The relationship among health literacy, health knowledge, and adherence to treatment in patients with rheumatoid arthritis

Adherence to the antirheumatic drugs: a systematic review and meta-analysis

Introduction

This systematic review and meta-analysis aimed to analyze the adherence rate for conventional and biological disease-modifying antirheumatic drugs (DMARDs) utilizing different assessment measures.

Method

A systematic literature search was performed in four electronic databases, including PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL), covering the time frame from April 1970 to April 2023. Studies that present data on medication adherence among adult patients with rheumatoid arthritis (RA), specifically focusing on DMARDs (conventional or biological), were included in the analysis. The adherence rate for different assessment measures was documented and compared, as well as for conventional and biological DMARDs. A random-effects meta-analysis was performed to assess adherence rates across different adherence assessment measures and drug groups.

Results

The search identified 8,480 studies, out of which 66 were finally included in the analysis. The studies included in this meta-analysis had adherence rates ranging from 12 to 98.6%. Adherence rates varied across several adherent measures and calculation methods. Using the subjective assessment measures yielded the outcomes in terms of adherence rate: 64.0% [0.524, 95% CI 0.374-0.675] for interviews and 60.0% [0.611, 95% CI 0.465-0.758] for self-reported measures (e.g., compliance questionnaires on rheumatology CQR-5), p > 0.05. In contrast, the objective measurements indicated a lower adherence rate of 54.4% when using the medication event monitoring system (p > 0.05). The recorded rate of adherence to biological DMARDs was 45.3% [0.573, 95% CI 0.516-0.631], whereas the adherence rate for conventional DMARDs was 51.5% [0.632, 95% CI 0.537-0.727], p > 0.05. In the meta-regression analysis, the covariate "Country of origin" shows a statistically significant (p = 0.003) negative effect with a point estimate of -0.36, SE (0.12), 95% CI, -0.61 to -0.12.

Discussion

Despite its seemingly insignificant factors that affect the adherence rate, this meta-analysis reveals variation in adherence rate within the types of studies conducted, the methodology used to measure adherence, and for different antirheumatic drugs. Further research is needed to validate the findings of this meta-analysis before applying them to clinical practice and scientific research. In order to secure high reliability of adherence studies, compliance with available reporting guidelines for medication adherence research is more than advisable.

Prison healthcare service use and associated factors: a cross sectional study in Northwestern Ethiopia

Introduction

Studies on inmates' Health Care Service (HCS) utilization are scarce globally, infrequent in Ethiopia while findings about the factors associated with HCS utilization are inconsistent. The present study, therefore, examined inmates' HCS utilization and associated socio-demographic and imprisonment related factors in Northwestern Ethiopia.

Methods

The study employed institution-based cross sectional research design and data was collected using questionnaire from 422 inmates in three prisons. The questionnaire collected data about prisoners' demographic characters, imprisonment related information and HCS utilization. Descriptive statistical techniques as well as bi-variate and multiple logistic regressions were used to analyse the data.

Results and discussions

The study found that 72.5%, 66.1% and 13.3% of the inmates, respectively, used medical services, guidance and counseling services, and psychiatric services. Inmates with primary education, with secondary education, and who know the availability of the services were more likely to use medical services. Inmates with accused status were less likely to use medical services than inmates with convict status. Divorced marital status and knowledge of the service availability were associated with high guidance and counseling service use. An increase in the length of stay in the prison was associated with a decrease in psychiatry service use while knowledge of service availability was associated with higher odds of psychiatry service use. There are high medical care service utilization while low mental health care service utilization among inmates in Northwestern Ethiopia. Results of the study implied that there is a critical need for immediate health care service promotion and education measures. Besides, there are also needs for large scale, longitudinal and potentially cross-cultural studies to better understand additional factors that influence inmates' HCS utilization.

The Effect of an Online Health Literacy Promotion Program for Filipino Domestic Workers: A Mixed Method Study

Introduction

Health literacy refers to acquiring and utilizing health information to make health-related actions and decisions. Filipino domestic workers with low health literacy are often vulnerable to health problems due to poor living and working conditions.

Objective

This study examined the effect of an online health literacy promotion program on health literacy and health knowledge of Filipino domestic workers in Macao.

Methods

The mixed method combined quantitative findings of a quasi-experimental study with qualitative results applied. The quasi-experiment included three parallel groups: a synchronous online education group (videoconference group), an asynchronous online education group (video group), and a control group. A total of 88 Filipino domestic workers were assigned to one of these groups, and eight respondents participated in two focus-group interviews respectively after the intervention.

Results

For quantitative data, both synchronous and asynchronous online education interventions had positive effects. While comparing with the control group, participants in the videoconference group were more likely to have better health promotion health literacy after the intervention (β = 5.36, p = .02), and participants in the video group were more likely to have better general health literacy (β = 5.17, p = .01), disease prevention health literacy (β = 5.31, p = .04), health promotion health literacy (β = 5.97, p = .01). For qualitative data, three themes and eight subthemes were extracted after the online health literacy promotion program. After integrating the findings of this study, the study found that this program was essential and beneficial for Filipino domestic workers' health knowledge and health literacy.

Conclusion

Overall, online health literacy promotion programe had positive impacts on participants revealed in this study. Asynchronous online education has made significant progress in overall health literacy, which may be more suitable as a widely promoted education method because of the characteristics and working conditions of this population.

Assessment Tools for Measuring Health Literacy and Digital Health Literacy in a Hospital Setting: A Scoping Review

Assessment of (digital) health literacy in the hospital can raise staff awareness and facilitate tailored communication, leading to improved health outcomes. Assessment tools should ideally address multiple domains of health literacy, fit to the complex hospital context and have a short administration time, to enable routine assessment. This review aims to create an overview of tools for measuring (digital) health literacy in hospitals. A search in Scopus, PubMed, WoS and CINAHL, following PRISMA guidelines, generated 7252 hits; 251 studies were included in which 44 assessment tools were used. Most tools (57%) were self-reported and 27% reported an administration time of <5 min. Almost all tools addressed the domain 'understanding' (98%), followed by 'access' (52%), 'apply' (50%), 'appraise' (32%), 'numeracy' (18%), and 'digital' (18%). Only four tools were frequently used: the Newest Vital Sign (NVS), the Short Test of Functional Health Literacy for Adults ((S)TOFHLA), the Brief Health Literacy Screener (BHLS), and the Health Literacy Questionnaire (HLQ). While the NVS and BHLS have a low administration time, they cover only two domains. HLQ covers the most domains: access, understanding, appraise, and apply. None of these four most frequently used tools measured digital skills. This review can guide health professionals in choosing an instrument that is feasible in their daily practice, and measures the required domains.

Associations of eHealth literacy and knowledge with preventive behaviours and psychological distress during the COVID-19 pandemic: a population-based online survey

OBJECTIVES

To compare the associations of COVID-19 preventive behaviours and depressive and anxiety symptoms with eHealth literacy and COVID-19 knowledge among Korean adults.

DESIGN

A cross-sectional online survey was conducted in April 2020.

SETTING

Seoul metropolitan area in South Korea.

PARTICIPANTS

1057 Korean adults were recruited.

MAIN OUTCOME MEASURES

Associations between eHealth literacy, COVID-19 knowledge, COVID-19 preventive behaviours and psychological distress were computed using Pearson's correlation and logistic regression analyses. eHealth literacy, COVID-19 knowledge, COVID-19 preventive behaviours and psychological distress were weighted by sex and age distribution of the general population in Seoul Metropolitan area.

RESULTS

68.40% (n=723) perceived high eHealth literacy level (eHEALS ≥26), while 57.43% (n=605) had high levels of COVID-19 knowledge (score ≥25). No significant association between eHealth literacy and COVID-19 knowledge was identified (r=0.05, p=0.09). eHealth literacy and COVID-19 knowledge were significantly associated with COVID-19 preventive behaviours (aOR=1.99, 95% CI 1.51 to 2.62 L; aOR=1.81, 95% CI 1.40 to 2.34, respectively). High eHealth literacy was significantly associated with anxiety symptom (aOR=1.71, 95% CI 1.18 to 2.47) and depressive symptom (aOR=1.69, 95% CI 1.24 to 2.30). COVID-19 knowledge had negative and no associations with the symptoms (aOR=0.62, 95% CI 0.46 to 0.86; aOR=0.79, 95% CI 0.60 to 1.03, respectively). High eHealth literacy with low COVID-19 knowledge was positively and significantly associated with COVID-19 preventive behaviours (aOR=2.30, 95% CI 1.52 to 3.43), and anxiety (aOR=1.81, 95% CI 1.09 to 3.01) and depressive symptoms (aOR=2.24, 95% CI 1.41 to 3.55). High eHealth literacy with high COVID-19 knowledge were significantly associated with more preventive behaviours (aOR=3.66, 95% CI 2.47 to 5.42) but no significant associations with anxiety and depressive symptoms.

CONCLUSION

We identified that eHealth literacy and COVID-19 knowledge were not associated each other, and differently associated with individuals' COVID-19 preventive behaviours and psychological well-being. Public health strategies should pay attention to enhancing both eHealth literacy and COVID-19 knowledge levels in the public to maximise their COVID-19 preventive behaviours and mitigate their psychological distress during COVID-19 pandemic.

Development and validation of a Systemic Sclerosis Health Literacy Scale

Background and aim

Health literacy levels are strongly associated with clinical outcomes and quality of life in patients with chronic diseases, and patients with limited health literacy often require more medical care and achieve poorer clinical outcomes. Among the large number of studies on health literacy, few studies have focused on the health literacy of people with systemic sclerosis (SSc), and there is no specific tool to measure health literacy in this group. Therefore, this study plans to develop a health literacy scale for patients with SSc.

Methods

This study included 428 SSc patients from the outpatient and inpatient departments of the Department of Rheumatology and Immunology, the first affiliated Hospital of Anhui Medical University and the first affiliated Hospital of University of Science and Technology of China. The formulation of the scale was completed by forming the concept of health literacy of SSc patients, establishing the item pool, screening items, and evaluating reliability and validity. Classical measurement theory was used to screen items, factor analysis was used to explore the construct validity of the scale, and Cronbach's alpha coefficient was used to assess the internal consistency.

Results

Our study population was predominantly middle-aged women, with a male to female ratio of 1:5.7 and a mean age of 51.57 ± 10.99. A SSc Health Literacy scale with 6 dimensions and 30 items was developed. The six dimensions are clinic ability, judgment/evaluation information ability, access to information ability, social support, treatment compliance and application information ability. The Cronbach's alpha coefficient of the scale is 0.960, retest reliability is 0.898, split-half reliability is 0.953, content validity is 0.983, which has good reliability and validity.

Conclusion

The Systemic Sclerosis Health Literacy Scale may become a valid tool to evaluate the health literacy level of patients with SSc.

Use of prognostic gene expression profiling tests in primary breast cancer treatment: a German real-world patient survey

Aims: In primary breast cancer, gene expression profiling tests can support adjuvant chemotherapy treatment decisions. Real-world test use in Germany was investigated in an online survey of female breast cancer patients (n = 475). Materials & methods: Relationships between three groups were examined for clinical and statistical relevance: no test indication (n = 353), test indication and tested (n = 65), and test indication but not tested (n = 57). Results: A total of 47% of participants with a test indication were not tested. Test rates increased by 23% from 2012-2018 (49%) to 2019-2021 (60%). A total of 65% of patients without testing received chemotherapy, whereas only 38% of tested patients received chemotherapy. Conclusion: The use of gene expression profiling tests correlates with a real-world chemotherapy reduction. Gene expression profiling testing may improve patient confidence in the decision for or against chemotherapy.

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Who Knows? Information Received, and Knowledge about, Cancer, Treatment and Late Effects in a National Cohort of Long-Term Childhood, Adolescent and Young Adult Cancer Survivors

Simple Summary

With the growing population of cancer survivors, survivorship management has become central for both medical professionals and patients. This entails, among other factors, empowering survivors with the necessary knowledge about their medical history and their risk for late effects, because informed patients make better lifestyle and health choices. Although a lack of information and low satisfaction with information received are fairly well-documented phenomena among childhood cancer survivors, less is known about survivors of young adult cancer and populations of long-term survivors no longer engaged in follow-up care. This paper aims to fill this gap by investigating information provision in childhood, adolescent and young adult cancer survivors.

Abstract

Background: Knowledge of medical history and late effects is central in modern survivorship management, especially for long-term childhood, adolescent and young adult cancer survivors’ (CAYACS) with long life expectancy rates and high risks of late effects. Identifying information and knowledge gaps is, therefore, important. As part of the population-based NOR-CAYACS study, we investigated the following: (1) written information received about their disease and treatment, and any information about late effects; (2) satisfaction with this information and associated factors; (3) knowledge about late effects and factors associated with low knowledge of specific late effects. Material and methods: A questionnaire-based survey (Nor-CAYACS) was mailed to 5361 CAYACS (childhood cancers, breast and colorectal cancer, acute lymphatic leukemia, non-Hodgkin lymphoma and malignant melanoma) identified by the Cancer Registry of Norway (CRN). Of these, 2018 answered questions about disease and late effects information and knowledge. Exposure variables were extracted from the questionnaire and CRN. Unfortunately, it was not possible to stratify by treatment in the analyses. We ran descriptive statistics for comparisons and logistic regressions to identify factors associated with outcomes of interest. Results: Overall, 50% to 60% of survivors reported not having received written information about their disease and treatment, or any information about late effects. There was a large variation in reported knowledge across 17 late effects. Lower levels of knowledge were associated with male sex, lower education and poorer health literacy in multivariable regression models. Conclusions: Knowledge of cancer history and risks of late effects is essential for effective self-management, yet significant information and knowledge gaps were reported in this population-based sample of long-term CAYACS. Systematic approaches to making (up-to-date) information available to long-term survivors are needed to ensure that information does not get lost in medical and life transitions.

Health Literacy in Patients’ Clinical Records of Hospital Settings: A Systematic Review

Introduction

Health literacy (HL) can be defined as the individual's ability to understand and process health information. A low level of HL can be viewed as a stronger predictor of a person's health status than age, education level, and race. Although HL is an important determinant of health, it is often underestimated. This systematic review investigates the evidence on HL assessment in hospital settings.

Methods

PubMed Medline, CINAHL, Scopus, Web of Science and Educational Resources Information Centre databases were searched, with the date last searched being 16 March 2020. The PRISMA guidelines were applied, and the protocol of the study was registered with PROSPERO (CRD42021236029). The quality of the included studies was appraised using the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Results

Five studies reported HL assessments in hospital patients’ clinical records. Four main strategies were used to implement HL routine assessment in hospitals: multidisciplinary teams, stakeholders, training, and monitoring. Different performance measures were used to monitor the feasibility of incorporating HL assessment into electronic health records (EHRs).

Conclusion

This review examined how inpatients’ HL is recorded in hospital settings. HL is poorly measured in a hospital setting. These results guide hospital leadership in involving nurses in HL assessment implementation in hospitals and support nurses in creating a specific performance measure dashboard to monitor effective HL assessments in hospitals.

Explaining juvenile idiopathic arthritis to paediatric patients using illustrations and easy-to-read texts: improvement of disease knowledge and adherence to treatment

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is the leading chronic rheumatic disease in childhood. To achieve adherence to therapy, in-depth understanding of disease and treatment options are important.

OBJECTIVE

Development of specifically designed illustrations and standardised, easy-to-read texts for children and adolescents with JIA. Education materials were tested for comprehensibility and content validity. We hypothesised that children would be able to increase their knowledge about JIA after presentation of materials.

METHODS

The illustrations were designed by a graphic artist and the informative texts consecutively transformed to easy-to-read language. The materials appear as a modular system to allow individualized information for each patient. The illustrations and texts were tested for knowledge gain and improvement of self-efficacy in children affected by JIA/ rheumatic diseases and controls. Health-related quality of life (HRQoL) was tested as an overall assessment of patients' well-being.

RESULTS

46 controls (71% female) and 38 patients (48% female) with a median age of 11 years were tested in a standardised setting. In both groups knowledge gain was significant (controls: t (44) = 11.08, p < 0.001, d = 1.65; patients: t (37) = 7.48, p < 0.001, d = 1.21). The control group had a significantly higher enhancement of disease knowledge compared to patients' group (p = .046) The follow-up testing was only performed in one school class (20 controls) due to Covid-19 pandemic with significant improvement compared to the pre-test results (p = .002). The enhancement of self-efficacy through the teaching session was significantly higher in the patients' group. No impairment of HRQoL was seen.

CONCLUSION

Explaining juvenile rheumatic diseases and therapeutic strategies is an important task in paediatric rheumatology. To avoid incomprehensible explanations in medical jargon, illustrations and easy-to-read texts were developed. Standardised presentation of the newly created materials resulted in a significant improvement of disease knowledge in patients and controls in addition to an enhancement of self-efficacy in patients.

Development of a Clinical-Academic-Community Collaboration to Improve Health Literacy

Limited health literacy is associated with poor patient health outcomes and increased hospitalization rates. Patient-provider communication plays an important role in patient health literacy and the understanding of medical terminology. This study demonstrates how a collaboration between clinical, academic, and community partners was instrumental in the design and implementation of a clinic readiness assessment and a clinic-based pilot intervention to encourage patient-provider communication and improve patient health literacy. A state hospital association, academic research team, and community adult literacy center director collaborated to develop a 60-item clinic readiness assessment and an evidence-informed pilot intervention. The clinic readiness assessment captured clinics’ motivation and capacity for pilot implementation and providers’ current communication strategies. The intervention centered around AskMe3™ educational materials and involved 2 patient visits (initial and follow-up visits). Data collection instruments for the intervention were administered verbally and included questions about patient demographics and communication needs, and a single-item health literacy measure. Descriptive statistics (frequencies/percentages) were used to analyze results from the clinic readiness assessment and pilot intervention. Establishment of the partnership, and collaborative, iterative development of the clinic readiness assessment and pilot intervention are described. This pilot project resulted in important lessons learned which led to critical modifications that will inform future expansion of the intervention. Collaboration between healthcare leaders, researchers, and community partners is recommended for developing clinic-based health literacy initiatives.

Addressing Health Literacy Needs in Rheumatology: Which Patient Health Literacy Profiles Need the Attention of Health Professionals?

Objective

To identify and describe health literacy profiles of patients with rheumatic diseases and explore whether the identified health literacy profiles can be generalized to a broader rheumatology context.

Methods

Patients with rheumatoid arthritis, spondyloarthritis, and gout from 3 hospitals in different regions in The Netherlands completed the Health Literacy Questionnaire (HLQ). Hierarchical cluster analysis was used to identify patients’ health literacy profiles based on 9 HLQ domains. A multinomial regression model with the identified health literacy profiles as the dependent variable was fitted to assess whether patients with a given disease type or attending a given hospital were more likely to belong to a specific profile.

Results

Among 895 participating patients, the lowest mean HLQ domain scores (indicating most difficulty) were found for “critical appraisal,” “navigating the health system,” and “finding good health information.” The 10 identified profiles revealed substantial diversity in combinations of strengths and weaknesses. While 42% of patients scored moderate to high on all 9 domains (profiles 1 and 3), another 42% of patients (profiles 2, 4, 5, and 6) clearly struggled with 1 or several aspects of health literacy. Notably, 16% (profiles 7–10) exhibited difficulty across a majority of health literacy domains. The probability of belonging to one of the profiles was independent of the hospital where the patient was treated or the type of rheumatic disease.

Conclusion

Ten distinct health literacy profiles were identified among patients with rheumatic diseases, independent of disease type and treating hospital. These profiles can be used to facilitate the development of health literacy interventions in rheumatology.

Telemedicine in the management of rheumatoid arthritis: maintaining disease control with less health-care utilization

Objectives

We aimed to evaluate the use of an eHealth platform and a self-management outpatient clinic in patients with RA in a real-world setting. The effects on health-care utilization and disease activity were studied.

Methods

Using hospital data of patients with RA between 2014 and 2019, the use of an eHealth platform and participation in a self-management outpatient clinic were studied. An interrupted time series analysis compared the period before and after the introduction of the eHealth platform. The change in trend (relative to the pre-interruption trend) for the number of outpatient clinic visits and the DAS for 28 joints (DAS28) were determined for several scenarios.

Results

After implementation of the platform in April 2017, the percentage of patients using it was stable at ∼37%. On average, the users of the platform were younger, more highly educated and had better health outcomes than the total RA population. After implementation of the platform, the mean number of quarterly outpatient clinic visits per patient decreased by 0.027 per quarter (95% CI: -0.045, -0.08, P = 0.007). This was accompanied by a significant decrease in DAS28 of 0.056 per quarter (95% CI: -0.086, -0025, P = 0.001). On average, this resulted in 0.955 fewer visits per patient per year and a reduction of 0.503 in the DAS28.

Conclusion

The implementation of remote patient monitoring has a positive effect on health-care utilization, while maintaining low disease activity. This should encourage the use of this type of telemedicine in the management of RA, especially while many routine outpatient clinic visits are cancelled owing to COVID-19.

Racial and ethnic differences in medication use among beneficiaries of social security disability insurance with rheumatoid arthritis

OBJECTIVE

To determine racial/ethnic differences in the use of conventional synthetic or biologic disease-modifying anti-rheumatic drugs (csDMARDs or bDMARDs, respectively) and long-term glucocorticoids (GC) or opioids among beneficiaries of the Social Security Disability Insurance (SSDI) with rheumatoid arthritis (RA) and <65 years old.

METHODS

Serial cross-sectional analyses of Centers for Medicare and Medicaid Services claims data (2007, 2011, and 2014) for individuals <65 years old with RA receiving SSDI Medicare and Medicaid, no longer working because they were considered disabled. Generalized estimating equation models were used to determine whether the proportion of patients who used csDMARD, bDMARD, long-term GC, and long-term opioids differed by race/ethnicity.

RESULTS

There were 12,931; 15,033; and 15,599 participants in 2007, 2011, and 2014, respectively. The overall use of csDMARD without bDMARD among beneficiaries of the SSDI were 31.1%, 30.3%, and 29.2%; 50.2%, 51.7%, and 53.8% used bDMARDs; 37.6%, 36.1%, and 34.4% used long-term GC; and 61.1%, 63.8%, and 63.7% used long-term opioids in years 2007, 2011, and 2014 respectively. The use of csDMARDs without bDMARDs was higher and the use of bDMARDs was lower among Blacks compared to Whites (adjusted absolute difference: +3.0%, +5.0%, and +3.3% for csDMARDs without bDMARDs and -4.6%, -5.7%, and -4.0% for bDMARDs in 2007, 2011, and 2014, respectively; all p<0.05). The use of bDMARDs was higher among Hispanics compared to Whites (adjusted absolute difference: +7.1%, +7.3%, and +7.5% in 2007, 2011, and 2014, respectively; all p<0.05). Long-term GC use was lower among Hispanics than among Whites only in year 2014 (absolute percentage point difference of -4.2%); no other difference in long-term GC use was identified. Whites were the patients with the highest use of long-term opioids (more than two third in each calendar year).

CONCLUSION

Racial and ethnic differences exists in regards to the treatment of RA among beneficiaries of the SSDI. These findings suggest that this already vulnerable population of patients with RA can also have a racial and ethnic disparity that can contribute to additional disease burden and that should be examined in order to inform future interventions or even inform future policy changes to the SSDI.

Using pictures to convey health information: A systematic review and meta-analysis of the effects on patient and consumer health behaviors and outcomes

OBJECTIVE

Assess the effect of pictorial health information on patients' and consumers' health behaviors and outcomes, evaluate these effects in lower health literacy populations, and examine the attributes of the interventions.

METHODS

We included randomized controlled trials (RCTs) that assessed the effect of pictorial health information on patient and consumer health behaviors and outcomes. We conducted a meta-analysis of RCTs that assessed knowledge/understanding, recall, or adherence, and a subgroup analysis of those outcomes on lower health literacy populations. We narratively reviewed characteristics of pictorial health interventions that significantly improved outcomes for lower health literacy populations.

RESULTS

From 4160 records, we included 54 RCTs (42 in meta-analysis). Pictorial health information moderately improved knowledge/understanding and recall overall, but largely increased knowledge/understanding for lower health literacy populations (n = 13), all with substantial heterogeneity. Icons with few words may be most helpful in conveying health information.

CONCLUSION

Our results support including pictures in health communication to improve patient knowledge. Our results should be interpreted with caution considering the significant heterogeneity of the meta-analysis outcomes.

PRACTICE IMPLICATIONS

Future research should assess which types and characteristics of pictures that best convey health information and are most useful and the implementation and sustainability in healthcare contexts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084743.

A Pantheoretical Framework to Optimize Adherence to Healthy Lifestyle Behaviors and Medication Adherence: The Use of Personalized Approaches to Overcome Barriers and Optimize Facilitators to Achieve Adherence

Patient nonadherence to healthy lifestyle behaviors and medical treatments (like medication adherence) accounts for a significant portion of chronic disease burden. Despite the plethora of behavioral interventions to overcome key modifiable/nonmodifiable barriers and enable facilitators to adherence, short- and long-term adherence to healthy lifestyle behaviors and medical treatments is still poor. To optimize adherence, we aimed to provide a novel mobile health solution steeped in precision and personalized population health and a pantheoretical approach that increases the likelihood of adherence. We have described the stages of a pantheoretical approach utilizing tailoring, clustering/profiling, personalizing, and optimizing interventions/strategies to obtain adherence and highlight the minimal engineering needed to build such a solution.

Predictors and Level of Knowledge Regarding Parkinson's Disease among Patients: A Cross-sectional Study from Thailand

Background:

Parkinson's disease (PD) is a neurodegenerative disorder that results in gradual decline of motor, autonomic, and neuropsychiatric functions of the patient. Knowledge and factors responsible for Parkinson's disease (PD) are important among patients that could positively affect their attitude and perceptions. This study was conducted to determine the factors influencing and level of the knowledge regarding Parkinson's disease in Thailand.

Methods:

This cross-sectional study was conducted on 125 patients admitted in King Chulalongkorn Memorial Hospital Bangkok, Thailand. Sociodemographic variables and clinical characteristics were collected as predictors of knowledge, treatment, and self-care for PD. A validated, piloted, pretested tool was used for data collection. Multiple linear regressions were used to find the most influencing predictor of knowledge about PD. The study was approved by the Ethical Board of Chulalongkorn University, Thailand.

Results:

The level of education was found to be the most significant (P = 0.005) predictor of PD knowledge. PD patients with high education had significantly higher knowledge scores than those with low education in all aspects of disease (P = 0.041), treatment (P = 0.014), and self-care (P = 0.011). PD knowledge was poor in variables such as levodopa (62%), nonmotor symptoms (54%), and stem cell transplantation (40%), respectively.

Conclusion:

The study results conclude that educational level is the most important predictor of knowledge about Parkinson's disease.

Mediators of the association of limited English health literacy with medication non-adherence among Singaporean elderly

Background:

In Singapore, English is predominantly used on prescription medication labels (PMLs). However, many older Singaporeans cannot read English, and among those who read English, their English health literacy (EHL) proficiency varies. It is thus pertinent to examine the link between EHL and medication use outcomes in this population. The present research aims to address this question.

Methods:

Data from a national survey, on 1167 home-dwelling elderly on ⩾1 prescribed medication was analysed. The validated Health Literacy Test for Singapore was used to determine EHL. Medication non-adherence was self-reported. Path analysis examined the association between limited EHL and medication non-adherence and tested possible mediators.

Results:

Limited EHL was associated with medication non-adherence (total effect=0.35; p-value: 0.032), and ‘uncertainty in taking medications correctly due to difficulty in understanding written information on PMLs’ was a significant mediator (indirect effect=0.23, 95% confidence interval (0.12–0.39)).

Conclusions:

Elderly people with limited EHL were significantly more likely than those with adequate EHL to report that they were uncertain about taking medications correctly because they had difficulty understanding the information on PMLs and this misunderstanding contributed to medication non-adherence. Interventions focused on incorporating bilingual text and/or pictograms on PMLs may reduce uncertainty in taking medication correctly and improve medication adherence among the elderly.

Adherence and health literacy as related to outcome of patients treated for rheumatoid arthritis : Analyses of a large-scale observational study

BACKGROUND

Disabilities in daily living and quality of life are key endpoints for evaluating the treatment outcome for rheumatoid arthritis (RA). Factors possibly contributing to good outcome are adherence and health literacy.

METHODS

The survey included a representative nationwide sample of German rheumatologists and their patients with RA. The physician questionnaire included the disease activity score (DAS28) and medical prescriptions. The patient questionnaire included fatigue (EORTC QLQ-FA13), health assessment questionnaire (HAQ), quality of life (SF-12), health literacy (HELP), and patients' listings of their medications. Adherence was operationalized as follows: patient-reported (CQR5), behavioral (concordance between physicians' and patients' listings of medications), physician-assessed, and a combined measure of physician rating (1 = very adherent, 0 = less adherent) and the match between physicians' prescriptions and patients' accounts of their medications (1 = perfect match, 0 = no perfect match) that yielded three categories of adherence: high, medium, and low. Simple and multiple linear regressions (controlling for age, sex, smoking, drinking alcohol, and sport) were calculated using adherence and health literacy as predictor variables, and disease activity and patient-reported outcomes as dependent variables.

RESULTS

708 pairs of patient and physician questionnaires were analyzed. The mean patient age (73% women) was 60 years (SD = 12). Multiple regression analyses showed that high adherence was significantly associated with 5/7 outcome variables and health literacy with 7/7 outcome variables.

CONCLUSION

Adherence and health literacy had weak but consistent effects on most outcomes. Thus, enhancing adherence and understanding of medical information could improve outcome, which should be investigated in future interventional studies.

Determinants of knowledge, attitude and practice in patients with both type 2 diabetes and chronic kidney disease in Fiji

Background: In Fiji, Type 2 diabetes mellitus (T2DM) and Chronic kidney disease (CKD) are amongst the top four causes of premature mortality, disability and death. This study aims to identify the determinants of knowledge, attitude and practice (KAP) in T2DM patients with CKD in Fiji in 2018. Methods: A cross-sectional study was conducted at Sigatoka Sub-divisional Hospital (SSH) in Fiji in July-August, 2018 using a self-structured questionnaire to test KAP of 225 patients. The inclusion criteria were confirmed T2DM patients (Fijian citizens) with CKD, aged 30 years or above and attending Special Out-Patient's Department (SOPD) at SSH. Independent t-test and ANOVA was used to test differences between demographic variable and practice score while non-parametric tests were used for knowledge and attitude. Spearman correlation and multiple linear regressions were conducted. All tests were set at 5% level of significance. Results: From 249 questionnaires distributed, 225 responded thus response rate was 95%. The mean KAP level was high: knowledge, 23.3/30 (SD±3.25); attitude, 23.1/30 (SD±2.73) and practice, 7.1/10 (SD±2.04). A high level of knowledge was seen in those with university-level education (p<0.001), unemployed (p=0.05) and high average monthly income (p=0.03). Those aged 61-70 years had a 0.53-point lower attitude score (p=0.05) than other age categories, while those >70 years had a 1.78-point lower attitude score (p=0.01) than other age categories. Fijians of Indian descent (FID) had lower attitude (p=0.002) and higher practice (p=0.001) scores. Conclusion: Patients with both T2DM and CKD at SSH have high levels of KAP. The determinants of KAP have been shown and thus, this study identified high-risk groups for low KAP, which can become the focus of future public health intervention.

Polypharmacy in the oldest old (≥80 years of age) patients in China: a cross-sectional study

Background

The oldest old generally have worse health and more comorbidities than the general population of older adults, and they are more likely to be exposed to polypharmacy. Reliable investigation of polypharmacy among the oldest old (≥80 years of age) in China are lacking. So this study aims to describe the polypharmacy status of oldest old patients ≥80 years of age and to assess the factors influencing medication compliance.

Methods

This was a cross-sectional study of 258 oldest old patients ≥ 80 years of age and hospitalized at a tertiary hospital in Beijing between December 1, 2014 and June 30, 2015. They completed three validated questionnaires to assess their pre-admission status (general demographics, medication knowledge, and medication adherence). Potentially inappropriate medications (PIM) use was evaluated by physicians.

Results

The majority of the patients (55.4%) took < 10 types of drugs. The numbers of drugs taken ranged from 8 to 60 drugs (median of 22.9). Patients taking 11–20 drugs accounted for 46.1% of the patients. Subjects with a history of adverse drug reactions accounted for 40.3%. The proportion of PIMs was 27.1%. Compliance was only 32.6% among the oldest old patients with polypharmacy. Age and medication classes were independently negatively associated with compliance, and medication knowledge was independently positively associated with compliance.

Conclusion

Oldest old patients (≥ 80 years of age) had a poor medication knowledge. Age, medication classes, and medication knowledge were independently associated with medication compliance.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0754-y) contains supplementary material, which is available to authorized users.

Demographic correlates of medication knowledge in Hong Kong early psychosis patients

AIM

Patient knowledge of prescribed medications is important for accurate medication consumption. Not many studies have identified the demographic correlates of medication knowledge in psychiatric patients, and fewer have performed so for non-Western societies, which may present different results owing to distinct cultural factors. Our objective was to identify the demographic correlates of medication knowledge in early psychosis patients from Hong Kong.

METHODS

A short questionnaire comprising questions on six components of medication knowledge was administered to 105 consecutive early psychosis patients from an outpatient clinic in Hong Kong. A suite of patient demographics was assembled from clinicians' records.

RESULTS

Poor medication knowledge was characterized by patients of older age (>30 years), low education level (≤Form 3), overall negative family relationships (as compared with overall positive ones) and shorter treatment duration (≤4 years). Shorter treatment duration most consistently predicted poor medication knowledge, displaying significant (P < 0.05) associations with four out of six knowledge components. Patients (54.3%) did not know the English names of their medication.

CONCLUSIONS

Specific groups of early psychosis patients are at risk of having poor medication knowledge; these individuals should be identified to receive regular health education. Contrary to findings from non-psychosis groups, short treatment duration was unequivocally associated with poorer medication knowledge in patients with early psychosis. Local replacements for English medication names should be considered in non-English speaking societies, especially in areas of mental health treatment.

Accuracy in 24-hour Urine Collection at a Tertiary Center

There is a paucity of studies addressing the accuracy of 24-hour urine collection for assessing stone risk parameters. Collection accuracy is thought to be essential for assigning optimal therapy for stone prevention. The objective of this study was to determine factors associated with accurate and inaccurate collections. During a 2-year period (2015-2016), 241 stone formers completed 24-hour urine collections. They were divided into accurate collectors (AC), defined as at least one accurate urine collection, and inaccurate collectors (IC). Accuracy was assessed by 24-hour urine creatinine (Cr) excretion indexed to body weight (normal: males, 20-25 mg Cr/kg; females, 15-20 mg Cr/kg). Demographic data analyzed included age, gender, race, insurance status, partner status, income, and education. Statistical analysis methods included the chi-square test, Fisher's exact test, and the two-group t-test. Average age was 50.7 years at the time of collection; 50.2% were men, 86% were white, and 14% were black. Overall, 51.0% of collections were inaccurate. There was no statistical significance between AC and IC for gender (P = 0.85), race (P = 0.90), insurance status (P = 0.85), recurrence (P = 0.87), stone type (P = 0.57), education (P = 0.35), income (P 5 0.42), or poverty (P = 0.35). Older age (P = 0.017) and having a partner (P = 0.022) were significantly associated with AC. The high rate of inaccurate 24-hour urine collections is a concern. The only factors we identified as influencing collection accuracy were age and partner status. These results underscore the importance of developing methods to improve the accuracy of collecting 24-hour urine samples.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

Medication understanding among patients living with multiple chronic conditions: Implications for patient-reported measures of adherence

BACKGROUND

Low health literacy is associated with poor medication adherence and poor health outcomes. Limited understanding of prescribed medications may decrease validity of patient-reported adherence measures.

OBJECTIVES

To assess knowledge of names and purposes of prescribed medications among patients with multiple chronic conditions.

METHODS

Individual interviews were conducted with a convenience sample of patients from six U.S. primary care clinics. Participants (n = 57) were English and/or Spanish-speaking patients prescribed 3+ medications for chronic conditions, for which non-adherence may lead to disability or death. In individual interviews, patients were asked to name their medications, explain the purpose of each, and to explain how they distinguish them from one another. Interviews were audio recorded, transcribed, and coded; coded content was quantified by 1) whether or not the patient could name medications; 2) method of categorizing medications; 3) whether or not the purpose of the medication was understood. Descriptive statistics were compiled using Fisher's exact test to determine the relationship between patient knowledge and medication characteristics.

RESULTS

Thirty percent of patients could not name at least one of their medications; 19% did not know their purpose; 30% held misconceptions about the purpose of one or more medications. There was no significant difference in ability to name medications or state their medication's purpose between patients using medi-sets, pre-packaged rolls, or blister packs, and patients who stored pills in their original containers (p = 0.56 and p = 0.73, respectively), or across demographic groups (p = 0.085 to 0.767).

CONCLUSIONS

Many patients demonstrated difficulty identifying the name and purpose of prescribed medications; this did not differ by demographic group or medication storage type. Patients may benefit from routine review of medications with their provider in order to improve health literacy, outcomes, and patient-reported adherence measurement.

Impact of Treatment-Related Beliefs on Medication Adherence in Immune-Mediated Inflammatory Diseases: Results of the Global ALIGN Study

INTRODUCTION

Medication adherence is critical in chronic immune-mediated inflammatory diseases (IMIDs) and could be affected by patients' treatment-related beliefs. The objective of this study was to determine beliefs about systemic medications in patients with IMIDs and to explore the association of those beliefs and other factors with adherence.

METHODS

This was a multi-country, cross-sectional, self-administered survey study. Included were adults diagnosed with one of six IMIDs receiving conventional systemic medications and/or tumor necrosis factor inhibitors (TNFi). Patients' necessity beliefs/concerns towards and adherence to treatments were assessed by the Beliefs about Medicines Questionnaire and four-item Morisky Medication Adherence Scale. Correlation of patients' beliefs about treatment and other factors with adherence were evaluated by multivariable regression analyses.

RESULTS

Among studied patients (N = 7197), 32.0% received TNFi monotherapy, 27.7% received TNFi-conventional combination therapy, and 40.3% received conventional medications. Across IMIDs, high adherence to systemic treatment was more prevalent in TNFi groups (61.3-80.7%) versus corresponding conventional treatment groups (28.4-64.7%). In at least four IMIDs, greater perception of the illness continuing forever (P < 0.001), of the treatment helping (P < 0.001), and more concerns about the illness (P < 0.01), but not clinical parameters, were associated with higher treatment necessity beliefs. Higher treatment necessity beliefs, older age, Caucasian race, and TNFi therapy were associated with high medication adherence in at least four IMIDs.

CONCLUSIONS

Treatment necessity beliefs were higher than concerns about current medication in patients with IMID. Illness perceptions had a greater impact on treatment necessity beliefs than clinical parameters. Older age, greater treatment necessity beliefs, and TNFi therapy were associated with high self-reported medication adherence in at least four IMIDs.

TRIAL REGISTRATION

ACTRN12612000977875.

FUNDING

AbbVie.

Impact of Treatment-Related Beliefs on Medication Adherence in Immune-Mediated Inflammatory Diseases: Results of the Global ALIGN Study

Introduction

Medication adherence is critical in chronic immune-mediated inflammatory diseases (IMIDs) and could be affected by patients’ treatment-related beliefs. The objective of this study was to determine beliefs about systemic medications in patients with IMIDs and to explore the association of those beliefs and other factors with adherence.

Methods

This was a multi-country, cross-sectional, self-administered survey study. Included were adults diagnosed with one of six IMIDs receiving conventional systemic medications and/or tumor necrosis factor inhibitors (TNFi). Patients’ necessity beliefs/concerns towards and adherence to treatments were assessed by the Beliefs about Medicines Questionnaire and four-item Morisky Medication Adherence Scale. Correlation of patients’ beliefs about treatment and other factors with adherence were evaluated by multivariable regression analyses.

Results

Among studied patients (N = 7197), 32.0% received TNFi monotherapy, 27.7% received TNFi–conventional combination therapy, and 40.3% received conventional medications. Across IMIDs, high adherence to systemic treatment was more prevalent in TNFi groups (61.3–80.7%) versus corresponding conventional treatment groups (28.4–64.7%). In at least four IMIDs, greater perception of the illness continuing forever (P < 0.001), of the treatment helping (P < 0.001), and more concerns about the illness (P < 0.01), but not clinical parameters, were associated with higher treatment necessity beliefs. Higher treatment necessity beliefs, older age, Caucasian race, and TNFi therapy were associated with high medication adherence in at least four IMIDs.

Conclusions

Treatment necessity beliefs were higher than concerns about current medication in patients with IMID. Illness perceptions had a greater impact on treatment necessity beliefs than clinical parameters. Older age, greater treatment necessity beliefs, and TNFi therapy were associated with high self-reported medication adherence in at least four IMIDs.

Trial registration

ACTRN12612000977875.

Funding

AbbVie.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0441-3) contains supplementary material, which is available to authorized users.

Predictors of medication adherence: fact or artifact

Numerous studies have examined socio-demographic, psychosocial, and other factors as potential contributors to poor adherence. Variability exists in the strength and consistency of findings. We speculated that the method of measuring adherence might be a factor in the variability in identification of predictor variables. We examined the identification of predictors of adherence by method of measurement in two randomized, controlled trials of adherence interventions. Both studies used the Aardex Medication Event Monitor and the Morisky Self-Report Scale. Twenty-one days of baseline data from 698 subjects were examined in relation to measures of depression, functional status, perceived therapeutic efficacy, number of co-morbidities, and socio-demographic indices. Analysis included Spearman rho, Pearson r, and multiple logistic regression. Differences in the identification of predictors between adherence measurement methods were identified. These data support the hypothesis that different measurement methods yield different predictors of adherence.

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

BACKGROUND

Self-management-based interventions can lead to improved health outcomes in people with chronic diseases, and multiple patient characteristics are associated with the development of self-management behaviors. Low health literacy (HL) has been implicated in poorer self-management behaviors and increased costs to health services. However, the mechanisms behind this relationship remain unclear. Therefore, the aim of the current review is to assess the association between HL and patient characteristics related to self-management behaviors (i.e., disease-related knowledge, beliefs, and self-efficacy).

METHODS

The review comprised 3 phases: 1) database searches, 2) eligibility screening, and 3) study quality assessment and strength of evidence. Inclusion criteria specified that a valid HL screening tool was used, that at least one self-management behavior was assessed, and that patients had a chronic condition.

RESULTS

An initial search generated a total of 712 articles, of which 31 studies fulfilled the eligibility criteria. A consistent association was found between low HL and poorer disease-related knowledge in respiratory diseases, diabetes, and multiple disease categories. A significant association between low HL and poorer self-efficacy was reported in cardiovascular diseases, diabetes, human immunodeficiency virus, and multiple disease categories. HL was significantly associated with poorer beliefs in respiratory, musculoskeletal, and cardiovascular diseases.

DISCUSSION

The findings from the current review suggest that low HL may affect behaviors necessary for the development of self-management skills. Given that self-management strategies are core components for effective treatment of a range of chronic diseases, low HL poses a considerable health concern. Further research is needed to understand the mediating influence of HL on disease-related knowledge, self-efficacy, and beliefs. From this, HL-sensitive, self-management interventions ought to be devised and implemented.

A Study Evaluating Adherence and Compliance of Anti-rheumatic Drugs in Women Suffering from Rheumatoid Arthritis

BACKGROUND

Treatment of Rheumatoid arthritis (RA) has always remained challenging, complex and associated with high level of non adherence, noncompliance in clinical practice.

AIM

To evaluate the satisfaction/adherence/compliance rates of most commonly prescribed anti-rheumatic drugs among Indian women.

MATERIALS AND METHODS

A cross-sectional descriptive obser-vational study was undertaken to evaluate the adherence/compliance rates of most commonly prescribed anti-rheumatic drugs among women in a tertiary care teaching hospital in North India. Hundred women on anti rheumatic treatment for rheumatoid arthritis diagnosed by American College of Rheumatology (ACR) criteria were evaluated at one point analysis for adherence/compliance/satisfaction.

RESULTS

Dissatisfaction rate with the anti rheumatic treatment was significantly high p<0.0001 among 68% of the women. Non compliance/ non adherence rate was also recorded very high among 52% and interrupted compliance rate was noticed among 6% of the women suffering from RA. Switch over rate to other treatment or doctors was also significantly (p<0.0001) very high among 66% of the women. Switch over to alternative treatment, treatment under quacks and intermittent self medication was recorded by 12%, 4% & 16% respectively. Among the self medication 12% of the women took corticosteroids and 4% preferred taking intermittent NSAIDs.

CONCLUSION

Treatment compliance is not very good with anti-rheumatic drugs among women patients of RA due to multi-factorial reasons.

A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases

BACKGROUND

Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence.

OBJECTIVE

To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology.

DESIGN

Systematic review.

DATA SOURCES

Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from January 1, 1980 to February 14, 2014.

STUDY SELECTION

Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence.

DATA EXTRACTION

Data were extracted by the first reviewer using a standardized 23-item form and verified by a second/third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist.

RESULTS

73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional-patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment.

CONCLUSIONS

While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence.

Improving treatment adherence in patients with rheumatoid arthritis: what are the options?

Low adherence to therapeutic regimens is a prevalent and persistent healthcare problem, particularly for patients with chronic disorders. Many patients with rheumatoid arthritis (RA) show inadequate therapeutic adherence resulting in poor health outcomes. Reasons for nonadherence can be unintentional or intentional. The characteristics of patient-doctor interactions are also likely to play a role although they have not been well studied for patients with RA. While many educational and cognitive behavioral interventions have been proposed to improve adherence, the few studies that have examined the efficacy of these programs in RA have had disappointing results. Future studies involving the use of mobile technologies have shown promise in other chronic diseases and could prove useful for patients with RA.

Heterogeneous Disease Trajectories Explain Variable Radiographic, Function and Quality of Life Outcomes in the Canadian Early Arthritis Cohort (CATCH)

Our objective was to identify distinct trajectories of disease activity state (DAS) and assess variation in radiographic progression, function and quality of life over the first two years of early rheumatoid arthritis (ERA). The CATCH (Canadian early ArThritis CoHort) is a prospective study recruiting ERA patients from academic and community rheumatology clinics in Canada. Sequential DAS28 scores were used to identify five mutually exclusive groups in the cohort (n = 1,586) using growth-based trajectory modeling. Distinguishing baseline sociodemographic and disease variables, treatment required, and differences in radiographic progression and quality of life measures over two years were assessed. The trajectory groups are characterized as: Group 1 (20%) initial high DAS improving rapidly to remission (REM); Group 2 (21%) initial moderate DAS improving rapidly to REM; Group 3 (30%) initial moderate DAS improving gradually to low DAS; Group 4 (19%) initial high DAS improving continuously to low DAS; and Group 5 (10%) initial high DAS improving gradually only to moderate DAS. Groups differed significantly in age, sex, race, education, employment, income and presence of comorbidities. Group 5 had persistent steroid requirements and the highest biologic therapy use. Group 2 had lower odds (OR 0.22, 95%CI 0.09 to 0.58) and Group 4 higher odds (OR 1.94, 95%CI 0.90 to 4.20) of radiographic progression compared to Group 1. Group 1 had the best improvement in physical function (Health Assessment Questionnaire 1.08 (SD 0.68) units), Physical Component Score (16.4 (SD 10.2) units), Mental Component Score (9.7 (SD 12.5) units) and fatigue (4.1 (SD 3.3) units). In conclusion, distinct disease activity state trajectories explain variable outcomes in ERA. Early prediction of disease course to tailor therapy and addressing social determinants of health could optimize outcomes.

Medication adherence in patients with rheumatoid arthritis: the effect of patient education, health literacy, and musculoskeletal ultrasound

BACKGROUND

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting <1% of the population. Incompletely controlled RA results in fatigue, joint and soft tissue pain, progressive joint damage, reduced quality of life, and increased cardiovascular mortality. Despite an increasing range of disease modifying agents which halt disease progression, poor patient adherence with medication is a significant barrier to management.

OBJECTIVE

The goal of this review was to examine the effectiveness of measures to improve patient medication adherence.

METHODS

Studies addressing treatment adherence in patients with RA were identified by trawling PsycINFO, Medline, Cochrane, Pubmed, and ProQuest for studies published between January 2000 and October 2014. Articles were independently reviewed to identify relevant studies.

RESULTS

Current strategies were of limited efficacy in improving patient adherence with medications used to treat RA.

CONCLUSION

Poor medication adherence is a complex issue. Low educational levels and limited health literacy are contributory factors. Psychological models may assist in explaining medication nonadherence. Increasing patient knowledge of their disease seems sensible. Existing educational interventions appear ineffective at improving medication adherence, probably due to an overemphasis on provision of biomedical information. A novel approach to patient education using musculoskeletal ultrasound is proposed.

The influence of patients' knowledge on adherence to their chronic medications: a cross-sectional study in Jordan

BACKGROUND

Non-adherence to long-term therapy for chronic illnesses is considered the major reason why patients fail to reach their clinical goals, resulting in suboptimal health outcomes, death, and extra costs on the health care systems. Knowledge about the disease and prescription medications, an understanding of the reason the medication is needed, and good expectations or attitudes toward treatment, all contribute to a better medication-taking behavior and are associated with higher rates of adherence.

OBJECTIVE

This study examines the relationship between knowledge and adherence of patients receiving long-term therapy for one or more chronic illnesses in Jordan.

SETTINGS

The study was conducted in the out-patient clinics of two Jordanian hospitals (The University of Jordan Hospital and Jordan Hospital).

METHODS

This was a cross-sectional study that included 902 patients. The correlation between patients' knowledge about their chronic medications and adherence was assessed. Effects of several sociodemographic characteristics were investigated in regard to knowledge and adherence.

MAIN OUTCOME MEASURES

Knowledge was assessed by a modified version of the McPherson index, and the Morisky Medication Adherence Scale was used to assess medication adherence.

RESULTS

A significant correlation was found between patients' knowledge and their adherence to medications (r = 0.357, p < 0.001). Most of the participants had low adherence. Younger age, higher education levels, high income, fewer medications and diseases were significant predictors of higher knowledge levels. Knowledgeable patients were found to be twice as likely to have moderate-to-high adherence as their unknowledgeable counterparts. Similarly, high income and higher education were associated with higher adherence scores.

CONCLUSION

Forgetfulness and aversion toward medications were the most common barriers to medication adherence. This implicates that clinicians and health care policy makers should direct their effort toward two main strategies to improve adherence increasing awareness and education of effective ways to remind patients about their medications.

Blending Health Literacy With an English as a Second Language Curriculum: A Systematic Literature Review

About 21% of the U.S. population ages 5 and older speaks a language other than English at home, and many of them cannot communicate in English fluently. A possible intervention to improve health literacy for people with limited English proficiency is the use of an English as a second language curriculum. The purpose of this systematic review is to assess the characteristics (e.g., theoretical framework, developing processes, classroom activities, goals and topics) and effectiveness of English as a second language health literacy curricula that are currently available in English-dominant countries. We searched the online databases of ERIC, Sage, Springer, PubMed, Medline, and Scopus, identifying 7 curricula within 18 published reports. We synthesize the strengths and weaknesses of the reviewed curricula and provide recommendations for improving future health literacy interventions and research.

Assessing the impact of health literacy on education retention of stroke patients

INTRODUCTION

Inadequate health literacy is a pervasive problem with major implications for reduced health status and health disparities. Despite the role of focused education in both primary and secondary prevention of stroke, the effect of health literacy on stroke education retention has not been reported. We examined the relationship of health literacy to the retention of knowledge after recommended stroke education.

METHODS

This prospective cross-sectional study was conducted at an urban safety-net hospital. Study subjects were patients older than 18 admitted to the hospital stroke unit with a diagnosis of acute ischemic stroke who were able to provide informed consent to participate (N = 100). Health literacy levels were measured by using the short form of Test of Functional Health Literacy in Adults. Patient education was provided to patients at an inpatient stroke unit by using standardized protocols, in compliance with Joint Commission specifications. The education outcomes for poststroke care education, knowledge retention, was assessed for each subject. The effect of health literacy on the Stroke Patient Education Retention scores was assessed by using univariate and multivariate analyses.

RESULTS

Of the 100 participating patients, 59% had inadequate to marginal health literacy. Stroke patients who had marginal health literacy (mean score, 7.45; standard deviation [SD], 1.9) or adequate health literacy (mean score, 7.31; SD, 1.76) had statistically higher education outcome scores than those identified as having inadequate health literacy (mean score, 5.58; SD, 2.06). Results from multivariate analysis indicated that adequate health literacy was most predictive of education outcome retention.

CONCLUSIONS

This study demonstrated a clear relationship between health literacy and stroke education outcomes. Studies are needed to better understand the relationship of health literacy to key educational outcomes for primary or secondary prevention of stroke and to refine stroke education for literacy levels of high-risk populations.