Social stigma concerns and HIV medication adherence

The threat of social stigma may prevent people living with HIV from revealing their status to others and serve as a barrier to HIV treatment adherence. We evaluated the effect of such concerns on self-reported treatment adherence using a short, three-item measure among 204 people living with HIV. Overall, the mean age of participants was 40.1 years, 45% were African American, and 80% were male. People with high HIV stigma concerns were 2.5 times less likely to define and interpret the meaning of CD4 count correctly and 3.3 times more likely to be nonadherent to their medication regimen than those with low concerns. Concern over revealing HIV status was the only statistically significant, independent predictor of adherence in multivariate analysis. Clinical care directed to individuals living with HIV should therefore include considerations for patient sensitivity to social stigma, such as modifications to medication schedules and referrals for counseling prior to enrollment in antiretroviral therapies.

Infant hearing screening: stakeholder recommendations for parent-centered communication

OBJECTIVES

The purpose of this study was to identify what stakeholders considered best practices for parent-provider communication regarding newborn hearing screening and diagnosis. We used consensus data to develop educational materials for parents.

METHODS

We conducted 29 focus groups and 23 individual interviews between October 2003 and May 2004. Participants included (1) English- and Spanish-speaking parents of infants <18 months of age who had experience with hospital-based newborn hearing screening; (2) parents of children with hearing loss; (3) primary care providers who provide prenatal care or care for newborns; and (4) audiologists, audiology technicians, and hospital nurses.

RESULTS

Communication to parents about hospital-based newborn hearing screening was limited. Most parents first learned about the screening in the hospital, but all stakeholders thought a more opportune time for education was before the birth. For parents of infants who did not pass the newborn hearing screening, stakeholders recommended direct communication about the urgency of diagnostic testing. They also indicated that primary care providers needed current information regarding hearing screening, diagnostic testing, and early intervention. All stakeholders thought that a brief brochure for parents to take home would be helpful for hospital-based screening and, if necessary, subsequent diagnostic testing. Primary care providers requested basic, to-the-point information.

CONCLUSIONS

The most opportune time to begin discussion of newborn hearing screening is before the birth. Providers need up-to-date information on current standards of hearing screening, diagnosis, and intervention. User-friendly patient education materials, such as those we developed, could assist providers in educating parents.

Recommendations for effective newborn screening communication: results of focus groups with parents, providers, and experts

OBJECTIVES

The aims of this study were to determine parent and provider knowledge and awareness of newborn screening; to gather opinions from parents, providers, and newborn screening professionals about the content and timing of newborn screening education; and to use consensus data to formulate recommendations and to develop educational materials for parents and providers.

METHODS

We conducted 22 focus groups and 3 individual interviews between October 2003 and May 2004, with English- and Spanish-speaking parents of infants <1 year of age who had experience with initial testing, retesting, or false-positive screenings; health professionals who provide prenatal care or health care for newborns; and state newborn screening program health professionals.

RESULTS

Parents and providers had limited knowledge and awareness about newborn screening practices. Parents wanted brief to-the-point information on newborn screening and its benefits, including the possible need for retesting and the importance of returning promptly for retesting if initial results are abnormal. Parents wanted the information orally from the primary care provider. Parents, providers, and newborn screening professionals all thought that an accompanying concise, easy-to-read brochure with contact information would be helpful. All focus group participants thought that parents should receive this information before the birth of the infant, preferably in the third trimester of pregnancy. Providers wanted a brief checklist of information and resources to prepare them to educate parents effectively.

CONCLUSIONS

We recommend prenatal and primary care providers be more involved in educating parents about newborn screening. Professional societies and state health officials should work together to encourage parent and provider education. User-friendly patient and provider education materials, such as those we developed, could form the basis for this educational approach.

Assessment of newborn screening parent education materials

OBJECTIVE

The purpose of this study was to measure the readability and user-friendliness (clarity, complexity, organization, appearance, and cultural appropriateness of materials) of parent education brochures on newborn screening.

METHODS

We studied English-language versions of the brochures that state newborn screening programs prepare and distribute. We obtained brochures from 48 states and Puerto Rico. We evaluated each brochure for readability with the Flesch reading ease formula. User-friendliness of the brochures was assessed with an instrument we created that contained 22 specific criteria grouped into 5 categories, ie, layout, illustrations, message, manageable information, and cultural appropriateness.

RESULTS

Most current newborn screening brochures should be revised to make them more readable and user-friendly for parents. Ninety-two percent of brochures were written at a reading level that is higher than the average reading level of US adults (eighth-grade level). In most brochures, the essential information for parents was buried. Although all brochures were brief and focused on the newborn screening tests being performed, 81% needed improvement in getting to the point quickly and making it easy for parents to identify what they needed to know or to do. None of the brochures scored high in all 22 criteria on the user-friendliness checklist.

CONCLUSIONS

Parent education materials about newborn screening should be revised to be easier to read and more user-friendly, by lowering the reading difficulty to eighth-grade level and focusing on issues such as layout, illustrations, message, information, and cultural appropriateness. It is important that state newborn screening programs and organizations work with parents to develop and to evaluate materials to ensure that they are user-friendly.

A qualitative study of literacy and patient response to HIV medication adherence questionnaires

The purpose of this study was to elicit patient feedback regarding the perceived clarity and level of difficulty associated with self-report human immunodeficiency virus (HIV) medication adherence measurement tools. HIV-infected patients from clinics in Shreveport, Louisiana, and Chicago, Illinois, were recruited to participate in four focus group discussions. Three groups consisted of patients with limited literacy skills (< ninth-grade reading ability), and one group contained patients with adequate literacy skills (> or = ninth-grade reading ability). Five themes emerged: (1) respondent understanding of the term "adherence," (2) recall, (3) question format, (4) visual aids, and (5) instrument administration. Participants struggled to define adherence, relied on visual cues to identify medications, and had a short recall time frame for missed doses (< or =3 days). Most preferred simple question formats and for their physician to assess adherence orally. Patients receiving treatment for HIV infection, especially those with limited literacy skills, may find it difficult to respond to existing HIV medication adherence questionnaires.

Colorectal cancer screening among African-American and white male veterans

BACKGROUND

Population-based studies from Medicare and privately insured individuals have consistently identified lower rates of colorectal cancer-screening tests among African-American versus white individuals. The purpose of this study was to evaluate whether, at a Veterans Affairs (VA) medical center, similar racial/ethnic differences in colorectal cancer screening could be identified.

METHODS

Study participants were male veterans, aged > or =50, attending a general medicine clinic in a VA hospital, who had not had either a fecal occult blood test (FOBT) within the past year or a flexible sigmoidoscopy/colonoscopy within the past 5 years. Based on review of electronic medical records, rates of physician recommendation for FOBT, flexible sigmoidoscopy, or colonoscopy, and patient completion of these tests were obtained and compared by race/ethnicity.

RESULTS

Sixty percent of 1599 veterans had not undergone recent colorectal cancer screening. Physicians recommended colorectal screening tests equally among African-American and white patients (71.0% vs 68.2%, p=0.44). African-American patients were 1.3 times more likely than white patients to receive colorectal screening procedures (36.3% vs 28.9%, p=0.03).

CONCLUSIONS

In contrast to other settings, in a general medicine clinic at a VA hospital, rates of colorectal cancer-screening tests were not lower for African-American patients compared to white patients.

Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial

PURPOSE

Colorectal cancer screening is the most underused cancer screening tool in the United States. The purpose of this study was to test whether a health care provider-directed intervention increased colorectal cancer screening rates.

PATIENTS AND METHODS

The study was a randomized controlled trial conducted at two clinic firms at a Veterans Affairs Medical Center. The records of 5,711 patients were reviewed; 1,978 patients were eligible. Eligible patients were men aged 50 years and older who had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4 to 6 months, they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients.

RESULTS

Colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (P = .02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (P = .003). Among patients with health literacy skills less than ninth grade, screening was completed by 55.7% of patients in the intervention group versus 30% of controls (P < .01).

CONCLUSION

A provider-directed intervention with feedback on individual and firm-specific screening rates significantly increased both recommendations and colorectal cancer screening completion rates among veterans.

Development of a brief survey on colon cancer screening knowledge and attitudes among veterans

INTRODUCTION

Poor knowledge of and negative attitudes toward available screening tests may account in part for colorectal cancer screening rates being the lowest among 17 quality measures reported for the Department of Veterans Affairs health care system, the largest integrated health system in the United States. The purpose of this study was to develop a brief assessment tool to evaluate knowledge and attitudes among veterans toward colorectal cancer screening options.

METHODS

A 44-item questionnaire was developed to assess knowledge, attitudes, and beliefs about colorectal cancer and screening and was then administered as part of an ongoing randomized controlled trial among 388 veterans receiving care in a general medicine clinic. Sixteen candidate items on colorectal cancer knowledge, attitudes, and beliefs were selected for further evaluation using principal components analysis. Two sets of items were then further analyzed.

RESULTS

Because the Cronbach alpha for beliefs was low (alpha = 0.06), the beliefs subscale was deleted from further consideration. The final scale consisted of seven items: a four-item attitude subscale (alpha = 0.73) and a three-item knowledge subscale (alpha = 0.59). Twelve-month follow-up data were used to evaluate predictive validity; improved knowledge and attitudes were significantly associated with completion of flexible sigmoidoscopy (P = .004) and completion of either flexible sigmoidoscopy or colonoscopy (P = .02).

CONCLUSION

The two-factor scale offers a parsimonious and reliable measure of colorectal cancer screening knowledge and attitudes among veterans. This colorectal Cancer Screening Survey (CSS) may especially be useful as an evaluative tool in developing and testing of interventions designed to improve screening rates within this population.

Health literacy and patient knowledge in a Southern US HIV clinic

Pharmaceutical management of HIV infection is complex, and proper adherence to antiretroviral regimens is contingent on active patient involvement in treatment. We examined the relationship between patient understanding of HIV and its treatment and health literacy. Structured interviews were conducted with 157 HIV-infected individuals receiving care at a community-based clinic in Shreveport, Louisiana, USA. In all, 48% of patients were reading below a 9th grade level. One-third of patients could not name their HIV medications and this was significantly related to low literacy (P < 0.01). Two-thirds of those reading below the 9th grade level did not know how to take their medications correctly (P < 0.05), and 75% did not know the meaning of a CD4 count or viral load (P < 0.001). Patients with low literacy skills were more likely to state that their physician was their sole source of HIV information (P < 0.005). Physicians may require training to appropriately convey health information to patients of low literacy.

Tipping the Scales: The Effect of Literacy on Obese Patients’ Knowledge and Readiness to Lose Weight

OBJECTIVES

The purpose of this study was to determine the association between the literacy level of overweight/obese patients and their weight-loss knowledge, attitudes, and readiness.

METHODS

Structured patient interviews and a literacy screening instrument were administered in two primary care clinics at a university-based public hospital.

RESULTS

A convenience sample of 210 overweight or obese adult outpatients (body mass index > or =25 kg/m2 or > or =30 kg/m2, respectively) were enrolled. Mean respondent age was 52 years; 74% were female, and 76% were black. Two thirds of patients read below a 9th grade level. Half of patients across all literacy levels reported currently attempting weight loss. There was a significant relation between literacy level and weight-loss knowledge, attitudes, and readiness (P < 0.05).

CONCLUSIONS

Patients with low literacy were significantly less likely to understand the adverse health consequences of obesity and the need to lose weight and to report being ready to lose weight. Patient education and counseling for weight loss should be tailored for patients with low literacy skills.

Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: does literacy make a difference?

PURPOSE

To evaluate whether lower literacy is associated with poorer knowledge and more negative attitudes and beliefs toward colorectal cancer screening among veterans without recent colorectal cancer screening.

PATIENTS AND METHODS

Three hundred seventy-seven male veterans, age 50 years and older, who had not undergone recent colorectal cancer screening, were surveyed about their knowledge, attitudes, and beliefs regarding colorectal cancer screening. Patients' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine, an individually administered screening test for reading.

RESULTS

Thirty-six percent of the 377 men had an eighth grade literacy level or higher. Men with lower literacy were 3.5 times as likely not to have heard about colorectal cancer (8.8% v 2.5%; P =.006), 1.5 times as likely not to know about screening tests (58.4% v 40.9%; P =.0001), and were more likely to have negative attitudes about fecal occult blood testing (FOBT), but not about flexible sigmoidoscopy. Specifically, men with lower literacy skills were two times as likely to be worried that FOBT was messy (26.7% v 13.3%; P =.008), 1.5 times as likely to feel that FOBT was inconvenient (28.7% v 18%; P =.05), and four times as likely to state they would not use an FOBT kit even if their physician recommended it (17.9% v 4.0%; P =.02).

CONCLUSION

Limited literacy may be an overlooked barrier in colorectal cancer screening among veterans.

Health literacy: implications for family medicine

As many as 90 million Americans have difficulty understanding and acting on health information. This health literacy epidemic is increasingly recognized as a problem that influences health care quality and cost. Yet many physicians do not recognize the problem or lack the skills and confidence to approach the subject with patients. In this issue of Family Medicine, several articles address health literacy in family medicine. Wallace and Lennon examined the readability of American Academy of Family Physicians patient education materials available via the Internet. They found that three of four handouts were written above the average reading level of American adults. Rosenthal and colleagues surveyed residents and found they lacked the confidence to screen and counsel adults about literacy. They used a Reach Out and Read program with accompanying resident education sessions to provide a practical and effective means for incorporating literacy assessment and counseling into primary care. Chew and colleagues presented an alternative to existing health literacy screening tests by asking three questions to detect inadequate health literacy. Likewise, Shea and colleagues reviewed the prospect of shortening the Rapid Estimate of Adult Literacy in Medicine (REALM), a commonly used health literacy screening tool. Both the Chew and Shea articles highlight the need for improved methods for recognizing literacy problems in the clinical setting. Further research is required to identify effective interventions that will strengthen the skills and coping strategies of both patients and providers and also prevent and limit poor reading and numeracy ability in the next generation.

Childhood immunization refusal: provider and parent perceptions

BACKGROUND AND OBJECTIVES

Parental concerns may contribute to immunization refusals and low infant immunization rates. Little knowledge is available about how often and why parents refuse immunizations for their children. This study was conducted to estimate, based on reports from health care providers and parents, the frequency of and reasons for immunization refusal.

METHODS

In 1998, we conducted 32 focus groups of parents and providers in six cities. We then mailed a survey to a random sample of private practice family physicians and pediatricians and public health nurses who immunize children. The overall survey response rate was 77%, and the final sample size was 544.

RESULTS

Focus group findings indicated that parents rarely refused vaccines but occasionally resisted specific vaccines. Parents who were unsure about vaccinating were open to discussions about vaccines with a trusted provider. Most of these parents agreed to immunize after discussing concerns with their provider. In a subsequent survey of providers, respondents estimated that they immunized a mean of 3536 (median 1560) children annually. The reported mean number of refusals per 1000 children age >18 years immunized was 7.2 (median 0.4), with varicella vaccine being the most commonly refused. Means did not vary by region or specialty. Providers indicated that fear of side effects heard about from media/word of mouth was the most commonly expressed reason for parents to refuse vaccines (52%). Religious (28%) or philosophical (26%) reasons or belief that the disease was not harmful (26%) were less common reasons. Providers reported that few parents refused because of anti-government sentiment (8%).

CONCLUSIONS

Providers indicate low vaccine refusal rates within offices of traditional primary care providers and in public health clinics. Strategies for efficient provider-patient communication are needed to address parental concerns about vaccines.

Childhood Vaccine Risk/Benefit Communication Among Public Health Clinics: A Time-Motion Study

United States law requires that immunization providers use Centers for Disease Control Vaccine Information Statements (VISs) and inform parents about vaccine risks and benefits prior to every childhood immunization. A recent national survey found that public health clinics (PHCs) reported high compliance with this law. To further investigate these findings, we conducted an immunization time-motion study in two PHCs in Kansas and Louisiana. Research assistants observed a convenience sample of 246 child immunization visits to record distribution of the VISs and content and time of vaccine communication. Thirty percent of parents read below a ninth grade level, 53% had Medicaid insurance, and 56% were Black. VISs were given with every dose of vaccine administered in 89% of visits. Public health nurses (PHNs) frequently discussed potential vaccine side effects (91%), treatment of side effects (91%), and the vaccine schedule (93%). Contraindications were screened in 71% of visits. Benefits were discussed in 48% of visits and severe risks in 29%. The national Vaccine Injury Compensation Program (VICP) was never discussed. The immunization visits lasted for a mean of 20 min. Vaccine communication of side effects, risks, benefits, screening for contraindications, and the next visit lasted for an average of 16 s for all vaccines. PHC compliance with mandated VIS distribution and practical vaccine communication was high. Room for improvement exists in discussion of benefits, serious risks, and the VICP.

Health literacy and cancer communication

Health literacy is increasingly recognized as a critical factor affecting communication across the continuum of cancer care. We reviewed research on health literacy and examined its impact on cancer outcomes and communication. According to the National Adult Literacy Survey (NALS), considered the most accurate portrait of literacy in our society, about one in five American adults may lack the necessary literacy skills to function adequately in our society. As patients, such individuals are at a disadvantage in their capacity to obtain, process, and understand cancer information and services needed to make appropriate health care decisions. Patients with poor health literacy have a complex array of difficulties with written and oral communication that may limit their understanding of cancer screening and of symptoms of cancer, adversely affecting their stage at diagnosis. In addition, these barriers impair communication and discussion about risks and benefits of treatment options, and patient understanding of informed consent for routine procedures and clinical trials. More research is needed to identify successful methods for educating and communicating with patients who have limited health literacy. Based on our own experience, we offer practical communication aids that can help bridge the cancer communication gap.

Improving vaccine risk/benefit communication with an immunization education package: a pilot study

INTRODUCTION

The National Childhood Vaccine Injury Act (NCVIA) requires that physicians distribute the appropriate Vaccine Information Statements (VIS) at each immunization visit and discuss the risks/benefits of every vaccine given. In a national study, 31% of pediatricians reported not using the VIS and 56% indicated that time was a barrier to vaccine risk/benefit communication. Parents, however, indicated they want their primary providers to personally tell them about risks/benefits.

OBJECTIVE

To test the feasibility of an Immunization Education Package (IEP) intervention to improve compliance with the federal mandate and to improve physician/parent vaccine risk/benefit communication.

SETTING

Two multi-physician private pediatric practices in Shreveport, La.

DESIGN

A before-after trial with comparison of 130 pre-intervention and 78 post-intervention visits. Research assistants recorded content and duration of immunization discussions during well-baby visits during which immunizations were scheduled. Clinic staffs were masked as to variables recorded.

INTERVENTION

The IEP was a multifaceted intervention, involving a practice-based in-service and distribution and discussion of ready-to-use materials including an exam room poster entitled "7 Questions Parents Need To Ask About Baby Shots."

RESULTS

Patients were 90% white and 96% privately insured. Pre and post results revealed a significant increase in VIS distribution (33% vs 91%, P <.001) and physician and nurse initiation of verbal teaching about the vaccine (65% vs 100%, 32% vs 72%, respectively; P <.001 for both), and parent initiation of questions (0% vs 32%, P <.001). A significant increase was found in the discussion of 6 of 8 major immunization IEP topics: contraindications, common side effects, treatment of common side effects, severe side effects, management of severe side effects, and schedule of the next vaccination. These vaccine communication improvements were made with a very small (20-s) increase in physician time. In post-intervention focus groups, provider staff endorsed the IEP method.

CONCLUSIONS

This IEP was a feasible way to facilitate compliance with the NCVIA. A significant amount of additional information was provided to parents with only a slight increase in time.

The role of inadequate health literacy skills in colorectal cancer screening

Colorectal cancer is ideally suited for early detection strategies that are likely to improve survival rates. Screening with either a fecal occult blood test (FOBT) or flexible sigmoidoscopy has been shown to identify precancerous polyps or cancers in early stages. However, persons with limited education and of lower socioeconomic status infrequently participate in screening programs in general and have very low rates of colorectal screening. Low literacy, which is common among persons with limited education and low income, may be an overlooked factor in understanding patients' decision making about colorectal cancer screening. This article provides information from focus groups about colorectal cancer screening, which we examine in the context of relevant literature on cancer screening and literacy. Using the health belief model, we examine the association between inadequate health literacy skills and low rates of colorectal cancer screening. The theoretical model also provides insights into strategies for improving knowledge, attitudes, and beliefs and screening rates for this challenging patient population.

Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women

BACKGROUND

Smoking during pregnancy increases the health risks of the unborn child as well as the mother. Although smoking rates for the population as a whole have declined drastically in the past generation, since 1992 there has been an increase in smoking among women, teenagers, and adults living in poverty. The purpose of this study was to assess reading level, tobacco knowledge, attitudes, and practices of tobacco use among pregnant adult and adolescent women in the public health system in north Louisiana.

METHODS

A convenience sample of 600 pregnant women was interviewed in person in the Obstetrics Clinics at Louisiana State University Health Sciences Center at Shreveport and E.A. Conway in Monroe. The structured interview contained detailed questions about smoking practices, tobacco knowledge, and attitudes. Reading was assessed using the Rapid Estimate of Adult Literacy in Medicine. Smoking practices were assessed by self-report and verified by measuring urine cotinine levels. The Cochran-Mantel-Haenszel test was used to estimate the relationship between reading level and knowledge and attitude; multiple logistic regression was used to determine which variable(s) predicted current smoking practices.

RESULTS

Knowledge about the effects of smoking and concern about the health effect of smoking on their baby varied significantly by reading level, with participants with higher reading levels having more knowledge and greater concern. Smoking practices did not vary by reading level even when race, age, and living with a smoker were controlled. Race was a significant determinant of smoking practices, with more white women reporting currently smoking during pregnancy than African Americans (34% vs 8%).

CONCLUSIONS

Reading level was related to knowledge about health effects of smoking. Women with higher reading levels were also more concerned about the adverse health effects of smoking on themselves and their babies. However, reading level was not correlated with smoking prevalence. The most significant determinant of smoking was race (with whites smoking significantly more than African Americans).

Childhood vaccine risk/benefit communication in private practice office settings: a national survey

Communication about childhood vaccine risks and benefits has been legally required in pediatric health care for over a decade. However, little is known about the actual practice of vaccine risk/benefit communication.

OBJECTIVES

This study was conducted to identify current practices of childhood vaccine risk/benefit communication in private physician office settings nationally. Specifically, we wanted to determine what written materials were given, by whom, and when; what information providers thought parents wanted/needed to know, the content of nurse and doctor discussion with parents, and the time spent on discussion. We also wanted to quantify barriers to vaccine risk/benefit discussion and to prioritize materials and dissemination methods preferred as solutions to these barriers.

METHODS

We conducted 32 focus groups in 6 cities, and then administered a 27-question cross-sectional mailed survey from March to September 1998, to a random national sample of physicians and their office nurses who immunize children in private practices. Eligible survey respondents were active fellows of the American Academy of Pediatrics or American Academy of Family Physicians in private practice who immunized children and a nurse from each physician's office. After 3 mailings, the response rate was 71%.

RESULTS

Sixty-nine percent of pediatricians and 72% of family physicians self-reported their offices gave parents the Centers for Disease Control and Prevention Vaccine Information Statement, while 62% and 58%, respectively, gave it with every dose. In ~70% of immunization visits, physicians and nurses reported initiating discussion of the following: common side effects, when to call the clinic and the immunization schedule. However, physicians reported rarely initiating discussion regarding contraindications (<50%) and the National Vaccine Injury Compensation Program (<10%). Lack of time was considered the greatest barrier to vaccine risk/benefit communication. Nurses reported spending significantly more time discussing vaccines with parents than pediatricians or family physicians (mean: 3.89 vs 9.20 and 3.08 minutes, respectively). Both physicians and nurses indicated an additional 60 to 90 seconds was needed to optimally discuss immunization with parents under current conditions. Stratified analysis indicated nurses played a vital role in immunization delivery and risk/benefit communication. To improve vaccine risk/benefit communication, 80% of all providers recommended a preimmunization booklet for parents and approximately one half recommended a screening sheet for contraindications and poster for immunization reference. The learning method most highly endorsed by all providers was practical materials (80%). Other desirable learning methods varied significantly by provider type.

CONCLUSIONS

There was a mismatch between the legal mandate for Vaccine Information Statement distribution and the actual practice in private office settings. The majority of providers reported discussing some aspect of vaccine communication but 40% indicated that they did not mention risks. Legal and professional guidelines for appropriate content and delivery of vaccine communication need to be clarified and to be made easily accessible for busy private practitioners. Efforts to improve risk/benefit communication in private practice should take into consideration the limited time available in an office well-infant visit and should be aimed at both the nurse and physician.

Osteomas of the internal auditory canal: a report of two cases

OBJECTIVES

To determine the optimal medical or surgical treatment of osteomas of the internal auditory canal (IAC) as well as their growth characteristics.

STUDY DESIGN

Information was obtained from case histories, images from computed tomography and magnetic resonance imaging, surgical and pathologic findings, and long-term clinical results.

METHODS

Two patients, along with 10 additional patients reported in the literature, with osteomas of the IAC with varying symptoms were studied. Clinical history, audiometric and vestibular test results, and radiographic studies were reviewed on all patients. Histopathologic examination of the surgical specimens confirmed the presence of osteomas. The clinical outcomes were studied to determine if the preoperative symptoms had resolved.

RESULTS

Eight of 12 patients underwent surgical removal of their IAC osteomas. Three of eight patients had total resolution of all symptoms. Three patients had improvement of their sensorineural hearing loss. Five patients had resolution of their dizziness. Four patients noted resolution of their tinnitus. In the absence of auditory symptoms, vestibular symptoms may be controlled with medical therapy. Long term follow-up of the two patients discussed showed little or no growth over a 4- to 5-year period.

CONCLUSIONS

Surgical intervention may be warranted to remove an osteoma of the IAC if symptoms are present. Patients should be made aware that symptoms may or may not improve. Continuation of symptoms may be a result of chronic compression of the auditory and vestibular nerves.

Students' perceptions and reported use of their memories after a memory-improvement course

23 college students who had taken a memory-improvement course completed a questionnaire at three different times: the beginning of the course, the end of the course, and two months after the end of the course. The questionnaire assessed the students' perceptions of their memory abilities, e.g., how good their memories were and how confident they were in their memories and knowledge about their memories, and their reported use of the memory techniques; it did not assess actual memory performance or ability. The students' responses to the questionnaire were compared with those of 23 control students who completed the questionnaire at the same three times. The memory students reported more positive changes in how they perceived their memory abilities and knowledge, and these reported changes in perceptions were still evident two months later. The students also reported that they were still using their memory techniques two months later.

Low literacy and violence among adolescents in a summer sports program

PURPOSE

To investigate the relationship between inadequate literacy and violent behavior among adolescents.

METHODS

This descriptive study involved a convenience sample of 386 adolescents who participated in a summer track and field and literacy program serving youths in low-income neighborhoods in Shreveport, Louisiana, during 1994-1996. Self-reported violence was measured using the Youth Risk Behavior Survey (YRBS) and reading grade levels were measured by the Slosson Oral Reading Test-Revised (SORT-R).

RESULTS

Youths ranged in age from 11 to 18 years; 66% were male, and 86% were African-American. Forty-three percent of adolescents tested had below-grade reading levels (> or = 2 grades). Participants with below-grade reading skills had higher rates of self-reported violent behaviors compared with those reading at grade level. When gender, race, and age were controlled for, adolescents reading below grade level were significantly more likely to report carrying weapons [odds ratio (OR) = 1.9; 95% confidence interval (CI) 1.1-3.5], carrying guns (OR = 2.6; CI 1.1- 6.2), to have been in a physical fight at school (OR = 1.7; CI 1.1-2.6), and to have been in a physical fight resulting in injuries requiring treatment (OR = 3.1; CI 1.6-6.1). In addition, youths reading below grade level were significantly more likely to be threatened at school with a weapon (OR = 2.1; CI 1.2-3.7) and to report missing days of school in the previous 30 days because they felt unsafe at school (OR = 2.3; CI 1.3-4.3). In characterizing the violence related behaviors, we found that low reading-level adolescents were more likely to be both aggressor/perpetrator and victim (44% vs. 32%; p = .02) and less likely to be only a victim (6% vs. 12%; p = .04) compared to adolescents with grade-appropriate reading skills.

CONCLUSIONS

Below-grade-level reading was significantly related to violence behaviors among adolescents who volunteered for a summer track and field program. Longitudinal studies are needed to further investigate the relationship of below-grade-level reading and aggressive/perpetrator and victim behaviors.

QOL and outcomes research in prostate cancer patients with low socioeconomic status

The VA Cancer of the Prostate Outcomes Study (VA CaPOS) is collecting quality-of-life (QOL) information from prostate cancer patients, spouses, and physicians at six VA medical centers. Currently, 601 men with prostate cancer are included in the study, most of whom are of low socioeconomic status and over half of whom are African-American. Quality-of-life responses were most favorable for newly diagnosed patients, intermediate for those with stable metastatic disease, and poorest for those with progressive metastatic disease. Patients could not provide reliable estimates of their own preferences for future QOL states but responded reliably to questions phrased as a comparison of the preferences of two hypothetical patients. High out-of-pocket costs for hormonal therapies, lack of health insurance, and a belief that the non-VA system offered poorer services were the most common reasons for patient transferral to the VA system. Satisfaction with medical care was generally high. While African-American patients were more likely to have advanced prostate cancer at diagnosis, after adjustment for differences in health literacy, race was no longer a significant predictor of advanced disease. The VA CaPOS provides useful information on health status and patient satisfaction of VA prostate cancer patients. Long-term evaluations are needed to detect clinically meaningful QOL information as the disease progresses.

Practical assessment of adult literacy in health care

Low literacy is a pervasive and underrecognized problem in health care Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.

Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer

PURPOSE

Diagnosis of advanced prostate cancer is a major health problem, especially among low-income men. Opportunities vary for early detection of prostate cancer for low-income black and white men because of financial, cultural, and social factors. In this study, we evaluated the association of poor literacy skills with higher rates of presentation of advanced stages of prostate cancer among low-income black and white men who received care in equal-access medical systems.

PATIENTS AND METHODS

Literacy and stage at diagnosis of prostate cancer were evaluated in 212 low-income men who received medical care in Shreveport, LA, and Chicago, IL. The patients' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM), an individually administered reading screening test designed specifically for use in the medical setting. Logistic regression models were used to evaluate predictors of metastatic disease at presentation as a function of patient age, race, literacy, and city.

RESULTS

Whereas black men were almost twice as likely to present with stage D prostate cancer (49.5% v 35.9%; P < .05), they were significantly more likely to have literacy levels less than sixth grade (52.3% v 8.7%; P < .001). However, after adjustment for differences in literacy, age, and city, race was not a significant predictor of advanced-stage prostate cancer.

CONCLUSION

Low literacy may be an overlooked but significant barrier to the diagnosis of early-stage prostate cancer among low-income white and black men. The development of culturally sensitive, low-literacy educational materials may improve patient awareness of prostate cancer and improve the frequency of diagnosis of early-stage cancer.

Self-reported characterization of seventh-grade students' fights

PURPOSE

To determine the characteristics of recent fights among seventh-grade students at public middle schools in three dissimilar U.S. communities.

METHODS

The study sample was composed of 289 seventh-grade students at public middle schools in three U.S. communities who participated in fights during the previous 6 months. Students at each site completed a self-administered two-part questionnaire (developed for this study) in May or October 1991. Pearson Chi-square test was performed to determine the association among characteristics of the fights, weapon use, and injury severity.

RESULTS

One or more weapons were present at 43% of the fights, weapons were used to threaten or injure in 23%, and stab or gunshot wounds were reported in 10%. Fights with five or more participants or with participants who were intoxicated or gang members involved more weapon use and more severe injury (p < 0.02). There was more frequent weapon use occurring away from home and school (p < 0.01). Spectators were present at 87% of the fights, and when they attempted to mediate or end the fighting, injury severity was lower. Students who often carry a weapon were much more likely to report involvement in fights in which weapons were used and to suffer more severe injuries (p < 0.02).

CONCLUSIONS

Seventh-graders' fights frequently involve the threat and actual use of weapons. The large number of participants and spectators at many of the fights with the most severely injurious outcomes implies that social factors and not exclusively poor conflict resolution skills are important factors precipitating fights among seventh-grade students.

Fighting and weapon-carrying among seventh-grade students in Massachusetts and Louisiana

PURPOSE

The purpose of this study was to compare attitudes toward violence and weapon-carrying among seventh-grade students in three dissimilar U.S. communities. A second focus was to determine students' understanding of their parents' violence-related guidance and behavior.

METHODS

Five hundred sixty-seven seventh-grade students (48% male, 46% white, 35% African-American, 13% Latino) completed a self-administered questionnaire in May or October 1991.

RESULTS

Thirty-four percent of the students had fought at least once, and 7% more than four times during the previous month. Also, within that period, 5% had skipped school owing to fear of violence. Students whose parents used nonviolent disciplinary techniques fought less frequently than those whose parents relied on hitting and more violent disciplinary methods (p < 0.001). Fighting was significantly more common among students who believe their parents want them to fight if insulted (p = 0.001). Students who reported that they try to stay out of fights usually succeeded (p = 0.001). Those students who more frequently participated in and observed fighting were more likely to carry a weapon (p = 0.001).

CONCLUSIONS

Fighting is a frequent occurrence in the lives of seventh-grade students. Students' understanding of their parents' attitudes and behavior correlate strongly with violent behavior. While many students feel that weapons confer safety, those students who actually carry weapons are much more likely to fight.

Presentation and reading level of sleep brochures: are they appropriate for sleep disorders patients?

OBJECTIVE

Sleep-disorders patients must be given information and health education they understand. The purpose of this study was twofold: (1) to assess suitability of American Sleep Disorders Association and National Sleep Foundation patient education brochures; and (2) to assess one widely used brochure, using patient input and patient literacy level, as a model for development of future materials.

DESIGN

Twelve American Sleep Disorders Association and National Sleep Foundation brochures were assessed for reading level using Grammatik, and for design, presentation, and motivating qualities using the Suitability Assessment of Materials (SAM). Patient literacy level was assessed using the Rapid Estimate Of Adult Literacy in Medicine (REALM).

SETTING

The Louisiana State University Medical Center sleep clinic, faculty private sleep clinic, and in the sleep center laboratory.

PATIENTS OR PARTICIPANTS

During the months of February-May 1997, 170 sleep disorders patients, 39% African American, 59% white participated in the study. Participants ranged in age from 18-73 years, with a mean age of 46.

MEASUREMENTS AND RESULTS

Suitability scores for the 12 brochures indicate that none scored in the superior range, 83% scored adequate, and 17% scored not suitable. Ninety-four percent of the brochures were written on a 12th grade level or higher, yet 37% of the sleep patients tested were reading at less than a 9th grade level. Low-level readers were significantly more likely than their higher-reading-level counterparts to report that a brochure was too long (22% vs 12%; p < .05), and that they would need help reading it (44% vs 3%; p < .001).

CONCLUSIONS

Patients need sleep information given to them on a level they understand. When developing and selecting appropriate materials, reading level, length, and suitability of written material should be considered.

Informed consent for clinical trials: a comparative study of standard versus simplified forms

BACKGROUND

A high level of reading skill and comprehension is necessary to understand and complete most consent forms that are required for participation in clinical research studies. This study was conducted to test the hypothesis that a simplified consent form would be less intimidating and more easily understood by individuals with low-to-marginal reading skills.

METHODS

During July 1996, 183 adults (53 patients with cancer or another medical condition and 130 apparently healthy participants) were tested for reading ability and then asked to read either the standard Southwestern Oncology Group (SWOG) consent form (16th grade level) or a simplified form (7th grade level) developed at Louisiana State University Medical Center-Shreveport (LSU). Participants were interviewed to assess their attitudes toward and comprehension of the form read. Then they were given the alternate consent form and asked which one they preferred and why.

RESULTS

Overall, participants preferred the LSU form (62%; 95% confidence interval [CI] = 54.8%-69.2%) over the SWOG form (38%; 95% CI = 30.8%-45.2%) (P = .0033). Nearly all participants thought that the LSU form was easier to read (97%; 95% CI = 93.1%-99.9%) than the SWOG form (75%; 95% CI = 65.1%-85.7%) (P<.0001). However, the degree to which the participants understood the forms was essentially the same for the LSU form (58%; 95% CI = 48.6%-67.0%) and the SWOG form (56%; 95% CI = 43.8%-66.8%).

IMPLICATIONS

These findings raise serious questions regarding the adequacy of the design of written informed consent documents for the substantial proportion of Americans with low-to-marginal literacy skills.

Intervention to increase mammography utilization in a public hospital

OBJECTIVE

To study the effects of three approaches to increasing utilization of screening mammography in a public hospital setting in Northwest Louisiana.

DESIGN

Randomized intervention study.

POPULATION

Four hundred forty-five women aged 40 years and over, predominantly low-income and with low literacy skills, who had not had a mammogram in the preceding year.

INTERVENTION

All interventions were chosen to motivate women to get a mammogram. Group 1 received a personal recommendation from one of the investigators. Group 2 received the recommendation plus an easy-to-read National Cancer Institute (NCI) brochure. Group 3 received the recommendation, the brochure, and a 12-minute interactive educational and motivational program, including a soap-opera-style video, developed in collaboration with women from the target population.

MEASUREMENTS AND MAIN RESULTS

Mammography utilization was determined at 6 months and 2 years after intervention. A significant increase (p = .05) in mammography utilization was observed after the intervention designed in collaboration with patients (29%) as compared with recommendation alone (21%) or recommendation with brochure (18%) at 6 months. However, at 2 years the difference favoring the custom-made intervention was no longer significant.

CONCLUSIONS

At 6 months there was at least a 30% increase in the mammography utilization rate in the group receiving the intervention designed in collaboration with patients as compared with those receiving the recommendation alone or recommendation with brochure. Giving patients an easy-to-read NCI brochure and a personal recommendation was no more effective than giving them a recommendation alone, suggesting that simply providing women in a public hospital with a low-literacy-level, culturally appropriate brochure is not sufficient to increase screening mammography rates. In a multivariate analysis, the only significant predictor of mammography use at 6 months was the custom-made intervention.

A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level

We used a randomized trial to compare two polio vaccine pamphlets written on a sixth grade level--the vaccine information statement prepared by the Centers for Disease Control (CDC) and an easy-to-read pamphlet we developed (LSU)--for reading ability, comprehension and preference among 610 parents with a broad range of demographic characteristics. Parents at all reading levels and incomes preferred LSU (76% vs. 21%, P < 0.001). Although readers of LSU achieved significantly higher comprehension (65% vs. 60%, P < 0.05) this difference may not be clinically significant. The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance. Comprehension was lowest for the CDC mandated information on risks and the National Injury Compensation. Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal, but such modification may not raise comprehension to an acceptable level without use of instructional graphics. Health education materials intended for general parent populations, which are written on a sixth grade reading level, may not adequately educate parents or prepare them for a discussion with their physicians.

Literacy in patients with a chronic disease: systemic lupus erythematosus and the reading level of patient education materials

OBJECTIVE

(1) To assess literacy in a sample of patients with systemic lupus erythematosus (SLE); (2) to evaluate the reading level of patient education materials specific to SLE; and (3) to compare patient literacy levels to the readability of materials written for patients with SLE.

METHODS

Rapid Estimate of Adult Literacy in Medicine, a reading recognition test, was given to 94 patients with SLE. Socioeconomic status was assessed using Nam-Powers. Patient education materials frequently used with these patients were assessed for readability grade level.

RESULTS

The patients with SLE were reading on an average 7th-8th grade level; their average educational level (last grade completed in school) was 11.9. The average socioeconomic status (SES) according to the Nam-Powers assessment was 43, indicating high school completed, no college, an income range of $5000-$10,000, and occupations such as household workers and laborers. Multiple linear regression revealed that race and education correlated with reading (p < 0.001), but age, sex, and SES did not. The readability of surveyed SLE patient education materials ranged from 7th-15th grade level. Eighty-nine percent were written at a 9th grade level or above and were therefore inappropriate for about half the patients surveyed.

CONCLUSION

Reading skills below high school level existed for 48% of patients surveyed, yet only 11% of SLE patient education materials were written below a 9th grade level. Current SLE patient education materials are written on too high a level for many patients. Identifying patients with low literacy may help provide more appropriate patient education and better medical care.

Tobacco use among male high school athletes

PURPOSE

The purpose of this study was to compare tobacco use among high school male athletes with their nonathlete counterparts. We hypothesized that there was an inverse correlation between the intensity level of the sport and frequency of tobacco use.

METHODS

Students were surveyed at seven high schools in northwest Louisiana using a 109-item questionnaire. Of the 1,200 males tested, 83% participated in one or more sports. The mean age was 15.8, and mean grade level was 10th. Sixty-seven percent were white, 27% African-American (AA), and 6% other.

RESULTS

Forty-one percent of the adolescent males tested were one or more tobacco products, 31% reported cigarette smoking, 21% chewed tobacco, and 18% used snuff. Eleven percent reported using all three tobacco products. Race was a significant determinant of tobacco use, with whites being more likely to use each of the three tobacco products (P < .001). Medium- and high-intensity athletes were significantly (P < .01) less likely to be heavy smokers than athletes participating in low-intensity sports and nonathletes. However, athletes of each intensity sport used chewing tobacco and snuff at significantly higher rates (P < .001) than nonathletes. When race and grade point average were controlled, sports intensity was a significant predictor of smokeless tobacco use but not overall smoking behavior. Both AA and white high school male athletes at all sport intensity levels were using chewing tobacco and snuff at a rate higher at least 1.5 times that of their nonathlete counterparts.

CONCLUSIONS

In our study, high school males' sports participation was a predictor of smokeless tobacco use but not overall smoking behavior. Although the probability of AA high school athletes using smokeless tobacco was low compared to whites, the pattern of use was similar across intensity levels of sports.

Knowledge and attitude on screening mammography among low-literate, low-income women

BACKGROUND

Low-income women utilize screening mammography less frequently, present at more advanced stages of disease, and have higher breast cancer mortality rates then women with higher incomes. The purpose of this study was to examine the relationship of reading ability to the knowledge and attitudes that low-income women have regarding screening mammography.

METHODS

A convenience sample of 445 women were interviewed for this study. These women, age 40 years and older, had not had a mammogram in the past year. They were waiting to see a doctor in one of two outpatient clinics at Louisiana State University Medical Center in Shreveport when they were interviewed. A structured questionnaire assessed mammography knowledge and attitudes. Each patient's reading ability was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM).

RESULTS

The women interviewed had a mean age of 56 years. Sixty-nine percent were African American, and 97% lived in households with annual incomes of less than $20,000. On the average, the highest grade completed in school was tenth grade. The average reading level was fourth to sixth grade, with 76% reading below a 9th-grade level. Lower reading ability correlated significantly with less mammography knowledge (P < 0.0001). A lack of accurate information about mammography was prevalent among low-level readers. Thirty-nine percent of women reading at or below a third-grade level did not know why women are given mammograms, compared with 12% of those reading at or above a ninth-grade level. Cost was a great concern in general, but cost concerns did not vary by reading level; 41% of all participants were very concerned about cost.

CONCLUSIONS

Limited literacy skills and lack of knowledge about screening mammography may contribute considerably to the underutilization of screening mammograms in low-income women. Screening for reading level may identify a subset of low-income patients who could benefit from specialized education. These results could help guide effective educational interventions and better provider-patient communication about screening mammography for low-literate, low-income women.

Parent comprehension of polio vaccine information pamphlets

BACKGROUND

Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined, as is whether parents reading at higher levels will accept low-reading-level materials.

METHODS

To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,177 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured.

RESULTS

Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU.

CONCLUSIONS

A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.

Improving patient education for patients with low literacy skills

Patients who misunderstand their diagnosis and treatment plans usually exhibit poor compliance. The 90 million adult Americans with low literacy skills struggle to understand such essential health information as discharge instructions, consent forms, oral instructions and drug labels. The Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that instructions be given on a level understandable to the patient. Most physicians tend to give too much information on too high a level for many patients to understand. Physicians who speak in simpler language, repeat their instructions and demonstrate key points, while avoiding too many directives, enhance their patients' understanding. Combining easy-to-read written patient education materials with oral instructions has been shown to greatly enhance patient understanding. To be effective with patients whose literacy skills are low, patient education materials should be short and simple, contain culturally sensitive graphics and encourage desired behavior. Compliance with therapy also may be improved by including family members in the patient education process.

Literacy and self-reported educational levels in relation to Mini-mental State Examination scores

BACKGROUND AND OBJECTIVES

Because of its brevity and ease of use, the Mini-mental State Examination (MMSE) is commonly used to screen and follow patients with cognitive impairment. This pilot study attempted to determine the relationships between literacy, age, and self-reported educational level and the total MMSE score.

METHODS

Cross-sectional analysis of all patients was followed by a family practice group at five local nursing homes. The associations between the patients' MMSE scores; literacy, as measured by the Rapid Estimate of Adult Literacy in Medicine (REALM); self-reported educational level; and age were determined using Pearson's correlation coefficient and stepwise multivariate linear regression.

RESULTS

A total of 105 patients completed the study. Linear regression analysis showed that MMSE scores were significantly predicted by REALM score (P < .001) and the patient's age (P < .02). However, after accounting for REALM score and age, the self-reported educational level was not related to the MMSE score (P < .8). A significant relationship was seen between the REALM score and the subjects' self-reported educational levels (r = .44, P < .001) but not the subjects' ages (r = -.17, P < 0.09). A significant linear correlation was found between the MMSE and REALM scores (r = .71, P < .0001) and a significant inverse correlation was seen between MMSE scores and the patients' ages (r = -.28, P < .004). The correlation coefficient between the patients' MMSE scores and the self-reported educational levels was .33 (P < .0007).

CONCLUSIONS

Practitioners who rely on the MMSE should be aware that patients may score in the demented range because they cannot read well enough to accurately complete the test. Literacy testing with REALM or other instruments may help identify such patients.

Reading deficiencies in older patients

To participate effectively in their health care, older patients often are expected to read a wide variety of materials, including written instructions, brochures, and consent forms. This study quantitates the reading ability of older patients and compares it to that of younger patients. Two hundred seventy-two patients 30 and older were selected from five outpatient clinics at a public teaching hospital and tested for objective reading ability using the Peabody Individual Achievement Test--Revised. The 76 patients 60 and older read significantly worse (grade level 2.9) than the 196 patients younger than 60 (grade level 5.8) (P < 0.0001). Older patients also completed significantly fewer years of school than younger patients (7.3 years versus 10.6 years). Analysis of variance for age categories 30-44, 45-59, 60-74, and 75 and older confirmed declining reading ability and educational status with advancing age. Multiple regression analysis helped show that an equation could be derived to predict reading ability from age, educational status, race, and sex, but the coefficient of determination was so low (r2 = 0.39) that it cannot be considered clinically useful for individual patients. In this study, older patients read significantly worse than younger patients, and a formula that combines age, race, sex, and educational status cannot reliably predict reading ability for individual patients. Most older patients read on a level so low that they cannot be expected to read most commonly used written materials. Routine testing of reading ability may allow more appropriate design and use of written materials.

Sophomore medical students as substance abuse prevention teachers

Medical education should emphasize health promotion and disease prevention and should offer educational experiences that require students to be active, independent learners and problem solvers. The purpose of this project was to enable sophomore medical students to apply their own innovative methods of instruction to a program for adolescent substance abuse prevention. Medical students developed and taught a school-based prevention program to 36 middle school students who represented a variety of socioeconomic backgrounds and abilities. They used demonstrations, role-playing, and drug abuse prevention commercials created by the adolescents for their peers. Medical students kept weekly journals to record their thoughts about and activities used in teaching substance abuse prevention to adolescents. The journals revealed an increased understanding of adolescent thinking and behavior and an increased confidence in teaching substance abuse prevention to adolescents.

Reading ability of parents compared with reading level of pediatric patient education materials

OBJECTIVES

To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings.

DESIGN

Prospective survey.

SETTING

Pediatrics outpatient clinic in a large, public university, teaching hospital.

PARTICIPANTS

Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients.

MEASUREMENTS

Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised. Written educational materials were assessed for readability levels with a computer program (Grammatik IV).

RESULTS

The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level.

CONCLUSION

This study demonstrates that parents' self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.

Rapid estimate of adult literacy in medicine: a shortened screening instrument

BACKGROUND

This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training.

METHODS

Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability.

RESULTS

The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001).

CONCLUSIONS

The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.

Reading ability in patients in substance misuse treatment centers

Adult inpatients in state-supported (public) and private substance misuse treatment settings were tested for reading ability. Patient education materials and consent forms were assessed for readability levels. Public patients' mean reading levels were significantly lower than those of private patients, and were 4 to 5 years below the level needed to read and understand standard treatment materials. More than half of the public and almost one-third of the private patients tested were reading below a 9th grade level. Standard treatment materials were written on 11th to 12th grade reading levels; admission and consent forms were written on 12th to 18th grade levels. Patients in substance misuse settings should be tested for literacy levels upon admission and provided with materials commensurate with their reading ability.

Acquaintance rape and the high school student

The purpose of this study was to determine the prevalence of forced sex among high school students and to assess student attitudes about it. The questionnaires were given in conjunction with a presentation on date rape to 9th through 12th grade students in health and science classes in three large metropolitan Louisiana public high schools. The first questionnaire, given before the presentation, elicited demographic information and attitudes about forced sex in 11 scenarios; the second, given after the program, asked if the student had ever been in a situation involving forced sex and, if so, whether he or she had told anyone. The two questionnaires were completed by all 237 students. Although one out of five students (20%) reported they had experienced forced sex, only half had told about the experience. A majority of boys (60%) found it acceptable in one or more situations for a boy to force sex on a girl. Male, black, and older students were significantly more likely (p < 0.05) to indicate that it was acceptable for a boy to force sex on a girl in certain circumstances. These findings should alert physicians to the risk of acquaintance rape among their high school student patients. Student attitudes, particularly those of males, may provide an important focus of preventive sex education in the physician's office, the classroom, and the community.

Patient reading ability: an overlooked problem in health care

Health care workers often assume that patients who have completed a certain grade in school can read at that level. This study examines the relationships between patient reading ability, the last grade completed, and the reading ability necessary to comprehend commonly used written materials. We tested 528 patients during regular visits to seven outpatient clinics serving a predominantly indigent population. In addition, we analyzed the readability of 280 brochures and consent forms used in these clinics. Most patients had reading abilities on a level far below their last grade completed, while almost all materials tested were written on a level far above average patient reading ability. We conclude that patient reading ability should be routinely tested and that written materials should be developed on a level commensurate with patient reading ability.