Health literacy among Medicare enrollees in a managed care organization

Disparities in the outcomes of lumbar spinal stenosis surgery based on insurance status

STUDY DESIGN

Retrospective cohort study using Thomson Reuter's MarketScan database.

OBJECTIVE

To evaluate the extent to which Medicaid versus commercial insurance status affects outcomes after lumbar stenosis surgery.

SUMMARY OF BACKGROUND DATA

The Affordable Care Act aims to expand health insurance and to help narrow existing health care disparities. Medicaid patients have previously been noted to be at an increased risk for impaired access to health care. Conversely, those with commercial insurance may be subject to overtreatment. We examine the surgical treatment of low back pain as an example that has raised significant public health concerns.

METHODS

A total of 28,462 patients, ages 18 and older, were identified who had undergone laminectomy or fusion for spinal stenosis between 2000 and 2009. Patients were characterized by baseline demographic information, comorbidity burden, and type of insurance (Medicaid vs. commercial insurance). Multivariate analysis was performed comparing the relative effect of insurance status on reoperation rates, timing and type of reoperations, postoperative complications, and total postoperative health resource use.

RESULTS

Medicaid patients had similar reoperation rates to commercially insured patients at 1 year (4.60% vs. 5.42%, P = .38); but had significantly lower reoperation rates at 2 (7.22% vs. 10.30%; adjusted odds ratio [aOR] = 0.661; 95% confidence interval [CI], 0.533-0.820; P = .0002) and more than 2 years (13.92% vs. 16.89%; aOR = 0.722; 95% CI, 0.612-0.851; P <.0001). Medicaid patients were particularly less likely to undergo fusion as a reoperation (aOR = 0.478; 95% CI, 0.377-0.606; P < 0001). Medicaid patients had greater health care resource utilization as measured by hospital days, outpatient services and medications prescribed; however, commercially insured patients had significantly higher overall health utilization costs at 1 and 2 years.

CONCLUSION

There are insurance disparities that affect important surgical outcomes after initial surgery for spinal stenosis. Efforts for national health care reform should include explicit efforts to identify such system factors that will reduce current inequities in care.

LEVEL OF EVIDENCE

2.

Older Hispanic Women, Health Literacy, and Cervical Cancer Screening

Approximately 90 million people in the United States lack basic literacy skills, which affect health behaviors. Cervical cancer is preventable and treatable, yet few older Hispanic women seek screening and continue to be a high-risk group for cervical cancer. A literature review was conducted to address the relationship between cervical cancer screening, health literacy, and older Hispanic women. Eighty studies were reviewed, and nine addressed health literacy and Hispanic women. One study addressed the association between functional health literacy and Pap smear screening among older Hispanic women. Few studies have explored the association between preventive cervical cancer screening and health literacy among older Hispanic women. Nurses must assess health literacy and be prepared to provide care, which is culturally, and linguistically appropriate to improve health outcomes. Further research is needed to be inclusive of all populations including older Hispanic women.

Investigation of residents' health literacy status and its risk factors in Jiangsu Province of China

Health literacy has become an important public health concern. Multistage cluster random sampling was used to select 12 450 individuals. Using the 2009 Chinese Health Literacy questionnaire, participants were divided into groups with poor or not poor health literacy status. The knowledge rates for 6 areas of health literacy were determined with the following results: science concept of health (60.0%), literacy for preventing acute infectious disease (66.8%), literacy for preventing noncommunicable chronic disease (51.9%), safety and first aid (66.8%), obtaining and making use of basic medical care (55.3%), and comprehensive health literacy (52.5%). Multiple logistic regression showed that living in a rural area, fewer individuals in a household, younger age, low education, agricultural or rural migrant occupation workers, and low family income were associated with a poor health literacy status. Our results support the use of health education and promotion interventions to improve health literacy in this high-risk population in China.

Health literacy of Dutch adults: a cross sectional survey

BACKGROUND

Relatively little knowledge is available to date about health literacy among the general population in Europe. It is important to gain insights into health literacy competences among the general population, as this might contribute to more effective health promotion and help clarify socio-economic disparities in health. This paper is part of the European Health Literacy Survey (HLS-EU). It aims to add to the body of theoretical knowledge about health literacy by measuring perceived difficulties with health information in various domains of health, looking at a number of competences. The definition and measure of health literacy is still topic of debate and hardly any instruments are available that are applicable for the general population. The objectives were to obtain an initial measure of health literacy in a sample of the general population in the Netherlands and to relate this measure to education, income, perceived social status, age, and sex.

METHODS

The HLS-EU questionnaire was administered face-to-face in a sample of 925 Dutch adults, during July 2011. Perceived difficulties with the health literacy competences for accessing, understanding, appraising and applying information were measured within the domains of healthcare, disease prevention and health promotion. Multiple linear regression analyses were applied to explore the associations between health literacy competences and education, income, perceived social status, age, and sex.

RESULTS

Perceived difficulties with health information and their association with demographic and socio-economic variables vary according to the competence and health domain addressed. Having a low level of education or a low perceived social status or being male were consistently found to be significantly related to relatively low health literacy scores, mainly for accessing and understanding health information.

CONCLUSIONS

Perceived difficulties with health information vary between competences and domains of health. Health literacy competences are associated with indicators of socio-economic position and with the domain in which health information is provided.

Evaluation of a health literacy screening tool in primary care patients: evidence from Serbia

Improving health literacy skills is important for patient comprehension of health-related topics and their ability to attend to their medical problems. Promoting health literacy is a pivotal policy for maintaining and promoting health. The objective of the present study was to translate the Test of Functional Health Literacy in Adults (TOFHLA; long and short versions) into Serbian and evaluate the translated and cross-culturally adapted questionnaires in Serbian primary care patients. The translated TOFHLA questionnaires were administered to 120 patients. Additionally, a self-completed questionnaire was used. Both descriptive and inferential statistics were measured. The mean score for the TOFHLA was 73.49 (median, 78; SD = 17.94; range, 0-100) and the mean score for the Short Test of Functional Health Literacy in Adults (STOFHLA) was 29.28 (median, 32; SD = 6.16; range, 0-36). Sex, age, education, self-perceived health and presence of any chronic disease were associated with health literacy scores. The internal consistency (Cronbach's alpha) was 0.73 for the TOFHLA numeracy subset, 0.95 for reading comprehension, 0.94 for the TOFHLA and 0.90 for the STOFHLA. The Pearson correlation between the TOFHLA and STOFHLA was 0.89. The area under the curve of these two tests was 0.79 (95% CI, 0.602-0.817). The Serbian translated versions of the TOHFLA questionnaires offer valid measures of functional health literacy. There were no differences between the reliability and validity of the short and long TOFHLA forms.

Health Literacy Assessment of the STOFHLA: Paper versus electronic administration continuation study

Low health literacy is associated with poor health outcomes. Research is needed to understand the mechanisms and pathways of its effects. Computer-based assessment tools may improve efficiency and cost-effectiveness of health literacy research. The objective of this preliminary study was to assess if administration of the Short Test of Functional Health Literacy in Adults (STOFHLA) through a computer-based medium was comparable to the paper-based test in terms of accuracy and time to completion. A randomized, crossover design was used to compare computer versus paper format of the STOFHLA at a Midwestern family medicine residency program. Eighty participants were initially randomized to either computer (n = 42) or paper (n = 38) format of the STOFHLA. After a 30-day washout period, participants returned to complete the other version of the STOFHLA. Data analysis revealed no significant difference between paper- and computer-based surveys (p = .9401; N = 57). The majority of participants showed "adequate" health literacy via paper- and computer-based surveys (100% and 97% of participants, respectively). Electronic administration of STOFHLA results were equivalent to the paper administration results for evaluation of adult health literacy. Future investigations should focus on expanded populations in multiple health care settings and validation of other health literacy screening tools in a clinical setting.

Effects of prospective-user factors and sign design features on guessability of pharmaceutical pictograms

OBJECTIVE

To examine the associations between the guessing performance of 25 pharmaceutical pictograms and five sign features for naïve participants. The effect of prospective-user factors on guessing performance was also investigated.

METHODS

A total of 160 Hong Kong Chinese people, drawn largely from a young student population, guessed the meanings of 25 pharmaceutical pictograms that were generally not familiar to them. Participants then completed a questionnaire about their drug buying and drug label reading habits, and their demographics and medication history. Finally they rated five features (familiarity, concreteness, complexity, meaningfulness, and semantic distance) of the pharmaceutical pictograms using 0-100 scales.

RESULTS

For all pharmaceutical pictograms, mean and standard deviation of guessability score were 64.8 and 17.1, respectively. Prospective-user factors of 'occupation', 'age' and 'education level' significantly affected guessing performance. For sign features, semantic closeness was the best predictor of guessability score, followed by simplicity, concreteness, meaningfulness and familiarity.

CONCLUSION

User characteristics and sign features are critical for pharmaceutical pictograms. To be effective, pharmaceutical pictograms should have obvious and direct connections with familiar things and it is recommended that pharmaceutical pictograms should be designed with consideration of the five sign features investigated here.

PRACTICE IMPLICATIONS

This study provides useful information and recommendations to assist interface designers to create and evaluate icons for pharmaceutical products and to design more user-friendly pharmaceutical pictograms. However, further work is needed to see how older people respond to such pharmaceutical pictograms.

Impact of Comorbidities on Racial/Ethnic Disparities in Hypertension in the United States

Background. Racial/ethnic disparities in hypertension (HTN) prevalence continue to persist in United States. We aimed in this study to examine the racial/ethnic disparities in hypertension prevalence and to determine whether or not health disparities may be explained by racial/ethnic disparities in co-morbidities. Materials and Methods. A cross-sectional design was used to examine the prevalence of hypertension among African Americans (AAs), Caucasians, and Hispanics in the National Health Interview Survey, 2003. The overall sample comprised 30, 852 adults. Results. There was a statistically significant racial/ethnic variability in hypertension prevalence, with AA/Blacks with the highest prevalence, χ2=393.0 (3), P<0.01. Hypertension was associated with co-morbidities, age, education, physical inactivity, marital status, income, sex, alcohol, and cigarette consumption, but not insurance. Relative to Caucasians, AAA/Blacks were 43% more likely while Hispanics were 40% less likely to report being diagnosed with high blood pressure, prevalence odds ratio (POR)  =  1.43, 99% CI, 1.25–1.64, P=0.002, and POR  =  0.60, 99% CI, 0.55–0.66, P<0.001, respectively. After adjustment for the relevant covariates including co-morbidities, racial/ethnic disparities in hypertension persisted; thus compared to Caucasians, African Americans were 61% more likely to be told by their health care providers that they were hypertensive, adjusted prevalence odds ratio (APOR)  =  1.61, 99% CI, 1.39–1.86, P<0.001. In contrast, Hispanics were 27% less likely to be diagnosed with hypertension compared to Caucasians, APOR  =  0.73, 99% CI, 0.68–0.79, P<0.001. Conclusions. There was racial/ethnic variability in hypertension prevalence in this large sample of non-institutionalized US residents, with the highest prevalence of hypertension observed among African Americans. These disparities were not removed after controlling for relevant covariates including co-morbidities.

The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Health literacy and patient empowerment in health communication: the importance of separating conjoined twins

OBJECTIVE

Patient empowerment and health literacy have both been studied empirically, but they have hardly ever been explicitly linked.

METHODS

Pertinent literature from the development of both concepts was studied, drawing not only on health care literature, but also on management research.

RESULTS

This article argues that it is important to recognize that the concepts are distinct, both conceptually and empirically. At the same time, the impacts of health literacy and patient empowerment are deeply intertwined. High literacy does not necessarily entail empowerment and vice versa, and mismatches of the two can have deleterious consequences. High levels of health literacy without a corresponding high degree of patient empowerment creates an unnecessary dependence of patients on health professionals, while a high degree of empowerment without a corresponding degree of health literacy poses the risk of dangerous health choices.

CONCLUSION

We discuss the importance of carefully conceptualizing both approaches, the implications for their measurement and the design of health interventions.

PRACTICE IMPLICATIONS

Communication programs must include the empowerment that motivates consumers to engage and the literacy that enables them to make informed and reasoned choices.

Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians

Studies reveal high levels of inadequate health literacy and numeracy in African Americans and older veterans. The authors aimed to investigate the distribution of health literacy, numeracy, and graph literacy in these populations. They conducted a cross-sectional survey of veterans receiving outpatient care and measured health literacy, numeracy, graph literacy, shared decision making, and trust in physicians. In addition, the authors compared subgroups of veterans using analyses of covariance. Participants were 502 veterans (22-82 years). Low, marginal, and adequate health literacy were found in, respectively, 29%, 26%, and 45% of the veterans. The authors found a significant main effect of race qualified by an age and race interaction. Inadequate health literacy was more common in African Americans than in Whites. Younger African Americans had lower health literacy (p <.001), graph literacy (p <.001), and numeracy (p <.001) than did Whites, even after the authors adjusted for covariates. Older and younger participants did not differ in health literacy, objective numeracy, or graph literacy after adjustment. The authors found no health literacy or age-related differences regarding preferences for shared decision making. African Americans expressed dissatisfaction with their current role in decision making (p =.03). Older participants trusted their physicians more than younger participants (p =.01). In conclusion, African Americans may be at a disadvantage when reviewing patient education materials, potentially affecting health care outcomes.

The conceptualization and measurement of cognitive health sophistication

This article develops a conceptualization and measure of cognitive health sophistication--the complexity of an individual's conceptual knowledge about health. Study 1 provides initial validity evidence for the measure--the Healthy-Unhealthy Other Instrument--by showing its association with other cognitive health constructs indicative of higher health sophistication. Study 2 presents data from a sample of low-income adults to provide evidence that the measure does not depend heavily on health-related vocabulary or ethnicity. Results from both studies suggest that the Healthy-Unhealthy Other Instrument can be used to capture variability in the sophistication or complexity of an individual's health-related schematic structures on the basis of responses to two simple open-ended questions. Methodological advantages of the Healthy-Unhealthy Other Instrument and suggestions for future research are highlighted in the discussion.

Health literacy and glaucoma

PURPOSE OF REVIEW

This review discusses the concept and measurement of health literacy, with a focus on the care of patients with glaucoma.

RECENT FINDINGS

Nearly one-fourth of adults in the USA lack the skills needed to fully comprehend and act on verbal or written information in the healthcare environment. This problem, referred to as poor health literacy, is associated with worse health-related outcomes in many chronic diseases, including glaucoma. Patients with glaucoma and poor literacy skills are less likely to refill their prescribed medications and miss more scheduled appointments than their more literate peers. Moreover, ophthalmic educational materials are often written at a level of readability that surpasses the skills of many patients with glaucoma.

SUMMARY

Patients with chronic eye diseases such as glaucoma and limited health literacy skills are vulnerable to poor visual outcomes. Attention to health literacy may improve the care and outcomes of these patients.

Medicare beneficiary knowledge of the Part D program and its relationship with voluntary enrollment

BACKGROUND

The 2003 Medicare Modernization Act established the Part D drug benefit in 2006. Because the benefit involves a voluntary enrollment process with numerous plan options, there has been concern about whether beneficiaries have adequate knowledge of the program, but research on this issue has been limited.

OBJECTIVES

To examine Medicare beneficiary knowledge of the Part D program and estimate how knowledge affected voluntary enrollment decisions at the program's outset.

METHODS

We linked data from the 2005 Medicare Current Beneficiary Survey with CMS administrative data regarding beneficiary 2006 drug coverage and market characteristics. We estimated a multivariate logistic regression model to explore the relationship between Part D knowledge and beneficiaries' voluntary enrollment in a Part D plan.

RESULTS

At the inception of the Medicare Part D benefit, no single knowledge test question was correctly answered by more than three-fourths of beneficiaries. Correct responses to five knowledge test questions were positively associated with enrollment: "everyone has plan choices" (adjusted odds ratio = 1.4); "plans can change costs once per year" (aOR = 1.2); "beneficiaries must use plan pharmacies" (aOR = 1.5); "beneficiaries must pay a penalty if they enroll late" (aOR = 1.3); "assistance is available for low income beneficiaries" (aOR = 1.2).

CONCLUSION

Beneficiary understanding of the Part D program in early 2006 was limited. Beneficiary knowledge of Part D program details was associated with enrollment in Medicare Part D. Efforts to educate Medicare beneficiaries about Part D may improve rates of prescription drug coverage.

Readability assessment of concussion and traumatic brain injury publications by Centers for Disease Control and Prevention

Health literacy is associated with a person’s capacity to find, access, contextualize, and understand information needed for health care-related decisions. The level of health literacy thus has an influence on an individual’s health status. It can be argued that low health literacy is associated with poor health status. Health care literature (eg, pamphlets, brochures, postcards, posters, forms) are published by public and private organizations worldwide to provide information to the general public. The ability to read, use, and understand is critical to the successful application of knowledge disseminated by this literature. This study assessed the readability, suitability, and usability of health care literature associated with concussion and traumatic brain injury published by the United States Centers for Disease Control and Prevention. The Flesch–Kincaid Grade Level, Flesch Reading Ease, Gunning Fog, Simple Measure of Gobbledygook, and Suitability Assessment of Materials indices were used to assess 40 documents obtained from the Centers for Disease Control and Prevention website. The documents analyzed were targeted towards the general public. It was found that in order to be read properly, on average, these documents needed more than an eleventh grade/high school level education. This was consistent with the findings of other similar studies. However, the qualitative Suitability Assessment of Materials index showed that, on average, usability and suitability of these documents was superior. Hence, it was concluded that formatting, illustrations, layout, and graphics play a pivotal role in improving health care-related literature and, in turn, promoting health literacy. Based on the comprehensive literature review and assessment of the 40 documents associated with concussion and traumatic brain injury, recommendations have been made for improving the readability, suitability, and usability of health care-related documents. The recommendations are presented in the form of an incremental improvement process cycle and a list of dos and don’ts.

Diabetes control among Hispanics in the action to control cardiovascular risk in diabetes trial

BACKGROUND

Hispanics in the United States represent diverse racial, ethnic, and socioeconomic groups, and manifest heterogeneous cardiovascular risks including diabetes. It is not known if there are residual differences in the control of diabetes among Hispanic groups given uniform access to diabetes care.

OBJECTIVE

To evaluate glucose control differences among Mexicans, Puerto Ricans, and Dominicans receiving substantial diabetes care and support in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

DESIGN

Secondary analysis of data from a randomized trial comparing two treatment strategies: intensive, targeting glycated hemoglobin below 6.0 %, and standard, targeting glycated hemoglobin between 7.0 % and 7.9 %.

PARTICIPANTS

Seven hundred and sixteen Hispanic and 6066 non-Hispanic white participants were recruited from 77 clinical sites across the United States and Canada. There were 243 Mexicans, 199 Puerto Ricans, and 150 Dominicans; and 135 of these Hispanic groups were born in the United States.

MAIN MEASURE

Glycated hemoglobin

RESULTS

Compared to Puerto Ricans, Mexicans were more likely (HR=1.38, CI:0.90-2.10) and Dominicans as likely (HR=1.01, CI:0.66-1.54) to achieve glycated hemoglobin goal in the intensive arm. Participants born in the United States achieved glycated hemoglobin goal at a higher rate than those born elsewhere (HR=1.57, CI:0.99-2.51 in the intensive arm, HR=1.51, CI:0.95-2.43 in the standard arm). These differences were not statistically significant. In the intensive arm, Puerto Ricans (OR=0.47, CI:0.31-0.71), and Dominicans (OR=0.41, CI:0.26-0.66) were less likely than non-Hispanic whites to achieve glycated hemoglobin goal, whereas the difference between non-Hispanic whites and Mexicans was not statistically significant, (OR=0.66, CI:0.43-1.02).

CONCLUSIONS

Hispanic groups, given access to comprehensive diabetes care, differed from each other non-significantly and had a variable divergence from non-Hispanic whites in achieving intensive glycated hemoglobin goal. These differences, if confirmed, could be due to such factors as variable acculturation and functional health literacy levels that were not measured in the ACCORD trial, but should be further explored in future studies.

Legibility of USP pictograms by clients of community pharmacies in Portugal

BACKGROUND

Effective and safe use of medicines depends on patients' good understanding of the pharmacotherapy. Pictograms are a communication tool, as complement of verbal/written information, to facilitate drug use and, avoiding errors, being useful for drug effectiveness and safety.

OBJECTIVE

To assess the ability of pharmacy's clients, in understanding USP pictograms, establishing the relationship with their socio demographic profiles.

SETTING

The study was developed in community pharmacies, in Lisbon region.

METHODS

Cross sectional study, carried out in pharmacies in Lisbon. A structured questionnaire was used in pharmacies clients of 18 years old and above. Legibility of fifteen USP pictograms was studied using ISO and ANSI criteria. Correlation between the legibility of pictograms and pharmacies clients' demographic profile (age, gender, scholarship, frequency of medicines use) was evaluated. SPSS data base version 18 was used for descriptive analysis.

MAIN OUTCOME MEASURE

Legibility of fifteen United States Pharmacopeia (USP) pictograms and, its relationship with clients' demographic data (scholarship degree, age, frequency of medicines use and, gender) was studied.

RESULTS

From 751 responders, ten pictograms were legible by ISO and seven by ANSI. More than 30 % of the responders weren't able to understand five of the pictograms. It was found statistically significant relationships between some the understanding of some pictograms and clients' scholarships degree, age and frequency of medicines use.

CONCLUSION

It was found that not all the fifteen tested USP pictograms were correctly comprehended by Portuguese pharmacies' clients, having found correlations with scholarship degree, daily use of medicines and age group, for some pictograms. To ensure the effectiveness of USP pictograms it is advisable to test patients' comprehension, before their use in general practice.

Heart failure rehospitalization of the Medicare FFS patient: a state-level analysis exploring 30-day readmission factors

PURPOSE OF STUDY

Heart failure readmission among the elderly is frequent and costly to both the patient and the Medicare trust fund. In this study, the authors explore the factors that are associated with states having heart failure readmission rates that are higher than the U.S. national rate.

PRIMARY PRACTICE SETTING(S)

Acute inpatient hospital settings.

METHODOLOGY AND SAMPLE

50 state-level data and multivariate regression analysis is used. The dependent variable Heart Failure 30-day Readmission Worse than U.S. Rate is based on adult Medicare Fee-for-Service patients hospitalized with a primary discharge diagnosis of heart failure and for which a subsequent inpatient readmission occurred within 30 days of their last discharge.

RESULTS

One key variable found--states with a higher resident population speaking a primary language other than English at home--that is significantly associated with a decrease in probability in states ranking "worse" on heart failure 30-day readmission. Whereas, states with a higher median income, more total days of care per 1,000 Medicare enrollees, and a greater percentage of Medicare enrollees with prescription drug coverage have a greater probability for heart failure 30-day readmission to be "worse" than the U.S. national rate.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case management interventions targeting health literacy may be more effective than other factors to improve state-level hospital status on heart failure 30-day readmission. Factors such as total days of care per 1,000 Medicare enrollees and improving patient access to postdischarge medication(s) may not be as important as literacy. Interventions aimed to prevent disparities should consider higher income population groups as vulnerable for readmission.

The Cancer Message Literacy Tests: psychometric analyses and validity studies

OBJECTIVE

To examine the psychometric properties of two new health literacy tests, and to evaluate score validity.

METHODS

Adults aged 40-71 completed the Cancer Message Literacy Test-Listening (CMLT-Listening), the Cancer Message Literacy Test-Reading (CMLT-Reading), the REALM, the Lipkus numeracy test, a brief knowledge test (developed for this study) and five brief cognitive tests. Participants also self-reported educational achievement, current health, reading ability, ability to understand spoken information, and language spoken at home.

RESULTS

Score reliabilities were good (CMLT-Listening: alpha=.84) to adequate (CMLT-Reading: alpha=.75). Scores on both CMLT tests were positively and significantly correlated with scores on the REALM, numeracy, cancer knowledge and the cognitive tests. Mean CMLT scores varied as predicted according to educational level, language spoken at home, self-rated health, self-reported reading, and self-rated ability to comprehend spoken information.

CONCLUSION

The psychometric findings for both tests are promising. Scores appear to be valid indicators of comprehension of spoken and written health messages about cancer prevention and screening.

PRACTICE IMPLICATIONS

The CMLT-Listening will facilitate research into comprehension of spoken health messages, and together with the CMLT-Reading will allow researchers to examine the unique contributions of listening and reading comprehension to health-related decisions and behaviors.

Pneumonia rehospitalization of the Medicare fee-for-service patient: a state-level analysis: exploring 30-day readmission factors

PURPOSE OF THE STUDY

Pneumonia hospitalization and subsequent readmission among the elderly are frequent and costly both to patient and to the Medicare trust fund. In this study, we explored the factors that are associated with states having pneumonia readmission rates that are higher than the U.S. national rate.

PRIMARY PRACTICE SETTING(S)

Acute inpatient hospital settings.

METHODOLOGY AND SAMPLE

Fifty state-level data and multivariate regression analysis were used. The dependent variable pneumonia 30-day readmission worse than U.S. rate was based on adult Medicare fee-for-service patients hospitalized with a primary discharge diagnosis of pneumonia and for which a subsequent inpatient readmission occurred within 30 days of their last discharge.

RESULTS

Two key variables--discharge information given to the patient and giving correct initial antibiotic(s)--explain a decreased chance for states ranking "worse" on pneumonia 30-day readmission. States with a higher percentage of White Medicare enrollees, a higher median income, more total days of care, and more Medicare enrollees with prescription drug coverage have a greater chance for pneumonia 30-day readmission to be worse than the U.S. national rate.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case management interventions targeting (1) inpatient clinical processes on antibiotic treatment and (2) patient discharge instructions may be more effective than other factors to improve state-level hospital performance on pneumonia 30-day readmission. Improving patient access to postdischarge medication(s) may not be as important a factor as are antibiotic treatment and patient discharge preparedness. Hospital programs aimed to prevent readmission disparities should not overlook nonminority and higher income population groups.

Short Assessment of Health Literacy for Portuguese-speaking Adults

OBJECTIVE

To develop and validate a short health literacy assessment tool for Portuguese-speaking adults.

METHODS

The Short Assessment of Health Literacy for Portuguese-speaking Adults is an assessment tool which consists of 50 items that assess an individual's ability to correctly pronounce and understand common medical terms. We evaluated the instrument's psychometric properties in a convenience sample of 226 Brazilian older adults. Construct validity was assessed by correlating the tool scores with years of schooling, self-reported literacy, and global cognitive functioning. Discrimination validity was assessed by testing the tool's accuracy in detecting inadequate health literacy, defined as failure to fully understand standard medical prescriptions.

RESULTS

Moderate to high correlations were found in the assessment of construct validity (Spearman's coefficients ranging from 0.63 to 0.76). The instrument showed adequate internal consistency (Cronbach's alpha=0.93) and adequate test-retest reliability (intraclass correlation coefficient=0.95). The area under the receiver operating characteristic curve for detection of inadequate health literacy was 0.82. A version consisting of 18 items was tested and showed similar psychometric properties.

CONCLUSIONS

The instrument developed showed good validity and reliability in a sample of Brazilian older adults. It can be used in research and clinical settings for screening inadequate health literacy.

The relationship between literacy and multimorbidity in a primary care setting

BACKGROUND

Multimorbidity is now acknowledged as a research priority in primary care. The identification of risk factors and people most at risk is an important step in guiding prevention and intervention strategies. The aim of this study was to examine the relationship between literacy and multimorbidity while controlling for potential confounders.

METHODS

Participants were adult patients attending the family medicine clinic of a regional health centre in Saguenay (Quebec), Canada. Literacy was measured with the Newest Vital Sign (NVS). Multimorbidity was measured with the Disease Burden Morbidity Assessment (DBMA) by self-report. Information on potential confounders (age, sex, education and family income) was also collected. The association between literacy (independent variable) and multimorbidity was examined in bivariate and multivariate analyses. Two operational definitions of multimorbidity were used successively as the dependent variable; confounding variables were introduced into the model as potential predictors.

RESULTS

One hundred three patients (36 men) 19-83 years old were recruited; 41.8% had completed 12 years of school or less. Forty-seven percent of patients provided fewer than four correct answers on the NVS (possible low literacy) whereas 53% had four correct responses or more. Literacy and multimorbidity were associated in bivariate analyses (p < 0.01) but not in multivariate analyses, including age and family income.

CONCLUSION

This study suggests that there is no relationship between literacy and multimorbidity when controlling for age and family income.

Patients' understanding of prescription instructions in a semi-urban setting in Cameroon

OBJECTIVE

This cross-sectional study investigates the factors associated with patient comprehension of frequently used prescription patterns and explores patients' preferences for the various methods.

METHODS

We interviewed two hundred and four consenting patients selected consecutively from the waiting rooms of the St. Elizabeth Catholic Hospital-Shisong in the north west region of Cameroon. We recorded socio-demographic data and their understanding and preference for four prescription modalities: pictograms, written out, symbols and Latin abbreviations. We studied the relationship between these variables in a logistic multivariate analysis.

RESULTS

Understanding was best with symbols (89.7%) and worst when Latin abbreviations (26.9%) were used. Higher levels of education were associated with better understanding of Latin abbreviations (OR 18.87; 95% CI 2.44-142.86), written out prescriptions (OR 58.82; 95% CI 23.25-333.33), symbols (OR 1.47; 95% CI 4.25-50.00) and pictograms (OR 52.63; 92% CI 1.85-142.86) after controlling for confounding. Participants mostly preferred pictograms (40.7%) and written-out prescriptions (30.9%).

CONCLUSION

Latin abbreviations were the most difficult to understand and should no longer be used. Symbols are more easily understood.

PRACTICE IMPLICATIONS

Latin abbreviations should be discouraged. Symbols are better, especially for patients with low levels of education. Prescribing using pictograms and plain text may facilitate understanding in this setting.

Health information literacy in everyday life: A study of Finns aged 65–79 years

This article examines the health information literacy of elderly Finns. The results are based on a survey conducted in January 2011. The questionnaire was distributed to 1000 persons that were randomly drawn from the Finnish Population Register. The respondents were aged 65–79 years (mean age 70 years) and lived in the Turku region in Finland. A total of 281 questionnaires (28%) were returned. χ2 analyses were used to find possible relationships between demographic factors, as well as interest, seeking activity, current self-rated health and different dimensions of health information literacy, including needs, seeking and use of health-related information. Significant relationships were found between education level, interest in health information, seeking activity, self-rated current health and dimensions of health information literacy. Some categories of elderly people are more vulnerable regarding obtaining and use of health information: those with lower levels of education, those with poor health, and those who are not interested in and active at seeking information. For people who are found in any of these categories, it is important that available health-related information is understandable and can be accessed without too much effort—something that information providers should take into account.

Letramento funcional em saúde: reflexões e conceitos sobre seu impacto na interação entre usuários, profissionais e sistema de saúde

Letramento funcional em saúde (LFS) é o grau pelo qual os indivíduos têm a capacidade para obter, processar e entender informações básicas e serviços necessários para a tomada de decisões adequadas em saúde. O tema preocupa pesquisadores/profissionais da saúde/formuladores de políticas públicas. Sua natureza interdisciplinar, relacional e interacional indica que o LFS sofre a influência dos sistemas de saúde/educacional, mídia, família, ambiente de trabalho/comunidade/decisão política. Analisam-se conceitos de LFS versus interação usuários-profissionais-sistema de saúde, norteando-se pelas questões: Em que consiste o LFS? Em que medida interfere na comunicação entre usuários, profissionais e sistema de saúde? Quais são suas consequências na saúde pública? Medidas para elevação do LFS devem melhorar as competências individuais e serviços de saúde humanizados, aperfeiçoando suas comunicações, escritas/orais, satisfazendo as necessidades/habilidades dos usuários.

The impact of numeracy ability and technology skills on older adults' performance of health management tasks using a patient portal

Patient portals, which allow patients to access their health record via the Internet, are becoming increasingly widespread and are expected to be used by diverse consumer populations. In addition to technology skills, numeracy skills are also likely to be critical to performing health management tasks, as much of the data contained in the portal are numeric. This study examined how factors such as Internet experience, numeracy, and education impacted the performance of common tasks using a simulated patient portal among a sample of older adults. In addition, information was gathered on the ability of older adults to estimate their numeracy skills. Results indicated that numeracy and Internet experience had a significant impact on their ability to perform the tasks and that older adults tended to overestimate their numeracy skills. Results from this study can help to identify interventions that may enhance the usability of patient portals for older adults.

Improving medication management among at-risk older adults

Low health literacy is common among Medicare recipients and affects their understanding of complex medication regimens. Interventions are needed to improve medication use among older adults, while addressing low health literacy. Community-dwelling older adults in this study were enrolled at an inner-city adult day center. They completed a baseline measure of health literacy, medication self-efficacy, and medication adherence. They were provided with a personalized, illustrated daily medication schedule (PictureRx™). Six weeks later, their medication self-efficacy and adherence were assessed. Among the 20 participants in this pilot project, 70% had high likelihood of limited health literacy and took an average of 13.20 prescription medications. Both self-efficacy and medication adherence increased significantly after provision of the PictureRx cards (p < 0.001 and p < 0.05, respectively). All participants rated the PictureRx cards as very helpful in terms of helping them remember the medication's purpose and dosing. Illustrated daily medication schedules improve medication self-efficacy and adherence among at-risk, community-dwelling older adults.

Improving Access to HIV and AIDS Information Resources for Patients, Caregivers, and Clinicians: Results from the SHINE Project

BACKGROUND

Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) remains a significant international public health challenge. The Statewide HIV/AIDS Information Network (SHINE) Project was created to improve HIV/AIDS health information use and access for health care professionals, patients, and affected communities in Indiana.

OBJECTIVE

Our objective was to assess the information-seeking behaviors of health care professionals and consumers who seek information on the testing, treatment, and management of HIV/AIDS and the usability of the SHINE Project's resources in meeting end user needs. The feedback was designed to help SHINE Project members improve and expand the SHINE Project's online resources.

METHODS

A convenience sample of health care professionals and consumers participated in a usability study. Participants were asked to complete typical HIV/AIDS information-seeking tasks using the SHINE Project website. Feedback was provided in the form of standardized questionnaire and usability "think-aloud" responses.

RESULTS

Thirteen participants took part in the usability study. Clinicians generally reported the site to be "very good," while consumers generally found it to be "good." Health care professionals commented that they lack access to comprehensive resources for treating patients with HIV/AIDS. They requested new electronic resources that could be integrated in clinical practice and existing information technology infrastructures. Consumers found the SHINE website and its collected information resources overwhelming and difficult to navigate. They requested simpler, multimedia-content rich resources to deliver information on HIV/AIDS testing, treatment, and disease management.

CONCLUSIONS

Accessibility, usability, and user education remain important challenges that public health and information specialists must address when developing and deploying interventions intended to empower consumers and support coordinated, patient-centric care.

Tailored Information and Automated Reminding to Improve Medication Adherence in Spanish- and English-Speaking Elders Treated for Memory Impairment

Medication adherence is recognized as an issue of critical importance within health care, as many patients do not take their medications as prescribed. This study evaluated two interventions targeted at improving adherence in elderly patients being treated for memory impairments. Twenty-seven participants were randomly assigned to control (n = 11), automated reminding (n = 8), or tailored information conditions (n = 8). Medication adherence was evaluated with an electronic pill bottle. Generalized estimating equation (GEE) models assessed the effects of the interventions on electronically monitored medication adherence after controlling for covariates. Results showed that individuals in both intervention groups had higher levels of medication adherence than those in the control group. The presence of a caregiver was associated with substantially higher levels of adherence. Verbal memory, but not general cognitive status, predicted better adherence. Mood, health literacy, and executive functions were not associated with adherence. Results thus suggest that both automated reminding and tailored information interventions may improve medication adherence in elders, even among those with memory impairments.

Patterns of arthritis medication use in a community sample

BACKGROUND

Although arthritis is disabling, highly prevalent, and often treated without health professional input, little is known about the treatments selected by affected individuals. Such information is important because of the toxicity associated with some arthritis treatments.

OBJECTIVE

To describe the pattern of drug treatment use in a sample of persons with arthritis.

METHOD

The authors distributed an 11-item survey to veterans attending veterans' organization post meetings in southeastern Wisconsin during November and December 2009. Of 32 posts, 26 (81%) returned surveys from 446 persons; survey count and attendance figures suggest that the majority of attendees completed surveys at participating posts. Most respondents were older (75% aged 60 years or older) men (90%). Respondents with arthritis reported whether they had used each of seven drug therapies in the past year.

RESULTS

Almost all members of participating posts responded to the survey, increasing the likelihood that this was a representative sample. Most respondents (290 of 446, 65%) reported having arthritis, which impaired function in 78.6% of them. Most of those with arthritis (252 of 290, 86.9%) had used at least one drug treatment for arthritis in the last year. Acetaminophen use (41.0%) and use of an over-the-counter nonsteroidal anti-inflammatory drug (42.1%) were common. Nonsteroidal anti-inflammatory drug use did not decrease with older age or increase with greater functional impairment.

CONCLUSIONS

Self-medication for arthritis is common and often does not follow clinical guidelines. Efforts to improve the quality of osteoarthritis care that focus solely on health care providers are unlikely to ensure optimal osteoarthritis care.

Assessing health literacy in heart failure patients

BACKGROUND

Health literacy has important implications for health interventions and clinical outcomes. The Shortened Test of Functional Health Literacy in Adults (S-TOFHLA) is a timed test used to assess health literacy in many clinical populations. However, its usefulness in heart failure (HF) patients, many of whom are elderly with compromised cognitive function, is unknown. We investigated the relationship between the S-TOFHLA total score at the recommended 7-minute limit and with no time limit (NTL).

METHODS AND RESULTS

We enrolled 612 rural-dwelling adults with HF (mean age 66.0 ± 13.0 years, 58.8% male). Characteristics affecting health literacy were identified by multiple regression. Percentage of correct scores improved from 71% to 86% (mean percent change 15.1 ± 18.1%) between the 7-minute and NTL scores. Twenty-seven percent of patients improved ≥1 literacy level with NTL scores (P < .001). Demographic variables explained 24.2% and 11.1% of the variance in % correct scores in the 7-minute and the NTL scores, respectively. Female gender, younger age, higher education, and higher income were related to higher scores.

CONCLUSION

Patients with HF may be inaccurately categorized as having low or marginal health literacy when the S-TOFHLA time limits are enforced. New ways to assess health literacy in older adults are needed.

Assembly and insertion of a self-fitting hearing aid: design of effective instruction materials

A self-fitting hearing aid has been proposed as a viable option to meet the need for rehabilitation in areas where audiology services are unreliable. A successful outcome with a self-fitting hearing aid pivots in part on the clarity of the instructions accompanying the device. The aims of this article are (a) to review the literature to determine features that should be incorporated into written health-care materials and factors to consider in the design process when developing written instructions for a target audience of older adults and (b) to apply this information to the development of a set of written instructions as the first step in self-fitting of a hearing aid, assembling four parts and inserting the aid into the ear. The method involved a literature review of published peer reviewed research. The literature revealed four steps in the development of written health-care materials: planning, design, assessment of suitability, and pilot testing. Best practice design principles for each step were applied in the development of instructions for how to assemble and insert a hearing aid. Separate booklets were developed for the left and right aids and the content of each consisted of simple line drawings accompanied by captions. The reading level was Grade 3.5 equivalent and the Flesch Reading Ease Score was 91.1 indicating that the materials were "very easy" to read. It is essential to follow best practice design principles when developing written health-care materials to motivate the reader, maximize comprehension, and increase the likelihood of successful application of the content.

Health literacy associated with blood pressure but not other cardiovascular disease risk factors among dialysis patients

BACKGROUND

Limited health literacy is prevalent and has been linked to adverse patient outcomes. We examined the relationship between health literacy and cardiovascular disease (CVD) risk factors, including blood pressure (BP) parameters, lipids, waist-to-hip ratio (WHR), body mass index (BMI), and tobacco utilization among dialysis patients.

METHODS

We conducted a cross-sectional study of 72 participants in a prospective cohort study of vascular calcification in newly initiated dialysis patients. Health literacy was assessed using the Short Test of Functional Health Literacy (S-TOFHLA) in Adults. The study population was dichotomized into those with and without adequate literacy. Linear and logistic regression analyses were used to predict continuous and dichotomous cardiovascular risk factor variables, respectively.

RESULTS

Twenty-one percent had limited health literacy. Compared to limited health literacy, adequate health literacy was associated with lower BP parameters in multivariable analyses (systolic blood pressure (SBP): β -16.8, s.e. 6.7, P = 0.01; diastolic blood pressure (DBP): β -13.8, s.e. 4.1, P = 0.001; mean arterial pressure (MAP): β -14.8, s.e. 4.6, P = 0.002). Health literacy was not a statistically significant predictor of low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, WHR, BMI, or tobacco utilization.

CONCLUSIONS

Limited health literacy is common in individuals on dialysis. Individuals with adequate health literacy skills had DBP readings that were on average 13.8 mm Hg lower and MAP that was 14.8 mm Hg lower than those with inadequate health literacy. Prospective studies to elucidate if improvements in health literacy skills will lead to improvement in BP control are needed.

Health literacy and self-care of patients with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Today's complex healthcare system relies heavily on sophisticated self-care regimens. To navigate the system and follow self-care protocols, patients must be able to understand and use health information, which requires health literacy. However, nearly 90 million Americans lack the necessary health literacy skills to adequately care for themselves in the face of a complex healthcare system and self-care regimens. Understanding how to effectively care for one's self is thought to improve heart failure symptoms and patient outcomes, but little is actually known about how health literacy influences self-care in patients with heart failure. The purpose of this pilot study was to examine the relationship between health literacy and self-care of patients with heart failure.

SUBJECTS AND METHODS

Patients with a diagnosis of heart failure were recruited from a variety of community settings. Participants completed the Short-Form Test of Functional Health Literacy (measured health literacy), the Self-care Index of Heart Failure (measured self-care maintenance, management, and confidence), and a demographic questionnaire. Spearman ρ correlations were used to assess the strength of the relationship between health literacy level and self-care scores.

RESULTS AND CONCLUSIONS

Among the 49 participants recruited, health literacy was positively related to self-care maintenance (Rs = 0.357, P = .006). Health literacy had a negative relationship with self-care management (Rs = -0.573, P = .001). There was no association between health literacy and self-care confidence (Rs = 0.201, P = .083). This project provides preliminary data regarding the association between health literacy and self-care in heart failure, showing support for higher health-literate patients performing more self-care maintenance, which has been shown to improve patient outcomes in heart failure. Patients with higher health literacy trended toward having greater self-care confidence, which can increase the likelihood of performing self-care, but this finding was not statistically significant. It was unexpected to find that lower health-literate patients performed more self-care management.

Pain Management in the Elderly: An FDA Safe Use Initiative Expert Panel's View on Preventable Harm Associated with NSAID Therapy

Optimization of current pain management strategies is necessary in order to reduce medication risks. Promoting patient and healthcare provider education on pain and pain medications is an essential step in reducing inadequate prescribing behaviors and adverse events. In an effort to raise awareness on medication safety, the FDA has launched the Safe Use Initiative program. The program seeks to identify areas with the greatest amount of preventable harm and help promote new methods and practices to reduce medication risks. Since the establishment of the program, FDA's Safe Use initiative staff convened a panel of key opinion leaders throughout the medical community to address pain management in older adults (≥65 years of age). The aim of the expert panel was to focus on areas where significant risk occurs and where potential interventions will be feasible, implementable, and lead to substantial impact. The panel suggested one focus could be the use of NSAIDs for pain management in the elderly.

Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications

BACKGROUND

Inadequate health literacy is prevalent among seniors and is associated with poor health outcomes. At hospital discharge, medications are frequently changed and patients are informed of these changes via their discharge instructions.

OBJECTIVES

Explore the association between health literacy and medication discrepancies 48 hours after hospital discharge and determine the causes of discharge medication discrepancies.

DESIGN

Face-to-face surveys assessing health literacy at hospital discharge using the short form of the Test of Functional Health Literacy in Adults (sTOFHLA). We obtained the medication lists from the written discharge instructions. At 48 hrs post-discharge, we phoned subjects to assess their current medication regimen, any medication discrepancies, and the causes of the discrepancies.

PARTICIPANTS

Two hundred and fifty-four community-dwelling seniors ≥ 70 years, admitted to acute medicine services for >24 hours at an urban hospital.

RESULTS

Of 254 seniors [mean age 79.3 yrs, 53.1% female], 142 (56%) had a medication discrepancy between their discharge instructions and their actual home medication use 48 hrs after discharge. Subjects with inadequate and marginal health literacy were significantly more likely to have unintentional non-adherence--meaning the subject did not understand how to take the medication [inadequate health literacy 47.7% vs. marginal 31.8% vs. adequate 20.5% p = 0.002]. Conversely, those with adequate health literacy were significantly more likely to have intentional non-adherence--meaning the subject understood the instructions but chose not to follow them as a reason for the medications discrepancy compared with marginal and inadequate health literacy [adequate 73.3% vs. marginal 11.1% vs. inadequate 15.6%, p < 0.001]. Another common cause of discrepancies was inaccurate discharge instructions (39.3%).

CONCLUSION

Seniors with adequate health literacy are more inclined to purposefully not adhere to their discharge instructions. Seniors with inadequate health literacy are more likely to err due to misunderstanding their discharge instructions. Together, these results may explain why previous studies have shown a lack of association between health literacy and overall medication discrepancies.

Relationship between self-reported racial composition of high school and health literacy among community health center patients

Intervention and policy approaches targeting the societal factors that affect health literacy (e.g., educational systems) could have promise to improve health outcomes, but little research has investigated these factors. This study examined the associations between self-reported racial composition of prior educational and neighborhood contexts and health literacy among 1,061 English- and Spanish-speaking adult community health center patients. The authors found that self-reported racial composition of high school was a significant predictor of health literacy among those who received schooling in the United States, controlling for race/ethnicity, education, age, country of birth, and survey language. Black and Hispanic patients had significantly lower health literacy than White patients within educational strata among those schooled in the United States. The findings revealed substantial disparities in health literacy. Self-reported racial composition of school context was a significant predictor of health literacy. Transdisciplinary, multilevel intervention approaches are likely to be needed to address the health literacy needs of this population.

A validation study of the spoken knowledge in low literacy in diabetes scale (SKILLD)

BACKGROUND

In 2005 the Spoken Knowledge in Low Literacy in Diabetes scale (SKILLD) was introduced as a diabetes knowledge test. The SKILLD has not been validated since its introduction.

OBJECTIVE

To perform a validation analysis on the SKILLD.

DESIGN AND PARTICIPANTS

Cross-sectional observational study of 240 patients with diabetes at an academic family practice center.

MAIN MEASURES

SKILLD's correlation with an oral form of the Diabetes Knowledge Test (DKT) was used to assess criterion validity. A regression model tested construct validity, hypothesizing that SKILLD score was independently related to health literacy and education level. Content validity was tested using Cronbach's Alpha for inter-item relatedness and by comparing SKILLD items with the content of a National Institutes of Health (NIH) diabetes education website. We assessed inter-rater reliability and bias using Spearman correlation coefficients and sign-rank tests between interviewers scoring the same interview.

KEY RESULTS

The SKILLD demonstrated fair correlation with the DKT (Pearson's coefficient 0.54, 95% CI=0.49 to 0.66, p<0.001). Health literacy, education level, male gender, household income, and years with diabetes were independent predictors of SKILLD score in the regression model. Cronbach's Alpha for inter-item relatedness was 0.54. There were some topics on the NIH website not addressed by the SKILLD. The inter-rater correlation coefficient was 0.79 (95% CI 0.56 to 0.91, p<0.001).

CONCLUSIONS

The SKILLD is an adequate diabetes knowledge test and is appropriate for people of all literacy levels. However, it should be expanded to more completely evaluate diabetes knowledge.

Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in hospitalized patients

Heart failure (HF) patients with inadequate health literacy are at increased risk for poor self-care and negative health outcomes such as hospital readmission. The purpose of the present study was to examine the prevalence of inadequate health literacy, the reliability of the Dutch HF Knowledge Scale (DHFKS) and the Self-care of Heart Failure Index (SCHFI), and the differences in HF knowledge, HF self-care, and 30-day readmission rate by health literacy level among patients hospitalized with HF. The convenience sample included adults (n = 95) admitted to a large, urban, teaching hospital whose primary diagnosis was HF. Measures included the Short Test of Functional Health Literacy in Adults, the DHFKS, the SCHFI, and readmission at 30 days after discharge. The sample was 59 ± 14 years in age, 51% male, and 67% African American; 35% had less than a high school education, 35% were employed, 73% lived with someone who helps with their HF care, and 16% were readmitted within 30 days of index admission. Health literacy was inadequate for 42%, marginal for 19%, and adequate for 39%. Reliability of the DHFKS and SCHFI scales was comparable to prior reports. Mean knowledge score was 11.43 ± 2.26; SCHFI subscale scores were 56.82 ± 17.12 for maintenance, 63.64 ± 18.29 for management, and 65.02 ± 16.34 for confidence. Those with adequate health literacy were younger and had higher education level, HF knowledge scores, and HF self-care confidence compared with those with marginal or inadequate health literacy. Self-care maintenance and management scores and 30-day readmission rate did not differ by health literacy level. These findings demonstrate the high prevalence of inadequate and marginal health literacy and that health literacy is an important consideration in promoting HF knowledge and confidence in self-care behaviors, particularly among older adults and those with less than a high school education.

Home monitoring for heart failure management

With a prevalence of 5.8 million in the United States alone, heart failure (HF) is a common syndrome associated with substantial morbidity, mortality, and healthcare expenditures. Close to 1 million HF hospitalizations occur annually in the United States, with the majority of these resulting from worsening congestion in patients previously diagnosed with HF. An estimated $37.2 billion is spent each year on HF in the United States. These statistics emphasize the need to develop and implement more effective strategies to assess, monitor, and treat HF. It has also become increasingly apparent that interventions geared toward identifying and monitoring subclinical congestion would be of value in the home management of chronic HF. Earlier identification and treatment of congestion together with improved care coordination, management of comorbid conditions, and enhanced patient self-management may help to prevent hospitalizations in patients with chronic HF. Such home monitoring extends from the promotion of self-care and home visitations to telemedicine and remote monitoring of external or implantable devices. This paper discusses the challenges in monitoring patients with HF, reviews clinical trials testing different monitoring strategies in HF, and highlights ongoing investigations into the optimal approaches to home monitoring for HF.

Using basic ethical principles to evaluate safety efforts in transfusion medicine

Pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. Decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety and availability of blood transfusion. Regulations have been formulated by governmental agencies with limited input from the medical community. The decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. Policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. Being guided by the ethical principles of nonmaleficence, beneficence, autonomy, and justice, we need to evaluate our actions in the context of overall blood safety rather than narrowly focusing on any one area.

Measurement variation across health literacy assessments: implications for assessment selection in research and practice

National priorities and recent federal initiatives have brought health literacy to the forefront in providing safe accessible care. Having valid and reliable health literacy measures is a critical factor in meeting patients' health literacy needs. In this study, the authors examined variation across three brief health literacy instruments in categorizing health literacy levels and identifying associated factors. The authors screened 378 veterans using the short form of the Test of Functional Health Literacy in Adults; the Rapid Estimate of Adult Literacy in Medicine; and a 4-Item Brief Health Literacy Screening Tool (known as the BRIEF). They analyzed data using prevalence estimates, Pearson product moment correlations, and logistic regression. When categorizing individuals' health literacy, agreement among instruments was present for 37% of the sample. There were consistencies; however, categorization and estimated risk factors varied by instrument. Depending on instrument, increased age, low education, minority status, and self-reported poor reading level were associated with low health literacy. Findings suggest that these instruments measure health literacy differently and are likely conceptually different. As the use of health literacy screening gains momentum, alignment between instrument and intended purpose is essential; in some cases, multiple instruments may be appropriate. When selecting an instrument, one should consider style of administration, purpose for measure, and availability of time and resources.

Limited health literacy is a common finding in a public health hospital's rheumatology clinic and is predictive of disease severity

BACKGROUND

Health literacy (HL) is associated with outcomes in many conditions, but little is known about its impact on arthritic diseases.

OBJECTIVES

We sought to determine whether HL is related to disease activity and severity in patients with rheumatoid arthritis (RA).

METHODS

English-speaking adult RA patients were recruited for this cross-sectional study. Background information was ascertained by medical record review; Disease Activity Score 28 (DAS-28) scores were determined by providers; subjects completed the Multidimensional Health Assessment Questionnaire (MDHAQ), demographic questionnaires, and validated HL instruments, including the Short Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and the single-item literacy screener. We used linear regression to assess whether HL was associated with MDHAQ and DAS-28 scores.

RESULTS

One hundred ten subjects participated in the study. Limited HL was a common finding, especially among ethnic minorities. The single-item literacy screener results were predictive of lower MDHAQ scores by univariate regression analysis. Similar trends were observed for the Short Test of Functional Health Literacy in Adults and Rapid Estimate of Adult Literacy in Medicine. The relationship between the single-item literacy screener and MDHAQ remained statistically significant in multivariate analysis that controlled for the impact of demographic features and RA disease characteristics. Health literacy scores were not associated with DAS-28 scores.

CONCLUSIONS

Health literacy was independently associated with functional impairment in English-speaking RA patients at an urban safety-net clinic. This new finding suggests that RA functional status might be improved by strategies that target limited HL's causal pathways.

Online health information seeking: the influence of age, information trustworthiness, and search challenges

OBJECTIVE

The Internet holds great potential to support information gathering and decision making surrounding health education and self-care. Older adults, however, underutilize the Internet for health information searches relative to younger adults. The goal of the present study was to examine age differences in the role of trust and ease of search in predicting whether or not individuals use (adopters) or do notuse (nonadopters) the Internet to search for health information.

METHOD

We used logistic regressions todetermine whether there were age differences in the extent to which trust and ease of search predicted online health information searches within a nationally-representative sample of 3796 adults from the Health Information National Trends Survey (HINTS).

RESULTS

Adopters were more trusting of Internet health informationthan nonadopters. However, a significant age by trust interaction indicated that this difference increased in magnitude with age, a pattern that held even after controlling for demographic and health variables.

CONCLUSIONS

Older adults may benefit from special instructions designed to boost Internet trust, for example, learning how to distinguish between high and low quality health-related websites.

The influence of sociocultural factors on colonoscopy and FOBT screening adherence among low-income Hispanics

Few studies have examined barriers and facilitators to colorectal cancer (CRC) screening among Hispanics, particularly sociocultural factors that may be relevant. This paper examines the influence of sociocultural factors on adherence to fecal occult blood testing (FOBT) and colonoscopy. A survey was conducted among a sample of 400 low-income Hispanics in East Harlem, New York. Fatalism and health literacy were both significantly associated with colonoscopy screening adherence in bivariate models, though fatalism became non-significant and health literacy became less significant in multivariable models. With respect to adherence to colonoscopy or FOBT, both fatalism and health literacy were associated in bivariate models, though only fatalism remained significant in multivariable models (p=.03; OR: .94; 95% CI: .881-.992). These findings suggest fatalism and health literacy may play a role in shaping CRC screening adherence among low-income Hispanics. Researchers should continue investigating how sociocultural factors influence screening adherence among Hispanics, using larger and more geographically diverse samples.