The talking touchscreen: a new approach to outcomes assessment in low literacy

Improving the Implementation of Patient-Reported Outcome Measure in Clinical Practice: Tackling Current Challenges With Innovative Digital Communication Technologies

Implementation of patient-reported outcome measures (PROMs) in clinical practice is challenging. We believe effective communication is key to realizing the clinical benefits of PROMs. Communication processes for PROMs in clinical practice typically involve (1) health care professionals (HCPs) inviting patients to complete PROMs, (2) patients completing PROMs, (3) HCPs and patients interpreting the resulting patient-reported outcomes (PROs), and (4) HCPs and patients using PROs for health management. Yet, communication around PROMs remains underexplored. Importantly, patients differ in their skills, knowledge, preferences, and motivations for completing PROMs, as well as in their ability and willingness to interpret and apply PROs in managing their health. Despite this, current communication practices often fail to account for these differences. This paper highlights the importance of personalized communication to make PROMs accessible to diverse populations. Personalizing communication manually is highly labor-intensive, but several digital technologies can offer a feasible solution to accommodate various patients. Despite their potential, these technologies have not yet been applied to PROMs. We explore how existing principles and tools, such as automatic data-to-text generation (including multimodal outputs like text combined with data visualizations) and conversational agents, can enable personalized communication of PROMs in practice.

Are quality of care instruments inclusive of older people living with dementia? A scoping review in long-term care settings

More than half of older people in long-term care facilities have dementia. Little is currently known about the methods and instruments which can be used to capture the perspectives of older people, including those with dementia, regarding the quality of care provided in such facilities. The main aims of this scoping review were two-fold. Firstly, to identify quality of care instruments that have been applied in long-term care settings. Secondly, to evaluate how these instruments have been developed and validated, particularly in terms of their applicability among older people with dementia. Seven databases (Medline, Web of Science, Scopus, ProQuest, Ageline, CINHAL and google scholar) were searched for relevant literature without any date limit. We used quality criteria adapted from COSMIN (Consensus-based Standards for the selection of health status Measurement Instruments) guidelines to assess the psychometric properties of the instruments. The search identified 16 quality of care instruments which had been used in long-term care settings. Of which, two (12.5%) were specifically designed for older people with dementia, and three instruments (18.7%) were modified for use with older people with mild to moderate dementia. A variety of methods were used to develop the identified instruments including literature reviews, qualitative interviews, expert panel reviews, pre-testing and piloting with older people. None of the identified instruments had been subjected to comprehensive psychometric assessment. Most instruments for assessing quality of care in long term care settings lack alternative communication techniques tailored to people with dementia. This review highlights the need for more rigorous psychometric testing of existing instruments for assessing quality of care in long-term care settings. Several existing measures show promise and may be taken forward for further testing and development for widespread application with older people, including those living with dementia, in long term care settings.

Publishing clinical trial results in plain language: a clash of ethical principles?

Plain language resources (PLR) are lay summaries of clinical trial results or plain language summaries of publications, in digital/visual/language formats. They aim to provide accurate information in jargon-free, and easy-to-understand language that can meet the health information needs of the general public, especially patients and caregivers. These are typically developed by the study sponsors or investigators, or by national public health bodies, research hospitals, patient organizations, and non-profit organizations. While the usefulness of PLR seems unequivocal, they have never been analyzed from the perspective of ethics. In this commentary, we do so and reflect on whether PLR are categorically advantageous or if they solve certain issues but raise new problems at the same time. Ethical concerns that PLR can potentially address include but are not limited to individual and community level health literacy, patient empowerment and autonomy. We also highlight the ethical issues that PLR may potentially exacerbate, such as fair balanced presentation and interpretation of medical knowledge, positive publication bias, and equitable access to information. PLR are important resources for patients, with promising implications for individual as well as community health. However, they require appropriate oversight and standards to optimize their potential value. Hence, we also highlight recommendations and best practices from our reading of the literature, that aim to minimize these biases.

A scoping review of the use of visual tools and adapted easy-read approaches in Quality-of-Life instruments for adults

PURPOSE

Self-Reporting using traditional text-based Quality-of-Life (QoL) instruments can be difficult for people living with sensory impairments, communication challenges or changes to their cognitive capacity. Adapted communication techniques, such as Easy-Read techniques, or use of pictures could remove barriers to participation for a wide range of people. This review aimed to identify published studies reporting adapted communication approaches for measuring QoL, the methodology used in their development and validation among adult populations.

METHODS

A scoping review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews checklist was undertaken.

RESULTS

The initial search strategy identified 13,275 articles for screening, with 264 articles identified for full text review. Of these 243 articles were excluded resulting in 21 studies for inclusion. The majority focused on the development of an instrument (12 studies) or a combination of development with some aspect of validation or psychometric testing (7 studies). Nineteen different instruments were identified by the review, thirteen were developed from previously developed generic or condition-specific quality of life instruments, predominantly aphasia (7 studies) and disability (4 studies). Most modified instruments included adaptations to both the original questions, as well as the response categories.

CONCLUSIONS

Studies identified in this scoping review demonstrate that several methods have been successfully applied e.g. with people living with aphasia post-stroke and people living with a disability, which potentially could be adapted for application with more diverse populations. A cohesive and interdisciplinary approach to the development and validation of communication accessible versions of QOL instruments, is needed to support widespread application, thereby reducing reliance on proxy assessors and promoting self-assessment of QOL across multiple consumer groups and sectors.

Implementing patient-reported outcomes in routine clinical care for diverse and underrepresented patients in the United States

BACKGROUND

Patient-reported outcomes (PROs) are used increasingly in routine clinical care and inform policies, reimbursements, and quality improvement. Less is known regarding PRO implementation in routine clinical care for diverse and underrepresented patient populations.

OBJECTIVE

This review aims to identify studies of PRO implementation in diverse and underrepresented patient populations, elucidate representation of clinical specialties, assess implementation outcomes, and synthesize patient needs, concerns, and preferences.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched September 2021 for studies aiming to study PRO implementation in diverse and underrepresented patient populations within the United States. Studies were screened and data extracted by three independent reviewers. Implementation outcomes were assessed according to Proctor et al. taxonomy. A descriptive analysis of data was conducted.

RESULTS

The search yielded 8,687 records, and 28 studies met inclusion criteria. The majority were observational cohort studies (n = 21, 75%) and conducted in primary care (n = 10, 36%). Most studies included majority female (n = 19, 68%) and non-White populations (n = 15, 54%), while fewer reported socioeconomic (n = 11, 39%) or insurance status (n = 9, 32.1%). Most studies assessed implementation outcomes of feasibility (n = 27, 96%) and acceptability (n = 19, 68%); costs (n = 3, 11%), penetration (n = 1, 4%), and sustainability (n = 1, 4%) were infrequently assessed.

CONCLUSION

PRO implementation in routine clinical care for diverse and underrepresented patient populations is generally feasible and acceptable. Research is lacking in key clinical specialties. Further work is needed to understand how health disparities drive PRO implementation outcomes.

Developing a protocol for adapting multimedia patient-reported outcomes measures for low literacy patients

BACKGROUND

Self-administration of patient-reported outcomes measures (PROMs) by patients with low literacy is a methodologic and implementation challenge. There is an increasing emphasis on patient-centered care and wider adoption of PROMs to understand outcomes and measure healthcare quality. However, there is a risk that the use of PROMs could perpetuate health disparities unless they are implemented in an inclusive fashion. We present a protocol to adapt validated, text-based PROMs to a multimedia format (mPROMs) to optimize self-administration in populations with limited literacy. We describe the processes used to develop the protocol and the planned protocol implementation.

METHODS/DESIGN

Our study protocol development was guided by the International Quality of Life Assessment (IQOLA) protocol for translating and culturally adapting PROMs to different languages. We used the main components of IQOLA's protocol to generate a conceptual framework to guide development of a Multimedia Adaptation Protocol (MAP). The MAP, which incorporates human-centered design (HCD) and takes a community-engaged research approach, includes four stages: forward adaptation, backward adaptation, qualitative evaluation, and validation. The MAP employs qualitative and quantitative methods including observation, cognitive and discovery interviews, ideation workshops, prototyping, user testing, co-creation interviews, and psychometric testing. An iterative design is central to the MAP and consistent with both the IQOLA protocol and HCD processes. We will pilot test and execute the MAP to adapt the Patient Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Short Form for use in a mixed literacy hand and upper extremity patient population in Baltimore, Maryland.

DISCUSSION

The MAP provides an approach for adapting PROMs to a multimedia format. We encourage others to evaluate and test this approach with other questionnaires and patient populations. The development and use of mPROMs has the potential to expand our ability to accurately capture PROs in limited literacy populations and promote equity in PRO measurement.

A Low Literacy, Multimedia Health Information Technology Intervention to Enhance Patient-Centered Cancer Care in Safety Net Settings Increased Cancer Knowledge in a Randomized Controlled Trial

We tested whether a low-literacy-friendly, multimedia information and assessment system used in daily clinical practice enhanced patient-centered care and improved patient outcomes. This was a prospective, parallel-group, randomized controlled trial with 2 arms, CancerHelp-Talking Touchscreen (CancerHelp-TT) versus control, among adults with Stage I-III breast or colorectal cancer receiving chemotherapy and/or radiation therapy in safety net settings. Each patient was assessed for outcomes at 4 timepoints: after starting treatment (baseline), during treatment, immediately after treatment, and at follow-up assessment. The primary outcomes were health beliefs, cancer knowledge, self-efficacy, and satisfaction with communication about cancer and its treatments. Health-related quality of life (HRQOL) was a secondary outcome. A total of 129 patients participated in the study (65 intervention and 64 control), and approximately 50% of these completed the study. Patients randomized to receive the CancerHelp-TT program had a significantly larger increase in their cancer knowledge in comparison to those randomized to the control arm (effect size = .48, P = .05). While effect sizes for differences between randomized groups in self-efficacy, health beliefs, HRQOL, and satisfaction with communication were small (.10-.48), there was a consistent trend that participants in the intervention group showed larger increases over time in all outcomes compared to the control group. The CancerHelp-TT software was favorably rated by intervention participants. The CancerHelp-TT program showed promise to increase vulnerable cancer patients' cancer knowledge and adaptive health beliefs and attitudes. However, vulnerable patients may need additional interventional support in settings outside cancer clinics.

Gerontechnological factors affecting successful aging of elderly

In this article, the gerontological factors affecting the successful aging of the elderly have been uncovered, the quality of life and successful aging issues have been related to gerontology and investigated on a different dimension. It has been emphasized that the importance of gerontechnology on the successful aging, creation of awareness through formal and non-formal education, qualitative and quantitative researches should be increased. Qualitative and quantitative researches on the subject were evaluated together, gerontology and gerontechnology were considered together with successful aging, and gerontology functions and ergonomics should be taken into consideration in increasing quality of life. In addition, the concept of geronsafety, a new concept in gerontology, has been put forward, emphasizing the effects of safety on gerontology and successful aging.

Secondary care provider attitudes towards patient generated health data from smartwatches

Wearable devices, like smartwatches, are increasingly used for tracking physical activity, community mobility, and monitoring symptoms. Data generated from smartwatches (PGHD_SW) is a form of patient-generated health data, which can benefit providers by supplying frequent temporal information about patients. The goal of this study was to understand providers' perceptions towards PGHD_SW adoption and its integration with electronic medical records. In-depth, semi-structured qualitative interviews were conducted with 12 providers from internal medicine, family medicine, geriatric medicine, nursing, surgery, rehabilitation, and anesthesiology. Diffusion of Innovations was used as a framework to develop questions and guide data analysis. The constant comparative method was utilized to formulate salient themes from the interviews. Four main themes emerged: (1) PGHD_SW is perceived as a relative advantage; (2) data are viewed as compatible with current practices; (3) barriers to overcome to effectively use PGHD_SW; (4) assessments from viewing sample data. Overall, PGHD_SW was valued because it enabled access to information about patients that were traditionally unattainable. It also can initiate discussions between patients and providers. Providers consider PGHD_SW important, but data preferences varied by specialty. The successful adoption of PGHD_SW will depend on tailoring data, frequencies of reports, and visualization preferences to correspond with the demands of providers.

Implementation of the PROMIS-29 in Routine Care for People With Diabetes: Challenges and Opportunities

Using patient-reported outcome measures (PROMs) in care planning has the potential to improve care, but information about routine implementation in settings serving disadvantaged groups is needed. Two primary care clinics serving populations predominantly eligible for Medicaid and diverse in race/ethnicity implemented the PROMIS-29 as part of clinical care planning. Of the target population with diabetes, 26% (n = 490) completed the PROMs; the proportion that set a goal based on the PROMs differed by site. This report describes factors influencing the PROMs process and the results of interviews with patients and members of the care team about PROMs' implementation and impact.

Implementing Patient-Reported Outcome Measures in Clinical Breast Cancer Care: A Systematic Review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly being used to improve care delivery and are becoming part of routine clinical practice.

OBJECTIVE

This systematic review aims to give an overview of PROM administration methods and their facilitators and barriers in breast cancer clinical practice.

METHODS

A systematic literature search was conducted in Embase, MEDLINE, PsycINFO, Cochrane Central, CINAHL, and Web of Science for potentially relevant articles from study inception to November 2017. Reference lists of screened reviews were also checked. After inclusion of relevant articles, data were extracted and appraised by 2 investigators.

RESULTS

A total of 2311 articles were screened, of which 34 eligible articles were ultimately included. Method and frequency of PROM collection varied between studies. The majority of studies described a promising effect of PROM collection on patients (adherence, symptom distress, quality of life, acceptability, and satisfaction), providers (willingness to comply, clinical decision making, symptom management), and care process or system outcomes (referrals, patient-provider communication, hospital visits). A limited number of facilitators and barriers were identified, primarily of a technical and behavioral nature.

CONCLUSION

Although interpreting the impact of PROM collection in breast cancer care is challenging owing to considerations of synergistic (multicomponent) interventions and generalizability issues, this review found that systematic PROM collection has a promising impact on patients, providers, and care processes/ systems. Further standardization and reporting on method and frequency of PROM collection might help increase the effectiveness of PROM interventions and is warranted to enhance their overall impact.

A Mobile Patient-Reported Outcome Measure App With Talking Touchscreen: Usability Assessment

Background

In the past years, a mobile health (mHealth) app called the Dutch Talking Touch Screen Questionnaire (DTTSQ) was developed in The Netherlands. The aim of development was to enable Dutch physical therapy patients to autonomously complete a health-related questionnaire regardless of their level of literacy and digital skills.

Objective

The aim of this study was to evaluate the usability (defined as the effectiveness, efficiency, and satisfaction) of the prototype of the DTTSQ for Dutch physical therapy patients with diverse levels of experience in using mobile technology.

Methods

The qualitative Three-Step Test-Interview method, including both think-aloud and retrospective probing techniques, was used to gain insight into the usability of the DTTSQ. A total of 24 physical therapy patients were included. The interview data were analyzed using a thematic content analysis approach aimed at analyzing the accuracy and completeness with which participants completed the questionnaire (effectiveness), the time it took the participants to complete the questionnaire (efficiency), and the extent to which the participants were satisfied with the ease of use of the questionnaire (satisfaction). The problems encountered by the participants in this study were given a severity rating that was used to provide a rough estimate of the need for additional usability efforts.

Results

All participants within this study were very satisfied with the ease of use of the DTTSQ. Overall, 9 participants stated that the usability of the app exceeded their expectations. The group of 4 average-/high-experienced participants encountered only 1 problem in total, whereas the 11 little-experienced participants encountered an average of 2 problems per person and the 9 inexperienced participants an average of 3 problems per person. A total of 13 different kind of problems were found during this study. Of these problems, 4 need to be addressed before the DTTSQ will be released because they have the potential to negatively influence future usage of the tool. The other 9 problems were less likely to influence future usage of the tool substantially.

Conclusions

The usability of the DTTSQ needs to be improved before it can be released. No problems were found with satisfaction or efficiency during the usability test. The effectiveness needs to be improved by (1) making it easier to navigate through screens without the possibility of accidentally skipping one, (2) enabling the possibility to insert an answer by tapping on the text underneath a photograph instead of just touching the photograph itself, and (3) making it easier to correct wrong answers. This study shows the importance of including less skilled participants in a usability study when striving for inclusive design and the importance of measuring not just satisfaction but also efficiency and effectiveness during such studies.

Interviewer- versus self-administration of PROMIS® measures for adults with traumatic injury

OBJECTIVE

To assess differential item functioning and observed mean differences across two modes of administration for PROMIS® measure scores in a sample of adults with traumatic injury.

METHOD

Items from 7 PROMIS® adult measures (v1.0 Physical Function, Fatigue, Pain Interference, Anger, Anxiety, and Depression and v2.0 Social Health-Emotional Support) were administered as fixed-length short forms in random order to a cross-sectional sample. Participants were randomly assigned to interviewer-administered (phone or in-person) or self-administered (via the Assessment Center website) conditions. The research was conducted at 5 medical rehabilitation institutions across the U.S. Participants included 277 adults with spinal cord injury (n = 148) or traumatic brain injury (n = 129).

RESULTS

DIF analyses indicated that all items were invariant to mode of administration. There was no significant effect of mode of administration for the majority of PROMIS® measures tested. Regarding observed scores, there were small but significant effects of mode of administration on the Emotional Support and Depression measures, with participants in the interview condition reporting better support/fewer symptoms.

CONCLUSIONS

PROMIS® instruments demonstrated measurement equivalence across interviewer-administered and self-administered conditions. These findings are particularly important for research or clinical applications where administration of PROMIS® measures by independent web- or tablet-based administration is not ideal, for example with individuals with physical or cognitive disabilities or with individuals who lack computer and/or Internet access. PROMIS® v1.0 Depression and PROMIS® v2.0 Emotional Support scores displayed a tendency toward social desirability that should be considered when these measures are interviewer-administered. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Try to see it my way: exploring the co-design of visual presentations of wellbeing through a workshop process

AIMS

A 10-month project funded by the NewMind network sought to develop the specification of a visualisation toolbox that could be applied on digital platforms (web- or app-based) to support adults with lived experience of mental health difficulties to present and track their personal wellbeing in a multi-media format.

METHODS

A participant co-design methodology, Double Diamond from the Design Council (Great Britain), was used consisting of four phases: Discover - a set of literature and app searches of wellbeing and health visualisation material; Define - an initial workshop with participants with lived experience of mental health problems to discuss wellbeing and visualisation techniques and to share personal visualisations; Develop - a second workshop to add detail to personal visualisations, for example, forms of media to be employed, degree of control over sharing; and Deliver - to disseminate the learning from the exercise.

RESULTS

Two design workshops were held in December 2017 and April 2018 with 13 and 12 experts-by-experience involved, respectively, including two peer researchers (co-authors) and two individual-carer dyads in each workshop, with over 50% of those being present in both workshops. A total of 20 detailed visualisations were produced, the majority focusing on highly personal and detailed presentations of wellbeing.

DISCUSSION

While participants concurred on a range of typical dimensions of wellbeing, the individual visualisations generated were in contrast to the techniques currently employed by existing digital wellbeing apps and there was a great diversity in preference for different visualisation types. Participants considered personal visualisations to be useful as self-administered interventions or as a step towards seeking help, as well as being tools for self-appraisal.

CONCLUSION

The results suggest that an authoring approach using existing apps may provide the high degree of flexibility required. Training on such tools, delivered via a module on a recovery college course, could be offered.

Investigation of a multimedia, computer-based approach to improve knowledge, attitudes, self-efficacy, and receptivity to cancer clinical trials among newly diagnosed patients with diverse health literacy skills

BACKGROUND

Enrollment in therapeutic cancer trials remains low, and is especially challenging for patients with low health literacy. The authors tested an interactive technology designed for patients with diverse health literacy skills with the aim of improving patient receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials.

METHODS

Patients presenting for their first oncology appointment were eligible. Patients viewed an interactive teaching video concerning clinical trials that was adapted from the National Institutes of Health. Validated surveys assessing receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials were administered before and after the test.

RESULTS

A total of 120 patients with cancer were enrolled. Approximately 80% were non-Hispanic white, 33% were female, 69% had >high school education, and 8% reported an income <$20,000. Approximately 33% scored within the low health literacy range. Changes between pretest and posttest demonstrated increases in knowledge (P < .001), self-efficacy (P < .001), and positive beliefs (P = .004); a slight decrease in willingness (P = .009); and no difference in patient receptivity (P = .31). Higher health literacy was associated with improved willingness (P = .049) and non-Hispanic white race was associated with improved receptivity (P = .034).

CONCLUSIONS

Interactive technology that was designed for patients with diverse health literacy skills demonstrated the ability to improve knowledge, self-efficacy, and positive beliefs regarding cancer clinical trials. Contrary to the hypothesis of the current study, patients with lower health literacy did not appear to derive a greater advantage from this technology. There was no improvement noted with regard to patient willingness or receptivity, and clinical trial enrollment remained at historical institutional levels. Talking touchscreen technology has a potential role as an important element in informed decision making for patients, but likely needs to be coupled with more robust and multitargeted interventions.

Survey response burden in caregivers of civilians and service members/veterans with traumatic brain injury

PURPOSE

Caregivers have expressed interest in survey research, yet there is limited information available about survey response burden, ie, the time, effort, and other demands needed to complete the survey. This may be particularly important for caregivers due to excessive time demands and/or stress associated with caregiving.

METHOD

Survey response burden indicators were collected as part of a study to develop and validate a patient-reported outcome (PRO) measurement system for caregivers of civilians or service members/veterans (SMVs) with traumatic brain injury (TBI).

RESULTS

Compared to the group caring for civilians (n=335), the group caring for SMVs (n=123) was comprised of all women, was younger, had fewer racial/ethnic minorities, had more education, and nearly all were the spouse of a person with TBI. All PRO outcomes were poorer for the group caring for SMVs. Although the caregivers of SMVs had poorer PRO outcomes compared to caregivers of civilians, they were more likely to report that they would recommend the study to others. Caregivers with less education and those from racial/ethnic minority groups had more favorable ratings of their study participation experience, even though they needed more help using the computer or answering the questions.

CONCLUSION

The results of this study provide useful information about the acceptability of computer-based survey administration for caregiver PROs. PROs are widely gathered in clinical and health services research and could be particularly useful in TBI care programs. More data are needed to determine the best assessment strategies for individuals with lower education who are likely to require some assistance completing PRO surveys. Studies evaluating PROs administered by multimedia platforms could help researchers and clinicians plan the best strategies for assessing health-related quality of life in TBI caregivers.

Translation, psychometric validation, and baseline results of the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric measures to assess health-related quality of life of patients with pediatric lymphoma in Malawi

INTRODUCTION

Internationally validated tools to measure patient-reported health-related quality of life (HRQoL) are available, but efforts to translate and culturally validate such tools in sub-Saharan Africa (SSA) are scarce, particularly among children.

METHODS

The Patient-Reported Outcomes Measurement Information System 25-item pediatric short form (PROMIS-25) assesses six HRQoL domains-mobility, anxiety, depression, fatigue, peer relationships, and pain interference-by asking four questions per domain. There is a single-item pain intensity item. The PROMIS-25 was translated into Chichewa and validated for use in Malawi using mixed qualitative and quantitative methods. The validity and reliability of the PROMIS-25 was assessed.

RESULTS

Fifty-four pediatric patients with lymphoma completed the PROMIS-25. Structural validity was supported by interitem correlations and principal component analysis. Reliability of each scale was satisfactory (range alpha = 0.71-0.93). Known group validity testing showed that anemic children had worse fatigue (P = 0.016) and children with poor performance status had worse mobility (P < 0.001) and pain interference (P = 0.005). Compared to children with cancer in the United States, children from Malawi reported lower levels of mobility, higher anxiety, higher depressive symptoms, higher fatigue, better satisfaction with peer relationships, and higher pain interference.

CONCLUSION

Translation and cultural validation of the PROMIS-25 into Chichewa for Malawi was successful. Baseline HRQoL for patients with pediatric lymphoma in Malawi is poor for all domains except peer relationships. This emphasizes an urgent need to address HRQoL among children undergoing cancer treatment in SSA using self-reported instruments validated within the local context.

Understanding the need for assistance with survey completion in people with Huntington disease

PURPOSE

In Huntington disease (HD), motor, cognitive, and psychiatric changes can have a detrimental impact on health-related quality of life (HRQOL). The purpose of this paper is to describe the extent and type of assistance needed to complete online HRQOL surveys, and the impact of assistance on HRQOL scores.

METHODS

A patient-reported outcome measurement system was developed for HD-specific HRQOL. Individuals across the prodromal and diagnosed disease severity spectrum (n = 532) completed surveys by computer, and reported the amount and type of assistance they received.

RESULTS

Some participants (n = 56; 10.5%) did not complete all surveys; this group had larger proportions with late stage disease, racial/ethnic minority status, low education and single marital status, and poorer motor, independence and cognitive function compared to those who completed all surveys (n = 476). Overall, 72% of individuals did not receive assistance, 11% received computer assistance only, and 17% received assistance answering the survey questions. The majority of late stage individuals (78%) received some assistance compared to early stage (29%) and prodromal individuals (< 1%). Those who received assistance had higher proportions with late stage disease, were older, had less education, and had poorer functional and cognitive skills. Before and after adjustment for sociodemographic and clinical characteristics, those who received assistance had poorer scores on some HRQOL outcomes than those who did not receive assistance.

CONCLUSIONS

Computer-based assessments are feasible for many persons with HD, although other methods may also be needed. Clinicians and researchers should develop strategies to assist people with HD to complete HRQOL surveys.

A Qualitative Investigation to Underpin the Development of an Electronic Tool to Assess Nutrition Literacy in Australians Adults

Nutrition literacy is linked to health via its influence on dietary intake. There is a need for a tool to assess nutrition literacy in research and dietetic practice. We sought guidance from nutrition professionals on topic areas and features of an electronic nutrition literacy assessment tool for Australian adults. 28 experienced nutrition professionals engaged in a range of nutrition and dietetic work areas participated in six focus groups using a semi-structured interview schedule. Data were analysed using an inductive approach using NVivo 10 (QSR International, Pty Ltd., Doncaster, Australia, 2012). Key areas identified to assess nutrition literacy included specific nutrients versus foods, labels and packaging, construction of the diet, knowledge of the Australian Dietary Guidelines and Australian Guide to Healthy Eating, understanding of serve and portion sizes, ability to select healthier foods, and demographics such as belief systems and culture. Exploitation of electronic features to enhance visual and auditory displays, including interactive animations such as "drag and drop" and virtual reality situations, were discussed. This study provided insight into the most relevant topic areas and presentation format to assess the nutrition literacy of adult Australians. The visual, auditory, and interactive capacity of the available technology could enhance the assessment of nutrition literacy.

A pilot replication of QUIT, a randomized controlled trial of a brief intervention for reducing risky drug use, among Latino primary care patients

BACKGROUND

QUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos.

DESIGN

Single-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up.

SETTING

Primary care waiting room of a federally qualified health center (FQHC) in East Los Angeles.

PARTICIPANTS

Adult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino.

INTERVENTIONS AND MEASURES

Intervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinician's advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up.

RESULTS

Controls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p<0.001). In an intent-to-treat linear regression analysis, intervention patients reduced past month HSD use by 4.5 more days than controls (p<0.042, 95% CI: 0.2, 8.7). Similar significant results were found using a complete sample regression analysis: 5.2 days (p<0.03, 95% CI: 0.5, 9.9). Additionally, on logistic regression analysis of test results from 47 urine samples at follow-up, intervention patients were less likely than controls to test HSD positive (p<0.05; OR: 0.10, 95% CI: 0.01, 0.99).

CONCLUSIONS

Findings support the efficacy of the QUIT brief intervention for reducing risky drug use.

Evaluating measurement invariance across assessment modes of phone interview and computer self-administered survey for the PROMIS measures in a population-based cohort of localized prostate cancer survivors

PURPOSE

To evaluate measurement invariance (phone interview vs computer self-administered survey) of 15 PROMIS measures responded by a population-based cohort of localized prostate cancer survivors.

METHODS

Participants were part of the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study. Out of the 952 men who took the phone interview at 24 months post-treatment, 401 of them also completed the same survey online using a home computer. Unidimensionality of the PROMIS measures was examined using single-factor confirmatory factor analysis (CFA) models. Measurement invariance testing was conducted using longitudinal CFA via a model comparison approach. For strongly or partially strongly invariant measures, changes in the latent factors and factor autocorrelations were also estimated and tested.

RESULTS

Six measures (sleep disturbance, sleep-related impairment, diarrhea, illness impact-negative, illness impact-positive, and global satisfaction with sex life) had locally dependent items, and therefore model modifications had to be made on these domains prior to measurement invariance testing. Overall, seven measures achieved strong invariance (all items had equal loadings and thresholds), and four measures achieved partial strong invariance (each measure had one item with unequal loadings and thresholds). Three measures (pain interference, interest in sexual activity, and global satisfaction with sex life) failed to establish configural invariance due to between-mode differences in factor patterns.

CONCLUSIONS

This study supports the use of phone-based live interviewers in lieu of PC-based assessment (when needed) for many of the PROMIS measures.

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana

BACKGROUND

Given the increased use of psychoactive substances on the United States-Mexico border, a binational study (Tijuana, Mexico-Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings.

OBJECTIVES

To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use.

METHODS

This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March-October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms.

RESULTS

Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico.

CONCLUSIONS

Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

Reliability and validity of PROMIS measures administered by telephone interview in a longitudinal localized prostate cancer study

PURPOSE

To evaluate the reliability and validity of six PROMIS measures (anxiety, depression, fatigue, pain interference, physical function, and sleep disturbance) telephone-administered to a diverse, population-based cohort of localized prostate cancer patients.

METHODS

Newly diagnosed men were enrolled in the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study. PROMIS measures were telephone-administered pre-treatment (baseline), and at 3-months and 12-months post-treatment initiation (N = 778). Reliability was evaluated using Cronbach's alpha. Dimensionality was examined with bifactor models and explained common variance (ECV). Ordinal logistic regression models were used to detect potential differential item functioning (DIF) for key demographic groups. Convergent and discriminant validity were assessed by correlations with the legacy instruments Memorial Anxiety Scale for Prostate Cancer and SF-12v2. Known-groups validity was examined by age, race/ethnicity, comorbidity, and treatment.

RESULTS

Each PROMIS measure had high Cronbach's alpha values (0.86-0.96) and was sufficiently unidimensional. Floor effects were observed for anxiety, depression, and pain interference measures; ceiling effects were observed for physical function. No DIF was detected. Convergent validity was established with moderate to strong correlations between PROMIS and legacy measures (0.41-0.77) of similar constructs. Discriminant validity was demonstrated with weak correlations between measures of dissimilar domains (-0.20--0.31). PROMIS measures detected differences across age, race/ethnicity, and comorbidity groups; no differences were found by treatment.

CONCLUSIONS

This study provides support for the reliability and construct validity of six PROMIS measures in prostate cancer, as well as the utility of telephone administration for assessing HRQoL in low literacy and hard-to-reach populations.

Development of a new multimedia instrument to measure cancer-specific quality of life in Portuguese-speaking patients with varying literacy skills

Purpose

To develop and validate a new multimedia instrument to measure health-related quality of life (HRQOL) in Portuguese-speaking patients with cancer.

Methods

A mixed-methods study conducted in a large Brazilian Cancer Hospital. The instrument was developed along the following sequential phases: identification of HRQOL issues through qualitative content analysis of individual interviews, evaluation of the most important items according to the patients, review of the literature, evaluation by an expert committee, and pretesting. In sequence, an exploratory factor analysis was conducted (pilot testing, n = 149) to reduce the number of items and to define domains and scores. The psychometric properties of the IQualiV-OG-21 were measured in a large multicentre Brazilian study (n = 323). A software containing multimedia resources were developed to facilitate self-administration of IQualiV-OG-21; its feasibility and patients’ preferences (“paper and pencil” vs. software) were further tested (n = 54).

Results

An exploratory factor analysis reduced the 30-item instrument to 21 items. The IQualiV-OG-21 was divided into 6 domains: emotional, physical, existential, interpersonal relationships, functional and financial. The multicentre study confirmed that it was valid and reliable. The electronic multimedia instrument was easy to complete and acceptable to patients. Regarding preferences, 61.1 % of them preferred the electronic format in comparison with the paper and pencil format.

Conclusions

The IQualiV-OG-21 is a new valid and reliable multimedia HRQOL instrument that is well-understood, even by patients with low literacy skills, and can be answered quickly. It is a useful new tool that can be translated and tested in other cultures and languages.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-2675-6) contains supplementary material, which is available to authorized users.

Measuring Access to Information and Technology: Environmental Factors Affecting Persons With Neurologic Disorders

OBJECTIVE

To develop and validate a patient-reported measure of access to information and technology (AIT) for persons with spinal cord injury, stroke, or traumatic brain injury.

DESIGN

A mixed-methods approach was used to develop items, refine them through cognitive interviews, and evaluate their psychometric properties. Item responses were evaluated with the Rasch rating scale model. Correlational and analysis-of-variance methods were used to evaluate construct validity.

SETTING

Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place.

PARTICIPANTS

Individuals with a diagnosis of spinal cord injury, stroke, or traumatic brain injury (aged ≥18y, English speaking) participated in cognitive interviews (n=12 persons), field testing of the items (n=305 persons), and validation testing of the final set of items (n=604 persons).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A set of items to measure AIT for people with disabilities.

RESULTS

A user-friendly multimedia touchscreen was used for self-administration of the items. A 23-item AIT measure demonstrated good evidence of internal consistency reliability, and content and construct validity.

CONCLUSIONS

This new AIT measure will enable researchers and clinicians to determine to what extent environmental factors influence health outcomes and social participation in people with disabilities. The AIT measure could also provide disability advocates with more specific and detailed information about environmental factors to lobby for elimination of barriers.

Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use

AIMS

To assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening.

DESIGN

Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated.

SETTING

Primary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA.

PARTICIPANTS

A total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian.

INTERVENTION(S) AND MEASUREMENT

Intervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up.

FINDINGS

Intervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P<0.001), and in the completed sample model, intervention patients used their HSD 2.2 fewer days than controls (P < 0.005). No compensatory increases in use of other measured substances were found.

CONCLUSIONS

A primary-care based, clinician-delivered brief intervention with follow-up coaching calls may decrease risky psychoactive drug use.

Health Literacy and Patient-Reported Outcomes: A Cross-Sectional Study of Underserved English- and Spanish-Speaking Patients With Type 2 Diabetes

This study examined associations between patient characteristics, health behaviors, and health outcomes and explored the role of health literacy as a potential mediator of outcomes. English- and Spanish-speaking adults with Type 2 diabetes used a bilingual multimedia touchscreen to complete questionnaires. The behavioral model for vulnerable populations guided multivariable regression and mediation testing. Dependent variables were diabetes self-care, health status, and satisfaction with communication. Independent variables included sociodemographic and clinical characteristics, health literacy, health beliefs, and self-efficacy. Spanish speakers had lower health literacy and poorer physical, mental, and overall health compared to English speakers. Higher health literacy was associated with less social support for diet, fewer diet and medication barriers, younger age, higher diabetes knowledge, and talking with health care professionals to get diabetes information. In contrast to expectations, health literacy was not associated with diabetes self-care, health status, or satisfaction with communication, and it did not mediate the effects of other factors on these outcomes. Diabetes self-efficacy was significantly associated with health behaviors and outcomes. The association between Spanish language preference and poorer health was not mediated by this group's lower health literacy. Increasing health-related self-efficacy might be an important clinical strategy for improving outcomes in underserved patients with Type 2 diabetes.

Development and validation of the comprehensive health activities scale: a new approach to health literacy measurement

Current health literacy measures have been criticized for solely measuring reading and numeracy skills when a broader set of skills is necessary for making informed health decisions, especially when information is often conveyed verbally and through multimedia video. The authors devised 9 health tasks and a corresponding 190-item assessment to more comprehensively measure health literacy skills. A sample of 826 participants between the ages of 55 and 74 years who were recruited from an academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois, completed the assessment. Items were reduced using hierarchical factor analysis and item response theory resulting in the 45-item Comprehensive Health Activities Scale. All 45 items loaded on 1 general latent trait, and the resulting scale demonstrated high reliability and strong construct validity using measures of health literacy and global cognitive functioning. The predictive validity of the Comprehensive Health Activities Scale using self-reported general, physical, and mental health status was comparable to or better than widely used measures of health literacy, depending on the outcome. Despite comprehensively measuring health literacy skills, items in the Comprehensive Health Activities Scale supported 1 primary construct. With similar psychometric properties, current measures may be adequate, depending on the purpose of the assessment.

English-Spanish equivalence of the Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT)

Unbiased measurement instruments are needed to reliably estimate health literacy in diverse populations. The study aimed (a) to evaluate measurement equivalence of Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT) and (b) to compare Health LiTT scores between English- and Spanish-speaking individuals. Health LiTT and several patient-reported outcome instruments were completed by adult patients receiving care for type 2 diabetes at a safety net clinic. English-Spanish measurement equivalence was evaluated with an item response theory approach to differential item functioning (DIF) detection and impact. Health LiTT scores were compared by language using multivariable linear regression. Approximately equal numbers of English-speaking patients (n=146) and Spanish-speaking patients (n=149) with type 2 diabetes were enrolled. English participants were primarily non-Hispanic Black (65%); all Spanish participants were Hispanic. Six Health LiTT items were flagged for DIF. The Pearson correlation between unadjusted and DIF adjusted scores was 0.995; the mean difference of individual difference scores was 0.0005 (SD=0.0888). After adjusting for predisposing characteristics, enabling resources and need for care, Health LiTT scores were comparable for Spanish-speaking individuals versus English-speaking individuals. The effect of DIF items on Health LiTT scores appeared to be trivial. English-Spanish equivalence of Health LiTT will permit researchers to determine the independent effects of limited English proficiency and limited literacy.

Capturing treatment decision making among patients with solid tumors and their caregivers

PURPOSE/OBJECTIVES

To examine the feasibility and acceptability of using a decision aid with an interactive decision-making process in patients with solid tumors and their caregivers during cancer-related treatment.

RESEARCH APPROACH

A phenomenologic approach was used to analyze qualitative data, with a focus on the meaning of participants' lived experiences. Interviews were conducted by telephone or in person.

SETTING

Outpatient clinics at two regional cancer centers.

PARTICIPANTS

160 total individuals; 80 patients with newly diagnosed breast (n = 22), advanced-stage prostate (n = 19), or advanced-stage lung (n = 39) cancer, and their caregivers (n = 80).

METHODOLOGIC APPROACH

Twenty-seven of the 80 pairs engaged in audio recorded interviews that were conducted using a semistructured interview guide. Continuous text immersion revealed themes. Validity of qualitative analysis was achieved by member checking.

FINDINGS

Significant findings included three themes: (a) the decision aid helped patients and caregivers understand treatment decisions better, (b) the decision aid helped patients and caregivers to be more involved in treatment decisions, and (c) frequent contact with the study nurse was valuable.

CONCLUSIONS

Decision making was more complex than participants expected. The decision aid helped patients and caregivers make satisfying treatment decisions and become integral in a shared treatment decision-making process.

INTERPRETATION

Decision aids can help patients and their caregivers make difficult treatment decisions affecting quantity and quality of life during cancer treatment. The findings provide valuable information for healthcare providers helping patients and their caregivers make treatment decisions through a shared, informed, decision-making process.

KNOWLEDGE TRANSLATION

Decision aids can be helpful with treatment choices. Caregivers' understanding about treatment is just as important in the decision-making process as the patients' understanding. Incorporating decision aids that are delivered by healthcare providers or trained personnel has the potential to improve patients' decision satisfaction.

Patient-reported outcome measures for chronic obstructive pulmonary disease : the exclusion of people with low literacy skills and learning disabilities

BACKGROUND

Patient-reported outcome measures (PROMs) are intended to reflect outcomes relevant to patients. They are increasingly used for healthcare quality improvement. To produce valid measures, patients should be involved in the development process but it is unclear whether this usually includes people with low literacy skills or learning disabilities. This potential exclusion raises concerns about whether these groups will be able to use these measures and participate in quality improvement practices.

METHODS

Taking PROMs for chronic obstructive pulmonary disease (COPD) as an exemplar condition, our review determined the inclusion of people with low literacy skills and learning disabilities in research developing, validating, and using 12 PROMs for COPD patients. The studies included in our review were based on those identified in two existing systematic reviews and our update of this search.

RESULTS

People with low literacy skills and/or learning disabilities were excluded from the development of PROMs in two ways: explicitly through the participant eligibility criteria and, more commonly, implicitly through recruitment or administration methods that would require high-level reading and cognitive abilities. None of the studies mentioned efforts to include people with low literacy skills or learning disabilities.

CONCLUSION

Our findings suggest that people with low literacy skills or learning disabilities are left out of the development of PROMs. Given that implicit exclusion was most common, researchers and those who administer PROMs may not even be aware of this problem. Without effort to improve inclusion, unequal quality improvement practices may become embedded in the health system.

Empowering Promotores de Salud to engage in Community-Based Participatory Research

BACKGROUND

Latino immigrants are less likely to be involved in addressing health-related issues affecting their own community. Community health workers have played a significant role in addressing the health of underserved communities in several countries.

OBJECTIVE

The objective of this article is to describe the development, implementation and evaluation of a community-based training program that empowers promotores to identify the health needs of recent Latino immigrants. Promotores were able to develop interventions based on the needs of recent Latino immigrants.

METHODS

Latino community members participated in a 30-hour training program. Training was provided in 15 two-hour sessions over 3 months. Training included field work accompanied by skills development in leadership, organization, interpersonal communication, and survey implementation. Upon completion of the training, promotores conducted household surveys designed to identify community health needs. The evaluation employed quantitative measures to track promotores' canvassing activities and assessment of health behaviors.

RESULTS

Out of the 22 promotores enrolled in the training program, 15 (68.18%) completed the training program. Within 3 months, promotores administered 105 household surveys and identified poor access to health care, lack of insurance (78.6%), low daily consumption of fruits (73%) and vegetables (37.5%) and frequent exposure to tobacco smoke (31.7%).

CONCLUSION

Our study demonstrated the feasibility of recruiting and engaging promotores to identify health priorities within the Latino community. This initial step will inform the development of future community-based interventions.

Using patient reported outcome measures in health services: a qualitative study on including people with low literacy skills and learning disabilities

Background

Patient reported outcome measures (PROMs) are self-report measures of health status increasingly promoted for use in healthcare quality improvement. However people with low literacy skills or learning disabilities may find PROMs hard to complete. Our study investigated stakeholder views on the accessibility and use of PROMs to develop suggestions for more inclusive practice.

Methods

Taking PROMs recommended for chronic obstructive pulmonary disease (COPD) as an example, we conducted 8 interviews with people with low literacy skills and/or learning disabilities, and 4 focus groups with 20 health professionals and people with COPD. Discussions covered the format and delivery of PROMs using the EQ-5D and St George Respiratory Questionnaire as prompts. Thematic framework analysis focused on three main themes: Accessibility, Ease of Use, and Contextual factors.

Results

Accessibility included issues concerning the questionnaire format, and suggestions for improvement included larger font sizes and more white space. Ease of Use included discussion about PROMs’ administration. While health professionals suggested PROMs could be completed in waiting rooms, patients preferred settings with more privacy and where they could access help from people they know. Contextual Factors included other challenges and wider issues associated with completing PROMs. While health professionals highlighted difficulties created by the system in managing patients with low literacy/learning disabilities, patient participants stressed that understanding the purpose of PROMs was important to reduce intimidation.

Conclusions

Adjusting PROMs’ format, giving an explicit choice of where patients can complete them, and clearly conveying PROMs’ purpose and benefit to patients may help to prevent inequality when using PROMs in health services.

Improvements in measuring the health-related quality of life of cancer patients

There have been considerable improvements in the collection of health-related quality of life (HRQOL) data in oncology over the past 20 years. The facility with which HRQOL information can now be collected from patients has also been associated with an improved understanding of the meaning of HRQOL and the association between HRQOL and patients' treatment and care plans. Therefore the role that HRQOL data can play in routine clinical practice is increasingly being recognized. The appearance of computer-adaptive tests will herald a new era in HRQOL where questionnaires will be individually tailored to each patient utilizing details unique to that person and linked to clinical management systems to allow a comprehensive assessment of HRQOL status.

A framework for understanding modifications to measures for diverse populations

OBJECTIVE

Research on health disparities and determinants of health disparities among ethnic minorities and vulnerable older populations necessitates use of self-report measures. Most established instruments were developed on mainstream populations and may need adaptation for research with diverse populations. Although information is increasingly available on various problems using these measures in diverse groups, there is little guidance on how to modify the measures. A framework of issues to consider when modifying measures for diverse populations is presented.

METHODS

The authors describe reasons for considering modifications, the types of information that can be used as a basis for making modifications, and the types of modifications researchers have made. Recommendations are made to test modified measures to assure their appropriateness, and suggestions are provided on reporting modifications in publications using the measures.

DISCUSSION

The issues open a dialogue about what appropriate guidelines would be for researchers adapting measures in studies of ethnically diverse populations.

Multimedia computerized smoking awareness education for low-literacy Hispanics

To meet the needs of low-literacy, underserved, Mexican-American patients, this transdisciplinary team created a freestanding computer kiosk. Smoking awareness and cessation were the topic chosen. Focus groups were used to inform the design and creation of each screen to include appropriate culturally based images and messages. A kiosk was placed in a primary care clinic in a West Texas city. User feedback was collected, showing that this method of patient education is acceptable.

Multimedia computerized smoking awareness education for low-literacy Hispanics

To meet the needs of low-literacy, underserved, Mexican-American patients, this transdisciplinary team created a freestanding computer kiosk. Smoking awareness and cessation were the topic chosen. Focus groups were used to inform the design and creation of each screen to include appropriate culturally based images and messages. A kiosk was placed in a primary care clinic in a West Texas city. User feedback was collected, showing that this method of patient education is acceptable.

Health literacy assessment using talking touchscreen technology (Health LiTT): a new item response theory-based measure of health literacy

The importance of health literacy has grown considerably among researchers, clinicians, patients, and policymakers. Better instruments and measurement strategies are needed. Our objective was to develop a new health literacy instrument using novel health information technology and modern psychometrics. We designed Health LiTT as a self-administered multimedia touchscreen test based on item response theory (IRT) principles. We enrolled a diverse group of 619 English-speaking, primary care patients in clinics for underserved patients. We tested three item types (prose, document, quantitative) that worked well together to reliably measure a single dimension of health literacy. The Health LiTT score meets psychometric standards (reliability of 0.90 or higher) for measurement of individual respondents in the low to middle range. Mean Health LiTT scores were associated with age, race/ethnicity, education, income, and prior computer use (p < .05). We created an IRT-calibrated item bank of 82 items. Standard setting needs to be performed to classify and map items onto the construct and to identify measurement gaps. We are incorporating Health LiTT into an existing online research management tool. This will enable administration of Health LiTT on the same touchscreen used for other patient-reported outcomes, as well as real-time scoring and reporting of health literacy scores.

Health literacy and ophthalmic patient education

In 1997, Ebrahimzadeh, Davalos, and Lee wrote in this journal that only 32% of the ophthalmic patient educational materials reviewed were written at or below the recommended eighth-grade reading level. Since that time, the National Assessment of Adult Literacy found that more than one-third of adult Americans possess only basic or below basic health literacy skills, defined as the ability to understand written information in a healthcare setting. Subsequently, investigators have shown that poor health literacy skills are associated with poor prescription medication adherence, increased hospital admissions, and increased mortality. We review the readability of currently available ophthalmic educational materials, with particular attention to the health literacy status of the patient population for which the materials are intended. Examples of prose at various readability levels are provided. Optimizing patient education and improving clinical outcomes requires understanding the attributes that the patient brings to the patient-physician relationship, including health literacy.

Use of electronic quality of life applications in cancer research and clinical practice

Outcome measures of cancer treatment should include measures of quality of life, in addition to survival and objective response. Electronic administration of quality of life measures has made regular monitoring of the quality of life of individual cancer patients possible and feasible. Electronic questionnaires were well accepted by patients, had good test-retest reliability and were comparable with traditional paper-and-pen methods. Several randomized studies have shown that using quality of life screening in clinical practice can facilitate patient-doctor communication, without increasing consultation time. In one study, the regular assessment of quality of life resulted in benefits for some patients, who had better well-being and emotional functioning. Research is ongoing in developing computer-adaptive questionnaires to reduce patient burden and provide a more precise measurement. Further research using randomized controlled studies is necessary before the monitoring of individual patients' quality of life is recommended for routine practice. Special attention should be paid to training physicians in using the quality of life scores.

Literacy-fair measurement of health-related quality of life will facilitate comparative effectiveness research in Spanish-speaking cancer outpatients

BACKGROUND

Health-related quality of life (HRQL) assessment is frequently used in comparative effectiveness research, but low-literacy patients are often excluded. Appropriately translated and user-friendly HRQL measures are essential to ensure inclusion of low-literate and non-English-speaking patients in comparative effectiveness research.

OBJECTIVES

To compare HRQL responses across literacy levels in Spanish-speaking patients with cancer using a multimedia touch screen program.

SUBJECTS

A total of 414 adult patients with cancer (213 with low literacy and 201 with high literacy).

RESEARCH DESIGN

The touch screen system administered 3 questionnaires: The Functional Assessment of Cancer Therapy-General, the Short Form-36 Health Survey, and the Standard Gamble Utility Questionnaire. Measurement bias was evaluated using item response theory. Effects of literacy on HRQL were evaluated using regression models.

RESULTS

Patients rated the touch screen easy to use and commented favorably on the multimedia approach. There was statistically significant item response theory measurement bias in 6 of 10 HRQL subscales; however, only 3 showed meaningful bias. Low-literacy patients had significantly lower mean scores on 3 of 4 Functional Assessment of Cancer Therapy-General subscales, before and after adjustment for patient characteristics. Low-literacy patients also had significantly lower mean scores on 5 of 6 Short Form-36 subscales; adjustment for patient characteristics attenuated or eliminated differences. Similar proportions of low- and high-literacy patients valued their current health as equivalent to perfect health.

CONCLUSIONS

This study demonstrates the feasibility of this multimedia touch screen program for low-literacy patients. The program will provide opportunities to evaluate the effectiveness of interventions in more diverse patient populations.

Interest and beliefs about BRCA genetic counseling among at-risk Latinas in New York City

BACKGROUND

Latinas are less likely to use genetic services (counseling and testing) for hereditary breast and/or ovarian cancer risk compared to other ethnic groups. Meanwhile, little is known about barriers to genetic counseling among Latinas at increased risk of inherited breast cancer.

METHODS

A two-phase pilot study was conducted to examine interest, barriers and beliefs about BRCA genetic counseling among at-risk Latinas in New York City and explore the potential for developing a culturally-tailored narrative educational tool for use in future studies. Phase 1 included quantitative telephone interviews (N = 15) with bilingual participants with a personal diagnosis at a young age and/or family history of breast and/or ovarian cancer. Quantitative results informed development of a narrative prototype educational presentation viewed by a subset of participants (N = 10) in Phase 2 focus groups.

RESULTS

Despite barriers, including lack of awareness/knowledge, concerns related to learning cancer risks of family members, and concerns about cost/health insurance, participants reported positive attitudes, beliefs and interest in learning about BRCA genetic counseling. Further, significant increases in knowledge were demonstrated from pre-post presentation (p = 0.04).

CONCLUSION

There is an unmet need to educate at-risk Latinas about BRCA genetic counseling. Culturally-tailored educational materials including narratives may increase knowledge about BRCA genetic counseling among this underserved group. The effectiveness of these approaches should be tested in future research with larger samples.

New clinical end points in rehabilitation medicine: tools for measuring quality of life

Traditional clinical end points in rehabilitation medicine have centered on objective measures of human performance, including quantitative muscle strength testing, functional independence measurements (FIM), and timed motor performance (TMP). However, it is now increasingly recognized that health-related quality of life (HRQoL) is a valid clinical end point. Health-related quality of life is a broad concept involving an individual's physical health, psychological state, personal beliefs, and interpersonal and social support relationships. The goals for this article are to show the value of performing HRQoL measurements and briefly describe methods used to assess quality of life (QoL).

Technology and quality of life outcomes

OBJECTIVES

To discuss recent technological advances in quality of life (QOL) data collection and guidance for use in research and clinical practice. The use of telephone-, computer-, and web/internet-based technologies to collect QOL data, reliability and validity issues, and cost will be discussed, along with the potential pitfalls associated with these technologies.

DATA SOURCES

Health care literature and web resources.

CONCLUSION

Technology has provided researchers and clinicians with an opportunity to collect QOL data from patients that were previously not accessible. Most technologies offer a variety of options, such as language choice, formatting options for the delivery of questions, and data management services. Choosing the appropriate technology for use in research and/or clinical practice primarily depends on the purpose for QOL data collection.

IMPLICATIONS FOR NURSING PRACTICE

Technology is changing the way nurses assess QOL in patients with cancer and provide care. As stakeholders in the health care delivery system and patient advocates, nurses must be intimately involved in the evaluation and use of new technologies that impact QOL and/or the delivery of care.

Acceptability of the talking touchscreen for health literacy assessment

Self-administration of a multimedia health literacy measure in clinic settings is a novel concept. Demonstrated ease of use and acceptability will help predicate the future value of this strategy. We previously demonstrated the acceptability of a "Talking Touchscreen" for health status assessment. For this study, we adapted the touchscreen for self-administration of a new health literacy measure. Primary care patients (n = 610) in clinics for underserved populations completed health status and health literacy questions on the Talking Touchscreen and participated in an interview. Participants were 51% women, 10% age 60+, 67% African American, 18% without a high school education, and 14% without any prior computer experience. The majority (93%) had no difficulty using the touchscreen, including those who were computer-naive (87%). Most rated the screen design as very good or excellent (72%), including computer-naive patients (71%) and older patients (75%). Acceptability of the touchscreen did not differ by health literacy level. The Talking Touchscreen was easy to use and acceptable for self-administration of a new health literacy measure. Self-administration should reduce staff burden and costs, interview bias, and feelings of embarrassment by those with lower literacy. Tools like the Talking Touchscreen may increase exposure of underserved populations to new technologies.

The brief fatigue inventory: comparison of data collection using a novel audio device with conventional paper questionnaire

An Electronic Portable Information Collection audio device (EPIC-Vox) has been developed to deliver questionnaires in spoken word format via headphones. Patients respond by pressing buttons on the device. The aims of this study were to determine limits of agreement between, and test-retest reliability of audio (A) and paper (P) versions of the Brief Fatigue Inventory (BFI). Two hundred sixty outpatients (204 male, mean age 55.7 years) attending a sleep disorders clinic were allocated to four groups using block randomization. All completed the BFI twice, separated by a one-minute distracter task. Half the patients completed paper and audio versions, then an evaluation questionnaire. The remainder completed either paper or audio versions to compare test-retest reliability. BFI global scores were analyzed using Bland-Altman methodology. Agreement between categorical fatigue severity scores was determined using Cohen's kappa. The mean (SD) difference between paper and audio scores was -0.04 (0.48). The limits of agreement (mean difference+/-2SD) were -0.93 to +1.00. Test-retest reliability of the paper BFI showed a mean (SD) difference of 0.17 (0.32) between first and second presentations (limits -0.46 to +0.81). For audio, the mean (SD) difference was 0.17 (0.48) (limits -0.79 to +1.14). For agreement between categorical scores, Cohen's kappa=0.73 for P and A, 0.67 (P at test and retest) and 0.87 (A at test and retest). Evaluation preferences (n=128): 36.7% audio; 18.0% paper; and 45.3% no preference. A total of 99.2% found EPIC-Vox "easy to use." These data demonstrate that the English audio version of the BFI provides an acceptable alternative to the paper questionnaire.

A multimedia patient education program on colorectal cancer screening increases knowledge and willingness to consider screening among Hispanic/Latino patients

OBJECTIVE

To test a multimedia patient education program on colorectal cancer (CRC) screening that was designed specifically for the Hispanic/Latino community, and developed with input from community members.

METHODS

A total of 270 Hispanic/Latino adults, age 50-80 years, participated in Spanish for all phases of this pretest-posttest design. Patients were randomly assigned to a version of the multimedia program that opened with either a positive or negative introductory appeal. Structured interviews assessed screening relevant knowledge (anatomy and key terms, screening options, and risk information), past screening behavior, willingness to consider screening options, intention to discuss CRC screening with the doctor, and reactions to the multimedia patient education program.

RESULTS

The multimedia program significantly increased knowledge of anatomy and key terms (e.g., polyp), primary screening options (FOBT, flexible sigmoidoscopy, colonoscopy), and risk information as well as willingness to consider screening (p<.001 for all). No significant differences emerged between positive and negative introductory appeals on these measures, intention to discuss CRC screening with their doctor, or rating the multimedia program.

CONCLUSION

Multimedia tools developed with community input that are designed to present important health messages using graphics and audio can reach Hispanic/Latino adults across literacy levels and ethnic backgrounds. Additional research is needed to determine effects on actual screening behavior.

PRACTICE IMPLICATIONS

Despite promising results for engaging a difficult-to-reach audience, the multimedia program should not be considered a stand-alone intervention or a substitute for communication with physicians. Rather, it is a priming mechanism intended to prepare patients for productive discussions of CRC screening.

The role of health kiosks in 2009: literature and informant review

Kiosks can provide patients with access to health systems in public locations, but with increasing home Internet access their usefulness is questioned. A literature and informant review identified kiosks used for taking medical histories, health promotion, self assessment, consumer feedback, patient registration, patient access to records, and remote consultations. Sited correctly with good interfaces, kiosks can be used by all demographics but many ‘projects’ have failed to become routine practice. A role remains for: (a) integrated kiosks as part of patient ‘flow’, (b) opportunistic kiosks to catch people’s attention. Both require clear ‘ownership’ to succeed.