Gesundheitskompetenz in der medizinischen Rehabilitation und die Bedeutung für die Patientenschulung

Do health literacy, physical health and past rehabilitation utilization explain educational differences in the subjective need for medical rehabilitation? Results of the lidA cohort study

BACKGROUND

Medical rehabilitation can be helpful for maintaining workers' health and work ability. Its contribution to longer working lives is of high economic relevance in aging populations. In Germany, individuals must apply for rehabilitative measures themselves. Therefore, the subjective need for rehabilitation (SNR) is a prerequisite for rehabilitation access. A low education level is associated with poor health, lower health literacy and more frequent utilization of health services. In the present study, we investigated whether lower educational levels are also associated with a greater SNR and whether health literacy, past rehabilitation utilization and physical health play a mediating role in this path in older employees.

METHODS

3,130 socially insured older employees (born in 1959 or 1965) who participated in the German prospective lidA (leben in der Arbeit) cohort-study in 2011, 2014 and 2018 were included. A causal mediation analysis with an inverse odds weighting approach was performed with the SNR as the dependent variable; educational level as the independent variable; and health, health literacy and past rehabilitation utilization as the mediating variables. Sociodemographic variables were adjusted for.

RESULTS

The SNR was significantly greater in subjects with a low education level, poor physical health, inadequate health literacy and those who had utilized rehabilitation in the past. For health literacy, past rehabilitation utilization and physical health, a significant partial mediating effect on the SNR was found for employees with low compared to those with high education levels. However, the combined mediating effect of all the mediators was lower than the sum of their individual effects. Among those with medium or high education levels, none of the variables constituted a significant mediator.

CONCLUSIONS

The path between a low education level and a high SNR is mediated by inadequate health literacy, past rehabilitation utilization and poor physical health; these factors do not act independently of each other. Promoting health education may lower the SNR by improving physical health and health literacy. While improving physical health is beneficial for individuals, improved health literacy can be economically advantageous for the health system by reducing inappropriate expectations of rehabilitation benefits and subsequent applications for rehabilitation.

Efficiency of Printed Patient Information Leaflets Written for Total Knee and Hip Arthroplasty Patients to Reduce Their Fear of Surgery

Background: Patient education plays a key role in health care. In our study, we created a new information guide for patients waiting for total knee (TKA) or hip (THA) arthroplasty. The goal of our study was to create patient education material that would reduce patients' fear of surgery and improve their postoperative lifestyle. Methods: Patients in the intervention group (n = 44) received newly developed paper-based patient education material before surgery. The surgical fear questionnaire (SFQ) was used to assess fear reduction. A self-designed assessment questionnaire was used to measure the effectiveness of the leaflet among the intervention group patients. Results: The SFQ scores decreased significantly both in patients with TKA (median 37.50 IQR 30.00-40.00 vs. median 20.00 IQR 16.00-24.00) and THA (median 34.50 IQR 28.00-42.00 vs. median 20.00 IQR 16.00-22.00). A control group with TKA (median 37.50 IQR 30.00-40.00 vs. median 64.50 IQR 54.00-82.00) and THA (median 34.50 IQR 28.00-42.00 vs. median 73.00 IQR 56.00-81.00) was also included. An assessment of the content, usability, and clarity of the new leaflet showed that patients rated the new leaflet as almost entirely usable (median score 12.00-10.00). Conclusions: Our results suggest that new printed patient education material may reduce the fear of surgery.

Longitudinal observational study on health literacy and clinical outcomes in older adults with total knee arthroplasty in the context of inpatient and outpatient rehabilitation

Purpose

To assess health literacy (HL) of patients with total knee arthroplasty (TKA) and evaluate its impact on patient reported outcome measures (PROMs) as well as investigating outcome differences in inpatient and outpatient rehabilitation.

Methods

In this study, HL and PROMs of older patients were assessed preoperatively (T0) and after 3 (T1), 6 (T2), and 12 (T3) months. HL was assessed with the short form of the European HL Questionnaire; pain scores, functional restrictions, and activity levels with standardized PROMs.

Results

Limited HL was observed in 70.6% of patients at T0. HL improved from baseline to follow-ups (p < 0.001). There was no impact of HL on PROMs. Pain scores were higher in patients undergoing outpatient rehabilitation (p = 0.022). No differences were found between the rehabilitation settings for the other outcomes.

Conclusion

The study shows that limited HL is prevalent in patients with scheduled TKA. Rehabilitation seems to have a positive effect on increasing HL.

Barriers to Organizational Health Literacy at Public Health Departments in Germany

BACKGROUND

Strengthening individual health literacy and knowledge about health challenges are important preventive approaches in public health to improve health equality. Health care organizations have come into focus in this regard. They need to raise their organizational health literacy (OHL) to help users to access and navigate information and services.

OBJECTIVE

In Germany, public health departments (PHDs) are responsible for public and environmental health at the population level. This study breaks new ground as it is the first to investigate the OHL of these health care organizations. The study attempts to answer what barriers keep them from raising their OHL and how can these be overcome?

METHODS

In this explorative study, 10 guideline-oriented interviews with experts from PHDs were conducted in two states in Germany. Qualitative content analysis was used to extract the results from the experts´ statements.

KEY RESULTS

Eleven barriers to raising OHL were identified. Obstacles were found in leadership and organizational culture, design and implementation of information, and in human resources. False expectations due to negative preconceptions about public service were identified as a new barrier that had not been elucidated in prior literature. The same applies to lack of cooperation on cross-sectoral topics as well as lack of accessibility. Clear communication of tasks and clear jurisdictional authority are some of the recommendations for lowering these barriers. Other examples include identifying and using synergies and involvement of target groups.

CONCLUSIONS

Overcoming these obstacles could improve the OHL of German PHDs. This, in turn, could improve the health of the general population and thus contribute significantly to overall public health. Extrapolating to the whole of Germany and other countries could further strengthen research on OHL. [HLRP: Health Literacy Research and Practice. 2021;5(3):e264-e271.] Plain Language Summary: Public health departments (PHDs) must be able to help their users access, understand, and use health information and services. This competence is called organizational health literacy (OHL). Ten experts from German PHDs were interviewed about barriers to raising OHL. This article reports the barriers identified and recommendations for lowering them, as well as three previously unknown obstacles.

Health literacy and clinical outcomes in patients with total knee arthroplasty in different rehabilitation settings: An exploratory prospective observational study

BACKGROUND

Limited health literacy is associated with negative clinical outcomes. Although research on health literacy has increased in recent years, there is still a lack of evidence for orthopaedic patients undergoing joint replacement and in the rehabilitation sector.

OBJECTIVES

The aims of this study were to assess health literacy of patients undergoing total knee arthroplasty (TKA) and to observe its course during rehabilitation. Furthermore, we aimed to investigate associations between health literacy and clinical outcomes as well as differences regarding rehabilitation settings.

METHODS

In this prospective observational study, data about (n = 92) patients' health literacy and clinical outcomes were collected. Baseline assessments were conducted preoperatively (T0) and followed-up after three (T1) and six (T2) months. Health literacy was assessed with the European Health Literacy Questionnaire, pain scores, functional restrictions and activity levels with standardised patient-reported outcome measures (PROMs). Subgroup analyses were conducted regarding inpatient and outpatient rehabilitation.

RESULTS

Out of 92 patients, 77 completed postoperative rehabilitation between T0 and T1. Health literacy improved from T0 to T1 (p < 0.001) and subsequently remained constant until T2. Although the study showed an average improvement in health literacy scores in post-discharge rehabilitation, subgroup analyses indicated that patients did not achieve higher levels of health literacy. Pain scores were higher in patients undergoing outpatient rehabilitation (p = 0.022). No differences were found in other outcomes regarding rehabilitation settings and health literacy.

CONCLUSIONS

Based on our results, there seems to be no association between health literacy and clinical outcomes. Furthermore, the results regarding health literacy over the rehabilitation period indicated a need for enhancement of educational strategies to strengthen health literacy in the context of inpatient and outpatient orthopaedic rehabilitation.

[The Impact of Health literacy on Health Outcomes in Cancer Patients Attending Inpatient Rehabilitation]

PURPOSE

Health literacy (HL) entails people's knowledge, motivation, and competences to access, understand, appraise, and apply health information. Lower HL is associated with poorer psychosocial health. However, there are no studies so far evaluating the impact of HL within oncological rehabilitation in Germany. Therefore, we explored HL in cancer patients in inpatient rehabilitation and its association with rehabilitation outcome.

METHODS

We conducted a secondary data analysis of a questionnaire survey with 449 cancer patients (breast, prostate, and colon cancer) at 3 measurement occasions (end of rehabilitation, 3- and 9 months follow-up). We assessed HL with the European Health Literacy Survey (HLS-EU-Q6). We evaluated rehabilitation outcomes by measuring fear of progression (FoP-Q-SF), need for psychosocial support, physical functioning and global quality of life (EORTC-QLQ-C30), and the work ability index (WAI). To explore the impact of HL on rehabilitation outcome, we used multiple regression analyses controlling for other factors.

RESULTS

At the end of rehabilitation, up to 56% of the patients reported difficulties in HL dimensions. Better HL was significantly associated with lower fear of progression (β=- 0,33) and need for psychosocial support (OR=0,28), higher physical functioning (β=0,22), higher global health status (β=0,23), and higher work ability (β=0,21). Longitudinal analyses showed that improvement in HL was significantly accompanied by improvements in all rehabilitation outcomes (0,18 ≤ β ≤ 0,24).

CONCLUSION

HL is a relevant factor within cancer rehabilitation. More than half of the patients showed problematic HL at discharge. Furthermore, HL is a predictor of psychosocial, somatic, and work-related rehabilitation outcomes up to 9 months. Effective strategies to support patients in dealing with health information are essential and should be promoted within rehabilitation.

The role of health literacy in orthopaedic rehabilitation after total knee and hip arthroplasty: A scoping review

BACKGROUND

Health literacy (HL) is a key aspect in empowering patient education as part of orthopaedic rehabilitation after total knee or hip arthroplasty (TKA/THA).

OBJECTIVES

This scoping review aims to demonstrate the prevalence of patient-related outcome measures in studies on the effectiveness of orthopaedic rehabilitation of older people after TKA/THA. The review also focuses on the identification of outcome measures that assess patients' HL or HL-related aspects.

METHODS

A scoping literature search was conducted using the JBI methodology for scoping reviews. The databases MEDLINE (PubMed), CINAHL Complete, The Cochrane Library, Academic Search Elite, and ERIC were searched with keywords and phrases to find relevant literature. Identified outcome measures were conceptually analysed in a peer reviewed procedure. Those with suspected HL-related content were analysed at item level. Text analyses were performed using MAXQDA.

RESULTS

117 papers were included in this review. 45 patient-related outcome measures could be found, 2 of which assess HL-related aspects. No paper could be found that assessed patients' HL in orthopaedic rehabilitation after TKA/THA.

CONCLUSIONS

HL has hitherto been of limited importance in orthopaedic rehabilitation. Health professionals are responsible for assessing patients' health literacy and developing appropriate strategies for patient education in the context of orthopaedic rehabilitation.

[Influence of Social Status on the Success of Rehabilitation among Patients with Chronic Low Back Pain - Results of a 2-year Follow-up after Inpatient Multidisciplinary Rehabilitation]

PURPOSE

Social inequality in medical rehabilitation is receiving increasing attention. The present study examined the impact of the social status on the long-term effectiveness of the pain competence and depression prevention training "Debora" among patients with chronic low back pain (CLBP) in an inpatient multidisciplinary rehabilitation.

METHODS

The control group study with cluster-block randomization investigated the long-term changes in pain self-efficacy, psychological burden, functional capacity, and subjective work ability among 394 patients with non-specific CLBP depending on the condition (control group, CG: pain competence training vs. intervention group, IG: additional depression prevention training) and the social status (lower, middle vs. upper class; according to Deck [1]). The data were collected at five sample points: pre (t₀), post (t₁), 6-(t₂), 12-(t₃) and 24-month follow-up (t₄). Multi- or univariate repeated-measures analyses of variance were conducted per protocol (pp). In a second step, results should be confirmed by multiple imputations (MI; N=1089).

RESULTS

In general, patients of the lower class showed significantly worse values in depressive symptoms, functional capacity, and subjective work ability compared to the upper class. In addition, positive long-term effects could not be found among patients of the lower class. In contrast, patients of the middle and upper class improved, especially in the IG. Furthermore, only the IG showed long-term improvements in subjective work capacity.

CONCLUSION

This study confirms the influence of the social status on the psychophysical health. Moreover, social inequality in long-term success of rehabilitation of CLBP was suggested, which could be mediated by health literacy. Therefore, these aspects should be taken into account already in the conception and especially in the application of psychological group trainings in inpatient rehabilitation.

Impact of cognitive performance on disease-related knowledge six months after multi-component rehabilitation in patients after an acute cardiac event

Background

Although associations between cardiovascular diseases and cognitive impairment are well known, the impact of cognitive performance on the success of patient education as a core component of cardiac rehabilitation remains insufficiently investigated so far.

Design

Prospective observational study in two inpatient cardiac rehabilitation centres between September 2014 and August 2015 with a follow-up six months after cardiac rehabilitation.

Method

At admission to and discharge from cardiac rehabilitation, the cognitive performance of 401 patients (54.5 ± 6.3 years, 80% men) following an acute coronary syndrome and/or coronary artery bypass graft was tested using the Montreal Cognitive Assessment. Patients’ disease-related knowledge was determined using a quiz (22 items for medical knowledge and 12 items for healthy lifestyle and behaviour) at both times and at follow-up. The change in knowledge after cardiac rehabilitation was analysed in multivariable regression models. Potentially influencing parameters (e.g. level of education, medication, cardiovascular risk factors, coronary artery bypass graft, comorbidities, exercise capacity) were considered.

Results

During cardiac rehabilitation, disease-related knowledge was significantly enhanced in both scales. At follow-up, the average level of medical knowledge was significantly reduced, while lifestyle knowledge remained at a stable level. The maintenance of knowledge after cardiac rehabilitation was predominantly predicted by prior knowledge, cognitive performance at discharge from cardiac rehabilitation and, in the case of medical knowledge, by coronary artery bypass graft.

Conclusion

Patient education in cardiac rehabilitation led to enhanced disease-related knowledge, but the maintenance of this essentially depended on patients’ cognitive performance, especially after coronary artery bypass graft. Therefore, patient education concepts in cardiac rehabilitation should be reconsidered and adjusted as needed.

Evaluation of a standardized patient education program for inpatient asthma rehabilitation: Impact on patient-reported health outcomes up to one year

OBJECTIVES

To modify and evaluate a patient education program for adult asthma patients in consideration of quality criteria for teaching.

METHODS

This was a prospective single-center controlled trial in an inpatient rehabilitation center. The control group (n=215) received the usual lecture-based education program, and the intervention group (n=209) the modified patient education program. Data were assessed at admission, discharge, 6 and 12 months post discharge. The primary outcome was asthma control, the secondary outcomes were asthma knowledge, quality of life, and program acceptance. Analysis of change was performed by ANCOVA for each follow-up, adjusting for baseline values.

RESULTS

Statistically significant increases in all health outcomes and in asthma control were maintained in both groups at 12 months: CG: +1.9 (95%-CI 1.3-2.6) IG: +1.6 (95%-CI 0.8-2.3). We observed no significant differences between the programs for asthma control and quality of life. Regarding practical asthma knowledge, after 12 months, a group*time interaction emerged with a small effect size (P=0.06, η2=0.01).

CONCLUSION

The modified program was not superior to traditional patient education concerning asthma control. It permanently increased self-management knowledge.

PRACTICAL IMPLICATIONS

Structured and behavioral patient education fosters patient's disease management ability. Possible ways of improving asthma control need to be explored.

Gesundheitskompetenz durch Patientenschulungen – ein Überblick

Chronisch Kranke benötigen Kompetenzen, die sie dazu befähigen, möglichst selbstbestimmt mit ihrer Erkrankung umzugehen (Selbstmanagement). Solche Kompetenzen können durch Patientenschulungen vermittelt werden (Empowerment). Kontrollierte Studien konnten Effekte innovativer, interaktiver Schulungsprogramme auf Gesundheitskompetenz und Selbstmanagement-Outcomes nachweisen. Außerdem zeigte sich, dass Verbesserungen der Gesundheitskompetenz Verbesserungen der Lebensqualität mit sich bringen.