Self-Management Skills in Chronic Disease Management: What Role Does Health Literacy Have?

Patient coaching in specialist consultations. Which patients are interested in a coach and what communication barriers do they perceive?

OBJECTIVE

To characterize patients interested in support by a patient coach to guide them in medical specialist consultations.

METHODS

We compared 76 patients interested in a patient coach with 381 patients without such an interest, using a representative panel of patients with a chronic disease in the Netherlands. Independent variables were demographic factors, socio-economic status, perceived efficacy in patient-provider interaction, communication barriers, health literacy, (duration and type of) disease(s) and activation level.

RESULTS

In univariate analyses, patients who are interested in a coach were significantly older, had lower health literacy skills and less self-efficacy and, overall, experienced more communication barriers (>4), than patients without such interest (1-2 barriers). Multivariate analyses indicated three communications barriers as determinants of patient interest in a coach: feeling tense, uncertainty about own understanding, and believing that a certain topic is not part of a healthcare providers' task.

CONCLUSION

Patients interested in a coach perceive specific barriers in communicating with their medical specialist. In addition, patients who are > = 65 years, have lower health literacy and low self-efficacy may have interest in a coach.

PRACTICE IMPLICATIONS

Characterizing patients interested in a patient coach facilitates identification of those who could benefit from such a coach in clinical practice.

Delineating the concept of self-management in chronic conditions: a concept analysis

OBJECTIVES

Self-management is a concept frequently used within healthcare but lacks consensus. It is the aim of this study to clarify the concept.

DESIGN

Concept analysis according to Walker and Avant, comprises eight steps: select concept, determine purpose, identify uses, determine defining attributes, identify model case, identify additional cases, identify antecedents and consequences and define empirical referents.

SOURCES USED

PubMed, Scopus and Web of Science.

RESULTS

Ten attributes delineating the concept have been identified and organised into three groups. Group (a): person-oriented attributes: the person must (1) actively take part in the care process, (2) take responsibility for the care process and (3) have a positive way of coping with adversity. Group (b): person-environment-oriented attributes: (4) the person must be informed about the condition, disease and treatment and self-management, (5) should be individualised, which entails expressing needs, values and priorities, (6) requires openness to ensure a reciprocal partnership with healthcare providers and (7) demands openness to social support. Finally, Group (c): summarising attributes: self-management (8) is a lifetime task, (9) assumes personal skills and (10) encompasses the medical, role and emotional management.

CONCLUSIONS

The findings of this study recognise the complexity of the concept, but also show the need for further investigation to make the concept more measurable. Clarity about the concept will enhance understanding and facilitate implementation in self-management programmes for chronic conditions.

An investigation of healthcare utilization and its association with levels of health literacy in individuals with chronic pain

OBJECTIVE

Chronic pain patients are frequent and recurrent users of health services, which may have an impact on levels of health literacy (HL). Therefore, the aim of the present study was to investigate associations between healthcare utilization and varying levels of HL in individuals with and without chronic pain.

METHODS

A cross-sectional questionnaire was distributed in three pain clinics in Dublin, Ireland, comprising a demographic section, a validated HL assessment tool (Newest Vital Sign) and self-reported healthcare utilization in the previous year (i.e., general practitioner [GP] visits, accident and emergency room attendance, hospital services and allied health services). Patients with chronic pain, and a control group (no pain) were recruited.

RESULTS

Overall, 262 participants were recruited: those with chronic pain (n = 131) and controls (n = 131). Those in the chronic pain group were more likely to be female (p = 0.004), have less education (p = 0.01), be unable to work (p < 0.001), have a lower monthly income (p = 0.001), be more likely to have a medical card (i.e., free access to public health services) (p = 0.002) and have a greater number of comorbidities (p < 0.0001). Although bivariate analyses demonstrated increased healthcare utilization in chronic pain patients (i.e., GP visits, hospital services and allied therapies; p < 0.05), there was no difference in HL levels between groups in multivariate analysis (chronic pain: 54%, n = 71; control group 49%, n = 64; p = 0.39). Higher educational attainment, greater levels of income and being younger remained independently associated with higher levels of HL.

CONCLUSIONS

Further research is needed to understand the nature of how HL is acquired, both from individual and organizational perspectives. Once this has been established, it may facilitate the development or advancement of current HL-sensitive management strategies.

Experiences using the poststroke checklist in Sweden with a focus on feasibility and relevance: a mixed-method design

OBJECTIVE

The wide range of outcomes after stroke emphasises the need for comprehensive long-term follow-up. The aim was to evaluate how people with stroke and health professionals (HPs) perceive the use of the poststroke checklist (PSC), with a focus on feasibility and relevance.

DESIGN

An exploratory design with a mix of qualitative and quantitative methods.

SETTING

Outpatient care at a university hospital and primary care centres in western Sweden.

PARTICIPANTS

Forty-six consecutive patients (median age, 70; range, 41-85; 13 women) and 10 health professionals (median age 46; range, 35-63; 7 women).

RESULTS

Most patients (87%) had one or more problems identified by the PSC. The most common problem areas were life after stroke (61%), cognition (56%), mood (41%) and activities of daily living (39%). Three organisational themes emerged from the focus group discussions. The perception of the content and relevance of the PSC was that common poststroke problems were covered but that unmet needs still could be missed. Identifying needs was facilitated when using the PSC as a tool for dialogue. The dialogue between the patient and HP as well as HPs stroke expertise was perceived as important. The PSC was seen as a systematic routine and a base for egalitarian follow-up, but participants stressed consideration given to each individual. Addressing identified needs and meeting patient expectations were described as challenging given available healthcare services.

CONCLUSIONS

The PSC is a feasible and relevant tool to support egalitarian follow-up and identify patients who could benefit from targeted poststroke interventions. Stroke expertise, room for dialogue and caring for identified needs emerged as important issues to consider when using the PSC. Nutrition, sexuality and fatigue were areas mentioned that might need to be addressed within the discussions. The PSC can facilitate patients in expressing their needs, enhancing their ability to participate in decision-making.

Assessing usability of eHealth technology: A comparison of usability benchmarking instruments

BACKGROUND

It is generally assumed that usability benchmarking instruments are technology agnostic. The same methods for usability evaluations are used for digital commercial, educational, governmental and healthcare systems. However, eHealth technologies have unique characteristics. They need to support patients' health, provide treatment or monitor progress. Little research is done on the effectiveness of different benchmarks (qualitative and quantitative) within the eHealth context.

OBJECTIVES

In this study, we compared three usability benchmarking instruments (logging task performance, think aloud and the SUS, the System Usability Scale) to assess which metric is most indicative of usability in an eHealth technology. Also, we analyzed how these outcome variables (task completion, system usability score, serious and critical usability issues) interacted with the acceptance factors Perceived benefits, Usefulness and Intention to use.

METHODS

A usability evaluation protocol was set up that incorporated all three benchmarking methods. This protocol was deployed among 36 Dutch participants and across three different eHealth technologies: a gamified application for older adults (N = 19), an online tele-rehabilitation portal for healthcare professionals (N = 9), and a mobile health app for adolescents (N = 8).

RESULTS

The main finding was that task completion, compared to the SUS, had stronger correlations with usability benchmarks. Also, serious and critical issues were stronger correlated to task metrics than the SUS. With regard to acceptance factors, there were no significant differences between the three usability benchmarking instruments.

CONCLUSIONS

With this study, we took a first step in examining how to improve usability evaluations for eHealth. The results show that listing usability issues from think aloud protocols remains one of the most effective tools to explain the usability for eHealth. Using the SUS as a stand-alone usability metric for eHealth is not recommended. Preferably, the SUS should be combined with task metrics, especially task completion. We recommend to develop a usability benchmarking instrument specifically for eHealth.

Development and Validation of a New Short-Form Health Literacy Instrument (HLS-SF12) for the General Public in Six Asian Countries

Background:

No comprehensive short-form health literacy (HL) survey tool has been available for general use across Asia.

Objective:

This study aimed to develop and validate a short-form HL instrument derived from the 47-item European Health Literacy Questionnaire (HLS-EU-Q47).

Methods:

A population survey (N = 10,024) was conducted from 2013 to 2015 using the HLS-EU-Q47 in 1,029 participants from Indonesia, 1,845 from Kazakhstan, 462 from Malaysia, 1,600 from Myanmar, 3,015 from Taiwan, and 2,073 from Vietnam. Validation of the short form was evaluated by principle component analysis, internal consistency, Pearson correlation, and regression analysis.

Key Results:

Based on responses from six countries, a 12-item short-form HL questionnaire (HLS-SF12) was developed, retaining the conceptual framework of the HLS-EU-Q47 and accounting for the high variance of the full-form (i.e., 90% in Indonesia, 91% in Myanmar, 93% in Malaysia, 94% in Taiwan, and 95% in both Kazakhstan and Vietnam). The HLS-SF12 was demonstrated to have adequate psychometric properties, including high reliability (Cronbach's alpha = .85), good criterion-related validity, a moderate and high level of item-scale convergent validity, no floor or ceiling effect, and good model-data-fit throughout the populations in these countries.

Conclusions:

The HLS-SF12 was shown to be a valid and reliable tool for HL surveys in the general public in six Asian countries. [HLRP: Health Literacy Research and Practice. 2019;3(2):e90–e102.]

Plain Language Summary:

A health literacy survey was conducted from 2013 to 2015 in six Asian countries using the European Health Literacy Questionnaire (HLS-EU-Q47). The collected data were used to develop and validate a comprehensive short-form questionnaire. A health literacy questionnaire with 12 items (HLS-SF12) that retains the original conceptual framework of the HLS-EU-Q47 was demonstrated to be reliable and valid.

The impact of health literacy on health outcomes in individuals with chronic pain: a cross-sectional study

OBJECTIVE

To establish if health literacy (HL) is linked to poorer outcomes and behaviours in patients with chronic pain.

DESIGN

A prospective cross-sectional observational study.

SETTING

Multidisciplinary out-patient pain clinics in three university teaching hospitals.

PATIENTS

New patients (n=131) referred to the pain clinic with a history of chronic pain (>12 weeks).

METHODS

A questionnaire was distributed to chronic pain patients attending their first appointment. Those eligible for inclusion were newly referred patients who had pain lasting longer than three months. The questionnaire comprised the following sections: demographics, chronic pain status and disease-related knowledge, quality of life (SF-36), beliefs (Beliefs About Pain Control Questionnaire), and a validated HL tool (Newest Vital Sign).

RESULTS

Of the 131 participants recruited, 54% had inadequate HL. The group was subsequently stratified according to HL level. In bivariate analysis, inadequate HL was associated with older age (p<0.001), being unemployed or retired (p=0.005), less education (p<0.001), lower income, increased comorbidities (p=0.038), being less likely to utilise allied health services (p=0.001), poorer disease-related knowledge (p=0.002), and poorer beliefs about pain (p<0.05). In multivariate analysis, disease-related knowledge (OR 2.5, 95%CI 1.0 to 6.3, p=0.05) and beliefs about pain (B=-2.3, S.E=0.9, p=0.01) remained independently associated with HL.

CONCLUSION

Inadequate HL is prevalent in chronic pain patients, and may impact on the development of certain characteristics necessary for effective self-management.

Geographic and Social Factors Associated With Chronic Disease Self-Management Program Participation: Going the "Extra-Mile" for Disease Prevention

Introduction

We examined geographic and social factors associated with participation in the Chronic Disease Self-Management Program (CDSMP) and the Diabetes Self-Management Program (DSMP) implemented at 144 sites in Illinois.

Methods

Programs were delivered by trained facilitators, once per week, during 6 weeks to 1,638 participants aged 50 or older. Of the 1,638 participants, we included in our analysis 1,295 participants with complete geographic information and baseline data on demographic characteristics, health history, and health behaviors. We assessed the following program data: program type (CDSMP or DSMP), workshop location, class size, and number of sessions attended by participants. We geocoded each participant’s home address, classified the home address as rural or urban, and calculated the distance traveled from the home address to a workshop. We used linear and logistic regression analyses to examine the associations between participant and program factors with number of sessions attended and odds of program completion by whether participants lived in an urban or rural county.

Results

Average program attendance was 4.2 sessions; 71.1% (1,106 of 1,556) completed 4 or more sessions. Most participants enrolled in CDSMP (59.6% [954 of 1,600]), but DSMP had greater completion rates. Less than 7% (85 of 1,295) of our sample lived in a rural county; these participants had better completion rates than those living in urban counties (89.4% [76 of 85] vs 75.6% [890 of 1,178]). Traveling shorter distances to attend a workshop was significantly associated with better attendance and program completion rates among urban but not rural participants. The number of sessions attended was significantly higher when class size exceeded 16 participants. Not having a high school diploma was significantly associated with lower levels of attendance and program completion.

Conclusion

Participation in CDSMP and DSMP was associated with distance traveled, program type, class size, and education. Increasing participation in self-management programs is critical to ensure participants’ goals are met.

Priority Topics for Health Education to Support HIV Self-Management in Limited-Resource Settings

PURPOSE

The purpose of this study was to identify and prioritize the information that persons living with HIV (PLWH) in a limited-resource setting need to effectively manage their health.

DESIGN AND METHODS

A data sources triangulation method was used to compare data from three separate sources: (a) 107 interviews with Spanish-speaking PLWH being seen at a healthcare clinic in the Dominican Republic (DR); (b) 40 interviews with Spanish-speaking healthcare providers from the same clinic in the DR; and (c) an integrative literature review of English- and Spanish-language articles that assessed the health information needs of PLWH in Latin America and the Caribbean. We compared information needs across sources and developed a prioritized list of the topics important to provide PLWH in a clinical setting.

FINDINGS

Triangulation identified the most important topics for HIV-related health education for PLWH as medication and adherence, followed by transmission, including risks and prevention strategies, mental health management, and knowledge of HIV in general.

CONCLUSIONS

The identification of evidence-based health education priorities establishes a guide that healthcare providers may use to help PLWH effectively manage their health and creates a foundation from which further studies on improving clinical interactions may be generated.

CLINICAL RELEVANCE

Using the priorities identified, nurses and other health educators can improve patient education, and consequently self-management, by making evidence-based choices about what information to provide to their patients.

Limited health literacy and adverse outcomes among kidney transplant candidates

More than one-third of US adults have limited health literacy, putting them at risk of adverse clinical outcomes. We evaluated the prevalence of limited health literacy among 1578 adult kidney transplant (KT) candidates (May 2014-November 2017) and examined its association with listing for transplant and waitlist mortality in this pilot study. Limited health literacy was assessed at KT evaluation by using a standard cutoff score ≤5 on the Brief Health Literacy Screen (score range 0-12, lower scores indicate worse health literacy). We used logistic regression and adjusted Cox proportional hazards models to identify risk factors for limited health literacy and to quantify its association with listing and waitlist mortality. We found that 8.9% of candidates had limited health literacy; risk factors included less than college education (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI]:1.86-4.43), frailty (aOR = 1.85, 95% CI:1.22-2.80), comorbidity (Charlson comorbidity index [1-point increase] aOR = 1.12, 95% CI: 1.04-1.20), and cognitive impairment (aOR = 3.45, 95% CI: 2.20-5.41) after adjusting for age, sex, race, and income. Candidates with limited health literacy had a 30% (adjusted hazard ratio = 0.70, 95% CI: 0.54-0.91) decreased likelihood of listing and a 2.42-fold (95% CI: 1.16- to 5.05-fold) increased risk of waitlist mortality. Limited health literacy may be a salient mechanism in access to KT; programs to aid candidates with limited health literacy may improve outcomes and reduce disparities.

Qualitative exploration of critical health literacy among Afghan and Congolese refugees resettled in the USA

Objectives:

Previous research that revealed a high prevalence of low health literacy among immigrants and refugees tended to over emphasise functional health literacy as a risk factor for low health status and poor disease management. Despite a significant knowledge gap, little has been investigated regarding critical health literacy (CHL) in refugee populations whose culture deeply interweaves individual and contextual capacity to promote health.

Design:

This study adopted a qualitative approach to explore CHL that is built through community health workshops (CHWs) with Afghan and Congolese refugee communities in US resettlement.

Setting:

As part of a community-based participatory research project, the study was conducted with Afghan and Congolese refugees resettled in the USA.

Method:

A series of open-ended questions for focus group interviews were embedded in each workshop session explore health literacy skills and capacity over time. This study adopted a hybrid thematic design whereby the conceptual framework of CHL was applied to emergent themes from the data.

Results:

Thematic analysis revealed four major CHL thematic domains, as experienced and demonstrated by Afghan and Congolese refugee participants: (1) critical appraisal, (2) self-efficacy and confidence, (3) empowerment, and (4) collective problem solving.

Conclusion:

Study findings underline the importance of health education validating existing cultural knowledge and practices in a group setting so as to facilitate the building and enhancement of social support systems and community action for health promotion.

Qualitative exploration of critical health literacy among Afghan and Congolese refugees resettled in the USA

Objectives:

Previous research that revealed a high prevalence of low health literacy among immigrants and refugees tended to over emphasise functional health literacy as a risk factor for low health status and poor disease management. Despite a significant knowledge gap, little has been investigated regarding critical health literacy (CHL) in refugee populations whose culture deeply interweaves individual and contextual capacity to promote health.

Design:

This study adopted a qualitative approach to explore CHL that is built through community health workshops (CHWs) with Afghan and Congolese refugee communities in US resettlement.

Setting:

As part of a community-based participatory research project, the study was conducted with Afghan and Congolese refugees resettled in the USA.

Method:

A series of open-ended questions for focus group interviews were embedded in each workshop session explore health literacy skills and capacity over time. This study adopted a hybrid thematic design whereby the conceptual framework of CHL was applied to emergent themes from the data.

Results:

Thematic analysis revealed four major CHL thematic domains, as experienced and demonstrated by Afghan and Congolese refugee participants: (1) critical appraisal, (2) self-efficacy and confidence, (3) empowerment, and (4) collective problem solving.

Conclusion:

Study findings underline the importance of health education validating existing cultural knowledge and practices in a group setting so as to facilitate the building and enhancement of social support systems and community action for health promotion.

Nursing and allied health professionals' views about using health literacy screening tools and a universal precautions approach to communication with older adults: a qualitative study

Purpose: Health literacy describes individuals' abilities to access, understand and use health information. Lower health literacy is associated with poor health outcomes, is more common among older adults and impacts on the effectiveness of rehabilitation/self-management interventions. This research explored nursing and allied healthcare professionals' views about identifying and responding to older adults' health literacy needs.Methods: Qualitative focus groups were conducted with a purposive sample of 22 UK nursing and AHPs working with older adults. Focus groups were audio-recorded, transcribed verbatim and analyzed using framework approach.Results: Participants used a variety of practices to identify older patients' health literacy levels, but primarily relied on subtle cues. Participants lacked knowledge and confidence in identifying and addressing health literacy needs. Participants expressed concerns about patient reactions and described practical barriers to using recommended health literacy strategies.Conclusions: Participants recognized the importance of addressing patients' health literacy needs, but do not routinely use health literacy strategies, lack confidence and have reservations about recommended health literacy strategies. This impacts on healthcare professionals' abilities to support patients to self-manage and participate in rehabilitation. Health literacy education for health professionals should consider barriers to using health literacy strategies and be tailored to accommodate variation in teams and professions.Implications for rehabilitationRehabilitation professionals need to standardise their practice to health literacy, using strategies which can be easily integrated into routine practice.To meet older adults' health literacy needs, rehabilitation professionals should use clear and accessible tailored communication, build trust, assess understanding and involve patients' social networks.Rehabilitation professionals would benefit from further education regarding health literacy to build their knowledge/confidence and address their concerns about implementing health literacy strategies.Professional education regarding health literacy needs to accommodate variation between individuals and teams.

Limited Health Literacy Is Associated With Worse Patient-Reported Outcomes in Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) face complex health tasks and decisions. Limited health literacy is a risk factor for poor health outcomes, but this has not been examined in IBD. This study aims to assess the role of health literacy for patients with IBD.

METHODS

We prospectively enrolled adults with IBD receiving care from the Section of Gastroenterology at the Boston Medical Center. In-person, standardized questionnaires were administered to measure health literacy with the Newest Vital Sign, self-efficacy with the Medication Use and Self-Efficacy Scale, quality of life with the 10-question Short Inflammatory Bowel Disease Questionnaire, depression with the Patient-Reported Outcomes Measurement System Short Form, and clinical disease activity for patients with Crohn's disease with the Harvey-Bradshaw Index and for patients with ulcerative colitis with the Simple Clinical Colitis Activity Index (SCCAI). The relationships between health literacy and these variables were subsequently examined.

RESULTS

Of 112 patients invited to participate, 99 enrolled and completed the interview. Limited health literacy was identified in 40% (n = 40) of patients. Patients with limited health literacy reported significantly worse overall health (P = 0.03) and more depressive symptoms (P = 0.01). Of the 56 patients with Crohn's disease, those with adequate health literacy were more likely to be in clinical remission (mean Harvey-Bradshaw Index score < 5), compared with those with limited health literacy (odds ratio, 4.15; 95% confidence interval, 1.37 to 13.45; P = 0.01). There was no significant association between health literacy and clinical disease activity (SCCAI) in patients with ulcerative colitis.

CONCLUSIONS

Limited health literacy is associated with lower ratings of subjective health and depression in IBD and more symptoms of active disease in patients with Crohn's disease.

A spotlight on chronic patients' hospitalization: Some exploratory insights

All over the world, health care systems are experiencing the challenges raised by the epidemiological transition from the prevalence of acute diseases to the preponderance of chronic illnesses. However, the traditional design for acute conditions of most of health care systems – which triggers a hospital-centric culture – is not consistent with the special health needs of people suffering from long-term conditions. In fact, the access of chronic patients to hospital services has been variously contested to be inappropriate and ineffective to meet their demand for care. Sticking to these considerations, this study investigates the factors that influence the occurrence of hospitalization and the length of hospital stays of a representative sample of Italian chronic patients. Secondary data were collected from the European Health Interview Survey. The sample consisted of 8,127 people. A probit model and a multiple regression analysis were performed to obtain some evidence on the regressors of Italian patients’ access to hospital care. Among others, gender, work condition, health services’ use and health status were found to have a role in influencing chronic patients’ behaviors. The study findings prompted the formulation of several avenues for future developments, which provide some food for thought to policy makers and inspire an agenda for further research.

The Impact of Inadequate Health Literacy in a Population with Musculoskeletal Pain

Musculoskeletal conditions are a major cause of ill health and disability. Inadequate health literacy may partly explain why musculoskeletal self-management programs are not effective for some patients. This study prospectively evaluated the impact of patients' health literacy level on their musculoskeletal pain and physical function (PF) following usual primary care. Primary care patients (N = 4,720) who had consulted for musculoskeletal pain were mailed a baseline questionnaire; responders were sent a 6-month follow-up questionnaire. The measure of health literacy used was the single-item Literary Screener at baseline, and the outcomes were PF and pain intensity at the 6-months follow-up. Analysis was conducted by linear regression. The number of patients who responded was 1,890 (40%); 17.3% (95% CI [15.6%–19%]) of them had inadequate health literacy. Inadequate health literacy was associated with older age (p < .05), lower education, mental health, and comorbidities (all p < .001), but not by gender (p = .642). At the 6-month follow-up stage, patients with inadequate health literacy had lower PF (mean difference −12.2; 95% CI [−16.7, −7.6]) and higher pain intensity (mean difference 1; 95% CI [0.6, 1.4]), which was adjusted for age, gender, education, mental health, and comorbidities. Differences in PF and particularly pain scores between patients with inadequate and adequate health literacy increased over 6 months. Future studies should develop interventions that better support patients who have musculoskeletal pain with inadequate health literacy to successfully manage their pain. [HLRP: Health Literacy Research and Practice. 2018;2(4):e214–e220.]

Patient education and health literacy

INTRODUCTION

Patient education is a relatively new science within the field of health care. In the past it consisted mainly of the transfer of knowledge and mostly biomedically based advice. Research has shown this to not be effective and sometimes counterproductive. As health care has moved away from applying a traditional paternalistic approach of 'doctor knows best' to a patient-centred care approach, patient education must be tailored to meet persons' individual needs.

PURPOSE

The purpose of this master paper is to increase awareness of patients' health literacy levels. Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course. Many patients have low health literacy skills, and have difficulty with reading, writing, numeracy, communication, and, increasingly, the use of electronic technology, which impede access to and understanding of health care information.

IMPLICATIONS

Multiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension by using the teach back cycle. Printed information should be written at or below sixth-grade reading level. Visual aids can enhance patient understanding.

Health literacy in solid-organ transplantation: a model to improve understanding

Optimizing wellness and health are the most critical goals for patients post solid-organ transplantation. Low health literacy has important implications for wellness and health, increasing patient risk for negative health outcomes. More than 30% of the general US patient population has low health literacy, and solid-organ transplant recipients (SOTRs) may be especially vulnerable to low health literacy and its adverse impact on health outcomes. A comprehensive literature review was conducted and a model was adapted to better depict factors associated with low health literacy. Based on the Paasche-Orlow and Wolf model of health literacy, the Health Literacy Model in Transplantation (HeaL-T) provides a foundation to visually demonstrate the relationships among variables associated with low health literacy and to develop evidence-based strategies to improve care. The model depicts a number of patient and healthcare level factors associated with health literacy, several of which have bi-directional or reciprocal relationships, including access and utilization of healthcare, provider-patient interaction, and self-management/adherence. The impact of these factors and their relationships to SOTR outcomes are reviewed. The HeaL-T represents an important step in developing holistic understanding of the complexity of health literacy in SOTRs and offers clinicians a base from which to design strategies to mitigate adverse health effects including increased hospitalizations, graft failure, and mortality.

A population-based study of treated mental health and persistent pain conditions after transport injury

BACKGROUND

Persistent pain and mental health conditions often co-occur after injury, cause enormous disability, reduce social and economic participation, and increase long-term healthcare costs. This study aimed to characterise the incidence, profile and healthcare cost implications for people who have a treated mental health condition, persistent pain, or both conditions, after compensable transport injury.

METHODS

The study comprised a population cohort of people who sustained a transport injury (n = 74,217) between 2008 to 2013 and had an accepted claim in the no-fault transport compensation system in Victoria, Australia. Data included demographic and injury characteristics, and payments for treatment and income replacement from the Compensation Research Database. Treated conditions were identified from 3 to 24-months postinjury using payment-based criteria developed with clinical and compensation system experts. Criteria included medications for pain, anxiety, depression or psychosis, and services from physiotherapists, psychologists, psychiatrists, and pain specialists. The data were analysed with Cox Proportional Hazards regression to examine rates of treated conditions, and general linear regression to estimate 24 month healthcare costs.

RESULTS

Overall, the incidence of treated mental health conditions (n = 2459, 3.3%) and persistent pain (n = 4708, 6.3%) was low, but rates were higher in those who were female, middle aged (35-64 years), living in metropolitan areas or neighbourhoods with high socioeconomic disadvantage, and for people who had a more severe injury. Healthcare costs totalled more than $A707 M, and people with one or both conditions (7.7%) had healthcare costs up to 7-fold higher (adjusting for demographic and injury characteristics) in the first 24 months postinjury than those with neither condition.

CONCLUSIONS

The incidence of treated mental health and persistent pain conditions was low, but the total healthcare costs for people with treated conditions were markedly higher than for people without either treated condition. While linkage with other public records of treatment was not possible, the true incidence of treated conditions is likely to be even higher than that found in this study. The present findings can be used to prioritise the implementation of timely access to treatment to prevent or attenuate the severity of pain and mental health conditions after transport injury.

Effect of Electronic Health Record-Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication Self-management: A Randomized Clinical Trial

Importance

Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy.

Objective

To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention.

Design, Setting, and Participants

This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat.

Interventions

Clinics were randomly assigned to to groups: electronic health record-based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care.

Main Outcomes and Measures

Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications.

Results

Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, -2.0 mm Hg; 95% CI, -5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (-5.6 mm Hg; 95% CI, -8.8 to -2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]).

Conclusions and Relevance

The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.

Trial Registration

ClinicalTrials.gov identifier: NCT01578577.

Health literacy in a population-based sample of Australian women: a cross-sectional profile of the Geelong Osteoporosis Study

Background

The term health literacy refers to the abilities and resources required to find, understand and use health information in managing health. This definition is reflected in the recent development of multidimensional health literacy tools that measure multiple facets of health literacy. The aim of this study was to determine the health literacy profile of a randomly selected, population-based sample of Australian women using a multidimensional tool, the Health Literacy Questionnaire (HLQ). A second aim was to investigate associations between independent HLQ scales, sociodemographic characteristics and lifestyle and anthropometric risk factors for chronic disease.

Methods

We surveyed women involved in the Geelong Osteoporosis Study (GOS), a longitudinal, population-based study. We included demographic data, lifestyle information and anthropometric measures as well as the HLQ. The HLQ has 44 items, scored on either 4- or 5-point scales, within nine conceptually distinct scales. Means for each scale were calculated, and HLQ scales were regressed on educational level and socioeconomic status. Risk factors for chronic disease were investigated using analysis of variance (ANOVA) and calculation of effect sizes.

Results

Higher mean scores were seen for the scales ‘Feeling understood and supported by healthcare professionals’ (mean 3.20, ± SD 0.52) and ‘Understanding health information well enough to know what to do’ (mean 4.28, ±SD 0.54), and lower mean scores were seen for ‘Appraisal of health information’ (mean 2.81, ±SD 0.48) and ‘Navigating the healthcare system’ (mean 4.09, ± SD 0.57). Associations were also seen between lower HLQ scores and poor health behaviours including smoking and being more sedentary, in addition to greater body mass index and waist circumference. Positive gradients were seen between several HLQ scales and education level, as well as SES. For some HLQ scales, these associations were non-linear.

Conclusions

The profile of this population-based cohort of women demonstrated associations between low health literacy and low SES, lower levels of education, increasing age, and anthropometric and lifestyle risk factors for chronic disease. These findings suggest implications of health literacy for health policy makers focusing on improving lifestyle prevention of chronic disease and promoting health equity at a population level.

Health literacy and uptake of anti-fracture medications in a population-based sample of Australian women

This study investigated associations between health literacy and use of anti-fracture medications in women with osteoporosis. Data were collected for women participating in the population-based Geelong Osteoporosis Study in Australia. Health literacy was ascertained using the Health Literacy Questionnaire (HLQ) and bone mineral density by dual x-ray absorptiometry. Self-reported current medications were classified using MIMS codes, with the category 'Agent affecting calcium and bone metabolism' indicating osteoporosis treatment. Analysis of Variance (p-value <0.1 indicating a trend) and Cohen's d effect sizes (ES [95%CI]) (categorised; Small >0.2-<0.5, Moderate >0.5-0.8, Large >0.8) were calculated for differences in HLQ scale scores between participants who did vs. did not self-report medication use. Among 620 women, 134 (21.6%) had osteoporosis, 14 (10.5%) of whom self-reported current anti-fracture medication use. Small/moderate ES indicated women taking medication had lower HLQ scores in scales 'Navigating the healthcare system', 'Ability to find health information' and 'Understand health information' (ES 0.36 [0.25-0.79], 0.41 [0.29-0.87] and 0.64 [0.54-1.03], respectively). A trend was observed (p = 0.09) for 'Understand health information' scale scores and utilisation of medication. These data suggest women with less confidence in their ability to find and understand health information may follow healthcare provider recommendations and utilise anti-fracture medications more readily.

A Mobile App to Improve Self-Management of Individuals With Type 2 Diabetes: Qualitative Realist Evaluation

BACKGROUND

The increasing use of Web-based solutions for health prevention and promotion presents opportunities to improve self-management and adherence to guideline-based therapy for individuals with type 2 diabetes (T2DM). Despite promising preliminary evidence, many users stop using Web-based solutions due to the burden of data entry, hidden costs, loss of interest, and a lack of comprehensive features. Evaluations tend to focus on effectiveness or impact and fail to evaluate the nuanced variables that may interact to contribute to outcome success (or failure).

OBJECTIVE

This study aimed to evaluate a Web-based solution for improving self-management in T2DM to identify key combinations of contextual variables and mechanisms of action that explain for whom the solution worked best and in what circumstances.

METHODS

A qualitative realist evaluation was conducted with one-on-one, semistructured telephonic interviews completed at baseline, and again toward the end of the intervention period (3 months). Topics included participants' experiences of using the Web-based solution, barriers and facilitators of self-management, and barriers and facilitators to effective use. Transcripts were analyzed using thematic analysis strategies, after which the key themes were used to develop statements of the relationships between the key contextual factors, mechanisms of action, and impact on the primary outcome (glycated hemoglobin, HbA_1c).

RESULTS

Twenty-six interviews (14 baseline, 12 follow-up) were completed with 16 participants with T2DM, and the following 3 key groups emerged: the easiest fit, the best fit, and those who failed to activate. Self-efficacy and willingness to engage with the solution facilitated improvement in HbA_1c, whereas competing priorities and psychosocial issues created barriers to engagement. Individuals with high baseline self-efficacy who were motivated, took ownership for their actions, and prioritized diabetes management were early and eager adopters of the app and recorded improvements in HbA_1c over the intervention period. Individuals with moderate baseline self-efficacy and no competing priorities, who identified gaps in understanding of how their actions influence their health, were slow to adopt use but recorded the greatest improvements in HbA_1c. The final group had low baseline self-efficacy and identified a range of psychosocial issues and competing priorities. These participants were uncertain of the benefits of using a Web-based solution to support self-management, ultimately resulting in minimal engagement and no improvement in HbA_1c.

CONCLUSIONS

Self-efficacy, competing priorities, previous behavior change, and beliefs about Web-based solutions interact to determine engagement and impact on the clinical outcomes. Considering the balance of these patient characteristics is likely to help health care providers identify individuals who are apt to benefit from a Web-based solution to support self-management of T2DM. Web-based solutions could be modified to incorporate the existing screening measures to identify individuals who are at risk of suboptimal adherence to inform the provision of additional support(s) as needed.

Disease understanding in patients newly diagnosed with atrial fibrillation

OBJECTIVE

To describe self-reported disease understanding for newly diagnosed patients with atrial fibrillation (AF) and assess (1) how disease understanding changes over the first 6 months after diagnosis and (2) the relationship between patient understanding of therapies at baseline and treatment receipt at 6 months among treatment-naïve patients.

METHODS

We analysed survey data from SATELLITE (Survey of Patient Knowledge and Personal Priorities for Treatment), a substudy of patients with new-onset AF enrolled in the national Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) II registry across 56 US sites. Patients were surveyed at the baseline and 6-month follow-up clinic visits using Likert scales.

RESULTS

Among 1004 baseline survey responses, patients' confidence in their understanding of rhythm control, ablation, anticoagulation and cardioversion was suboptimal, with 'high' understanding ranging from 8.5% for left atrial appendage closure to 71.3% for rhythm therapy. Of medical history and demographic factors, education level was the strongest predictor of reporting 'high' disease understanding. Among the 786 patients with 6-month survey data, significant increases in the proportion reporting high understanding were observed (p<0.05) only for warfarin and direct oral anticoagulants (DOACs). With the exception of ablation, high understanding for a given therapeutic option was not associated with increased use of that therapy at 6 months.

CONCLUSIONS

About half of patients with new-onset AF understood the benefits of oral anticoagulant at the time of diagnosis and understanding improved over the first 6 months. However, understanding of AF treatment remains suboptimal at 6 months. Our results suggest a need for ongoing patient education.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov. Identifier: NCT01701817.

Health literacy, pain intensity and pain perception in patients with chronic pain

Background

Chronic pain poses a large burden for the healthcare system and the individuals concerned. The impact of health literacy (HL) on health status and health outcomes is receiving more and more attention. The aim of this study was to evaluate the association of HL with chronic pain intensity and pain perception.

Methods

A total of 121 outpatients suffering from chronic pain (pain duration >3 months) were evaluated. The HL was measured using the health literacy screening questions. Pain intensity was measured with a Visual Analogue Scale (VAS) and pain perception with the short-form McGill Pain Questionnaire (SF-MPQ).

Results

Individuals with low HL had significantly higher VAS values (Pearson correlation coefficient= −0.270, p = 0.003). Stepwise regression analysis showed that HL has a significant association with pain intensity (odds ratio [OR] = 2.31; 95% confidence interval [CI] 1.11–4.83), even after controlling for age and sex (OR = 2.27; 95% CI 1.07–4.82), but no longer after controlling for education (OR = 2.10; 95% CI 0.95–4.64).

Conclusion

Individuals with a higher HL showed less pain intensity, which seems to be caused by a better pain management; therefore, supporting the development of HL in patients with chronic pain could be seen as an important objective of integrated care.

Awareness, self-management behaviors, health literacy and kidney function relationships in specialty practice

AIM

To determine the relationship between chronic kidney disease (CKD) awareness (CKD-A), self-management behaviors (CKD-SMB) knowledge, performance of CKD-SMBs, health literacy (HL) and kidney function.

METHODS

Participants were eligible patients attending an outpatient nephrology clinic. Participants were administered: Newest Vital Sign to measure HL, CKD self-management knowledge tool (CKD-SMKT) to assess knowledge, past performance of CKD-SMB, CKD-A. Estimated GFR (eGFR) was determined using the MDRD-4 equation. Duration of clinic participation and CKD cause were extracted from medical charts.

RESULTS

One-hundred-fifty patients participated in the study. eGFRs ranged from 17-152 mL/min per 1.73 m². Majority (83%) of respondents had stage 3 or 4 CKD, low HL (63%), and were CKD aware (88%). Approximately 40% (10/25) of patients in stages 1 and 2 and 6.4% (8/125) in stages 3 and 4 were unaware of their CKD. CKD-A differed with stage (P < 0.001) but not by HL level, duration of clinic participation, or CKD cause. Majority of respondents (≥ 90%) correctly answered one or more CKD-SMKT items. Knowledge of one behavior, “controlling blood pressure” differed significantly by CKD-A. CKD-A was associated with past performance of two CKD-SMBs, “controlling blood pressure” (P = 0.02), and “keeping healthy body weight” (P = 0.01). Adjusted multivariate analyses between CKD-A and: (1) HL; and (2) CKD-SMB knowledge were non-significant. However, there was a significant relationship between CKD-A and kidney function after controlling for demographics, HL, and CKD-SMB (P < 0.05).

CONCLUSION

CKD-A is not associated with HL, or better CKD-SMBs. CKD-A is significantly associated with kidney function and substantially lower eGFR, suggesting the need for focused patient education in CKD stages 1.

Shared heart failure knowledge and self-care outcomes in patient-caregiver dyads

BACKGROUND

Patient's knowledge about heart failure (HF) contributes to successful HF self-care, but less is known about shared patient-caregiver knowledge.

OBJECTIVES

The purpose of this analysis was to: 1) identify configurations of shared HF knowledge in patient-caregiver dyads; 2) characterize dyads within each configuration by comparing sociodemographic factors, HF characteristics, and psychosocial factors; and 3) quantify the relationship between configurations and patient self-care adherence to managing dietary sodium and HF medications.

METHODS

This was a secondary analysis of cross-sectional data (N = 114 dyads, 53% spousal). Patient and caregiver HF knowledge was measured with the Atlanta Heart Failure Knowledge Test. Patient dietary sodium intake was measured by 3-day food record and 24 h urine sodium. Medication adherence was measured by Medication Events Monitoring System caps. Patient HF-related quality of life was measured by the Minnesota Heart Failure Questionnaire; caregiver health-related quality of life was measured by the Short Form-12 Physical Component Summary. Patient and caregiver depression were measured with the Beck Depression Inventory-II. Patient and caregiver perceptions of caregiver-provided autonomy support to succeed in heart failure self-care were measured by the Family Care Climate Questionnaire. Multilevel and latent class modeling were used to identify dyadic knowledge configurations. T-tests and chi-square tests were used to characterize differences in sociodemographic, clinical, and psychosocial characteristics by configuration. Logistic/linear regression were used to quantify relationships between configurations and patient dietary sodium and medication adherence.

RESULTS

Two dyadic knowledge configurations were identified: "Knowledgeable Together" (higher dyad knowledge, less incongruence; N = 85, 75%) and "Knowledge Gap" (lower dyad knowledge, greater incongruence; N = 29, 25%). Dyads were more likely to be in the "Knowledgeable Together" group if they were White and more highly educated, if the patient had a higher ejection fraction, fewer depressive symptoms, and better autonomy support, and if the caregiver had better quality of life. In unadjusted comparisons, patients in the "Knowledge Gap" group were less likely to adhere to HF medication and diet. In adjusted models, significance was retained for dietary sodium only.

CONCLUSIONS

Dyads with higher shared HF knowledge are likely more successful with select self-care adherence behaviors.

Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach

Background

Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models.

Method

A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries.

Results

The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals.

Conclusion

The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.

Capturing health literacy assessment in the electronic health record through evidence-based concept creation: A review of the literature and recommendations for action

Health literacy is the capacity to understand and act upon health-related information and navigate the healthcare system. Published evidence demonstrates a relationship between health literacy and health status. Because of this, there are increasingly calls for a health literacy assessment to be collected and stored in the electronic health record for use by the healthcare team. This article describes the results of a literature review of health literacy assessment instruments with the goal of formulating semantically interoperable concepts that may be used to store the interpretation of the health literacy assessment in the electronic health record. The majority of health literacy instruments could be stored in the electronic health record using a three-concept solution of inadequate, marginal and adequate health literacy. This three-concept solution fully supports semantic interoperability needs across the patient care spectrum.

Short-term effectiveness of a culturally tailored educational intervention on foot self-care among type 2 diabetes patients in Morocco

BACKGROUND

Self-management education (SME) is an important yet unacknowledged aspect of diabetes care. Despite the raise of diabetes and its complications with significant burden in developing countries, research on SME interventions in Morocco is lacking.

AIMS

To assess the effectiveness of a culturally tailored SME intervention on foot-care self-management practices among type 2 diabetes patients and to identify factors associated with practices variation.

METHODS

We designed a pre-post prospective quasi-experimental study and recruited patients with type 2 diabetes aged 30 years old or above. The intervention consisted of an interactive group discussion using different materials: a narrative video, a PowerPoint presentation and a printed guide. Foot-care practices were assessed prior to the session and one month later using 2 items from the Summary of Diabetes Self-Care Activities (SDSCA). Binary logistic regression was performed to identify factors associated with a favorable variation, defined as an increase in the mean frequency score of foot-care by a minimum of 1 day/week.

RESULTS

A total of 199 participants were recruited and 133 completed the second assessment. Mean age was 55.2 ± 11.2 years old. Women represented 67% and 72% of participants was illiterate. The foot-care score mean increased from 3.5 ± 2.9 days to 5.9 ± 1.8 days one month after the intervention (mean variation was 2.4 ± 3.1 days; p < 0.001). A favorable variation was found among 75 (37.7%) participants. In multivariate analysis, literacy was associated with higher likelihood of a favorable variation of foot-care practices (OR = 2.82; 95%CI: 1.09-7.31) while previous education about diabetic foot was associated with lower likelihood of a favorable variation (OR = 0.26; 95%CI: 0.08-0.78).

CONCLUSIONS

There was a general improvement in foot-care practices after the intervention. Our findings suggest the role of literacy and previous patient education in shaping the observed variation. Culturally tailored interventions targeting other disease management domains are needed in our context.

Limited health literacy in advanced kidney disease

Limited health literacy may reduce the ability of patients with advanced kidney disease to understand their disease and treatment and take part in shared decision making. In dialysis and transplant patients, limited health literacy has been associated with low socioeconomic status, comorbidity, and mortality. Here, we investigated the prevalence and associations of limited health literacy using data from the United Kingdom-wide Access to Transplantation and Transplant Outcome Measures (ATTOM) program. Incident dialysis, incident transplant, and transplant wait-listed patients ages 18 to 75 were recruited from 2011 to 2013 and data were collected from patient questionnaires and case notes. A score >2 in the Single-Item Literacy Screener was used to define limited health literacy. Univariate and multivariate analyses were performed to identify patient factors associated with limited health literacy. We studied 6842 patients, 2621 were incident dialysis, 1959 were wait-listed, and 2262 were incident transplant. Limited health literacy prevalence was 20%, 15%, and 12% in each group, respectively. Limited health literacy was independently associated with low socioeconomic status, poor English fluency, and comorbidity. However, transplant wait-listing, preemptive transplantation, and live-donor transplantation were associated with increasing health literacy.

To Share or Not to Share: A Cross-Sectional Study on Health Information Sharing and Its Determinants Among Chinese Rural Chronic Patients

To examine the determinants of the health information sharing among rural Chinese chronic patients. Two large population-based surveys in rural China were carried out from July 2011 to April 2012. Data used in this study were second hand and sorted out from the two previous databases. A binary logistic regression analysis was employed to discover the impact of demographic characteristics, level of health literacy, and other factors on respondents' health information sharing behavior. Among the total 1,324 participants, 63.6% share health information with others. Among all significant predictors, those who acquire health information via family and friends are 6.0 times the odds of sharing health information than those who do not. Participants who have more than six household members, with middle and high levels of health knowledge, and who are moderately involved in discussions or settlements of village affairs are also more likely to share health information. The reliance on interpersonal communication channels for health information, household size, the patients' preexisting health knowledge, and their activity in village affairs are crucial determinants for health information sharing among rural chronic patients. A more sophisticated model needs to be established to reveal the complex processes of health information communication.

A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD

BACKGROUND AND OBJECTIVES

The self-management and decision-making skills required to manage CKD successfully may be diminished in those with low health literacy. A 2012 review identified five papers reporting the prevalence of limited health literacy in CKD, largely from United States dialysis populations. The literature has expanded considerably since.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used systematic review, pooled prevalence analysis, metaregression, and exploration of heterogeneity in studies of patients with CKD (all stages).

RESULTS

From 433 studies, 15 new studies met the inclusion criteria and were analyzed together with five studies from the 2012 review. These included 13 cross-sectional surveys, five cohort studies (using baseline data), and two using baseline clinical trial data. Most (19 of 20) were from the United States. In total, 12,324 patients were studied (3529 nondialysis CKD, 5289 dialysis, 2560 transplant, and 946 with unspecified CKD; median =198.5; IQR, 128.5-260 per study). Median prevalence of limited health literacy within studies was 23% (IQR, 16%-33%), and pooled prevalence was 25% (95% confidence interval, 20% to 30%) with significant between-study heterogeneity (I2=97%). Pooled prevalence of limited health literacy was 25% (95% confidence interval, 16% to 33%; I2=97%) among patients with CKD not on dialysis, 27% (95% confidence interval, 19% to 35%; I2=96%) among patients on dialysis, and 14% (95% confidence interval, 7% to 21%; I2=97%) among patients with transplants. A higher proportion of nonwhite participants was associated with increased limited health literacy prevalence (P=0.04), but participant age was not (P=0.40). Within studies, nonwhite ethnicity and low socioeconomic status were consistently and independently associated with limited health literacy. Studies were of low or moderate quality. Within-study participant selection criteria had potential to introduce bias.

CONCLUSIONS

Limited health literacy is common in CKD, especially among individuals with low socioeconomic status and nonwhite ethnicity. This has implications for the design of self-management and decision-making initiatives to promote equity of care and improve quality. Lower prevalence among patients with transplants may reflect selection of patients with higher health literacy for transplantation either because of less comorbidity in this group or as a direct effect of health literacy on access to transplantation.

The Third Time's a Charm: Psychometric Testing and Update of the Atlanta Heart Failure Knowledge Test

BACKGROUND AND OBJECTIVE

Since first being published in 2009, the Atlanta Heart Failure Knowledge Test (AHFKT) has proven a reliable and valid instrument and has been used in multiple studies. Given advances in heart failure (HF) self-care, we proposed to reevaluate the psychometric properties of the AHFKTv2 across these recent studies and update the instrument.

METHODS

Demographic, clinical, and baseline AHFKTv2 data from 4 intervention studies in persons with HF were combined for this analysis (N = 284). The 30 questions of the AHFKT are focused on 5 HF self-care knowledge domains: pathophysiology, nutrition, behavior, medications, and symptoms. Characteristics of the sample were analyzed using descriptive statistics; validity testing with t tests and Mann-Whitney 2-group tests and Pearson r and Spearman ρ correlations; and reliability calculations and factor analysis were performed based on tetrachoric correlations.

RESULTS

Participants were 22 to 84 years of age, 66% were African American, 63% were male, and 94% had New York Heart Association class II to III HF. Mean AHFKT score was 80.6% (±11%). Hypotheses that higher levels of knowledge would be associated with higher education level (t = -2.7, P < .01) and less sodium consumption (ρ = -0.22, P = .03) were validated. Factor analysis revealed 1 general knowledge factor with good reliability, Cronbach's α was .87. Item response analysis identified individual questions requiring review and revision.

CONCLUSION

Comprehensive psychometric evaluation of the AHFKTv2 confirmed its internal consistency reliability and validity and provided direction for production of the AHFKTv3 available for use in research and clinical practice.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain.

PERSPECTIVE

In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.