mediates the association between education, hypertension knowledge and control. METHODS In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control. RESULTS In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70). CONCLUSION Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure. PRACTICE IMPLICATIONS Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.
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Webb J, Davis TC, Bernadella P, Clayman ML, Parker RM, Adler D, Wolf MS. Patient-centered approach for improving prescription drug warning labels. PATIENT EDUCATION AND COUNSELING 2008; 72:443-449. [PMID: 18644691 DOI: 10.1016/j.pec.2008.05.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 05/17/2008] [Accepted: 05/28/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To use a patient-centered approach to refine warning labels promoting the safe use of prescription drugs among patients, regardless of literacy level. METHODS Ten discussion groups were conducted among adults recruited from a general internal medicine clinic and four adult education classes. Participants completed face-to-face cognitive interviews with literacy assessment to determine comprehension of the 10 most commonly used drug warning labels, followed by a discussion group that solicited feedback for revising text and icons. RESULTS In all, 85 adults participated; 56% had limited literacy skills. Feedback from discussion groups indicated that the majority of icons were confusing, used difficult language, and text and icons were often discordant. Participants sought actionable language in the most simple and concise manner. In comprehension testing, five of the warning labels reached a set standard of >80% comprehension; the remaining labels were revised and three others modified on patients' request. A universal icon that conveyed 'Caution' was used for one label ("use only on your skin") as patients were unable to agree on an acceptable visual representation. CONCLUSION A patient-centered approach to designing consumer medication information could improve the comprehensibility of existing warning labels. PRACTICE IMPLICATIONS Pharmacies should review existing drug warnings to assess adequacy among patients, particularly those with limited literacy. Pharmacists should confirm patients understand auxiliary warnings to support safe and effective use.
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Waite KR, Paasche-Orlow M, Rintamaki LS, Davis TC, Wolf MS. Literacy, social stigma, and HIV medication adherence. J Gen Intern Med 2008; 23:1367-72. [PMID: 18563494 PMCID: PMC2518013 DOI: 10.1007/s11606-008-0662-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 03/27/2008] [Accepted: 04/28/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have linked limited literacy to poorer HIV medication adherence, although the precise causal pathways of this relationship have only been initially investigated. OBJECTIVE To examine whether social stigma is a possible mediator to the relationship between literacy and self-reported HIV medication adherence. DESIGN Structured patient interviews with a literacy assessment, supplemented by medical chart review, were conducted among patients receiving care at infectious disease clinics in Shreveport, Louisiana and Chicago, Illinois. Literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), while stigma was measured using items taken from the Patient Medication Adherence Questionnaire (PMAQ). PARTICIPANTS Two hundred and four consecutive patients participated. RESULTS Approximately one-third of the patients (30.4%) were less than 100% adherent to their regimen, and 31.4% had marginal (7th-8th grade) or low (< or = 6th grade) literacy. In multivariate analyses, patients with low literacy were 3.3 times more likely to be non-adherent to antiretroviral regimens (95% CI 1.3-8.7; p < 0.001). Perceived social stigma was found to mediate the relationship between literacy and medication adherence (AOR 3.1, 95% CI 1.3-7.7). CONCLUSIONS While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, perceived social stigma mediated this relationship. Low literacy HIV intervention strategies may also need to incorporate more comprehensive psychosocial approaches to overcome stigma barriers.
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Davis TC, Wolf MS, Bass PF, Arnold CL, Huang J, Kennen EM, Bocchini MV, Blondin J. Provider and patient intervention to improve weight loss: a pilot study in a public hospital clinic. PATIENT EDUCATION AND COUNSELING 2008; 72:56-62. [PMID: 18346861 DOI: 10.1016/j.pec.2008.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 01/11/2008] [Accepted: 01/27/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy. METHODS The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy. RESULTS 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01). CONCLUSIONS This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital. PRACTICE IMPLICATIONS Hospital-based weight loss interventions need to target both physicians and patients.
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Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health literacy: an overlooked factor in understanding HIV health disparities. Am J Prev Med 2007; 33:374-8. [PMID: 17950402 DOI: 10.1016/j.amepre.2007.07.022] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 06/07/2007] [Accepted: 07/06/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Limited health literacy may be a contributing factor to racial disparities in health care. This study examined the mediating effect of limited health literacy on the relationship between race and HIV-medication adherence. METHODS A total of 204 patients infected with HIV were recruited from two clinics in 2001. Structured in-person interviews were conducted to obtain information on patient demographics, medication adherence, and health literacy. Multivariate regression models were run in 2006 to examine the associations among race, literacy, and HIV-medication adherence after adjusting for relevant covariates. RESULTS In an adjusted analysis that excluded literacy, African Americans were 2.40 times more likely to be nonadherent to their HIV-medication regimen than whites (95% confidence interval [CI]=1.14-5.08). When literacy was included in the final model, the effect estimates of race diminished 25% to nonsignificance. Literacy remained a significant independent predictor of nonadherence (adjusted odds ratio [AOR]=2.12, 95% CI=1.93-2.32). CONCLUSIONS In this study, limited health literacy mediated the relationship between race and HIV-medication adherence. Investigators need to consider the potential utility of responding to literacy and communication barriers in health care as part of interventions to reduce racial disparities.
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Fitzgibbon ML, Ferreira MR, Dolan NC, Davis TC, Rademaker AW, Wolf MS, Liu D, Gorby N, Schmitt BP, Bennett CL. Process evaluation in an intervention designed to improve rates of colorectal cancer screening in a VA medical center. Health Promot Pract 2007; 8:273-81. [PMID: 17606952 DOI: 10.1177/1524839907302210] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Colorectal cancer (CRC) is the third most common cancer in the United States. Although CRC screening is recommended for individuals 50 years and older, screening completion rates are low. This can be attributed to provider and patient barriers. We developed an intervention to improve provider recommendation and patient screening among noncompliant male veterans in a 2-year randomized controlled trial and examined the relationship between participation and study outcomes among patients and providers. Overall, providers who attended intervention sessions recommended CRC screening during 64% of patient visits and providers who did not attend any intervention sessions recommended screening during 54% of visits (p < .01). Patients of providers who attended intervention sessions also were more likely to be screened (42% versus 29%, p < .05). The patient intervention did not have the desired impact. The subgroup of patients in the patient intervention was not more likely to complete CRC screening.
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Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, Clayman M, Parker RM. To err is human: patient misinterpretations of prescription drug label instructions. PATIENT EDUCATION AND COUNSELING 2007; 67:293-300. [PMID: 17587533 DOI: 10.1016/j.pec.2007.03.024] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 03/28/2007] [Accepted: 03/30/2007] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To examine the nature and cause of patients' misunderstanding common dosage instructions on prescription drug container labels. METHODS In-person cognitive interviews including a literacy assessment were conducted among 395 patients at one of three primary care clinics in Shreveport, Louisiana, Jackson, Michigan and Chicago, Illinois. Patients were asked to read and demonstrate understanding of dosage instructions for five common prescription medications. Correct understanding was determined by a panel of blinded physician raters reviewing patient verbatim responses. Qualitative methods were employed to code incorrect responses and generate themes regarding causes for misunderstanding. RESULTS Rates of misunderstanding for the five dosage instructions ranged from 8 to 33%. Patients with low literacy had higher rates of misunderstanding compared to those with marginal or adequate literacy (63% versus 51% versus 38%, p<0.001). The 374 (19%) incorrect responses were qualitatively reviewed. Six themes were derived to describe the common causes for misunderstanding: label language, complexity of instructions, implicit versus explicit dosage intervals, presence of distractors, label familiarity, and attentiveness to label instructions. CONCLUSION Misunderstanding dosage instructions on prescription drug labels is common. While limited literacy is associated with misunderstanding, the instructions themselves are awkwardly phrased, vague, and unnecessarily difficult. PRACTICE IMPLICATIONS Prescription drug labels should use explicit dosing intervals, clear and simple language, within a patient-friendly label format. Health literacy and cognitive factors research should be consulted.
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Wolf MS, Davis TC, Parker RM. Editorial: The Emerging Field of Health Literacy Research. Am J Health Behav 2007. [DOI: 10.5993/ajhb.31.s1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Osborn CY, Weiss BD, Davis TC, Skripkauskas S, Rodrigue C, Bass PF, Wolf MS. Measuring Adult Literacy in Health Care: Performance of the Newest Vital Sign. Am J Health Behav 2007. [DOI: 10.5993/ajhb.31.s1.6] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Seligman HK, Wallace AS, DeWalt DA, Schillinger D, Arnold CL, Shilliday BB, Delgadillo A, Bengal N, Davis TC. Facilitating Behavior Change With Low-literacy Patient Education Materials. Am J Health Behav 2007. [DOI: 10.5993/ajhb.31.s1.9] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wolf MS, Davis TC, Osborn CY, Skripkauskas S, Bennett CL, Makoul G. Literacy, self-efficacy, and HIV medication adherence. PATIENT EDUCATION AND COUNSELING 2007; 65:253-60. [PMID: 17118617 DOI: 10.1016/j.pec.2006.08.006] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 07/25/2006] [Accepted: 08/13/2006] [Indexed: 05/12/2023]
Abstract
OBJECTIVE We examined the relationship between patient literacy level and self-reported HIV medication adherence, while estimating the mediating roles of treatment knowledge and self-efficacy on this relationship. METHODS Structured patient interviews with a literacy assessment, supplemented by medical chart review, were conducted among 204 consecutive patients receiving care at infectious disease clinics in Shreveport, Louisiana and Chicago, Illinois. Literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), while the Patient Medication Adherence Questionnaire (PMAQ) was used to assess medication self-efficacy and adherence to antiretroviral regimens in the past 4 days. RESULTS Approximately one-third of patients (30.4%) were less than 100% adherent to their regimen, and 31.4% had marginal to low literacy skills. In multivariate analyses, low literate patients were 3.3 times more likely to be non-adherent to their antiretroviral regimen (p < 0.001). Patients' self-efficacy, but not knowledge, mediated the impact of low literacy on medication adherence (AOR 7.4, 95% CI 2.7-12.5). CONCLUSION While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, self-efficacy mediated this relationship. PRACTICE IMPLICATIONS Comprehensive intervention strategies that go beyond knowledge transfer may be needed to address self-efficacy among patients across all literacy levels to be successful in the management of difficult medication schedules.
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Wolf MS, Davis TC, Arozullah A, Penn R, Arnold C, Sugar M, Bennett CL. Relation between literacy and HIV treatment knowledge among patients on HAART regimens. AIDS Care 2007; 17:863-73. [PMID: 16120503 DOI: 10.1080/09540120500038660] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Successful management of HIV requires patient understanding and ability to act on treatment information. We examined the relationship between patient literacy and understanding of HIV treatment. Literacy, knowledge of CD4 count and viral load, and correct identification of HIV medications in regimen were evaluated in 204 patients receiving care in Shreveport, Louisiana and Chicago, Illinois. One-third of patients had limited literacy skills. These patients were less able to describe CD4 count (p < 0.001), viral load (p < 0.001) and to correctly identify medications in their regimen (p < 0.001). In the multivariate analysis, limited literacy was an independent predictor of poor understanding of CD4 count (OR 2.9, 95% CI: 1.3-6.3) and viral load (OR 4.1, 95% CI: 1.9-8.8). For correct medication identification, a significant interaction was found between number of HIV medications and literacy level. Among patients taking only 1-2 HIV medications, 100% of higher literate patients were able to identify their medications, compared to none of the lower literate patients prescribed three or more HIV medications. Patients with limited literacy skills may lack essential knowledge related to their HIV treatment. Clinicians may require additional training for improving communication with these patients.
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Davis TC, Wolf MS, Bass PF, Thompson JA, Tilson HH, Neuberger M, Parker RM. Literacy and misunderstanding prescription drug labels. Ann Intern Med 2006; 145:887-94. [PMID: 17135578 DOI: 10.7326/0003-4819-145-12-200612190-00144] [Citation(s) in RCA: 407] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Health literacy has increasingly been viewed as a patient safety issue and may contribute to medication errors. OBJECTIVE To examine patients' abilities to understand and demonstrate instructions found on container labels of common prescription medications. DESIGN Cross-sectional study using in-person, structured interviews. SETTING 3 primary care clinics serving mostly indigent populations in Shreveport, Louisiana; Jackson, Michigan; and Chicago, Illinois. PATIENTS 395 English-speaking adults waiting to see their providers. MEASUREMENT Correct understanding of instructions on 5 container labels; demonstration of 1 label's dosage instructions. RESULTS Correct understanding of the 5 labels ranged from 67.1% to 91.1%. Patients reading at or below the sixth-grade level (low literacy) were less able to understand all 5 label instructions. Although 70.7% of patients with low literacy correctly stated the instructions, "Take two tablets by mouth twice daily," only 34.7% could demonstrate the number of pills to be taken daily. After potential confounding variables were controlled for, low (adjusted relative risk, 2.32 [95% CI, 1.26 to 4.28]) and marginal (adjusted relative risk, 1.94 [CI, 1.14 to 3.27]) literacy were significantly associated with misunderstanding. Taking a greater number of prescription medications was also statistically significantly associated with misunderstanding (adjusted relative risk, 2.98 [CI, 1.40 to 6.34] for > or =5 medications). LIMITATIONS The study sample was at high risk for poor health literacy and outcomes. Most participants were women, and all spoke English. The authors did not examine the association between misunderstanding and medication error or evaluate patients' actual prescription drug-taking behaviors. CONCLUSIONS Lower literacy and a greater number of prescription medications were independently associated with misunderstanding the instructions on prescription medication labels.
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Davis TC, Wolf MS, Arnold CL, Byrd RS, Long SW, Springer T, Kennen E, Bocchini JA. 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. Pediatrics 2006; 118:e1707-14. [PMID: 17142495 DOI: 10.1542/peds.2006-1139] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The magnitude and consequences of low literacy in adolescent health and health care are unknown. The purpose of this study was to validate the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen), a word-recognition test in English that can be used as a brief literacy-screening tool in health care settings. PATIENTS AND METHODS A total of 1533 adolescents aged 10 to 19 years attending 1 of 5 middle schools, 3 high schools, 1 pediatric clinic, or 2 summer programs in Louisiana and North Carolina participated in face-to-face interviews. Demographic information was solicited, and participants were administered a battery of reading tests, including the REALM-Teen, Wide Range Achievement Test-Revised (WRAT-3), and Slosson Oral Reading Test-Revised (SORT-R). Internal consistency for the REALM-Teen was determined using Cronbach's alpha, and criterion validity was established through correlations with both the WRAT-R and SORT-R. Using reading below grade level (according to SORT-R scores) as an outcome, instrument accuracy and corresponding cutoff scores were calculated by plotting receiver operating characteristic curves and stratum-specific likelihood ratios. RESULTS Participants were 50% black and 53% female; 34% were enrolled in middle school and 66% in high school. The average time required to administer the REALM-Teen was 3 minutes. Internal consistency was excellent, as was test-retest reliability. The REALM-Teen is strongly correlated with both the WRAT-R and SORT-R. Five reading level categories were identified: 3rd grade and below, 4th to 5th grade, 6th to 7th grade, 8th to 9th grade, and 10th grade and above. Forty-six percent of participants were reading below grade level according to the SORT-R and 28% had repeated at least 1 grade. CONCLUSION The REALM-Teen is a brief, reliable instrument for assessing adolescent literacy skills and reading below grade level.
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Wolf MS, Davis TC, Tilson HH, Bass PF, Parker RM. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm 2006; 63:1048-55. [PMID: 16709891 DOI: 10.2146/ajhp050469] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The common causes for misunderstanding prescription drug warning labels (PWLs) among adults with low literacy were studied. METHODS A total of 74 patients reading at or below the sixth-grade level and receiving care at the primary care clinic at the Louisiana State University Health Sciences Center in Shreveport were recruited to participate in structured interviews. Patients were asked to interpret and comment on eight commonly used warning labels found on prescription medications. Correct interpretation was determined by expert panel review of patients' verbatim responses. Qualitative methods were employed to code responses and generate themes regarding the misunderstanding of these PWLs. RESULTS Among this sample of patients with low literacy skills, rates of correct interpretation for the eight warning labels ranged from 0% to 78.7%. With the exception of the most basic label, less than half of all patients were able to provide adequate interpretations of the warning label messages. Five themes were derived to describe the common causes for misunderstanding the labels: single-step versus multiple-step instructions, reading difficulty of text, use of icons, use of color, and message clarity. Labels were at greater risk for being misunderstood if they included multiple instructions, had a greater reading difficulty, included unfamiliar terms, or used confusing icons that were discordant with text messages. Participants also frequently imposed an incorrect meaning on label colors, which led to further confusion. CONCLUSION Patients with low literacy skills demonstrated a lower rate of correct interpretation of the eight most commonly used PWLs than did those with higher literacy skills. Multiple-step instructions, reading difficulty of text, the use of icons, the use of color, and message clarity were the common causes of label misinterpretation.
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Davis TC, Gazmararian J, Kennen EM. Approaches to improving health literacy: lessons from the field. JOURNAL OF HEALTH COMMUNICATION 2006; 11:551-4. [PMID: 16950727 DOI: 10.1080/10810730600835517] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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Wolf MS, Davis TC, Shrank WH, Neuberger M, Parker RM. A critical review of FDA-approved Medication Guides. PATIENT EDUCATION AND COUNSELING 2006; 62:316-22. [PMID: 16884888 DOI: 10.1016/j.pec.2006.06.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 06/02/2006] [Accepted: 06/07/2006] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To investigate whether consumer-directed, FDA-approved Medication Guides issued for potentially harmful medications are likely to be useful to patients with limited literacy. METHODS Lexile analysis and the suitability assessment of materials (SAM) were conducted on the 40 currently issued Medication Guides to evaluate reading difficulty, content, and format. Structured interviews with a literacy assessment were also conducted among 251 primary care patients at a public hospital clinic in Louisiana to determine if patients directed attention to Medication Guides and other accompanying patient information materials. RESULTS The average Lexile score estimated an 11th-12th grade reading level for the guides (M=1223, S.D.=200). None of the 40 Medication Guides met federal recommendations (6th-8th grade level). Most Medication Guides were deemed unsuitable because they did not provide a summary of content (90.0%) or limit the scope of information (77.5%). Only 23.0% of patients reported having looked at Medication Guides or accompanying patient information materials; patients with low literacy were less likely to have looked at them (16.7% versus 32.9%, p=0.03). CONCLUSION Medication Guides in their current form are not likely to be useful to patients with limited literacy skills. PRACTICE IMPLICATIONS Reading level of text in Medication Guides should be reduced, summaries or "highlights" provided, and the scope of information limited to increase the likelihood of use among individuals with limited literacy. Consumers should be involved in their development.
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Davis TC, Fredrickson DD, Potter L, Brouillette R, Bocchini AC, Williams MV, Parker RM. Patient understanding and use of oral contraceptive pills in a southern public health family planning clinic. South Med J 2006; 99:713-8. [PMID: 16866052 DOI: 10.1097/01.smj.0000223734.77882.b2] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess patient understanding and use of oral contraceptive pills (OCPs) and determine if these are associated with literacy. METHODS Four hundred OCP users from a southern public health family planning clinic were orally tested post visit for literacy, demographics, contraceptive knowledge, OCP use, side effects, and adherence. RESULTS Patients were predominately African American (86%); 78% had completed high school and 42% read below a 9th grade level. Most (94%) understood what to do when they missed one pill, yet few knew the correct action to take after missing two or three pills (19% and 3% respectively); 33% reported missing one or more pills in the past 2 weeks. Literacy was not associated with OCP use, knowledge, or adherence. CONCLUSION Patients of all literacy levels had limited understanding of OCP side effects and what to do about multiple missed pills. This puts them at risk for misuse.
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Davis TC, Wolf MS, Bass PF, Middlebrooks M, Kennen E, Baker DW, Bennett CL, Durazo-Arvizu R, Bocchini A, Savory S, Parker RM. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med 2006; 21:847-51. [PMID: 16881945 PMCID: PMC1831578 DOI: 10.1111/j.1525-1497.2006.00529.x] [Citation(s) in RCA: 277] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adverse events resulting from medication error are a serious concern. Patients' literacy and their ability to understand medication information are increasingly seen as a safety issue. OBJECTIVE To examine whether adult patients receiving primary care services at a public hospital clinic were able to correctly interpret commonly used prescription medication warning labels. DESIGN In-person structured interviews with literacy assessment. SETTING Public hospital, primary care clinic. PARTICIPANTS A total of 251 adult patients waiting for an appointment at the Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) Primary Care Clinic. MEASUREMENTS Correct interpretation, as determined by expert panel review of patients' verbatim responses, for each of 8 commonly used prescription medication warning labels. RESULTS Approximately one-third of patients (n=74) were reading at or below the 6th-grade level (low literacy). Patient comprehension of warning labels was associated with one's literacy level. Multistep instructions proved difficult for patients across all literacy levels. After controlling for relevant potential confounding variables, patients with low literacy were 3.4 times less likely to interpret prescription medication warning labels correctly (95% confidence interval: 2.3 to 4.9). CONCLUSIONS Patients with low literacy had difficulty understanding prescription medication warning labels. Patients of all literacy levels had better understanding of warning labels that contained single-step versus multiple-step instructions. Warning labels should be developed with consumer participation, especially with lower literate populations, to ensure comprehension of short, concise messages created with familiar words and recognizable icons.
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Davis TC, Fredrickson DD, Kennen EM, Humiston SG, Arnold CL, Quinlin MS, Bocchini JA. Vaccine risk/benefit communication: effect of an educational package for public health nurses. HEALTH EDUCATION & BEHAVIOR 2006; 33:787-801. [PMID: 16861585 DOI: 10.1177/1090198106288996] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to determine whether an in-service for public health nurses (PHNs) and accompanying educational materials could improve vaccine risk/benefit communication. The content and timing of vaccine communication were recorded during 246 pre-and 217 postintervention visits in two public health immunization clinics. Pre-/postintervention comparisons showed PHN communication of severe side effects (13% vs. 44%, p < .0001) and their management (29% vs. 60%, p < .0001) increased. There was no significant change in discussion of vaccine benefits (48% vs. 51%) or common side effects (91% vs. 92%),screening for contraindications (71% vs. 77%), or distribution of written information (89% vs. 92%). More parents initiated vaccine questions postintervention (27% vs. 39%,p < .01) and were more satisfied with vaccine-risk communication (8.1 vs. 8.9 on a 10-point scale, p < .01). Average vaccine communication time increased from 16 to 22 seconds (p < .01).
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