Health literacy: an overlooked factor in understanding HIV health disparities

Readability of Patient Education Materials in Head and Neck Cancer: A Systematic Review

Importance

Patient education materials (PEMs) can promote patient engagement, satisfaction, and treatment adherence. The American Medical Association recommends that PEMs be developed for a sixth-grade or lower reading level. Health literacy (HL) refers to an individual's ability to seek, understand, and use health information to make appropriate decisions regarding their health. Patients with suboptimal HL may not be able to understand or act on health information and are at risk for adverse health outcomes.

Objective

To assess the readability of PEMs on head and neck cancer (HNC) and to evaluate HL among patients with HNC.

Evidence Review

A systematic review of the literature was performed by searching Cochrane, PubMed, and Scopus for peer-reviewed studies published from 1995 to 2024 using the keywords head and neck cancer, readability, health literacy, and related synonyms. Full-text studies in English that evaluated readability and/or HL measures were included. Readability assessments included the Flesch-Kincaid Grade Level (FKGL grade, 0-20, with higher grades indicating greater reading difficulty) and Flesch Reading Ease (FRE score, 1-100, with higher scores indicating easier readability), among others. Reviews, conference materials, opinion letters, and guidelines were excluded. Study quality was assessed using the Appraisal Tool for Cross-Sectional Studies.

Findings

Of the 3235 studies identified, 17 studies assessing the readability of 1124 HNC PEMs produced by professional societies, hospitals, and others were included. The mean FKGL grade ranged from 8.8 to 14.8; none of the studies reported a mean FKGL of grade 6 or lower. Eight studies assessed HL and found inadequate HL prevalence ranging from 11.9% to 47.0%.

Conclusions and Relevance

These findings indicate that more than one-third of patients with HNC demonstrate inadequate HL, yet none of the PEMs assessed were developed for a sixth grade or lower reading level, as recommended by the American Medical Association. This incongruence highlights the need to address the readability of HNC PEMs to improve patient understanding of the disease and to mitigate potential barriers to shared decision-making for patients with HNC. It is crucial to acknowledge the responsibility of health care professionals to produce and promote more effective PEMs to dismantle the potentially preventable literacy barriers.

A pilot test of an infographic-based health communication intervention to enhance patient education among Latino persons with HIV

OBJECTIVE

To pilot test an infographic-based health communication intervention that our team rigorously designed and explore whether its implementation leads to better health outcomes among Latino persons with HIV (PWH).

MATERIALS AND METHODS

Latino PWH (N = 30) living in New York City received the intervention during health education sessions at 3 study visits that occurred approximately 3 months apart. At each visit, participants completed baseline or follow-up assessments and laboratory data were extracted from patient charts. We assessed 6 outcomes (HIV-related knowledge, self-efficacy to manage HIV, adherence to antiretroviral therapy, CD4 count, viral load, and current and overall health status) selected according to a conceptual model that describes pathways through which communication influences health outcomes. We assessed changes in outcomes over time using quantile and generalized linear regression models controlling for the coronavirus disease 2019 (COVID-19) research pause and new patient status (new/established) at the time of enrollment.

RESULTS

Most participants were male (60%) and Spanish-speaking (60%); 40% of participants identified as Mixed Race/Mestizo, 13.3% as Black, 13.3% as White, and 33.3% as "other" race. Outcome measures generally improved after the second intervention exposure. Following the third intervention exposure (after the COVID-19 research pause), only the improvements in HIV-related knowledge and current health status were statistically significant.

DISCUSSION AND CONCLUSION

Our infographic-based health communication intervention may lead to better health outcomes among Latino PWH, but larger trials are needed to establish efficacy. From this work, we contribute suggestions for effective infographic use for patient-provider communication to enhance patient education in clinical settings.

Durable viral suppression among persons with HIV in the deep south: an observational study

This study assessed predictors of stable HIV viral suppression in a racially diverse sample of persons living with HIV (PWH) in the southern US. A total of 700 PWH were recruited from one of four HIV clinics in Metro Atlanta, GA. Data were collected from September 2012 to July 2017, and HIV viral loads were retrieved from EMR for 18 months. The baseline visits and EMR data were used for current analyses. Durable viral suppression was categorized as 1. Remain suppressed, 2. Remain unsuppressed, and 3. Unstable suppression. The number of antiretroviral medications and age were significantly associated with durable viral suppression. Older age, fewer ART medications and availability of social support were positively associated with durable viral suppression over the 18-month observation period. Findings suggest that regimen complexity is potentially a better predictor of viral suppression than self-reported medication adherence. The need for consensus on the definition of durable viral suppression is also urged.

Health literacy interventions in adult speech and language therapy: A scoping review

BACKGROUND

Reduced health literacy can negatively impact care seeking, satisfaction with care and overall health outcomes. These issues are particularly common among people living with communication difficulties who are seeking care from speech and language therapists (SLTs). As such, the SLT must be aware of and sensitive to health literacy needs within their clinical practice, proactively adapting materials and resources to the health literacy needs of their patients. Despite this required core competency, little is known about the health literacy interventions used by SLTs when working with adult patients, and as such, there is limited and unclear guidance for the practicing clinician, leading to potentially suboptimal care delivery.

OBJECTIVES

To explore the characteristics of health literacy interventions discussed in the literature for use by SLTs with adult patients.

SEARCH STRATEGY

PubMed, CINAHL, Web of Science and The Cochrane Database of Systematic Reviews were searched. Conference proceedings of the annual scientific meetings of the European Society for Swallowing Disorders and the Dysphagia Research Society were also searched. Grey literature was searched via the Open Grey database and, hand-searches of reference lists from included studies were conducted by both authors.

INCLUSION CRITERIA

Published and unpublished research investigating health literacy interventions provided by qualified SLTs providing care to adult patients in any setting for any speech and language related concerns. No language, geographic, study design or publication date limitations applied. Eligible participants in these studies were classified as: (1) patients and (2) professionals.

DATA EXTRACTION AND SYNTHESIS

Data were charted in accordance with guidelines from the Joanna Briggs Institute and the PRISMA ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) independently by both authors.

MAIN RESULTS

A total of 1112 potentially eligible studies were identified in the initial search, with 15 studies ultimately included in the synthesis. Study design and quality varied significantly. Most explored basic functional health literacy or narratively described core components of health literacy, which an SLT should understand, without employing an investigative research design.

DISCUSSION

Limited research has been conducted on the use of health literacy interventions within adult speech and language therapy practices. This finding is significant as SLTs regularly work with people living with communication problems, and therefore, addressing health literacy should be a core tenet of service delivery.

CONCLUSION

There is a need for valid, reliable and rigorous investigations of health literacy interventions within speech and language therapy to ultimately improve future patient access to and benefit from the care provided.

PATIENT OR PUBLIC CONTRIBUTION

Patient public involvement in review studies is an emerging area. Due to resource issues, it was not possible to include this element in this study.

Levels of health literacy among people living with HIV in outpatient care: a cross-sectional study from Denmark

BACKGROUND

Low health literacy (HL) among people living with HIV (PLWHIV) encounter more disease related complications, more difficulty understanding health-related information and low adherence. Considering that, the HL levels among PLWHIV needs to be further investigated. The objective of this study was to investigate the levels of HL and patient involvement among PLWHIV in an outpatient clinic in Denmark. A second objective was to examine differences in HL levels across socio-demographic characteristics.

METHODS

In 2019, a population of 682 PLWHIV from a Danish outpatient hospital clinic were enrolled in cross-sectional study. Patients who had a digital postbox received an electronic questionnaire including following domains; health literacy, patient involvement, and socio-demographic status. Health literacy was measured using the Health Literacy Questionnaire (HLQ) through scores on three subscales: social support for health (HLQ4), engaging with healthcare providers (HLQ6), and understanding health information (HLQ9). An unpaired t-test was used to investigate mean differences in the HLQ scores across socio-demographic variables.

RESULTS

A total of 338 (55%) patients responded to the questionnaire. The included participants demonstrated high levels of HLQ4 (mean = 4.2) and HLQ6 (mean = 4.2), but lower for HLQ9 (mean = 2.9). In total 70-80% reported being involved in decisions about their health. We found a positive association between high level of HL (HLQ9) and living with a partner and higher levels of HL (HLQ4, HLQ6, and HLQ9) and employment.

CONCLUSION

PLWHIV in a Danish out-patient care population were found to have high levels of HL despite differences in demographic characteristics. Further research is needed to examine the levels of HL among non-responders to develop HL approaches and strategies to meet the needs of individuals with different HL skills.

Validation of the Assessments of Adult Health Literacy: A Rasch Measurement Model Approach

Background

Both the World Health Organization and U.S. Department for Health and Human Services have emphasized the importance of health literacy (HL) to improving population health and reducing health disparities. HL includes three core areas/qualities: functional (i.e., health-related reading, writing, and numeracy), interactive/communicative (i.e., skills for interacting with multiple constituents and sources of information and navigating the health environment), and critical (i.e., personal and community advocacy for health). HL is implicated in medical adherence, preventive health, mental health stigma and help-seeking, and health decision-making. Though HL is critical to health and health decision-making, research on HL is still relatively limited, with most research focusing on functional HL. A major gap in research is related to the lack of measurement of interactive and critical HL. To address this gap, this study modified and assessed the validity of the Assessments of Adolescent Health Literacy (AAHL-Adolescent), test-based assessments of adolescents' functional, interactive, and critical HL, in an adult sample.

Methods

One item from the AAHL-Adolescent item bank was modified to be more appropriate for an adult sample. Adults (n=2346) completed a measurement battery that included the HL item bank (12 functional, 15 interactive, and 9 critical HL questions), Newest Vital Sign (NVS), Single-Item Literacy Scale (SILS), demographics, and questions about HL-related behaviors. The assessments were evaluated and validated using Rasch measurement models. Convergent and criterion validity were assessed.

Results

The final 7-item functional, 10-item interactive, and 7-item critical HL assessments and their composite (24 items) fit their respective Rasch models. Item-level invariance was established for gender, ethnicity, education, and age across all assessments. Differential item functioning for race was noted for two items on the interactive HL assessments. Good convergent validity with the NVS and SILS and good criterion validity with the HL-related behaviors were observed for all assessments.

Conclusions

The AAHL-Adult is the first test-based instrument validated in the U.S. that includes assessments for all three core qualities of HL. These assessments have utility across multiple settings, including public health program planning and evaluation, intervention development and evaluation, and clinical settings.

HIV and AIDS prevention: knowledge, attitudes, practices and health literacy of older persons in the Western Cape and KwaZulu-Natal Provinces, South Africa and in Lesotho

BACKGROUND

Population ageing and access to anti-retroviral therapies in South Africa have resulted in ageing of the HIV/AIDS epidemic, which has implications for policy, planning and practice. Impactful interventions on HIV/AIDS for older persons require knowledge on effects of the pandemic on this population. A study was undertaken to assess knowledge, attitudes, and practices (KAP) of HIV/AIDS, as well as health literacy (HL) level of a population aged ≥ 50 years.

METHODS

A cross-sectional survey was conducted at three sites in South Africa and two sites in Lesotho with an educational intervention at the South African sites. At baseline, data were collected for assessment of KAP of HIV/AIDS and HL levels. The pre- and post-intervention comprised participants at South African sites being familiarised with the contents of a specially constructed HIV/AIDS educational booklet. Participants' KAP was reassessed six weeks later. A composite score of ≥ 75% was considered adequate KAP and an adequate HL level.

RESULTS

The baseline survey comprised 1163 participants. The median age was 63 years (range 50-98 years); 70% were female, and 69% had ≤ 8 years' education. HL was inadequate in 56% and the KAP score was inadequate in 64%. A high KAP score was associated with female gender (AOR = 1.6, 95% CI = 1.2-2.1), age < 65 years (AOR = 1.9, 95% CI = 1.5-2.5) and education level (Primary school: AOR = 2.2; 95% CI = 1.4-3.4); (High school: AOR = 4.4; 95% CI = 2.7-7.0); (University/college: AOR = 9.6; 95% CI = 4.7-19.7). HL was positively associated with education but no association with age or gender. The educational intervention comprised 614 (69%) participants. KAP scores increased post intervention: 65.2% of participants had adequate knowledge, versus 36% pre-intervention. Overall, younger age, being female and higher education level were associated with having adequate knowledge about HIV/AIDS, both pre- and post-intervention.

CONCLUSIONS

The study population had low HL, and KAP scores regarding HIV/AIDS were poor but improved following an educational intervention. A tailored educational programme can place older people centrally in the fight against the epidemic, even in the presence of low HL. Policy and educational programmes are indicated to meet the information needs of older persons, which are commensurate with the low HL level of a large section of that population.

A mobile app for chronic disease self-management for individuals with low health literacy: A multisite randomized controlled clinical trial

Objective

The purpose of this study was to evaluate the effects of a mobile app designed to improve chronic disease self-management in older adult patients with low health literacy and who had at least one chronic health condition, and to assess the impact of delivering information at different levels of reading difficulty.

Methods

A randomized controlled trial was completed at two sites. Individuals 40 years of age and older screened for low health literacy who had at least one chronic health condition were randomly assigned to a tailored information multimedia app with text at one of three grade levels. Four primary outcomes were assessed: patient activation, chronic disease self-efficacy, health-related quality of life, and medication adherence.

Results

All groups showed overall increases in activation, self-efficacy, and health-related quality of life, but no change in medication adherence. No between-group differences were observed.

Conclusions

The mobile app was effective in increasing participants' levels of several psychosocial variables, but reading difficulty level was not significantly related to outcomes.Registered at clinicaltrials.gov NCT02922439.

Health literacy, financial insecurity and health outcomes among people living with HIV in Australia

It is well documented that lower socio-economic status is associated with poorer health outcomes, while health literacy is considered important for improving health. What is less clear, is the extent to which greater health literacy can improve health outcomes among people for whom poverty or financial insecurity are important barriers to health. The paper presents findings from an Australian survey of people living with HIV (PLHIV) (N = 835) in which we explored the relationship between financial insecurity and health outcomes, looking at the extent to which health literacy mediates this relationship. The study drew on a comprehensive definition of health literacy, measuring participant’s confidence to communicate with healthcare providers, navigate the health system and take an active stance in relation to their health. Findings showed that financial insecurity was associated with lower health literacy and poorer self-reported physical and mental health. Health literacy mediated 16.2% of the effect of financial insecurity on physical health scores and 16.6% of the effect of financial insecurity on mental health scores. This suggests that programmes which seek to build health literacy among PLHIV may improve health outcomes among PLHIV who are struggling financially. Health literacy programmes are likely to be effective if they build confidence and resourcefulness among people to engage with health information, decision-making and care.

A Systematic Review of Factors Critical for HIV Health Literacy, ART Adherence and Retention in Care in the U.S. for Racial and Ethnic Minorities

Despite advances in antiretroviral treatment (ART), the HIV epidemic persists in the United States (U.S.), with inadequate adherence to treatment and care a major barrier to ending the epidemic. Health literacy is a critical factor in maximizing ART adherence and healthcare utilization, especially among vulnerable populations, including racial and ethnic minorities. This U.S-based systematic review examines psychosocial variables influencing health literacy among persons with HIV (PWH), with a focus on racial and ethnic minorities. Although findings are limited, some studies showed that HIV-related stigma, self-efficacy, and patient trust in providers mediate the relationship between health literacy and both ART adherence and HIV care retention. To inform effective, equitable health literacy interventions to promote adherence to HIV treatment and care, further research is needed to understand the factors driving the relationship between health literacy and HIV outcomes. Such work may broaden our understanding of health literacy in the context of racial equity.

Development of a Complex Intervention for Health Care Professionals' Care of Patients With African Background and HIV Infection Using the Behavior Change Wheel Method

Introduction. Insufficient cultural competences among health care professionals (HCPs) working with ethnic minorities may result in poorer quality of care. This study aimed to develop a cultural intervention for HCPs. Method. The intervention was designed using the Behavior Change Wheel. The development phase contained empirical studies of patients with HIV and African background, literature review, observations from a migrant health clinic, and transcultural care theory. Results. Systematic development will facilitate an intervention tailored to focus on nurses' sensitivity and awareness, and aims to give them tools to identify narratives about patients' life situation and self-management as well as provide effective, compassionate, and culturally competent care. Discussion. Higher cultural competence among nurses may improve their support of patients to manage their disease.

Neurocognitive performance differences between black and white individuals with HIV disease are mediated by health literacy

Objective:Health disparities are evident for Black Americans with HIV disease, who are disproportionally affected by the epidemic in the United States. The current study investigated whether the higher rates of neurocognitive impairment in Black Americans with HIV disease may be at least partly attributable to health literacy, which is a potentially modifiable factor. Method: Participants were 61 White and 25 Black participants (ages 27-70) with HIV disease who were enrolled in studies at an urban academic center in Southern California. Neurocognitive function was assessed by an age-adjusted global score from the Cogstate battery. Health literacy was measured by a composite score derived from the Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign, and 3-Brief. Results: Bootstrap confidence interval mediation analyses showed that health literacy was a significant mediator of the relationship between race and neurocognition; that is, there were no direct ethnoracial differences in neurocognition after accounting for health literacy. A follow-up model to confirm the directionality of this association demonstrated that neurocognition was not a significant mediator of the relationship between race and health literacy. Conclusions: Low health literacy may contribute to the higher rates of neurocognitive impairment for Black Americans with HIV disease. Future studies might examine the possible mechanism of this mediating relationship (e.g., access to health information, health behaviors, socioeconomics) and determine whether culturally tailored interventions that improve health literacy also confer broader brain health benefits for Black Americans with HIV disease.

Clinician Use of HIV-Related Infographics During Clinic Visits in the Dominican Republic is Associated with Lower Viral Load and Other Improvements in Health Outcomes

We designed an infographic intervention to help clinicians provide health information to persons living with HIV. In this study, we assessed the extent to which our intervention may improve objectively and subjectively measured health outcomes (CD4 count, viral load, and engagement with clinician among others) when integrated into routine visits in the Dominican Republic. In this pretest-posttest study, we followed participants for 9 months at 3-month intervals. Physicians administered the intervention during participants' first 3 visits. Outcome measures, selected using a conceptual model, were assessed at 4 time points. We assessed changes in outcomes over time with general linear regressions and Wilcoxon Signed-Rank tests. Participants (N = 50) were mostly female (56%) and had been living with HIV for a mean of 6.3 years (SD = 6.1). All outcomes, except CD4 count, demonstrated statistically significant improvements by study end. This provides preliminary evidence our intervention may improve outcomes, but further testing is needed.

Social Disparities in Benign Lung Diseases

The many socioeconomic disparities in the myriad of diagnoses that make up benign lung diseases are unfortunately a global issue that was most recently highlighted by the COVID-19 pandemic of 2020. In this chapter, we will be reviewing the socioeconomic disparities in benign lung disease from both a United States perspective as well as a global perspective. We will cover the spectrum of infectious, obstructive, and restrictive lung disease and review the evidence on how social disparities affect these populations and their access to medical care.

Use of Pre-exposure Prophylaxis Among People Who Inject Drugs: Exploratory Findings of the Interaction Between Race, Homelessness, and Trust

Scale-up of pre-exposure prophylaxis (PrEP) in people who inject drugs (PWID) remains suboptimal. Patient-level factors are often complex and may contribute to scale-up. Using cross-sectional data from 234 opioid-dependent patients on methadone who met eligibility criteria for PrEP, we conducted logistic regression analyses to assess potential moderators associated with being on PrEP (n = 60). Mean provider trust was significantly higher among Blacks vs Whites (39.4 vs 34.9; p = 0.002) and non-homeless vs homeless participants (37.5 vs 34.8; p = 0.008). Though race/ethnicity was not a significant moderator on provider trust and PrEP use, increased provider trust was marginally associated with increased PrEP use among Blacks (p = 0.058). Additionally, homelessness significantly moderated provider trust and PrEP use (p = 0.024). Provider trust among non-homeless participants was positively correlated with PrEP use (p = 0.013) but not among homeless participants. Strategies that promote provider trust in Blacks and non-homeless PWID on methadone may improve PrEP scale-up.

Prevalence and Predictors of Limited Literacy in Public Mental Health Care

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and "other" race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

Malaysian Health Literacy: Scorecard Performance from a National Survey

Health literacy is an indicator of a society's ability to make better health judgements for themselves and the people around them. This study investigated the prevalence of health literacy among Malaysian adults and provided an overall picture of the society's current health literacy status, which has not been previously assessed. The study also highlighted socio-demographic markers of communities with limited health literacy that may warrant future intervention. A population-based self-administered survey using the Health Literacy Survey Malaysian Questionnaire18 (HLS-M-Q18) instrument was conducted as part of the National Health Morbidity Survey 2019 in Malaysia. The nationwide survey utilized a two-staged stratified random sampling method. A sample of 9478 individuals aged 18 and above, drawn from the living quarter list, participated in the study. The health literacy score was divided into three levels; limited, sufficient, and excellent. Findings showed a majority of the Malaysian population had a sufficient health literacy level in all three domains-healthcare, diseases prevention and health promotion (49.1%, 44.2%, and 47.5%, respectively)-albeit leaning towards the lower end of the category with an average score of 35.5. The limited health literacy groups were prevalent among respondents with older age (68%), lower education level (64.8%), and lower household income (49.5%). The overall health literacy status for Malaysia was categorized at a lower sufficiency level. Future health literacy improvements should focus on communities with a limited health literacy level to improve the overall score.

Hepatitis C Knowledge and Recent Diagnosis Affect Hepatitis C Treatment Willingness in Persons Living With HIV

BACKGROUND

We assessed the impact of health literacy and hepatitis C (HCV) knowledge on HCV treatment willingness among people living with HIV (PLWH) at an academic HIV clinic.

METHODS

Cross-sectional analysis of PLWH coinfected with HCV who completed health literacy, HIV literacy, and HCV knowledge inventories. We estimated the prevalence of low health literacy, HIV knowledge, and HCV knowledge sampled from 3-comparison groups: PLWH not referred for HCV, referred but who "not showed" to the HCV clinic, and referred and attended the HCV clinic. We used mixed-model linear and logistic regression to ascertain predictors of low health literacy, HIV knowledge, HCV knowledge, and predictors of willingness to start HCV treatment.

RESULTS

We enrolled 151 PLWH; 17% were female, 38% non-White, and 60% without a high-school education. Approximately, 68% were men who have sex with men, of whom 62% used intravenous drugs. The prevalence of low health, HIV knowledge, and HCV knowledge was 10%, 32%, and 29%, respectively. Predictors of low health literacy were being Hispanic, cirrhotic, and not completing high-school education. Low HCV knowledge was observed in female, non-White, and those diagnosed with HCV for a decade. In adjusted analyses, PLWH living with HCV for a decade (OR: 0.23) were less likely to be very willing to be treated for HCV. By contrast, those with high HCV knowledge were more likely to be very willing to receive treatment (OR: 1.27).

CONCLUSION

Low HCV knowledge and living with HCV for at least a decade are under-recognized negative predictors for PLWH's willingness to receive HCV treatment.

CLINICAL TRIALS REGISTRATION

ClinicaTrials.gov identifier: NCT20170991.

Effects of Race and Ethnicity on Diagnosis and Management of Inflammatory Bowel Diseases

Although Crohn's disease (CD) and ulcerative colitis (UC) have been considered as disorders that affect individuals of European ancestry, the epidemiology of the inflammatory bowel diseases (IBDs) is changing. Coupled with the increasing incidence of IBD in previously low-incidence areas, the population demographics of IBD in the United States are also changing, with increases among non-White races and ethnicities. It is therefore important to fully understand the epidemiology and progression of IBD in different racial and ethnic groups, and the effects of race and ethnicity on access to care, use of resources, and disease-related outcomes. We review differences in IBD development and progression among patients of different races and ethnicities, discussing the effects of factors such as access to care, delays in diagnosis, and health and disease perception on disparities in IBD care and outcomes. We identify research priorities for improving health equity among minority patients with IBD.

Adverse Effects of Radiotherapy and Chemotherapy for Common Malignancies: What Is the Quality of Information Patients Are Finding Online?

Little is known about the availability of high-quality online health information (OHI) for adverse effects (AEs) of radiotherapy (RT) and chemotherapy (CHT). Optimal search strategies for gaining access to high-quality OHI for these topics are not well-established. This study explores the quality of, potential disparities in, and possible search strategies for OHI pertaining to AEs of RT and CHT. One hundred twenty phrases on generalized and malignancy site-specific AEs of RT and CHT were searched on Google. The Health on the Net Foundation (HONcode) framework was applied to assess the quality of the first 100 websites for each search phrase. Comparisons of the availability of high-quality OHI were made between different languages, malignancy sites, and treatment modalities (RT vs CHT). Of the 12,000 RT and CHT AE websites analyzed, approximately half of the first 10 websites returned for each search were HONcode-accredited; approximately a fifth of the first 100 websites returned were HONcode-accredited. Such low availability of high-quality OHI persisted throughout different languages (English, French, Spanish) and common malignancy sites (breast, prostate, lung), with some variations between languages, malignancy sites, and RT vs CHT. Despite the important role of OHI in cancer patients' approach to health information gathering and decision-making, the availability of high-quality OHI for the AEs of common oncologic treatments, RT and CHT, is low across different languages and common malignancy sites. Our findings demonstrate the need for improvement in the availability of high-quality OHI. Therefore, providers should take an active stance in directing patients to high-quality OHI.

A Clinical Pilot Study of Spaced Retrieval Practice with a Self-Generation Booster to Improve Health-Related Memory in Persons With HIV Disease

Objective

Spaced retrieval practice (SRP) and self-generation are among the most replicated and effective mnemonic strategies in the cognitive psychology literature, but their benefits have not yet been realized in healthcare settings. This study used a randomized, between-subjects design to examine the hypothesis that SRP with a self-generation booster can improve memory for health-related information among clinically referred persons with HIV (PWH), who often have difficulty acquiring new health knowledge.

Method

A consecutive series of 41 PWH referred to a county-funded urban neuropsychology clinic were enrolled. Participants were randomly assigned to learn four statements about the treatment of a mock infectious disease in either a massed study control condition (n = 20) or an SRP condition (n = 21) in which they received two distributed free recall training tests supplemented with self-generation for missed items. The primary outcome was participants’ free recall of the four treatment statements after a 20-minute delay filled with nonverbal tests.

Results

PWH participants in the SRP condition were four times more likely than controls to recall at least one treatment statement at the 20-minute delay. SRP was not related to post-test recognition or health-related decision-making performance but was associated with moderately better self-efficacy for decision-making.

Conclusions

Findings from this pilot study show the potential of SRP with a self-generation booster to improve learning and memory for health-related information among PWH in clinic.

Patient-Physician Racial Concordance Associated with Improved Healthcare Use and Lower Healthcare Expenditures in Minority Populations

BACKGROUND

Racial concordance between patients and clinician has been linked to improved satisfaction and patient outcomes.

OBJECTIVES

(1) To examine the likelihood of clinician-patient racial concordance in non-Hispanic White, non-Hispanic Black, Asian, and Hispanic patients and (2) to evaluate the impact of patient-clinician race concordance on healthcare use and expenditures within each racial ethnic group.

METHODS

We analyzed data from the 2010-2016 Medical Expenditure Panel Survey (MEPS). We used bivariate and multivariate models to assess the association between patient-clinician race concordance and emergency department (ED) use, hospitalizations, and total healthcare expenses, controlling for patient socio-demographic factors, insurance coverage, health status, and survey year fixed effects.

RESULTS

Of the 50,626 adults in the analysis sample, 32,350 had racial concordance with their clinician. Among Asian and Hispanic patients, low income, less education, and non-private insurance were associated with an increased likelihood of patient-clinician racial concordance. Emergency department use was lower among Whites and Hispanics with concordant clinicians compared to those without a discordant clinician (15.6% vs. 17.3%, p = 0.02 and 12.9% vs. 16.2%, p = 0.01 respectively). Total healthcare expenditures were lower among Black, Asian, and Hispanic patients with race-concordant clinicians than those with discordant clinicians (14%, 34%, and 20%, p < 0.001 respectively).

CONCLUSIONS

These results add to the body of evidence supporting the hypothesis that racial concordance contributes to a more effective therapeutic relationship and improved healthcare. These results emphasize the need for medical education surrounding cultural humility and the importance of diversifying the healthcare workforce.

Development of a Diabetes-Focused Print Health Literacy Scale Using the Rapid Estimate of Adult Literacy in Medicine Model

BACKGROUND

A diabetes mellitus (DM)-specific health literacy (HL) measure that focuses on both oral and print HL is needed in clinical and research settings.

OBJECTIVE

The present study developed a psychometrically sound DM-specific HL instrument that measures oral and print HL.

METHODS

We developed the measure in three steps. First, we reviewed clinical guidelines and conducted focus groups with experts to generate items. Next, we conducted a psychometric evaluation of the scale in three language versions (English, Spanish, and Korean). Lastly, we identified and removed items with potential cultural bias and duplicate functions to produce shorter versions of the scale, using item response theory (IRT).

KEY RESULTS

We initially developed an 82-item DM-specific oral HL scale using the Rapid Estimate of Adult Literacy in Medicine (DM-REALM) model. To improve the clinical utility of the DM-REALM, we created shorter forms, a 40-item and 20-item version, and evaluated them by using IRT. All DM-REALM versions had high Cronbach alphas (.985, .974, and .945, respectively) and yielded sufficient convergent validity by positive correlations with existing functional HL scale (r = .49, p < .001), education (r = .14, p = .14 to r = .54, p < .001), and DM knowledge (r = .04, p = .70 to r = .36, p < .001). DM-REALM also demonstrated adequate sensitivity as an intervention evaluation tool that captures the changes induced by an intervention.

CONCLUSIONS

All forms of the DM-REALM tool were reliable, valid, and clinically useful measures of HL in the context of DM care. Both researchers and clinicians can use this tool to assess DM-specific HL across multiple racial and ethnic populations. [HLRP: Health Literacy Research and Practice. 2020;4(4):e237-e249.] PLAIN LANGUAGE SUMMARY: This article reported the process and findings of a newly developed health literacy scale for people with diabetes mellitus using three different language versions. Both long and short versions of the scale demonstrated adequate validity and reliability.

Health Knowledge and Adherence as Predictors of Viral Burden and CD4+ T-Cell Count in Youth and Young Adults Living With HIV

Health literacy influences HIV treatment for youth and, thus, is a research priority. We explored health knowledge and self-reported adherence, as indicators of health literacy, among youth living with HIV (YLWH) and the association between health literacy and health outcomes. A total of 102 YLWH ages 13-25 years participated in the study. Participants completed the Brief Estimate of Health Knowledge and Action-HIV Version; CD4 T-cell counts and viral loads were extracted from participant medical records. Participants had a moderate amount of HIV knowledge, and most reported taking their medications under most conditions. Decreasing action scores were statistically associated with an increased likelihood of having a detectable viral load. Health literacy is an important factor that should be addressed by practitioners working with YLWH. More research is needed to determine the best way to measure and improve health literacy.

Radiation Oncology Online: Quality, Strategies, and Disparities

Although much is known about the quality of online health information (OHI) for many malignancies, the availability of high-quality OHI for oncologic treatments remains undefined. Furthermore, search strategies that improve quality of radiation oncology OHI, and disparities in availability of high-quality OHI, are not well-described. Forty phrases describing malignancies and their treatment modalities (radiation, chemotherapy, and surgery), and 57 phrases describing radiation oncology treatments, including abbreviations for some treatments and translations in different languages, were generated. The Health on the Net Foundation framework for assessing OHI quality was applied to the top 100 websites listed for each search phrase. The availability of high-quality OHI between malignancies and treatment modalities, and among treatment modalities, was compared. The roles of radiation oncology term abbreviation, search result order, patient gender, and language, on availability of high-quality OHI, were also assessed. Among the first 10, 20, and 50 websites for each search phrase, there were significantly more high-quality websites for phrases describing malignancies compared with respective treatment modalities (P < 0.02 for all). There were no differences among treatment modalities. Among radiation oncology treatment phrases, there were no significant differences between searches for full-name phrases and their respective abbreviations, though earlier results were more likely to be of high quality. Gender did not affect quality of OHI, though language did. Availability of high-quality OHI for cancer treatments lags behind that of cancer OHI. For radiation oncology treatment OHI, search strategies and patient disparities highlight potential areas for provider intervention and increased quality of OHI.

An instrument to assess HIV-related knowledge and adjustment to HIV+ status, and their association with anti-retroviral adherence

Background

Findings on the association between health literacy and anti-retroviral (ARV) adherence are inconsistent. Health literacy is usually operationalized with simple tests of basic literacy, but more complex conceptions of health literacy include content knowledge. People living with chronic illness also conceptualize and experience illness in ways other than biomedical or mechanistic models of disease.

Objective

There are no instruments that comprehensively assess knowledge of people living with HIV concerning HIV disease and treatment; or psychological adjustment to being HIV+. Little is known about the relationship between factual knowledge, or positive identification as HIV+, and anti-retroviral (ARV) adherence.

Methods

Formative work with in-depth semi-structured interviews, and cognitive testing, to develop a structured instrument assessing HIV-related knowledge, and personal meanings of living with HIV. Pilot administration of the instrument to a convenience sample of 101 respondents.

Key results

Respondents varied considerably in their expressed need for in-depth knowledge, the accuracy of their understanding of relevant scientific concepts and facts about ARV treatment, and psychological adjustment and acceptance of HIV+ status. Most knowledge domains were not significantly related to self-reported ARV adherence, but accurate knowledge specifically about ARV treatment was (r = 0.25, p = .02), as was an adapted version of the Need for Cognition scale (r = .256, p = .012). Negative feelings about living with HIV (r = .33, p = .0012), and medication taking (r = .276, p = .008) were significantly associated with non-adherence.

Conclusion

The instrument may be useful in diagnosing addressable reasons for non-adherence, as a component of psychoeducational interventions, and for evaluation of such interventions.

Medication understanding and health literacy among patients with multiple chronic conditions: A study conducted in Bangladesh

Objectives: Medication understanding is critical for patients who suffer from multiple chronic conditions in order to reduce medication error and is often associated with poor health outcomes and low adherence. This study aims to identify the gap of medication knowledge among multiple chronic condition patients in Bangladesh, in order to aid physicians and other healthcare providers in improving health literacy. Methods: Individual interviews of a convenience sample of multiple chronic condition patients in Bangladesh were held where they were asked a number of questions for assessing medication related literacy. Results: More than 26% patients failed to cite the brand name of all their prescribed medications while the rate of patients not knowing the generic names was far worse (88.1%). Nearly 1 out of every 4 patients did not know the purpose of all their medications and more than half of the participants (55%) did not know the strengths of their drugs. While knowledge about medication routes and regimen was satisfactory, awareness regarding risk factors of medicine was lowest of all. Only 1 out of every 4 patients had a habit of reading drug information leaflet. Patient's ability to correctly state the purpose of their medication seemed to be positively associated with age (p=0.004) and negatively associated with number of medicines taken (p=0.03). Conclusions: Many patients demonstrated poor health literacy regarding medication. Routine review of medications from physician or health provider can significantly improve their health literacy, leading to better treatment outcome and medication adherence.

Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review

While socioeconomic disparities are among the most fundamental causes of health disparities, socioeconomic status (SES) does not impact health directly. One of the potential mediating factors that link SES and health is health literacy (HL). Yet although HL can be considered a modifiable risk factor of socioeconomic disparities in health, the relationship between SES, HL and health disparities is not well understood. This study reviewed the evidence regarding the mediating role of HL in the relationship between socioeconomic and health disparities. Medline, Cinahl, Embase, PsychInfo, Eric, Web of Science, Google, Google Scholar, Mednar, Doaj and Worldcat were used to retrieve studies that specifically addressed socioeconomic and socio-demographic factors related to low HL levels, as well as the mediating role of HL in the relationship between SES and disparities in health outcomes. Selected studies were assessed for methodological quality. Sixteen published studies were retained for inclusion and content analyzed using the constant comparison method. The review indicates that disadvantaged social and socioeconomic conditions contribute to low HL levels, whereby low SES, and particularly educational attainment, is the most important determinant of HL, and that HL mediates the relationship between SES and health status, quality of life, specific health-related outcomes, health behaviors and use of preventive services. HL can be considered as a modifiable risk factor of socioeconomic disparities in health. Enhancing the level of HL in the population or making health services more accessible to people with low HL may be a means to reach a greater equity in health.

A Path Analysis of Patient and Social-Level Factors on Health Literacy and Retention in Care Among African Americans Living with HIV

Low health literacy and poor retention in care may contribute to HIV health disparities among African Americans, but causal pathways have not been examined. We utilized an adapted health literacy model to examine the role of health literacy on racial disparities in retention in care. Retention in care for 699 participants was assessed 24-months post survey and operationalized as 100% visit adherence versus less than 100% visit adherence. Most participants were African American (60%) and virally suppressed (93%). Results from a path analysis revealed that non-African American race was related to greater health literacy (p = .023) and to 100% visit adherence (p = .024). Greater health literacy was associated with 100% visit adherence (p = .008), which was in turn related to viral suppression (p < .001). Findings indicate that health literacy partially mediates the relationship between race and retention in care and are among the first to suggest these causal pathways.

Promoting Transformative Community Change for Equitable Health: Peer Education and Intervention for Pre-Exposure HIV Prophylaxis

Many new HIV infections occur through individuals who are unaware of their HIV status. HIV disparities are more prevalent among underserved populations, and the number of new cases in the U.S. is highest in the Southern region. Using the Social Network Intervention, 63 undergraduate students delivered a face-to-face, communication-centered, peer education to 333 peers in the underserved communities; of those, 220 verified cases were analyzed. A baseline assessment was followed by the intervention and the second assessment, with the third assessment 2 weeks later. Assessments measured intervention impacts on health information sharing, knowledge about HIV/AIDS, and the dimensions of vested interest theory. The peer education was effective in making changes in participants' vestedness, knowledge regarding HIV/AIDS, and trust and expectation toward informational sources. Communication and tailored messages through established relationship channels were proven crucial for promoting positive behaviors about HIV sexual health, with strong evidence of change in stigma and the culture of silence.

Predictors of disparities in retention in care among African Americans living with HIV

Limited health literacy may contribute to racial disparities in retention in HIV care. The purpose of this study was to evaluate the effects of health literacy and patient and social-level factors on retention in care among African Americans living with HIV. This study included 699 participants recruited from outpatient HIV clinics and retention in care was defined as visit adherence. Multivariable logistic regression models were used to assess predictors of visit adherence among persons with 100% visit adherence compared to less than 100% visit adherence. Controlling for demographic factors, the odds of 100% visit adherence was greater among non-African Americans compared to African Americans. In models that included health literacy, race was no longer significant and health literacy was a significant predictor of 100% visit adherence. Among participants with less than 100% visit adherence, health literacy was not a significant predictor of visit adherence; however, age, marital status, and patient attitudes towards the health care provider were significant predictors. Findings suggest that health literacy may mediate the relationship between race and visit adherence. Future studies should further examine these relationships and develop interventions that target modifiable factors, with a goal of improving health equity and minimizing disparities.

Health Literacy and Health Outcomes in Persons Living with HIV Disease: A Systematic Review

Low health literacy is associated with challenges for those living with HIV including medication non-adherence and poorer health outcomes. The aim of this study was to systematically review the literature on health literacy and health outcomes in persons living with HIV. The extended guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, as well as A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist were utilized to guide the approach to the review. A variety of electronic databases including PubMed, CINAHL, PsychInfo, and Cochrane Library were searched. Additional literature available on U.S. government websites was also included in the search. Search terms were used in a variety of combinations and included HIV, health literacy, adherence, and health outcomes. Forty-eight studies were identified that addressed health literacy and health outcomes in HIV. Although several studies in this review did not provide robust results of statistical significance linking health literacy with health outcomes, all of the studies addressed the key significance of health literacy within the scope of living with HIV disease. The relationship between health literacy and the identified health outcomes requires further research and explication.

Trajectories and Predictors of Longitudinal Preexposure Prophylaxis Adherence Among Men Who Have Sex With Men

Background

Adherence is necessary for efficacy of preexposure prophylaxis (PrEP), and text-messaging methods are promising tools for both adherence assessment and support. Although PrEP adherence is variable, little research has examined patterns of variability or factors associated with longitudinal use.

Methods

In the context of a randomized controlled trial of text-messaging versus standard of care for PrEP adherence, 181 men who have sex with men received once-daily tenofovir disoproxil fumarate/emtricitabine and daily adherence texts for 48 weeks. Growth mixture modeling (GMM) was used to identify subgroups of individuals with similar trajectories of text-reported adherence. Between-group differences in pharmacologic measures of adherence (ie, tenofovir diphosphate and emtricitabine triphosphate levels), as well as predictors and study-end attitudes associated with group membership, were examined.

Results

GMM identified 4 trajectories of text-reported adherence. Classes with higher text-reported adherence had higher drug concentrations. Younger age and minority race were associated with lower adherence, and individuals in classes with lower adherence had greater baseline levels of depression, substance use concerns, and sexual risk. Differences in study satisfaction were also associated with adherence.

Conclusions

This study supports the use of text-reported PrEP adherence. Identifying factors associated with less-than-optimal adherence may aid clinicians in anticipating at-risk patients requiring augmented intervention.

Clinical trials registration

NCT01761643.

Developing Infographics to Facilitate HIV-Related Patient-Provider Communication in a Limited-Resource Setting

BACKGROUND

Productive patient-provider communication is a recognized component of high-quality health care that leads to better health outcomes. Well-designed infographics can facilitate effective communication, especially when culture, language, or literacy differences are present.

OBJECTIVES

This study aimed to rigorously develop infographics to improve human immunodeficiency virus (HIV)-related patient-provider communication in a limited-resource setting. A secondary purpose was to establish through participant feedback that infographics convey intended meaning in this clinical and cultural context.

METHODS

We adapted a participatory design methodology, developed in a high-resource setting, for use in the Dominican Republic. Initially, content to include was established using a data-triangulation method. Then, infographics were iteratively generated and refined during five phases of design sessions with three stakeholder groups: (1) 25 persons living with HIV, (2) 8 health care providers, and (3) 5 domain experts. Suggestions for improvement were incorporated between design sessions and questions to confirm interpretability of infographics were included at the end of each session.

RESULTS

Each participant group focused on different aspects of infographic designs. Providers drew on past experiences with patients and offered clinically and contextually relevant recommendations of symbols and images to include. Domain experts focused on technical design considerations and interpretations of infographics. While it was difficult for patient participants to provide concrete suggestions, they provided feedback on the meaning of infographics and responded clearly to direct questions regarding possible changes. Fifteen final infographics were developed and all participant groups qualitatively confirmed that they displayed the intended content in a culturally appropriate and clinically meaningful way.

CONCLUSION

Incorporating perspectives from various stakeholders led to the evolution of designs over time and generated design recommendations that will be useful to others creating infographics for use in similar populations. Next steps are to assess the feasibility of using infographics to improve clinical communication and patient outcomes.

Validation of the short assessment of health literacy (SAHL-D) and short-form development: Rasch analysis

Background

Accurate measurement of health literacy is essential to improve accessibility and effectiveness of health care and prevention. One measure frequently applied in international research is the Short Assessment of Health Literacy (SAHL). While the Dutch SAHL (SAHL-D) has proven to be valid and reliable, its administration is time consuming and burdensome for participants. Our aim was to further validate, strengthen and shorten the SAHL-D using Rasch analysis.

Methods

Available cross-sectional SAHL-D data was used from adult samples (N = 1231) to assess unidimensionality, local independence, item fit, person fit, item hierarchy, scale targeting, precision (person reliability and person separation), and presence of differential item functioning (DIF) depending on age, gender, education and study sample.

Results

Thirteen items for a short form were selected based on item fit and DIF, and scale properties were compared between the two forms. The long form had several items with DIF for age, gender, educational level and study sample. Both forms showed lower measurement precision at higher health literacy levels.

Conclusions

The findings support the validity and reliability of the SAHL-D for the long form and the short form, which can be used for a rapid assessment of health literacy in research and clinical practice.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0762-4) contains supplementary material, which is available to authorized users.

Critical, and not functional, health literacy is associated with missed HIV clinic visits in adults and older adults living with HIV in the Deep South

Engagement in care is a key component of the HIV treatment cascade and is influenced by biopsychosocial factors. Little is known about the association of health literacy with this impactful outcome in people living with HIV (PLWH). Ninety-five PLWH completed a comprehensive battery including health literacy measures covering several domains (i.e., numeracy, reading, self-efficacy, and ability to appraise and access health information). Engagement in care was operationalized as missed clinic visits (i.e., proportion of clinic visits in the prior 24 months where the participant did not attend and did not cancel or reschedule). The ability to appraise health information (measured by the Newest Vital Sign [NVS]) was the only significant health literacy predictor of missed clinic visits. Hierarchical linear regression including clinico-demographics and all health literacy variables showed that age, depression, neurocognition, and NVS were significant (p < 0.05) correlates of missed clinic visits. The ability to appraise health information was a strong and independent predictor of missed clinic visits in PLWH, even in the context of traditional correlates. Such measures may be useful in identifying PLWH with low health literacy who may be at risk for poorer engagement in care. Future research developing interventions targeting this health literacy dimension are warranted.

Health Literacy Mediates Racial Disparities in Cardiopulmonary Resuscitation Knowledge among Chronic Kidney Disease Patients

Black patients with chronic kidney disease (CKD) receive more cardiopulmonary resuscitation (CPR) than other racial groups, and knowledge of CPR influences preferences for care. As limited health literacy disproportionately affects Blacks and contributes to disparities in end-of-life (EOL) care, we investigated whether health literacy mediates racial disparities in CPR knowledge. Black and White adult patients with advanced CKD completed CPR knowledge surveys. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Among 149 patients, Black patients were more likely to have limited health literacy and lower mean CPR knowledge scores than White patients. In adjusted analyses, health literacy mediated racial differences in CPR knowledge. Knowledge of CPR is lower among Black compared with White CKD patients and health literacy is a mediator of this difference. Future CPR educational interventions should target health literacy barriers to improve informed decision-making and decrease racial disparities at the end of life.

Acceptability, Feasibility, and Preliminary Efficacy of a Theory-Based Relational Embodied Conversational Agent Mobile Phone Intervention to Promote HIV Medication Adherence in Young HIV-Positive African American MSM

An embodied conversational agent can serve as a relational agent and provide information, motivation, and behavioral skills. To evaluate the feasibility, acceptability, and preliminary efficacy of My Personal Health Guide, a theory-based mobile-delivered embodied conversational agent intervention to improve adherence to antiretroviral therapy in young African American men who have sex with men, we conducted this prospective pilot study using a 3-month pre-post design. Outcome measures included adherence, acceptability, feasibility, pre versus post health literacy, and pre versus post self-efficacy. There were 43 participants. Pill count adherence > 80% improved from 62% at baseline to 88% at follow-up (p = .05). The acceptability of the app was high. Feasibility issues identified included loss of usage data from unplanned participant app deletion. Health literacy improved whereas self-efficacy was high at baseline and follow-up. This pilot study of My Personal Health Guide demonstrated acceptability and preliminary efficacy in improving adherence in this important population.

Health Literacy and Income Mediate Racial/Ethnic Asthma Disparities

Background:

Health literacy and socioeconomic status (SES) are associated with both race/ethnicity and asthma outcomes. The extent to which health literacy and SES mediate racial/ethnic asthma disparities is less clear.

Objective:

To determine if health literacy and SES mediate racial/ethnic asthma disparities using advanced mediation analyses.

Methods:

A secondary analysis was performed using a Chicago-based longitudinal cohort study conducted from 2004 to 2007 involving 342 adults age 18 to 41 years with persistent asthma. Phone interviews were conducted every 3 months assessing asthma quality of life (AQOL; scored 1–7, with 7 being the highest) and asthma-related health care use measures. Structural equation models assessed mediation of race/ethnicity effects on AQOL and health care use through health literacy and SES. Covariates in the best-fit model included sex, year and season of interview, and cigarette smoking.

Key Results:

The study sample was 77.8% female, 57.3% African American/non-Hispanic, and 28.7% Hispanic. Race/ethnicity was significantly associated with AQOL and asthma-related emergency department (ED) visits, but only indirectly, through the effects of health literacy and income. Compared with White/non-Hispanics, African American/non-Hispanics and Hispanics had significantly higher odds of low health literacy and lower income. Low health literacy was associated with significantly lower AQOL scores (β = −0.24, 95% confidence interval (CI) [−0.38, −0.10]) and higher odds of an ED visit (adjusted odds ratio = 1.24, 95% CI [1.07, 1.43]). Increasing income was associated with significantly higher AQOL scores (β = 0.18, 95% CI [0.08, 0.28]) and lower odds of an ED visit (adjusted odds ratio = 0.88, 95% CI [0.80, 0.97]).

Conclusions:

The relationships between race/ethnicity and several asthma outcomes were mediated by health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers. [HLRP: Health Literacy Research and Practice. 2019;3(1):e9–e18.]

Plain Language Summary:

Using advanced statistical methods, this study suggests racial/ethnic differences in several asthma outcomes are largely due to effects of health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers.

Association Between Health Literacy, eHealth Literacy, and Health Outcomes Among Patients With Long-Term Conditions

Abstract. The objective of this paper is to synthesize and update findings from systematic review on health literacy and health outcomes among patients with long-term conditions, and extend the review to the digital domain. Health outcomes include clinical outcomes, processes of care, and health service use. Data sources are the following: (1) studies which appeared in two previous systematic reviews in 2004 and 2011 whose participants were people with long-term conditions or elderly ( n = 54); (2) articles on health literacy and health outcomes identified in an updated 2011–2016 search ( n = 26); (3) articles on eHealth literacy and its association with health outcomes ( n = 8). Strength of evidence was determined by a qualitative assessment of risk of bias, consistency, and directness. There was a lack of consistent evidence on the relationship between health literacy and clinical outcomes despite the consistent evidence on the association with mortality. There was low to insufficient evidence on the association between health literacy and self-rated health/function and emotional states of anxiety and depression, alongside high evidence on lack of association with quality of life. There was insufficient to low evidence on the association between health literacy and behavioral outcomes (medication adherence, other health behaviors) and finally also low to moderate evidence on the association between health literacy and use of health services such as hospitalization and emergency department. In the eHealth literacy domain, there were few studies reporting association with health behaviors and self-rated health with inconsistent results. In conclusion, it is advocated to examine performed heath literacy and eHealth literacy in large longitudinal studies.

Enhancing the Impact of Mobile Health Literacy Interventions to Reduce Health Disparities

Health literacy is a key factor in health outcomes that should be considered when creating mobile health promotion apps. In this paper, we detail our work over the past 10 years in developing the theory and practice of targeting the content of mobile apps at a level appropriate for the intended audience. We include a review of our theory of health literacy as expertise, the ASK model, and integrate it with the Theory of Planned Behavior. We then provide data that support both the model and its use. More recently, we have developed a predictive analytic model that uses demographic information and patient performance on a 10-item screening measure to determine patient level of health literacy at a high level of accuracy. The predictive model will enable apps to automatically provide content to users at an appropriate level of health literacy. This strategy, along with other aspects of tailoring, will allow apps to be more personally relevant to users, enhancing their effects in promoting health behavior change.

Racial Disparities in HIV Antiretroviral Medication Management are Mediated by Health Literacy

Background:

Despite the availability of antiretroviral (ARV) therapy in the United States, only 30% of people living with HIV/AIDS (PLWH) in the US are virally suppressed. Nonadherence to ARVs remains the strongest correlate of viral suppression. African Americans (AA) living with HIV/AIDS remain disproportionately affected by this disease, and studies report a greater proportion of infections and deaths among this group.

Objective:

Earlier studies by this team and others have shown that health literacy (HL) may negatively influence disparities in health behaviors, including management of ARV prescriptions, between AA and non-AA PLWH. This current study expands these findings and tests whether HL may explain disparities in medication management among AA and non-AA PLWH and includes important covariates and measures of participants' actual medication regimens.

Methods:

PLWH were recruited from HIV care clinics in the greater metropolitan area of Atlanta, GA, and completed a face-to-face study visit. A total of 699 PLWH, 65% of whom were AA, completed this study visit. Assessment of knowledge and management of participants' actual medication regimens showed highly skewed responses, demonstrating accurate verbal descriptions of ARV prescription instructions. A measure of problem-solving (how to manage a mock ARV regimen) showed significantly different performance by race and that HL measures (both reading comprehension and numeracy) mediated this relationship.

Key Results:

Findings suggest that although PLWH may be able to verbally explain how they are supposed to take their ARV medication, challenges may arise with management issues (eg, determining need for a refill, counting pills to determine if a dose was missed) and that PLWH with low HL (who are disproportionately AA) may be at greater risk for mistakes. Other characteristics, such as cognitive impairment, were also shown to influence medication management.

Conclusion:

Attention to PLWH's potential for mismanagement of ARV and other medications is important to identify for educational interventions. [Health Literacy Research and Practice. 2018;2(4):e205–e213.]

Plain Language Summary:

This study tested if problems with taking medicine to treat HIV may be caused by poor reading and math skills. Even though most people were able to correctly say how they should take their HIV pills, knowing if they had missed a pill or counting out a week's number of pills was harder for those with lower reading and math skills.

Randomized Trial of a Health Coaching Intervention to Enhance Retention in Care: California Collaborative Treatment Group 594

Poor linkage, engagement and retention remain significant barriers in achieving HIV treatment goals in the US. HIV-infected persons entering or re-entering care across three Southern California academic HIV clinics, were randomized (1:1) to an Active, Linkage, Engagement, Retention and Treatment (ALERT) specialist for outreach and health coaching, or standard of care (SOC). The primary outcome of time to loss to follow up (LTFU) was compared using Cox proportional hazards regression modeling. No differences in the median time to LTFU (81.7 for ALERT versus 93.6 weeks for SOC; HR 1.27; p = 0.40), or time to ART initiation was observed (N = 116). Although, ALERT participants demonstrated worsening depressive symptomatology from baseline to week 48 compared to SOC (p = 0.02). The ALERT intervention did not improve engagement and retention in HIV care over SOC. Further studies are needed to determine how best to apply resources to improve retention and engagement.

Health Literacy Among a Formerly Incarcerated Population Using Data from the Transitions Clinic Network

Health literacy is increasingly understood to be a mediator of chronic disease self-management and health care utilization. However, there has been very little research examining health literacy among incarcerated persons. This study aimed to describe the health literacy and relevant patient characteristics in a recently incarcerated primary care patient population in 12 communities in 6 states and Puerto Rico. Baseline data were collected from 751 individuals through the national Transitions Clinic Network (TCN), a model which utilizes a community health worker (CHW) with a previous history of incarceration to engage previously incarcerated people with chronic medical diseases in medical care upon release. Participants in this study completed study measures during or shortly after their first medical visit in the TCN. Data included demographics, health-related survey responses, and a measure of health literacy, The Newest Vital Sign (NVS). Bivariate and linear regression models were fit to explore associations among health literacy and the time from release to first clinic appointment, number of emergency room visits before first clinic appointment and confidence in adhering to medication. Our study found that almost 60% of the sample had inadequate health literacy. Inadequate health literacy was associated with decreased confidence in taking medications following release and an increased likelihood of visiting the emergency department prior to primary care. Early engagement may improve health risks for this population of individuals that is at high risk of death, acute care utilization, and hospitalization following release.

Health Literacy and Demographic Disparities in HIV Care Continuum Outcomes

Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.

A Realistic Talking Human Embodied Agent Mobile Phone Intervention to Promote HIV Medication Adherence and Retention in Care in Young HIV-Positive African American Men Who Have Sex With Men: Qualitative Study

Background

Avatars and embodied agents are a promising innovation for human health intervention because they may serve as a relational agent that might augment user engagement in a behavioral change intervention and motivate behavioral change such as antiretroviral adherence and retention in care.

Objective

This study aimed to develop a theory-driven talking avatar-like embodied agent mobile phone intervention guided by the information-motivation-behavioral skills model to promote HIV medication adherence and retention in care in young African American men who have sex with men (MSM).

Methods

We performed 5 iterative focus groups in Chicago with HIV-positive African American MSM aged 18-34 years to inform the ongoing development of a mobile phone app. Participants for the focus groups were recruited from 4 University of Illinois at Chicago Community Outreach Intervention Project sites located in different high HIV incidence areas of the city and the University of Illinois at Chicago HIV clinic using fliers and word of mouth. The focus group data analysis included developing an ongoing list of priorities for app changes and discussion between two of the investigators based on the project timeline, resources, and to what extent they served the app’s objectives.

Results

In this study, 16 men participated, including 3 who participated in two groups. The acceptability for an embodied agent app was universal in all 5 focus groups. The app included the embodied agent response to questions and antiretroviral regimen information, adherence tracking, CD4 count and viral load tracking, motivational spoken messages, and customizability. Concerns that were identified and responded to in the development process included privacy, stigma, avoiding the harsh or commanding tone of voice, avoiding negative motivational statements, and making reminder functions for a variety of health care interactions.

Conclusions

An avatar-like embodied agent mHealth approach was acceptable to young HIV-positive African American MSM. Its relational nature may make it an effective method of informing, motivating, and promoting health behavioral skills. Furthermore, the app’s ease of access, stigma-free environment, and audiovisual format may help overcome some adherence barriers reported in this population.

Health literacy and current CD4 cell count in a multiethnic U.S. sample of adults living with HIV infection

Hispanic and Black adults are disproportionately affected by HIV and experience poorer HIV-related health outcomes relative to non-Hispanic White adults. The current study adopted Sørensen's integrated model to test the hypothesis that lower functional and critical health literacy competencies contribute to poorer HIV-related health and CD4 cell count for Hispanic and Black individuals. Eighty-one non-Hispanic White, Hispanic, and Black HIV seropositive individuals from a large, Southwestern metropolitan area were administered measures of health literacy, including the Expanded Numeracy Scale, Newest Vital Sign, Rapid Estimate of Adult Literacy in Medicine, Test of Functional Health Literacy (TOHFLA)-numeracy, and TOHFLA-reading. Hispanic and Black individuals demonstrated less HIV knowledge than non-Hispanic White individuals. Black participants demonstrated fewer health literacy appraisal skills. Importantly, lower levels of health literacy were linked to poorer CD4 cell count (an index of immune functioning) for Hispanic and Black individuals and not for non-Hispanic White individuals. These findings suggest race group differences for health literacy on current CD4 cell count such as very specific dimensions of low health literacy (e.g. poorer judgment of health-related information), but not other presumed deficits (e.g. motivation, access), play an important role in clinical health outcomes in HIV.

An Analysis of Race-related Attitudes and Beliefs in Black Cancer Patients: Implications for Health Care Disparities

This research concerned relationships among Black cancer patients' health care attitudes and behaviors (e.g., adherence, decisional control preferences,) and their race-related attitudes and beliefs shaped by (a) general life experiences (i.e., perceived discrimination, racial identity) and (b) experiences interacting with health care systems (i.e., physician mistrust, suspicion about medical care). Perceived discrimination, racial identity, and medical suspicion correlated weakly with one another; mistrust and suspicion correlated only moderately. Race-related attitudes and beliefs were associated with health care attitudes and behavior, but patterns of association varied. Physician mistrust and medical suspicion each independently correlated with adherence and decisional control preferences, but discrimination only correlated with control preferences. Associations among patients' different racial attitudes/beliefs are more complex than previously assumed. Interventions that target patient attitudes/beliefs and health care disparities might be more productive if they focus on mistrust or suspicion specific to health care providers/systems and their correlates identified in this study.