Practical assessment of adult literacy in health care

Health literacy: an overlooked factor in understanding HIV health disparities

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.

Oral health literacy among adult patients seeking dental care

BACKGROUND

This study examined the association of knowledge, dental care visits and oral health status with oral health literacy in dental patients.

METHODS

The authors administered to adult patients in two private dental offices the short version of the Rapid Estimate of Adult Literacy in Dentistry-30 (REALD-30), a word-recognition test. An interview provided primary predictor variables for REALD-30 and variables that would serve as controls in multivariate logistic regression analyses.

RESULTS

About 29 percent of the sample scored below 22 on the 30-point test, a score that the authors defined as a low literacy level. Those with incorrect knowledge (odds ratio [OR] = 5.98; P < .01) and fair-to-poor oral health status (OR = 3.08; P = .06) were more likely to have a low literacy level than were their reference groups. Not having had a dental care visit in the last year was not associated with literacy (OR = 2.26; P = .17). A change from an unfavorable to favorable category for the primary predictor variables would decrease the probability of having a low literacy level by 35 to 61 percent.

CONCLUSIONS

A significant number of patients may have a low level of oral health literacy, which possibly interferes with their ability to process and understand oral health information.

PRACTICE IMPLICATIONS

Providers should identify patients who are having difficulty understanding and using dental health information and address their needs.

To err is human: patient misinterpretations of prescription drug label instructions

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.

Assisted living nursing practice: medication management: Part 1. Assessing the resident for self-medication ability

Self-administration of medication suggests that individuals are functionally and cognitively competent to manage their health care. Older adults take a significant number of medications (borderline polypharmacy) as well as an unaccounted for number of over-the-counter, as necessary, and herbal remedies. Assisted living residences, moving from a social to a more medical model, are responsible for the safety and well-being of their residents. In addition, the prospect of aging-in-place in the residence is increasingly associated with appropriate medical and medication management. Assisted living services in most states include assistance with medication, but the nature of the assistance varies widely, at times approaching what even a nonclinical observer would regard as medication administration. Although state assisted living regulations can be quite specific regarding medication storage, there are scant guidelines about the components of a thorough assessment as to whether a resident can safely self-administer his or her medications. This article discusses assessment criteria of self-medication ability, drawn from a variety of instruments. In keeping with assisted living nursing standards of practice, the assisted living nurse has a critical responsibility in assessment of this self-care ability.

Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD)

OBJECTIVE

This study aims to evaluate the reliability and validity of the Test of Functional Health Literacy in Dentistry (TOFHLiD), a new instrument to measure functional oral health literacy.

METHODS

TOFHLiD uses text passages and prompts related to fluoride use and access to care to assess reading comprehension and numerical ability. Parents of pediatric dental patients (n = 102) were administered TOFHLiD, a medical literacy comprehension test (TOFHLA), and two word recognition tests [Rapid Estimate of Adult Literacy in Dentistry (REALD), Rapid Estimate of Adult Literacy in Medicine (REALM)]. This design provided assessments of dental and medical health literacy by all subjects, both measured with two different methods (reading/numeracy ability and word recognition). Construct validity of TOFHLiD was assessed by entering the correlation coefficients for all pairwise comparisons of literacy instruments into a multitrait-multimethod matrix. Internal reliability of TOFHLiD was assessed with Cronbach's alpha. Criterion-related predictive validity was tested by associations between the TOFHLiD scores and the three measures of oral health in multivariate regression analyses.

RESULTS

The correlation coefficient for TOFHLiD and REALD-99 scores (monotrait-heteromethod) was high (r = 0.82, P < 0.05). Coefficients between TOFHLiD and TOFHLA (heterotrait-monomethod: r = 0.52) and REALM (heterotrait-heteromethod: r = 0.53) were smaller than coefficients for convergent validity Cronbach's alpha for TOFHLiD was 0.63. TOFHLiD was positively correlated with OHIP-14 (P < 0.05), but not with parent or child oral health. TOFHLA was not related to dental outcomes.

CONCLUSIONS

TOFHLiD demonstrates good convergent validity but only moderate ability to discriminate between dental and medical health literacy. Its predictive validity is only partially established, and internal consistency just meets the threshold for acceptability. Results provide solid support for more research, but not widespread use in clinical or public health practice.

Refining teratogen warning symbols for diverse populations

BACKGROUND

The current research reports on efforts to refine the design of recently developed teratogen warning symbols and to examine their interpretation by different populations such as those with low health literacy, adolescents, and individuals who are not fluent in English.

METHODS

Alternative symbols identified as most successful in an earlier study were further refined through the use of multiple focus groups and expert review. Six symbols emerged as potential candidates to replace the current symbol. A nationally distributed field trial (n = 700) examined these six alternate teratogen warnings in addition to the symbol presently in use.

RESULTS

Five of the alternate warning symbols exceeded the level of correct interpretation elicited by the current symbol. No symbol exceeded the ANSI limit of 5% critical confusion. Two symbols consistently elicited the most accurate responses in terms of message interpretation, target audience, intended action, and perceived consequences of ignoring the warning.

CONCLUSIONS

This effort produced at least two viable alternative symbols that appear to be more effective than the current symbol at communicating both the instruction to not take while pregnant and the consequence that exposure could cause birth defects. Several results varied by participant characteristics. Understanding how members of diverse subpopulations might interact with these warnings should be informative to healthcare professionals.

What do patients prefer: informed consent models for genetic carrier testing

The recent increased number of conditions for which patients can undergo genetic carrier testing raises the question of how best to obtain pre-test informed consent. Clinical approaches vary from a minimalist model to a model where patients are given detailed information about all conditions to be screened for. Few data exist as to patient preferences, or how information impacts decision-making. Eight high-literacy focus groups were conducted to assess the knowledge and preferences of pregnant patients and their male partners. Most groups indicated that some balance between details and brevity was optimal, recognizing that anxiety can occur when patients are provided with too much information and that the wide range of tests offered during pregnancy often led to confusion. Critical areas for the informed consent process included (1) details about the conditions and risk of being a carrier, (2) logistics of testing, (3) next steps if the test is positive, and (4) prognosis, options and resources if the child were to be affected with a disorder. It will be useful to develop model consent programs and prospectively assess their impact on informed consent and patient satisfaction, both when positive and negative results are received.

Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals

Identifying modifiable barriers to antiretroviral adherence remains an important aim. We hypothesized that mistaken beliefs regarding taking HIV medications mediated the relation between low literacy and poor adherence. We studied 87 HIV-infected individuals on standard antiretroviral regimens for >or= 3 months. Adherence was assessed using pharmacy refill records. Medication beliefs, including an individual's norm for acceptable adherence, were measured using questions developed by expert panel. Literacy was associated with >or=95% adherence (64% for >or=9th grade level vs. 40% for <9th grade level). Participants with <95% adherence had a lower threshold of acceptable adherence than those with >or=95% adherence [80% adherence (interquartile range 70-90%) vs. 90% adherence (interquartile range 80-90%)]. However, the effect was independent of literacy. No other beliefs assessed were associated with adherence. Although the beliefs assessed do not mediate the relation between literacy and adherence, we identified low adherence norms as a potentially modifiable belief associated with adherence.

Literacy, self-efficacy, and HIV medication adherence

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.

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

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.

A systematic review of readability and comprehension instruments used for print and web-based cancer information

Adequate functional literacy skills positively influence individuals' ability to take control of their health. Print and Web-based cancer information is often written at difficult reading levels. This systematic review evaluates readability instruments (FRE, F-K, Fog, SMOG, Fry) used to assess print and Web-based cancer information and word recognition and comprehension tests (Cloze, REALM, TOFHLA, WRAT) that measure people's health literacy. Articles on readability and comprehension instruments explicitly used for cancer information were assembled by searching MEDLINE and Psyc INFO from 1993 to 2003. In all, 23 studies were included; 16 on readability, 6 on comprehension, and 1 on readability and comprehension. Of the readability investigations, 14 focused on print materials, and 2 assessed Internet information. Comprehension and word recognition measures were not applied to Web-based information. None of the formulas were designed to determine the effects of visuals or design factors that could influence readability and comprehension of cancer education information.

Low literacy: a hidden problem in family planning clinics

OBJECTIVES

Low literacy is highly prevalent among UK adults. This study assessed functional health literacy among family planning clinic clients and whether this was associated with sexual health knowledge and behaviours. It also assessed the readability of patient leaflets.

METHODS

505 female family planning clinic attendees aged 16-35 years were interviewed about their sexual behaviour and knowledge. Their reading age was assessed using a validated test (REALM). The readability of leaflets on contraception supplied to clinic users was measured.

RESULTS

All respondents had a reading age of 12 years and above, 221 (43.8%) between 12 and 14 years and 284 (56.2%) greater than 14 years. Those in the lower literacy group were significantly more likely to have been aged under 16 years at time of first sexual intercourse, and significantly less likely to know the most fertile time of the menstrual cycle, to identify sexually transmitted infections and to know that sexual infections can be transmitted through oral and anal sex. The reading age of information leaflets in the clinics ranged from 11 to 17 years. Thus, clients with a reading level of 12-14 years would have difficulty in understanding some of the leaflets.

CONCLUSIONS

Functional health literacy is related to sexual behaviour and knowledge. Written information should be prepared with this in mind and other routes of communication considered.

Development of an easy-to-use Spanish Health Literacy test

OBJECTIVE

The study was intended to develop and validate a health literacy test, termed the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for the Spanish-speaking population.

STUDY DESIGN

The design of SAHLSA was based on the Rapid Estimate of Adult Literacy in Medicine (REALM), known as the most easily administered tool for assessing health literacy in English. In addition to the word recognition test in REALM, SAHLSA incorporates a comprehension test using multiple-choice questions designed by an expert panel.

DATA COLLECTION

Validation of SAHLSA involved testing and comparing the tool with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at UNC Health Care.

PRINCIPAL FINDINGS

With only the word recognition test, REALM could not differentiate the level of health literacy in Spanish. The SAHLSA significantly improved the differentiation. Item response theory analysis was performed to calibrate the SAHLSA and reduce the instrument to 50 items. The resulting instrument, SAHLSA-50, was correlated with the Test of Functional Health Literacy in Adults, another health literacy instrument, at r=0.65. The SAHLSA-50 score was significantly and positively associated with the physical health status of Spanish-speaking subjects (p<.05), holding constant age and years of education. The instrument displayed good internal reliability (Cronbach's alpha=0.92) and test-retest reliability (Pearson's r=0.86).

CONCLUSIONS

The new instrument, SAHLSA-50, has good reliability and validity. It could be used in the clinical or community setting to screen for low health literacy among Spanish speakers.

Vaccine risk/benefit communication: effect of an educational package for public health nurses

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).

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.

Health literacy: concept analysis

AIM

This paper reports an analysis of the concept of health literacy in order to clarify its meaning, reduce ambiguities associated with references to it, and promote consistency in using the concept in nursing dialogue and research.

BACKGROUND

Health literacy is a relatively new concept in health promotion research. Only within the last decade have researchers identified the problems associated with health literacy, the role it plays in an individual's ability to comprehend health and self-care information, and its relationship to health outcomes. Clarifying the concept is essential so that nurses develop an awareness of the phenomenon and its relationship to the outcomes of their communication and health education efforts.

METHOD

The method used for this concept analysis was that of Walker and Avant (1995).

FINDINGS

Health literacy empowers people to act appropriately in new and changing health-related circumstances through the use of advanced cognitive and social skills. The defining attributes of health literacy are reading and numeracy skills, comprehension, the capacity to use information in health care decision-making, and successful functioning as a healthcare consumer. Antecedents of health literacy are literacy and a health-related experience. Consequences of health literacy include improved self-reported health status, lower health care costs, increased health knowledge, shorter hospitalizations, and less frequent use of health care services. Empirical referents of the concept are the Test of Functional Health Literacy in Adults and the health literacy component of the National Assessment of Adult Literacy.

CONCLUSIONS

An analysis of the concept of health literacy enhances nurses' ability to assess more accurately their clients' levels of health literacy, thus identifying those at risk for misunderstanding health care instructions, shame associated with inadequate reading skills, and inability to adhere to health care recommendations.

The effect of illustrations on patient comprehension of medication instruction labels

BACKGROUND

Labels with special instructions regarding how a prescription medication should be taken or its possible side effects are often applied to pill bottles. The goal of this study was to determine whether the addition of illustrations to these labels affects patient comprehension.

METHODS

Study participants (N = 130) were enrolled by approaching patients at three family practice clinics in Toronto, Canada. Participants were asked to interpret two sets of medication instruction labels, the first with text only and the second with the same text accompanied by illustrations. Two investigators coded participants' responses as incorrect, partially correct, or completely correct. Health literacy levels of participants were measured using a validated instrument, the REALM test.

RESULTS

All participants gave a completely correct interpretation for three out of five instruction labels, regardless of whether illustrations were present or not. For the two most complex labels, only 34-55% of interpretations of the text-only version were completely correct. The addition of illustrations was associated with improved performance in 5-7% of subjects and worsened performance in 7-9% of subjects.

CONCLUSION

The commonly-used illustrations on the medication labels used in this study were of little or no use in improving patients' comprehension of the accompanying written instructions.

Development and validation of the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer)

We sought to develop a reliable and valid measure of patient self-efficacy within the context of productive communication and positive attitude for cancer patients. A set of 19 potential items for the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer) was pilot tested with 50 cancer patients. Based on the pilot test, item valence was made consistent (i.e., all items worded positively) and the response scale was simplified. The CASE-cancer was then administered to 127 persons receiving cancer treatment at general oncology clinics in Shreveport, Louisiana and Chicago, Illinois. Psychometric analyses revealed three 4-item factors: understanding and participating in care, maintaining a positive attitude, and seeking and obtaining information. The CASE-cancer proved to have high internal consistency and construct validity. Moreover, scale items performed similarly across literacy levels. The CASE-cancer is a psychometrically-sound tool that may provide new information on important mediating factors of cancer care. Our two-step approach to presenting response options may also provide a model for helping lower literate patients more accurately respond to survey items.

The Spoken Knowledge in Low Literacy in Diabetes scale: a diabetes knowledge scale for vulnerable patients

PURPOSE

The purpose of this study was to develop and validate a new knowledge scale for patients with type 2 diabetes and poor literacy: the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD).

METHODS

The authors evaluated the 10-item SKILLD among 217 patients with type 2 diabetes and poor glycemic control at an academic general medicine clinic. Internal reliability was measured using the Kuder-Richardson coefficient. Performance on the SKILLD was compared to patient socioeconomic status, literacy level, duration of diabetes, and glycated hemoglobin (A1C).

RESULTS

Respondents' mean age was 55 years, and they had diabetes for an average of 8.4 years; 38% had less than a sixth-grade literacy level. The average score on the SKILLD was 49%. Less than one third of patients knew the signs of hypoglycemia or the normal fasting blood glucose range. The internal reliability of the SKILLD was good (0.72). Higher performance on the SKILLD was significantly correlated with higher income (r = 0.22), education level (r = 0.36), literacy status (r = 0.33), duration of diabetes (r = 0.30), and lower A1C (r = -0.16). When dichotomized, patients with low SKILLD scores (< or = 50%) had significantly higher A1C (11.2% vs 10.3%, P < .01). This difference remained significant when adjusted for covariates.

CONCLUSION

The SKILLD demonstrated good internal consistency and validity. It revealed significant knowledge deficits and was associated with glycemic control. The SKILLD represents a practical scale for patients with diabetes and low literacy.

Understanding health literacy: an expanded model

A long and yet unfinished history of investigating how individual capabilities and social processes explain or predict health indicates that poor education, low literacy, poor health and early death are strongly linked around the world. However, the complexity of those relationships is not fully understood. In this article, we propose an expanded model of health literacy characterized by four domains: fundamental literacy (reading, writing, speaking and numeracy), science literacy, civic literacy and cultural literacy. To explore the utility of this model, we examine selected pieces of the public discourse about terrorism and bioterrorism that dominated the mass media during the anthrax threat in the United States during 2001. We conclude that this model of health literacy is useful to analyze health communication, to aid in constructing more understandable and appropriate health communication, and ultimately can lead to the development of a new measure to assess health literacy skills in individuals.

Promoting health literacy

This report reviews some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Several articles describe methods for assessing health literacy as well as methods for assessing the readability of texts, although generally these latter have not been developed with health materials in mind. Other studies have looked more closely at the mismatch between patients' literacy levels and the readability of materials intended for use by those patients. A number of studies have investigated the phenomenon of literacy from the perspective of patients' interactions in the health care setting, the disenfranchisement of some patients because of their low literacy skills, the difficulty some patients have in navigating the health care system, the quality of the communication between doctors and their patients including the cultural overlay of such exchanges, and ultimately the effect of low literacy on health outcomes. Finally, the impact of new information technologies has been studied by a number of investigators. There remain many opportunities for conducting further research to gain a better understanding of the complex interactions between general literacy, health literacy, information technologies, and the existing health care infrastructure.

Assessment Instruments

Assessment is the undergirding of palliative care and of geriatrics care. Both disciplines insist on a comprehensive assessment that includes personal and social aspects of the patient's illness experience. At the same time, both face challenges due to the amount of time and skill needed to encompass such a broad scope and the often heavy illness burden of the patients, which makes interaction stressful or difficult. This article examines question-based assessment instruments in palliative care for elders. Important in all aspects of medicine, reliance on verbal assessments is of special importance in palliative care.

The asthma kiosk: a patient-centered technology for collaborative decision support in the emergency department

The authors report on the development and evaluation of a novel patient-centered technology that promotes capture of critical information necessary to drive guideline-based care for pediatric asthma. The design of this application, the asthma kiosk, addresses five critical issues for patient-centered technology that promotes guideline-based care: (1) a front-end mechanism for patient-driven data capture, (2) neutrality regarding patients' medical expertise and technical backgrounds, (3) granular capture of medication data directly from the patient, (4) formal algorithms linking patient-level semantics and asthma guidelines, and (5) output to both patients and clinical providers regarding best practice. The formative evaluation of the asthma kiosk demonstrates its ability to capture patient-specific data during real-time care in the emergency department (ED) with a mean completion time of 11 minutes. The asthma kiosk successfully links parents' data to guideline recommendations and identifies data critical to health improvements for asthmatic children that otherwise remains undocumented during ED-based care.

Views and preferences of low-literate Hispanics regarding diabetes education: results of formative research

Hispanics are twice as likely as non-Hispanic Whites to have diabetes and are also at higher risk for diabetes-related complications and poorer outcomes. The prevalence of diabetes is inversely related to educational status. Low literacy is common, especially among older Hispanics. Little literature exists on formative research to create diabetes education materials for this audience. Two focus groups assessed views and preferences for diabetes education of low-literate, low-income, non-English-speaking urban Caribbean and Central American Hispanics with diabetes, as well as utility of materials developed specifically for this population, as part of the preliminary work for a pilot study of a diabetes intervention. Implications for practitioners and researchers are discussed.

The relationship between literacy and glycemic control in a diabetes disease-management program

PURPOSE

This study examined the role of literacy in patients with poorly controlled diabetes who were participating in a diabetes management program that included low-literacy-oriented interventions.

METHODS

A before-after analysis was performed of a pharmacist-led diabetes management program for 159 patients with type 2 diabetes and poor glycemic control (hemoglobin A1c [A1C] > or = 8.0%). Clinic-based pharmacists offered one-to-one education and medication management for these patients using techniques that did not require high literacy. Literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM) test and dichotomized at the 6th-grade level. The A1C values were collected prior to enrollment, at enrollment, and approximately 6 months after enrollment.

RESULTS

Of the 111 patients with follow-up data, 55% had literacy levels at the 6th-grade level or below. Lower literacy was more common among African Americans, older patients, and patients who required medication assistance. There was no significant relationship between literacy status and A1C prior to enrollment or at enrollment. Over the 6-month study period, patients with low and high literacy had similar improvements in A1C.

CONCLUSIONS

This diabetes care program, which used individualized teaching with low-literacy techniques, significantly improved A1C values independent of literacy status.

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.

A shortened instrument for literacy screening

The Rapid Estimate of Adult Literacy in Medicine (REALM-R), a new 8-item instrument designed to rapidly screen patients for potential health literacy problems, was administered to 157 patients. The REALM-R was correlated with Wide Range Achievement Test-Revised (WRAT-R) (.64) and demonstrated a Cronbach's alpha of 0.91. The REALM-R identified 26 of 30 persons scoring more than 1 standard deviation below the mean on the WRAT-R, corresponding to a sixth grade reading level. The REALM-R identified a substantial number of people who scored poorly on the WRAT-R, and depending on further studies of validity and reliability, may offer a practical approach to identify patients at risk for health literacy problems in a clinical setting.

Patient and physician factors predict patients' comprehension of health information

While patients frequently do not comprehend health information, little is known about patient and physician factors that influence lack of comprehension. To assess effectiveness of health information exchange, 19 physicians and 145 patients were given post-encounter questionnaires to evaluate the preceding visit. We analyzed differences in beliefs between patients who comprehended health information and patients who did not, and whether physicians' attitudes and self-assessment of their educational abilities influenced this comprehension. Patients with insufficient comprehension were more likely to have schooling below college and cited language as a barrier. Physicians who believed health information delivery to be important had fewer patients with comprehension difficulties, while physicians who assessed themselves as very effective educators had significantly more patients with lack of comprehension, compared with physicians who did not feel as effective. Patients' comprehension of health information was associated not only with patient factors but also with physicians' attitude and self-assessment.

Factors influencing consumer use of written drug information

OBJECTIVE

To provide an overview of the use and impact of written drug information (WDI) on consumers, and to review the literature on the factors influencing the use of WDI by consumers.

DATA SOURCES

Relevant articles published in English since the late 1970s were identified based on searches of on-line databases, texts, and cited references in published articles.

STUDY SELECTION

Articles reporting findings on the origin, use, and impact of WDI were included. Due to limited literature, articles reporting findings on factors influencing the use of written drug as well as disease information were included.

DATA EXTRACTION

Due to the lack of design consistency between studies and the comparatively small volume of work, subjective assessment rather than a criteria-based objective review was deemed more appropriate.

DATA SYNTHESIS

To date, research on WDI has focused on its use and impact. WDI has the potential to increase patients' knowledge, compliance, and satisfaction. However, there is also the potential for anxiety or premature cessation of therapy due to fear of possible adverse effects. Multiple factors may potentially influence the use of WDI by consumers including those associated with the written information document (readability, presentation), the patient (health literacy, role of caregiver, demographic factors, health locus of control, coping style, health belief model), and the environment (timing of provision, experience).

CONCLUSIONS

WDI has the potential to impact consumers positively and negatively. Although not widely investigated, a number of factors can potentially influence the use of WDI by consumers. The findings of this review can form the basis for much needed further research.

Health literacy: a review

Illiteracy has become an increasingly important problem, especially as it relates to health care. A national survey found that almost half of the adult population has deficiencies in reading or computation skills. Literacy is defined as the basic ability to read and speak English, whereas functional health literacy is the ability to read, understand, and act on health information. Up to 48% of English-speaking patients do not have adequate functional health literacy. The consequences of inadequate health literacy include poorer health status, lack of knowledge about medical care and medical conditions, decreased comprehension of medical information, lack of understanding and use of preventive services, poorer self-reported health, poorer compliance rates, increased hospitalizations, and increased health care costs. The medical community must acknowledge this issue and develop strategies to ensure that patients receive assistance in overcoming the barriers that limit their ability to function adequately in the health care environment.

Development and validation of a literacy assessment tool for persons with diabetes

PURPOSE

This research was conducted to develop a valid, reliable, quick, and nonstigmatizing tool for assessing literacy in the healthcare setting.

METHODS

The Literacy Assessment for Diabetes (LAD) instrument was developed as a word recognition test composed of 3 graded word lists in ascending difficulty. This literacy test, which was specific to diabetes, measured a patient's ability to pronounce terms that they would encounter during clinic visits and in reading menu and self-care instructions. The majority of the terms were on a 4th-grade reading level, with the remaining words ranging from the 6th-through 16th-grade levels. To assess reliability and validity, the LAD was compared with the Wide Range Achievement Test (WRAT3) and the Rapid Estimate of Adult Literacy in Medicine (REALM) by administering all 3 tests to 203 participants in a test-retest study design.

RESULTS

All 3 tests (LAD, REALM, and WRAT3) reliably detected true intrasubject variation in word recognition from test to retest. In addition, LAD measured word recognition ability similar to the REALM and WRAT3.

CONCLUSIONS

The LAD is a reliable and valid instrument for measuring literacy in adults with diabetes. It can be administered in 3 minutes or less, and the raw score is scaled to a reading grade level.

More than just a pamphlet: development of an innovative computer-based education program for cancer patients

Patients with cancer continue to lack practical information regarding their illness and report low levels of awareness and use of patient services. The challenge to educators is to find cost-effective and timely ways to deliver a complex mix of interesting and high-quality information and expertise to this large and diverse audience, while still tailoring the content to individual needs and situations. In the present article, we describe the Princess Margaret Hospital (PMH) computer-based patient education program. The program is aimed toward empowering those dealing with cancer and provides comprehensive medical information and support via an interactive Intranet web site containing information about cancer (the Oncology Interactive Education Series), library resources, Internet links, information about PMH services, and a hospital calendar of events. Preliminary evaluation results have provided valuable direction for on-going program development and suggest that the program is easy to use, informative, and enjoyable for patients, families, volunteers, and health professionals.

Therapeutic Interactions in a Medication Education Group Using the Psychopharmacology RACE

1. The Psychopharmacology RACE is an interactive, innovative game that emphasizes group teaching about psychiatric medications and disorders at the clients' levels of functioning. 2. Implementation of the Psychopharmacology RACE provides the opportunity to structure a medication group, impart information, and facilitate the development of therapeutic group factors. 3. Interactive group learning with the Psychopharmacology RACE can be a useful tool to enhance learning when clients are unable to read and understand written materials.

Patient-guided counseling in the community pharmacy setting

OBJECTIVE

To test a new prescription counseling method termed "patient-guided counseling" (PGC) in community pharmacies.

DESIGN

Post-test experimental design in which subjects were randomized to three groups.

SETTING

Six community pharmacies (three chain and three independent).

PATIENTS

Patients presenting new prescriptions.

INTERVENTIONS

Patients were randomly assigned to one of three comparison groups. The PGC group was given a written prompt instructing them to write any questions they wished to ask about their prescription or their medical condition. The pharmacist then incorporated these questions into the subsequent verbal counseling. A second group was given a written prompt encouraging them to ask the pharmacist questions. This was followed by customary verbal counseling. A third group served as the control. No prompts were provided, but the pharmacist did provide customary verbal counseling.

MAIN OUTCOME MEASURES

Patients' demographics, recall of medication information, and satisfaction with counseling. Patients were contacted by telephone 5 days after the start of drug therapy to measure compliance. Pharmacists rated their satisfaction with the information communicated and with their interactions with patients.

RESULTS

Compared with customary verbal counseling, the PGC method was associated with more supplemental questions asked by the patient. Compared with the other two methods, PGC was associated with greater pharmacist satisfaction with the information communicated and slightly longer counseling sessions. No significant differences were found for patients' overall satisfaction with counseling, recall of information, and compliance.

CONCLUSION

In the community pharmacy setting, PGC fosters patient participation in medication counseling, a necessary element for the provision of pharmaceutical care.

Perspectives on cancer patient education

OBJECTIVES

To provide an overview on cancer patient education.

DATA SOURCES

Literature related to demographic and health care trends, patient education, health literacy, and cancer patient information needs.

CONCLUSIONS

Cancer patients need information related to diagnosis, treatment, side effects, self-care needs, and effects on work and relationships. Planned patient teaching includes a variety of teaching strategies and written materials, and contributes to better patient outcomes. Inadequate health literacy and other barriers present challenges to providing effective patient education.

IMPLICATIONS FOR NURSING PRACTICE

More research is warranted in developing assessment tools and effective health education techniques and in measuring outcomes and costs related to patient education. The education needs of cancer patients will not drastically change in the next century. How nurses meet those needs, however, will change as we apply new learning theories and technologies of teaching.