The association between health literacy and indicators of cognitive impairment in a diverse sample of primary care patients

The Relationship Between Health Literacy and Outcomes Before and After Kidney Transplantation

Limited health literacy (HL) is associated with decreased kidney function and death in patients with chronic kidney disease. Less is known about the impact of HL on kidney transplant (KT) outcomes. The aim of this study was to examine the relationship between HL and KT outcomes, including rates of waitlisting, healthcare utilization, acute rejection, renal allograft function, renal allograft failure, and death.

Methods

We performed a retrospective review of HL data previously collected at our center. HL was assessed in a convenience sample of consecutive, English-speaking patients age ≥18 y who were evaluated for KT at Mayo Clinic in Minnesota between June 2015 and March 2017 as part of a practice improvement feasibility project (n = 690). HL was assessed using the 4-item Brief Health Literacy Screening Tool modified for the outpatient KT evaluation process. The 4 items assess confidence completing forms, reading comprehension, and oral literacy.

Results

Overall, 30.4% of patients had limited or marginal HL. Patients with limited or marginal HL were less likely than those with adequate HL to be waitlisted for KT (hazard ratio = 0.62 and 0.69, respectively), even after adjusting for age, marital status, body mass index, Charlson comorbidity index, or dialysis dependency. Patient HL was not associated with post-KT healthcare utilization, acute rejection, or renal allograft function. Patients with limited or marginal HL appeared to experience a higher risk of renal allograft failure and post-KT death, but the number of events was small, and the relationship was statistically significant only for marginal HL.

Conclusions

Inadequate HL is common in KT candidates and independently associated with decreased waitlisting for KT. We observed no statistically significant relationship between HL and posttransplant outcomes in our cohort. Further efforts to improve communication in patients with inadequate HL may improve access to KT.

The Influence of Health Literacy and Social Support on Loneliness Among Patients With Severe Mental Illness in Rural Southwest China

Loneliness is an important risk factor for poor health outcomes among adults, especially among those with severe mental illnesses (SMIs). Existing research has shown that adults with SMIs often lack health literacy, which contributes to more restricted social networks and low levels of social support. The objective of this cross-sectional study was to examine the influence of health literacy and social support on the loneliness of patients with SMI in rural Southwest China. We recruited 300 patients with SMI in rural Southwest China between December, 2017 to May, 2018 via a multi-stage stratified random sampling approach. We used structural equation modeling (SEM) test the hypothesized relationships among the variables of the 270 patients who completed the survey. Results of the SEM showed that health literacy was both directly and indirectly associated with loneliness, with social support playing a mediating role. These findings suggest psychoeducation for SMI patients, and their informal caregivers, may offer beneficial effects toward reducing loneliness in this vulnerable population. Further, social support is another potential target for intervention development for improving patient outcomes.

Change in Health Literacy over a Decade in a Prospective Cohort of Community-Dwelling Older Adults

BACKGROUND

Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health.

OBJECTIVES

We sought to examine health literacy over time among older adults using three widely used measures.

DESIGN

A prospective cohort study.

PARTICIPANTS

Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL.

MEASURES

Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points.

RESULTS

In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity.

CONCLUSION

We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.

Validation of the European Health Literacy Survey Questionnaire in Women With Breast Cancer

BACKGROUND

Health literacy enables effective communication, participation, and cooperation with clinicians of patients with breast cancer in healthcare processes. The European Health Literacy Survey Questionnaire (HLS-EU-Q) comprehensively assesses multiple conceptual domains of health literacy in a diverse range of health contexts. However, the HLS-EU-Q has not been validated in women with breast cancer.

OBJECTIVES

We examined the psychometric properties, particularly the factorial validity, of the HLS-EU-Q in women with breast cancer.

METHODS

We performed a first-order confirmatory factor analysis (CFA) to verify the 12-subdomain model of the 47-item HLS-EU-Q. A second-order CFA was conducted to investigate whether the 12 subdomains reflected the 3 domains of healthcare, disease prevention, and health promotion correspondingly.

RESULTS

A total of 475 women with breast cancer participated in this study. The first-order CFA fitted with the HLS-EU-Q containing 47 items. However, item 29, with a low factor loading (-0.05), was deleted. The modified first-order CFA adequately fitted the data of the HLS-EU-Q with 46 items. The second-order CFA model acceptably fitted with the data, but the 3 domains with high correlations (0.92-1.00) were merged into a single domain, health literacy.

CONCLUSIONS

Our results supported the factorial validity of the 12-subdomain HLS-EU-Q with 46 items in women with breast cancer. It is recommended that the 12 subdomain scores be summed up to represent overall health literacy.

IMPLICATIONS FOR PRACTICE

The HLS-EU-Q with 46 items is recommended for use in capturing the diverse health literacy competencies of women with breast cancer in different health contexts.

Subclinical Cognitive Impairment and Listing for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Cognitive impairment is common in patients with kidney disease and can affect physicians' perception and/or patients' ability to complete the pretransplant evaluation. We examined whether cognitive impairment influences the likelihood for transplant listing and whether patients with cognitive impairment take longer to be listed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a single-center longitudinal cohort study. Patients presenting for their index kidney transplant evaluation were screened for cognitive impairment using the Montreal Cognitive Assessment. A score <26 indicated cognitive impairment. The transplant selection committee was blinded to the scores. Kaplan-Meier analysis assessed time to active listing by level of cognition. A Cox proportional hazards model that included age, sex, race/ethnicity, smoking, coronary artery disease, and diabetes was constructed to evaluate the association between Montreal Cognitive Assessment score and listing for transplant.

RESULTS

In total, 349 patients who underwent Montreal Cognitive Assessment testing at their initial visit were included in the analysis. Patients with cognitive impairment were more likely to be older, black, and smokers. The time to listing in patients with cognitive impairment was longer than the time to listing in those with no cognitive impairment (median time, 10.6 versus 6.3 months; log rank test P=0.01). Cognitive impairment was independently associated with a lower likelihood of being listed for transplant (hazard ratio, 0.93 per unit lower Montreal Cognitive Assessment score; 95% confidence interval, 0.88 to 0.99; P=0.02). A lower proportion of patients with cognitive impairment were listed compared with patients without cognitive impairment at 1 month (2% versus 11%), 6 months (17% versus 37%), and 1 year (23% versus 41%), (P<0.001 for all).

CONCLUSIONS

Cognitive impairment is associated with a lower likelihood of being listed for kidney transplant, and is associated with longer time to transplant listing.

Association between an individual housing-based socioeconomic index and inconsistent self-reporting of health conditions: a prospective cohort study in the Mayo Clinic Biobank

OBJECTIVE

Using surveys to collect self-reported information on health and disease is commonly used in clinical practice and epidemiological research. However, the inconsistency of self-reported information collected longitudinally in repeated surveys is not well investigated. We aimed to investigate whether a socioeconomic status based on current housing characteristics, HOUsing-based SocioEconomic Status (HOUSES) index linking current address information to real estate property data, is associated with inconsistent self-reporting.

STUDY SETTING AND PARTICIPANTS

We performed a prospective cohort study using the Mayo Clinic Biobank (MCB) participants who resided in Olmsted County, Minnesota, USA, at the time of enrolment between 2009 and 2013, and were invited for a 4-year follow-up survey (n=11 717).

PRIMARY AND SECONDARY OUTCOME MEASURES

Using repeated survey data collected at the baseline and 4 years later, the primary outcome was the inconsistency in survey results when reporting prevalent diseases, defined by reporting to have 'ever' been diagnosed with a given disease in the baseline survey but reported 'never' in the follow-up survey. Secondary outcome was the response rate for the 4-year follow-up survey.

RESULTS

Among the MCB participants invited for the 4-year follow-up survey, 8508/11 717 (73%) responded to the survey. Forty-three per cent had at least one inconsistent self-reported disease. Lower HOUSES was associated with higher inconsistency rates, and the association remained significant after pertinent characteristics such as age and perceived general health (OR=1.46; 95% CI 1.17 to 1.84 for the lowest compared with the highest HOUSES decile). HOUSES was also associated with lower response rate for the follow-up survey (56% vs 77% for the lowest vs the highest HOUSES decile).

CONCLUSION

This study demonstrates the importance of using the HOUSES index that reflects current SES when using self-reporting through repeated surveys, as the HOUSES index at baseline survey was inversely associated with inconsistent self-report and the response rate for the follow-up survey.

A Systematic Review of Cognition in Chiari I Malformation

Displacement of the cerebellar tonsils in Chiari type I malformation (CMI) can affect functions controlled by the cerebellum and brainstem. While playing an integral role in the control of movement, the cerebellum also has widespread cortical connections, influencing a range of cognitive process. A systematic literature review was conducted to examine the relationship between cognition and CMI, assessing evidence for general or domain-specific cognitive change. The search protocol examined the AMED, CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Scopus databases. Articles meeting the following criteria were included in this review (i) examined children or adults with a clinically defined diagnosis of CMI, (ii) assessed cognitive function with a prospective examination, (iii) included at least one standardized instrument designed to measure general or specific domains of cognitive function, and (iv) were published in English in a peer-reviewed journal. Twelve articles were identified, including 783 cases aged 3 months to 64 years. General cognition, processing speed, and learning and memory appeared less affected, while language deficits appeared to diminish with age. Executive dysfunction was the most commonly reported cognitive impairment, while attention and working memory, and visuospatial and perceptual skills also appeared vulnerable. Numerous methodological limitations were identified that should be considered in interpreting the impact of CMI and planning future investigations. Overall, there is currently insufficient evidence to describe a valid and reliable profile of cognitive impairment in CMI. Further research is required to confirm these preliminary psychometric results and integrate them with pathophysiological models.

Health literacy assessment in adults with neurofibromatosis: electronic and short-form measurement using FCCHL and Health LiTT

Determining health literacy level is an important prerequisite for effective patient education. We assessed multiple dimensions of health literacy and sociodemographic predictors of health literacy in patients with neurofibromatosis. In 86 individuals with a confirmed diagnosis of neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2), or schwannomatosis, we assessed health literacy status using two HL tools-the adapted functional, communicative, and critical health literacy scale (adapted FCCHL) and health literacy assessment using talking touchscreen technology (Health LiTT). Factor analyses of the adapted FCCHL in NF patients showed factor structure and psychometric properties similar to pilot work in other patient populations. As a group, patients with NF had moderate scores on the Health LiTT and moderate to high scores on the adapted FCCHL, with the highest score on the functional health literacy subscale. Patients with NF1, those with lower education and those with learning disabilities had lower scores on Health LiTT; in multivariate analysis, learning disability and education remained significant predictors of HealthLiTT scores. Only lower education was associated with lower adapted FCCHL scores. Results suggest utilizing health literacy tools in NF patients is feasible and could provide physicians with valuable information to tailor health communication to subpopulations with lower health literacy levels.

Health and Functional Literacy in Physical Rehabilitation Patients

Background

People with disabilities, who face multiple barriers to care, experience health disparities, yet few studies have measured health literacy in this population.

Objective

This study evaluated functional literacy, health literacy, fluid cognitive function, and self-reported health in people who live in community dwellings with spinal cord injury, stroke, or traumatic brain injury.

Methods

Participants with a traumatic spinal cord injury, stroke, or traumatic brain injury, one-year postinjury, and age 18 to 85 years, completed a battery of instruments at three medical centers in the Midwestern U.S.: functional literacy (word recognition, vocabulary knowledge), health literacy (comprehension of prose, document, and quantitative health information), fluid cognitive function (memory, executive function, and processing speed), and patient-reported outcomes (mobility, fatigue, sadness, anxiety, social function, and overall health).

Key Results

There were strong correlations between functional literacy, health literacy, and fluid cognitive function. After adjustment for sociodemographic and clinical characteristics, higher health literacy was associated with better mobility, less anxiety, and better overall health; higher functional literacy was associated with less anxiety and better overall health; and higher fluid cognitive function was associated with better mobility, less sadness, better social function, and better overall health.

Conclusions

To effectively address limited health literacy among people with spinal cord injury, stroke, and traumatic brain injury, and ensure that they are able to be informed partners in their health care, intervention is required at the level of patients, providers, and health care delivery systems. A special consideration is to ensure that health information is both well-targeted to people's health literacy levels and accessible for people with a range of physical, cognitive, and sensory limitations. The multimedia self-administered health literacy measure used in this study could be useful to rehabilitation providers and designers of health information and interfaces. [Health Literacy Research and Practice. 2017;1(2):e71-e85.].

Plain Language Summary

Health literacy represents people's abilities to obtain, understand, and use health information to make informed decisions about their health and health care. People with disabilities face physical, attitudinal, economic, and structural barriers to care. Consideration of health literacy in rehabilitation practice can enhance the effectiveness of the patient-clinician relationship and help address the needs of this population.

Educational strategies and challenges in peritoneal dialysis: a qualitative study of renal nurses' experiences

AIMS AND OBJECTIVES

The aim of the study was to explore renal nurses' experiences, strategies and challenges with regard to the patient education process in peritoneal dialysis.

BACKGROUND

Patient education in peritoneal dialysis is essential to developing a successful home-based peritoneal dialysis program. In this area research is scarce and there is a particular lack of focus on the perspective of the renal nurse.

DESIGN

Qualitative design formed by thematic qualitative text analysis.

METHODS

Five group interviews (n = 20) were used to explore the challenges peritoneal dialysis nurses face and the training strategies they use. The interviews were analyzed with thematic qualitative content analysis using deductive and inductive subcategory application.

RESULTS

The findings revealed the education barriers perceived by nurses that patients may face. They also showed that using assessment tools is important in peritoneal dialysis patient education, as is developing strategies to promote patient self-management. There is a need for a deeper understanding of affective learning objectives, and existing teaching activities and materials should be revised to incorporate the patient's perspective. Patients usually begin having questions about peritoneal dialysis when they return home and are described as feeling overwhelmed. Adapting existing conditions is considered a major challenge for patients and nurses.

CONCLUSIONS

The results provided useful insights into the best approaches to educating peritoneal dialysis patients and served to raise awareness of challenges experienced by renal nurses. Findings underline the need for nosogogy - an approach of teaching adults (andragogy) with a chronic disease. Flexibility and cooperation are competencies that renal nurses must possess.

RELEVANCE TO CLINICAL PRACTICE

Still psychomotor skills dominate peritoneal dialysis patient training, there is a need of both a deeper understanding of affective learning objectives and the accurate use of (self-)assessment tools, particularly for health literacy.

Health Literacy Is Associated With Health Behaviors and Social Factors Among Older Adults: Results from the LifeLines Cohort Study

This study assesses the associations between health literacy and various health behaviors and social factors among older adults, and whether social factors moderate the other associations. Data from 3,241 participants in the LifeLines Cohort Study were analyzed (mean baseline age = 68.9 years). Data on health literacy, health behaviors (physical activity, fruit and vegetable consumption, smoking, breakfast consumption, alcohol consumption, and body mass index (BMI), and social factors (loneliness, social support, social activities, social contacts, and living situation) were collected in three waves. Logistic regression analyses were used, adjusted for age and gender. Low health literacy was associated with insufficient physical activity, insufficient fruit and vegetable consumption, lack of regular breakfast consumption, obesity (odds ratios (ORs) > 1.31, p-values < .005) and low alcohol use (OR = 0.81, p = .013), but not with smoking. Low health literacy was also associated with greater loneliness, engaging in fewer social activities, and having fewer social contacts (ORs > 1.48, p-values < .005), but not with social support or living situation. Only the association between health literacy and smoking was moderated by social contacts, but this finding needs confirmation in future studies. In conclusion, low health literacy is negatively associated with health behaviors and social factors in older adults, but social factors seldom moderate the associations between health literacy and health behaviors.

Association Between Cognitive Impairment and Chronic Kidney Disease in Mexican Americans

Objectives

To analyze the association between chronic kidney disease (CKD) and mild cognitive impairment (MCI) in Mexican Americans and to determine whether there is a blood‐based proteomic profile linking CKD to MCI.

Design

Retrospective analysis of cohort study.

Setting

Health and Aging Brain among Latino Elders study.

Participants

Mexican Americans (N = 437, 105 men, 332 women).

Measurements

Data were analyzed to examine the link between estimated glomerular filtration rate (eGFR) and detailed neuropsychological functioning. Serum proteomic markers were also examined.

Results

Lower eGFR levels were associated with significantly poorer neuropsychological functioning across multiple domains. After adjusting for age, sex, education, and diabetes mellitus, participants with an eGFR less than 45 mL/min per 1.73 m² performed significantly worse than those with an eGFR from 45 to 59 mL/min per 1.73 m² or 60 mL/min per 1.73 m² and higher in processing speed (F = 14.1, P < .001), executive functioning (F = 4.5, P = .01), visuospatial skills (F = 4.8, P = .009), and global cognitive functioning (F = 6.2, P = .002). Participants with an eGFR less than 45 mL/min per 1.73 m² also performed significantly worse than those with an eGFR of 60 mL/min per 1.73 m² or greater on delayed memory (F = 3.8, P = .02). There was a trend toward lower eGFR levels being associated with greater risk of MCI (odds ratio (OR) = 2.4, 95% confidence interval (CI) = 0.91–6.1, P = .07), which was stronger for men (OR = 9.6, 95% CI = 1.3–74.3, P = .03). A serum proteomic profile consisting of Factor VII, interleukin‐10, C‐reactive protein, and fatty acid binding protein was 93% accurate in detecting CKD‐related MCI.

Conclusion

Lower eGFR was associated with significantly poorer neuropsychological functioning in Mexican Americans. A blood‐based profile was generated that was highly accurate in detecting CKD‐related MCI. A blood profile capable of predicting CKD‐related cognitive impairment would be of benefit for the design of clinical interventions.

Health literacy: impact on the health of HIV-infected individuals

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

Abilities, skills and knowledge in measures of health literacy

OBJECTIVE

Health literacy has been recognized as an important factor in patients' health status and outcomes, but the relative contribution of demographic variables, cognitive abilities, academic skills, and health knowledge to performance on tests of health literacy has not been as extensively explored. The purpose of this paper is to propose a model of health literacy as a composite of cognitive abilities, academic skills, and health knowledge (ASK model) and test its relation to measures of health literacy in a model that first takes demographic variables into account.

METHODS

A battery of cognitive, academic achievement, health knowledge and health literacy measures was administered to 359 Spanish- and English-speaking community-dwelling volunteers. The relations of health literacy tests to the model were evaluated using regression models.

RESULTS

Each health literacy test was related to elements of the model but variability existed across measures.

CONCLUSION

Analyses partially support the ASK model defining health literacy as a composite of abilities, skills, and knowledge, although the relations of commonly used health literacy measures to each element of the model varied widely.

PRACTICE IMPLICATIONS

Results suggest that clinicians and researchers should be aware of the abilities and skills assessed by health literacy measures when choosing a measure.

Cognitive predictors of limited health literacy in adults with heterogeneous socioeconomic backgrounds

The purpose of this study was to explore the relationship between health literacy and specific cognitive abilities in hospital users. A neuropsychological battery was administered and the Short Test of Functional Health Literacy in Adults was used to classify individuals as having adequate or limited functional health literacy. Of the 322 participants, 102 (31.7%) presented limited health literacy. Even after adjusting for demographics, years of education, and quality of education, health literacy was strongly associated with measures of cognitive performance, but the strength of association was variable across different cognitive abilities.