Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer

Shared decision-making before prostate cancer screening decisions

Decisions around prostate-specific antigen screening require a patient-centred approach, considering the benefits and risks of potential harm. Using shared decision-making (SDM) can improve men's knowledge and reduce decisional conflict. SDM is supported by evidence, but can be difficult to implement in clinical settings. An inclusive definition of SDM was used in order to determine the prevalence of SDM in prostate cancer screening decisions. Despite consensus among guidelines endorsing SDM practice, the prevalence of SDM occurring before the decision to undergo or forgo prostate-specific antigen testing varied between 11% and 98%, and was higher in studies in which SDM was self-reported by physicians than in patient-reported recollections and observed practices. The influence of trust and continuity in physician-patient relationships were identified as facilitators of SDM, whereas common barriers included limited appointment times and poor health literacy. Decision aids, which can help physicians to convey health information within a limited time frame and give patients increased autonomy over decisions, are underused and were not shown to clearly influence whether SDM occurs. Future studies should focus on methods to facilitate the use of SDM in clinical settings.

Health literacy and diabetic retinopathy

Health literacy (HL) is defined as a cognitive and social skill that determines the motivation and ability of individuals to understand and use information to promote and maintain proper health. Inadequate HL has been associated with worse outcomes in diabetes control, poor self-care, and higher hospitalization rates for some chronic diseases. We hypothesized that HL influences the prevalence of diabetic retinopathy (DR) among individuals with type 2 diabetes mellitus (T2DM) and that inadequate glycemic control would mediate this association. This was a cross-sectional study carried out with 288 participants of the "Brazilian Diabetes Study" cohort. Inclusion criteria were people diagnosed with T2DM aged between 40 and 70 years and ability to read and write. In the adequate HL group, DR was found in 16.5% of participants and in the inadequate HL group, it was found in 32.8% (P=0.0081). Individuals with inadequate HL had a higher risk of having DR, and this association was still statistically significant after adjusting for HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure. In conclusion, HL is related to DR without the mediation of classical clinical variables.

Increasing the value of PSA through improved implementation

Low-value testing and treatment contribute to billions of dollars in waste to the United States health care system annually. High frequency, low-cost testing, including prostate-specific antigen (PSA) testing, is a major contributor to this inefficient health care delivery. Despite decreasing mortality of prostate cancer over the last few decades, the reputation of prostate specific antigen (PSA) for prostate cancer screening has fluctuated over the last decade due to lack of clarity of the benefits of screening and high risk for overtreatment. The value of PSA could be improved by efficient implementation of smarter testing strategies that reduce the harms and increase the benefits.

Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting

BACKGROUND

Moderately hypofractionated radiotherapy (MHRT) is an accepted treatment for localized prostate cancer; however, limited MHRT data address high-risk prostate cancer (HRPC) and/or African American patients. We report clinical outcomes and toxicity profiles for individuals with HRPC treated in an equal access system.

METHODS

We identified patients with HRPC treated with MHRT at a US Department of Veterans Affairs referral center. Exclusion criteria included < 12 months follow-up and elective nodal irradiation. MHRT included 70 Gy over 28 fractions or 60 Gy over 20 fractions. Acute and late gastrointestinal (GI) and genitourinary (GU) toxicities were graded using Common Terminology Criteria for Adverse Events, version 5.0. Clinical endpoints, including biochemical recurrence-free survival (BRFS), distant metastases-free survival (DMFS), overall survival (OS), and prostate cancer-specific survival (PCSS) were estimated using Kaplan-Meier methods. Clinical outcomes, acute toxicity, and late toxicity-free survival were compared between African American and White patients with logistic regression and log-rank testing.

RESULTS

Between November 2008 and August 2018, 143 patients with HRPC were treated with MHRT and followed for a median of 38.5 months; 82 (57%) were African American and 61 were White patients. Concurrent androgen deprivation therapy (ADT) was provided for 138 (97%) patients for a median duration of 24 months. No significant differences between African American and White patients were observed for 5-year OS (73% [95% CI, 58%-83%] vs 77% [95% CI, 60%-97%]; P = .55), PCSS (90% [95% CI, 79%-95%] vs 87% [95 % CI, 70%-95%]; P = .57), DMFS (91% [95% CI, 80%-96%] vs 81% [95% CI, 62%-91%]; P = .55), or BRFS (83% [95% CI, 70%-91%] vs 71% [95% CI, 53%-82%]; P = .57), respectively. Rates of acute grade 3+ GU and GI were low overall (4% and 1%, respectively). Late toxicities were similarly favorable with no significant differences by race.

CONCLUSIONS

Individuals with HRPC treated with MHRT in an equal access setting demonstrated favorable clinical outcomes that did not differ by race, alongside acceptable rates of acute and late toxicities.

Gender differences of health literacy in persons with a migration background: a systematic review and meta-analysis

OBJECTIVE

To investigate gender differences of health literacy in individuals with a migration background.

DESIGN

Systematic review and meta-analysis. OVID/MEDLINE, PsycINFO and CINAHL were searched in March 2018 and July 2020.

SETTING

Studies had to provide health literacy data for adult women and men with a migration background, collected with a standardised instrument, or report results that demonstrated the collection of such data. Health literacy data were extracted from eligible studies or requested from the respective authors. Using a random-effects model, a meta-analysis was conducted to assess standardised mean differences (SMDs) of health literacy in men and women. Two researchers independently assessed risk of bias for each included study using the Appraisal Tool for Cross-Sectional Studies.

RESULTS

Twenty-four studies were included in this systematic review. Thereof, 22 studies (8012 female and 5380 male participants) were included in the meta-analyses. In six studies, gender-specific health literacy scores were reported. The authors of additional 15 studies provided their data upon request and for one further study data were available online. Women achieved higher health literacy scores than men: SMD=0.08, 95% CI 0.002 to 0.159, p=0.04, I2=65%. Another 27 studies reported data on female participants only and could not be included due to a lack of comparable studies with male participants only. Authors of 56 other eligible studies were asked for data, but without success.

CONCLUSION

Men with a migration background-while being much less frequently examined-may have lower health literacy than women. As heterogeneity between studies was high and the difference became statistically insignificant when excluding studies with a high risk of bias, this result must be interpreted with caution. There is a paucity of research on the social and relational aspects of gender in relation to health literacy among people with a migration background, especially for men.

PROSPERO REGISTRATION NUMBER

CRD42018085555.

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.

Social Determinants, Health Literacy, and Disparities: Intersections and Controversies

This article synthesizes what is known about the relationship between social disadvantage and measures of health literacy (HL), and reviews the research examining whether low HL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a United States perspective, this article offers a novel conceptual framework that presents how the social determinants of health might interact with HL to result in health disparities. The framework articulates relationships that reflect public health pathways and health care pathways, which include their related health literacies. The article continues with several cautionary statements based on the inherent limitations of current HL research, including problems and concerns specific to the attribution of HL as an explanatory factor for extant socioeconomic and racial/ethnic health disparities. The article closes with recommendations regarding future research directions. [HLRP: Health Literacy Research and Practice. 2021;5(3):e233–e243.]

Dissemination of cancer survivorship care plans: who is being left out?

OBJECTIVES

The Institute of Medicine (IOM) and the American College of Surgeons Commission on Cancer (CoC) recommend a clear and effectively explained comprehensive survivorship care plan (SCP) be given to all cancer survivors. The objective of this study is to understand the relationship between social determinants of health (SDOH) and self-reported receipt of SCP by cancer survivors in the USA.

METHODS

We analyzed an adult population of cancer survivors in the 2016 Behavioral Risk Factor Surveillance System's (BRFSS) Survivorship modules. Weighted multivariable logistic regression was used to analyze the association of SDOH and reported receipt of SCP.

RESULTS

There were 7061 cancer patients eligible for an SCP. The probability of reporting receipt of SCP decreased with lower educational achievement (high school/some college: AOR = 0.82, 95% CI: 0.70-0.97, p = 0.02; < high school: AOR = 0.68, 95% CI: 0.47-0.97, p = 0.03) compared to those with at least one college degree. Additionally, being widowed/divorced/separated (widowed/divorced/separated: AOR = 0.72, 95% CI: 0.61-0.86, p < 0.01 vs. married/cohabiting) and uninsured (uninsured: AOR = 0.52, 95% CI: 0.0.34-0.80, p < 0.01 vs. insured) increased the odds of not receiving an SCP. Younger patients were more likely to receive an SCP than those over 65 (18-24 years: AOR = 6.62, 95% CI: 1.87-24.49, p < 0.01 vs. 65+ years).

CONCLUSION

Among cancer survivors, SDOH such as low educational achievement, widowed/divorced/separated marital status, and being uninsured were associated with a lower likelihood of receiving an SCP. Future studies should evaluate how omission of SCP in these patients influences the quality of care during the transition from oncologists to primary care.

The Intersections Between Social Determinants of Health, Health Literacy, and Health Disparities

This chapter synthesizes what is known about the relationship between social disadvantage and measures of low health literacy (LHL), and reviews the research examining whether LHL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a U.S. perspective, the chapter then offers a novel conceptual framework that presents how the social determinants of health might interact with LHL to result in health disparities. The framework articulates relationships that reflect public health pathways and healthcare pathways, which include their related health literacies. In addition, the chapter highlights as an exemplar one important potential causal mechanism in the healthcare pathway by exploring the communication model in outpatient care, as communication has been very well-studied with respect to both health disparities and HL. The chapter then, provides two examples of HL interventions aligned with the conceptual framework, one of which addresses the health care literacy pathway, and the other addresses the public health literacy pathway. The chapter continues with a number of cautionary statements based on the inherent limitations of current HL research, including problems and concerns specific to the attribution of HL as an explanatory factor for extant socioeconomic and racial/ethnic health disparities. The chapter closes with recommendations regarding future research directions.

Ethnographic investigation of patient-provider communication among African American men newly diagnosed with prostate cancer: a study protocol

INTRODUCTION

In the USA, African American men bear a disproportionate burden of prostate cancer (PCa) compared with all other groups, having a higher incidence and mortality, poorer quality of life and higher dissatisfaction with care. They are also less likely to receive guideline-concordant treatment (eg, undertreatment of aggressive disease). Inadequate patient-provider communication contributes to suboptimal care, which can be exacerbated by patients' limited health literacy, providers' lack of communication skills and time constraints in low-resource, safety net settings. This study is designed to examine the communication experiences of African American patients with PCa as they undertake treatment decision-making.

METHODS AND ANALYSIS

Using an ethnographic approach, we will follow 25 African American men newly diagnosed with PCa at two public hospitals, from diagnosis through treatment decision. Data sources include: (1) audio-recorded clinic observations during urology, radiation oncology, medical oncology and primary care visits, (2) field notes from clinic observations, (3) patient surveys after clinic visits, (4) two in-depth patient interviews, (5) a provider survey, and (6) in-depth interviews with providers. We will explore patients' understanding of their diagnoses and treatment options, sources of support in decision-making, patient-provider communication and treatment decision-making processes. Audio-recorded observations and interviews will be transcribed verbatim. An iterative process of coding and team discussions will be used to thematically analyse patients' experiences and providers' perspectives, and to refine codes and identify key themes. Descriptive statistics will summarise survey data.

ETHICS AND DISSEMINATION

To our knowledge, this is the first study to examine in-depth patient-provider communication among African American patients with PCa. For a population as marginalised as African American men, an ethnographic approach allows for explication of complex sociocultural and contextual influences on healthcare processes and outcomes. Study findings will inform the development of interventions and initiatives that promote patient-centred communication, shared decision-making and guideline-concordant care. This study was approved by the University of California San Francisco and the Alameda Health System Institutional Review Boards.

Examining the association of health literacy and numeracy with prostate-related knowledge and prostate cancer treatment regret

INTRODUCTION

Educational materials used in prostate cancer shared decision-making are often written above the health literacy levels of the patients that may benefit the most from such tools. Poor understanding the oncologic and functional outcomes of prostate cancer treatment may influence patient regret during this process. In this study, we assess the association between health literacy, numeracy, prostate-related knowledge and treatment regret in a diverse population.

MATERIALS AND METHODS

Patients obtaining care between June and August of 2016 at both community-based and academic tertiary care facilities were assessed for health literacy and numeracy using validated instruments. Prostate knowledge was tested in those patients without a history of prostate cancer using a 29-item questionnaire and patient-level predictors of knowledge were assessed. Prostate cancer treatment regret was assessed in those patients who had a history of prostate cancer.

RESULTS

A total of 90 patients were enrolled, 38 (42%) of whom had a history of prostate cancer. African American race (I = 0.039), financial strain (P < 0.001), and educational attainment (P < 0.001) were all associated with lower health literacy on multivariable analysis. Possessing a professional degree (P = 0.021) and higher health literacy (P = 0.001) were associated with greater prostate-related knowledge. Of those with a history of prostate cancer, 9 (24%) expressed treatment regret. Patients with regret were more likely to be African American (n = 6, 66.7% vs. 5, 17.2%, P = 0.004), not married (P = 0.016), and score lower on the literacy (1.0 vs. 8.0, P = 0.009) and numeracy (10.0 vs. 16.0, P = 0.016) scales.

CONCLUSIONS

We identified lower health literacy among African American men, and lower prostate-related knowledge in those with poor health literacy. To our knowledge, this is the first study to show an association between health literacy and prostate cancer treatment regret.

Association of polymorphisms of PTEN, AKT1, PI3K, AR, and AMACR genes in patients with prostate cancer

Polymorphic variants in the PTEN (rs2735343), PI3K (rs2699887), AKT1 (rs2494750), AR (rs17302090), and AMACR (rs3195676) genes were evaluated as possible molecular markers of susceptibility, prognosis, and progression of prostate cancer (PCa), in a case-control study. Samples consisted of 277 patients with PCa and 277 controls from Londrina, PR, Brazil. SNPs were analyzed by real-time PCR. A family history of cancer, including PCa, as well as level of schooling were risk factors for PCa. The data were obtained via logistic regression, using odds ratios with a CI 95%. The genotypes of AKT1 and AKT1+AR demonstrated an association with protection for the disease. The combination of SNPs with the histopathological tumor data between allele variants of AMACR, AKT1+AR, and AKT1+AMACR indicated an association with protection against seminal vesicle invasion. The polymorphisms AKT1+AR and PI3K+AR were associated with protection against tumor bilaterality. The genotype combinations PTEN+AMACR and PTEN+AR were associated with the risk of extracapsular extension. Of the five genes studied, two were associated with protection for PCa, four were associated with protection for some prognostic variables, and only one was associated with risk. Thus, these SNPs are candidates for markers to discriminate men with better or worse prognosis for PCa.

Test of health Literacy for Portuguese-speaking Adults

INTRODUCTION

Health literacy has been evaluated in several countries by tools developed for local language and culture. This study aimed to adapt and to validate the Health Literacy Test (TLS) for the Brazilian Portuguese language based on the Test of functional health literacy in adults (TOFHLA).

METHOD

The TLS, translated and adapted to the Brazilian scenario based on the Test of functional health literacy in adults, was administered to 302 users of a clinic of a University in Santa Catarina from September to October 2013. Cronbach's Alpha coefficient, Spearman's correlation and Analysis of Variance were used to assess the internal consistency, the correlation between the parts of the test and association between sociodemographic variables and the score of the Test, respectively.

RESULTS

The average score of the test was 72,2, and 54.6% of participants had adequate health literacy, 19.2% had marginal health literacy and 26.2% had inadequate health literacy. The average score of the test was inversely related to the age of the participants and directly related to the level of education. There was no significant difference in the other sociodemographic characteristics. The internal consistency (Cronbach's alpha) was 0.953. The coefficients for the numerical and reading passages were 0.808 and 0.951, respectively. All the sections correlated positively and significantly with the Test, and also with each other.

CONCLUSION

The validation of this test provides a new instrument to determine the literacy level in Brazilian adults.

Examining income-related inequality in health literacy and health-information seeking among urban population in China

Background

Health literacy and health-information seeking behaviour (HISB) play vital roles in health outcome improvements. This study examines the extent of income-related inequality in health literacy and health-information seeking as well as the contributions of the main socioeconomic determinants in China.

Methods

We analysed representative data of participants aged over 18 years as well as older adults from the Guangzhou Community Health Survey. A concentration index (CI) was used to quantify the degree of income-related inequity in health literacy and health-information seeking. Probit regression models were employed to decompose the CI into the contributions to each factor.

Results

Results showed a significant pro-rich distribution of adequate health literacy (CI: 0.0602, P < 0.001; horizontal index [HI]: 0.0562, P < 0.001) and HISB from healthcare professionals (CI: 0.105, P < 0.001; HI: 0.0965, P < 0.001). The pro-rich distribution of health literacy was mainly attributable to education background (contribution: 54.76%), whereas income inequalities contributed most to the pro-rich distribution of health-information seeking among an urban population (contribution: 62.53%).

Conclusion

Public interventions in China to reduce inequality in health literacy and HISBs among the urban population, coupled with easily accessible information sources on health, warrant further attention from policymakers.

Combined Effects of Race and Socioeconomic Status on Cancer Beliefs, Cognitions, and Emotions

AIM

To determine whether socioeconomic status (SES; educational attainment and income) explains the racial gap in cancer beliefs, cognitions, and emotions in a national sample of American adults.

METHODS

For this cross-sectional study, data came from the Health Information National Trends Survey (HINTS) 2017, which included a nationally representative sample of American adults. The study enrolled 2277 adults who were either non-Hispanic Black (n = 409) or non-Hispanic White (n = 1868). Race, demographic factors (age and gender), SES (i.e., educational attainment and income), health access (insurance status, usual source of care), family history of cancer, fatalistic cancer beliefs, perceived risk of cancer, and cancer worries were measured. We ran structural equation models (SEMs) for data analysis.

RESULTS

Race and SES were associated with perceived risk of cancer, cancer worries, and fatalistic cancer beliefs, suggesting that non-Hispanic Blacks, low educational attainment and low income were associated with higher fatalistic cancer beliefs, lower perceived risk of cancer, and less cancer worries. Educational attainment and income only partially mediated the effects of race on cancer beliefs, emotions, and cognitions. Race was directly associated with fatalistic cancer beliefs, perceived risk of cancer, and cancer worries, net of SES.

CONCLUSIONS

Racial gap in SES is not the only reason behind racial gap in cancer beliefs, cognitions, and emotions. Racial gap in cancer related beliefs, emotions, and cognitions is the result of race and SES rather than race or SES. Elimination of racial gap in socioeconomic status will not be enough for elimination of racial disparities in cancer beliefs, cognitions, and emotions in the United States.

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.

Health literacy of recently hospitalised patients: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)

BACKGROUND

Health literacy is simply defined as an individual's ability to access, understand and use information in ways that promote and maintain good health. Lower health literacy has been found to be associated with increased emergency department presentations and potentially avoidable hospitalisations. This study aimed to determine the health literacy of hospital inpatients, and to examine if associations exist between different dimensions of their health literacy, sociodemographic characteristics and hospital services use.

METHODS

A written survey was sent to 3,252 people aged ≥18 years in English, Arabic, Chinese, Vietnamese, Italian or Greek. The survey included demographic and health questions, and the Health Literacy Questionnaire (HLQ). The HLQ is a multidimensional instrument comprising nine independent scales. Use of hospital services was measured by length of stay, number of admissions in 12 months and number of emergency department presentations. Effect size (ES) for standardised differences in means described the magnitude of differences in HLQ scale scores between demographic and socioeconomic groups.

RESULTS

385 questionnaires were returned (13%); mean age 64 years (SD 17), 49% female. Aged ≥65 years (55%), using the Internet < once a month (37%), failure to complete high school (67%), low household income (39%), receiving means-tested government benefits (61%) and being from a culturally and linguistically diverse (CALD) background (24%), were all associated with lower scores in some health literacy scales. Being aged ≥65 years, not currently employed, receiving government benefits, and being from a CALD background were also associated with increased use of some hospital services. There was no association between lower scores on any HLQ scale and greater use of hospital services.

CONCLUSION

We found no association between lower health literacy and greater use of hospital health services. However increased age, having a CALD background and not speaking English at home were all associated with having the most health literacy challenges Strategies to address these are needed to reduce health inequalities.

Measuring Nutrition Literacy in Breast Cancer Patients: Development of a Novel Instrument

No nutrition literacy instruments have been tested in breast cancer survivors, yet nutrition is a critical lifestyle factor for optimizing weight and improving quality of life in breast cancer survival. Our objectives were to adapt our Nutrition Literacy Assessment Instrument for breast cancer populations and to pilot test its validity and reliability. We modified the instrument based on review by content experts in cancer and nutrition and cognitive interviews with 18 cancer survivors. The modified instrument (Nutrition Literacy Assessment Instrument for Breast Cancer, NLit-BCa) was pilot-tested with 17 high-risk women and 55 breast cancer survivors. We conducted the NLit-BCa on two separate occasions 4 weeks apart and assessed reliability by confirmatory factor analysis. Construct validity was evaluated by comparing results of the NLit-BCa to a Healthy Eating Index score derived from two separate 24-h dietary recalls. Content validity of the NLit-BCa was acceptable (0.93). Entire reliability for three instrument domains was substantial (>0.80), while remaining domains demonstrated fair or moderate reliability. Significant relationships were found between five of the six domains of nutrition literacy and diet quality (P < 0.05). The NLit-BCa is content valid and demonstrates promising reliability and construct validity related to diet quality, through a larger sample size, and removal of non-discriminating items is needed to confirm these findings. Thus, the NLit-BCa demonstrates potential for comprehensively measuring nutrition literacy in breast cancer populations.

Assessing Stigma among African Americans Living with HIV

PURPOSE

In the present study, we validated a culturally adapted stigma scale designed to assess stigma among African Americans living with HIV.

METHODS

We collected data on the scale using an audio computer assisted self-interview (ACASI) format. We validated the scale with a sample of 62 African American participants living with HIV.

RESULTS

Findings demonstrated that stigma can be measured succinctly and effectively in a 14-item scale with two subscales measuring enacted and internalized stigma.

DISCUSSION

We identified many advantages to using the scale, which demonstrated good psychometric properties when used with an audio computer assisted self-interview format and with an African American sample. We recommend this scale's use in both clinical practice and research study of HIV-stigma reduction interventions with African American populations.

An analysis of the readability of patient information materials for common urological conditions

INTRODUCTION

Health literacy has been shown to be an important determinant of outcomes in numerous disease states. In an effort to improve health literacy, the Canadian Urological Association (CUA) publishes freely accessible patient information materials (PIMs) on common urological conditions. We sought to evaluate the readability of the CUA's PIMs.

METHODS

All PIMs were accessed through the CUA website. The Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and the number of educational graphics were determined for each PIM. Low FRES scores and high FKGL scores are associated with more difficult-to-read text. Average readability values were calculated for each PIM category based on the CUA-defined subject categorizes. The five pamphlets with the highest FKGL scores were revised using word substitutions for complex multisyllabic words and reanalyzed. The Kruskal-Wallis test was used to identify readability differences between PIM categories and paired t-tests were used to test differences between FKGL scores before and after revisions.

RESULTS

Across all PIMs, FRES values were low (mean 47.5, standard deviation [SD] 7.47). This corresponded to an average FKGL of 10.5 (range 8.1-12.0). Among PIM categories, the infertility and sexual function PIMs exhibited the highest average FKGL (mean 11.6), however, differences in scores between categories were not statistically significant (p=0.38). The average number of words per sentence was also highest in the infertility and sexual function PIMs and significantly higher than other categories (mean 17.2; p=0.01). On average, there were 1.4 graphics displayed per PIM (range 0-4), which did not vary significantly by disease state (p=0.928). Simple words substitutions improved the readability of the five most difficult-to-read PIMs by an average of 3.1 grade points (p<0.01).

CONCLUSIONS

Current patient information materials published by the CUA compare favourably to those produced by other organizations, but may be difficult to read for low-literacy patients. Readability levels must be balanced against the required informational needs of patients, which may be intrinsically complex.

The Relationship between Health Literacy and Health Disparities: A Systematic Review

OBJECTIVES

Health literacy is commonly associated with many of the antecedents of health disparities. Yet the precise nature of the relationship between health literacy and disparities remains unclear. A systematic review was conducted to better understand in how far the relationship between health literacy and health disparities has been systematically studied and which potential relationships and pathways have been identified.

METHODS

Five databases, including PubMed/MEDLINE and CINAHL, were searched for peer-reviewed studies. Publications were included in the review when they (1) included a valid measure of health literacy, (2) explicitly conceived a health disparity as related to a social disparity, such as race/ethnicity or education and (3) when results were presented by comparing two or more groups afflicted by a social disparity investigating the effect of health literacy on health outcomes. Two reviewers evaluated each study for inclusion and abstracted relevant information. Findings were ordered according to the disparities identified and the role of health literacy in explaining them.

RESULTS

36 studies were included in the final synthesis. Most of the studies investigated racial/ethnic disparities, followed by some few studies that systematically investigated educational disparities. Some evidence was found on the mediating function of health literacy on self-rated health status across racial/ethnic and educational disparities, as well as on the potential effect of health literacy and numeracy on reducing racial/ethnic disparities in medication adherence and understanding of medication intake.

CONCLUSION

Overall the evidence on the relationship between health literacy and disparities is still mixed and fairly limited. Studies largely varied with regard to health(-related) outcomes under investigation and the health literacy assessments used. Further, many studies lacked a specific description of the nature of the disparity that was explored and a clear account of possible pathways tested.

The incidence and mortality of prostate cancer and its relationship with development in Asia

Purpose

Prostate cancer is a common cancer in men in the world. It is rapidly increasing. This study investigated the incidence and mortality of prostate cancer and the relationship with the Human Development Index (HDI) and its dimensions in Asia in 2012.

Methods

The study was conducted based on data from the world data of cancer and the World Bank (including the HDI and its components). The standardized incidence and mortality rates of prostate cancer were calculated for Asian countries. The correlation between incidence, mortality rates, and the HDI and its components were assessed with the use of the correlation test, using SPSS software.

Results

There was a total of 191,054 incidences and 81,229 death were recorded in Asian countries in 2012. Among the Asian countries, the five countries with the highest standardized incidence rates of prostate cancer were Israel, Turkey, Lebanon, Singapore, and Japan, and the five countries with the highest standardized mortality rates were Turkey, Lebanon, Timor-Leste, Armenia, and the Philippines. The correlation between standardized incidence rate of prostate cancer and the HDI was 0.604 (P ≤ 0.001), with life expectancy at birth 0.529 (P = 0.002), with mean years of schooling 0.427 (P = 0.001), and with level of income per each person of the population 0.349 (P = 0.013). Also, between the standardized mortality rate and the HDI, it was 0.228 (P = 0.127).

Conclusions

A significant and positive correlation was observed between the standardized incidence rate of prostate cancer, and the HDI and its dimensions, such as life expectancy at birth, mean years of schooling, and income level of the population per each person of population. However, there was no significant correlation between the standardized mortality rate, and the HDI and its dimensions.

Validation of a Visual Prostate Symptom Score in Men With Lower Urinary Tract Symptoms in a Health Safety Net Hospital

OBJECTIVE

To evaluate the correlation between the International Prostate Symptom Score (IPSS) and the Visual Prostate Symptom Score (VPSS), a visual assessment of urinary stream, frequency, nocturia, and quality of life using pictograms, in a health safety net population.

METHODS

Men presenting to San Francisco General Hospital with lower urinary tract symptoms completed the IPSS and the VPSS without and then with assistance. Statistical analysis was performed using the chi-square test, the Wilcoxon signed rank test, and the Spearman rank correlation.

RESULTS

One hundred twenty-one patients were enrolled between December 2013 and May 2014 with a mean age of 54 years. There were statistically significant correlations between total VPSS and total IPSS (ρ = 0.71; P <.001) and for frequency (ρ = 0.47; P <.001), nocturia (ρ = 0.69; P <.001), force of stream (ρ = 0.65; P <.001), and quality of life (ρ = 0.69; P <.001). In addition, there were statistically significant correlations between total VPSS and both VPSS quality of life (ρ = 0.69; P <.001) and Qmax (ρ = -0.473; P = .006). The mean absolute disagreement for participants who took the IPSS independently vs with assistance was greater than for those who took the VPSS independently vs assistance for all symptoms: frequency (0.64 vs 0.3, respectively; P <.001), weak stream (0.82 vs 0.14, respectively; P <.001), nocturia (0.38 vs 0.23, respectively; P = .023), and quality of life (0.63 vs 0.32, respectively; P = .005).

CONCLUSION

Many men altered their IPSS responses when they received assistance. There was significantly less alteration in responses using the VPSS, suggesting that the VPSS is useful in determining lower urinary tract symptoms, particularly in patients with limited education and literacy.

Health literacy and computer-assisted instruction: usability and patient preference

The authors investigated the feasibility of using computer-assisted instruction in patients of varying literacy levels by examining patients' preferences for learning and their ability to use 2 computer-based educational programs. A total of 263 participants 50-74 years of age with varying health literacy levels interacted with 1 of 2 educational computer programs as part of a randomized trial of a colorectal cancer screening decision aid. A baseline and postprogram evaluation survey were completed. More than half (56%) of the participants had limited health literacy. Regardless of literacy level, doctors were the most commonly used source of medical information-used frequently by 85% of limited and adequate literacy patients. In multivariate logistic regression, only those with health insurance (OR = 2.35, p = .06) and computer use experience (OR = 0.39, p = .03) predicted the ability to complete the programs without assistance compared with those without health insurance or prior computer use, respectively. Although patients with limited health literacy had less computer experience, the majority completed the programs without any assistance and stated that they learned more than they would have from a brochure. Future research should investigate ways that computer-assisted instruction can be incorporated in medical care to enhance patient understanding.

Can patient portals reduce health disparities? A perspective from asthma

Much asthma research directed at achieving health equity is focused on patient education for self-management. Although adults are more likely to die from asthma, most studies target children. With the advent of the electronic health record, patient portals potentially offer adult patients as well as children and their caretakers a resource for disease management education, facilitating communication with health care providers and improving patient access to health care. However, difficult, limited, or inconvenient access to these patient portals could increase health disparities, whereas features such as accompanying audio platforms, the use of multimedia, and the ability to communicate across language barriers and educational levels potentially could improve communication and reduce differences in health outcomes.

The role of health literacy and numeracy in contraceptive decision-making for urban Chicago women

Low functional health literacy and numeracy have known associations with poor health outcomes, yet little work has investigated these markers of health disparity in a family planning population. We used an in-depth qualitative process and 2 literacy and numeracy assessment tools, the REALM-7 and the Schwartz numeracy scale, to assess the role of literacy and numeracy in contraceptive decision-making in an urban Chicago population. Brief surveys and semi-structured interviews were conducted with 30 postpartum women who had received Medicaid-funded care at an obstetrics clinic in an academic medical center. In-person one-on-one interviews were then reviewed for themes using an iterative process. Qualitative analysis techniques identifying emergent themes were applied to interview data. Literacy and numeracy were assessed using REALM-7 and a validated 3-question numeracy scale. In this cohort of African American (63 %) and Hispanic (37 %) women (median age 26), 73 % had unplanned pregnancies. Although health literacy rates on the REALM-7 were adequate, numeracy scores were low. Low literacy and numeracy scores were associated with interview reports of poor contraceptive knowledge and difficulty with contraceptive use. Low health literacy and numeracy may play an important role in contraception decision-making in this low-income, minority population of women. We recommend further study of literacy and numeracy in a family planning population. Comprehensive contraception education and communication around the contraceptive decision-making process should take place at literacy and numeracy levels appropriate to each individual.

Limited health literacy is associated with low glomerular filtration in the Chronic Renal Insufficiency Cohort (CRIC) study

Background: Low health literacy in the general population is associated with increased risk of death and hospitalization. The evaluation of health literacy in individuals with predialysis chronic kidney disease (CKD) is limited. Methods: We conducted a cross-sectional study to evaluate the associations of limited health literacy with kidney function and cardiovascular disease (CVD) risk factors in 2,340 non-Hispanic (NH) Whites and Blacks aged 21 – 74 years with mild-to-moderate CKD. Limited health literacy was defined as a Short Test of Functional Health Literacy in Adults (STOFHLA) score ≤ 22. Outcomes evaluated included estimated glomerular filtration rate (eGFR), 24-hour urine protein excretion, and CVD risk factors. Results: The prevalence of limited health literacy was 28% in NH-Blacks and 5% in NH-Whites. Compared with participants with adequate health literacy, those with limited health literacy were more likely to have lower eGFR (34 vs. 42 mL/min/1.73 m²); higher urine protein/24-hours (0.31 vs. 0.15 g); and higher self-reported CVD (61 vs. 37%); and were less likely to have BP < 130/80 mmHg (51 vs. 58%); p ≤ 0.01 for each comparison. After adjustment, limited health literacy was associated with self-reported CVD (OR 1.51, 95% CI 1.13 – 2.03) and lower eGFR (β –2.47, p = 0.03). Conclusion: In this CKD cohort, limited health literacy was highly prevalent, especially among NH-Blacks, and it was associated with lower eGFR and a less favorable CVD risk factor profile. Further studies are needed to better understand these associations and inform the development of health literacy interventions among individuals with CKD.

Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis

Background

Increasing patient engagement in healthcare has become a health policy priority. However, there has been concern that promoting supported shared decision-making could increase health inequalities.

Objective

To evaluate the impact of SDM interventions on disadvantaged groups and health inequalities.

Design

Systematic review and meta-analysis of randomised controlled trials and observational studies.

Data Sources

CINAHL, the Cochrane Register of Controlled Trials, the Cochrane Database of Systematic Reviews, EMBASE, HMIC, MEDLINE, the NHS Economic Evaluation Database, Open SIGLE, PsycINFO and Web of Knowledge were searched from inception until June 2012.

Study Eligibility Criteria

We included all studies, without language restriction, that met the following two criteria: (1) assess the effect of shared decision-making interventions on disadvantaged groups and/or health inequalities, (2) include at least 50% of people from disadvantaged groups, except if a separate analysis was conducted for this group.

Results

We included 19 studies and pooled 10 in a meta-analysis. The meta-analyses showed a moderate positive effect of shared decision-making interventions on disadvantaged patients. The narrative synthesis suggested that, overall, SDM interventions increased knowledge, informed choice, participation in decision-making, decision self-efficacy, preference for collaborative decision making and reduced decisional conflict among disadvantaged patients. Further, 7 out of 19 studies compared the intervention's effect between high and low literacy groups. Overall, SDM interventions seemed to benefit disadvantaged groups (e.g. lower literacy) more than those with higher literacy, education and socioeconomic status. Interventions that were tailored to disadvantaged groups' needs appeared most effective.

Conclusion

Results indicate that shared decision-making interventions significantly improve outcomes for disadvantaged patients. According to the narrative synthesis, SDM interventions may be more beneficial to disadvantaged groups than higher literacy/socioeconomic status patients. However, given the small sample sizes and variety in the intervention types, study design and quality, those findings should be interpreted with caution.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A randomized trial of a prenatal genetic testing interactive computerized information aid

OBJECTIVE

The aim of this study was to determine whether an interactive computer program could improve patient knowledge regarding genetic screening and diagnostic concepts.

METHODS

In this randomized trial, women 6-26 weeks' gestation were assigned to standard care with provider-based counseling or to augmented counseling with an interactive computer program. The computer-based tool conveyed information about genetic testing options. Women were administered a 23-item test of content knowledge immediately and 2-4 weeks after exposure. Test scores were compared between groups at both points using T-tests.

RESULTS

A total of 150 women were randomized equally between groups. Groups were similar with regard to demographic characteristics. Women randomized to the interactive tool correctly answered a significantly greater proportion of questions than those who received standard counseling (69.4% ± 14.2% vs. 46.0% ± 15.2%, p < 0.001) on the immediate questionnaire. One hundred and twenty-three (82%) participants participated in the follow-up test. Women randomized to the tool continued to correctly answer a significantly greater proportion of questions (60.6% ± 16% vs. 49.7% ± 18.9%, p = 0.001). Education, health literacy, electronic health literacy, and other discussions with providers were not associated with a differential benefit from the educational intervention.

CONCLUSION

A patient-directed interactive computer program may help providers to convey relevant information about genetic screening and diagnostic concepts.

Patient barriers to follow-up care for breast and cervical cancer abnormalities

BACKGROUND

Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care.

METHODS

Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers.

RESULTS

The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier.

CONCLUSION

In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

Barriers to prostate cancer prevention and community recommended health education strategies in an urban African American community in Jackson, Mississippi

This article describes the use of survey research in collaboration with the African American urban community of Georgetown, Jackson, Mississippi to identify and understand prostate cancer knowledge, resource utilization, and health education strategies considered most effective in reaching the community with prostate cancer prevention messages. The study revealed profound needs in disease identification and resources awareness and utilization. Barriers to utilization were identified by participants to include lack of self-efficacy, low self-esteem, lack of trust in the health care system, limited knowledge of prostate pathology, and limited ability to pay. Participants' recommended strategies for reaching the community with prostate cancer education include traditional and nontraditional strategies. The list of recommendations exclude modern-day outlets such as handheld devices, Twitter, Facebook, blogs, wikis, and other Internet-based outlets. The findings provide a road map for program development and an intervention research agenda custom-tailored to the Georgetown community of Jackson, Mississippi.

Design of a prostate cancer patient navigation intervention for a Veterans Affairs hospital

BACKGROUND

Patient navigation programs have been launched nationwide in an attempt to reduce racial/ethnic and socio-demographic disparities in cancer care, but few have evaluated outcomes in the prostate cancer setting. The National Cancer Institute-funded Chicago Patient Navigation Research Program (C-PNRP) aims to implement and evaluate the efficacy of a patient navigation intervention for predominantly low-income minority patients with an abnormal prostate cancer screening test at a Veterans Affairs (VA) hospital in Chicago.

METHODS/DESIGN

From 2006 through 2010, C-PNRP implemented a quasi-experimental intervention whereby trained social worker and lay health navigators worked with veterans with an abnormal prostate screen to proactively identify and resolve personal and systems barriers to care. Men were enrolled at a VA urology clinic and were selected to receive navigated versus usual care based on clinic day. Patient navigators performed activities to facilitate timely follow-up such as appointment reminders, transportation coordination, cancer education, scheduling assistance, and social support as needed. Primary outcome measures included time (days) from abnormal screening to diagnosis and time from diagnosis to treatment initiation. Secondary outcomes included psychosocial and demographic predictors of non-compliance and patient satisfaction. Dates of screening, follow-up visits, and treatment were obtained through chart audit, and questionnaires were administered at baseline, after diagnosis, and after treatment initiation. At the VA, 546 patients were enrolled in the study (245 in the navigated arm, 245 in the records-based control arm, and 56 in a subsample of surveyed control subjects).

DISCUSSION

Given increasing concerns about balancing better health outcomes with lower costs, careful examination of interventions aimed at reducing healthcare disparities attain critical importance. While analysis of the C-PNRP data is underway, the design of this patient navigation intervention will inform other patient navigation programs addressing strategies to improve prostate cancer outcomes among vulnerable populations.

Impact of race on survival in patients with clinically nonmetastatic prostate cancer who deferred primary treatment

BACKGROUND

Prostate cancer (PCa) racial disparity studies typically focus on survival differences after curative treatment. The authors of this report hypothesized that comparing mortality rates between African American (AA) and Caucasian American (CA) patients who deferred primary treatment for clinically nonmetastatic PCa may provide a better assessment of the impact of race on the natural course of PCa.

METHODS

The pathology database of the New York Veterans Administration Medical Center (VAMC), an equal access-of-care facility, was searched for patients with biopsy-proven PCa. Inclusion criteria included 1) no evidence of metastatic disease or death within 3 years after diagnosis, 2) no primary treatment, and 3) a minimum of 5 years of follow-up for survivors.

RESULTS

In total, 518 patients met inclusion criteria between 1990 and 2005. AA patients were younger (P = .02) and had higher median prostate-specific antigen (PSA) levels (P = .001) at the time of diagnosis compared with CA patients. In a multivariate model, higher Gleason score and PSA level were associated with increased mortality (P = .001 and P = .03, respectively), but race was not a predictor of death from PCa.

CONCLUSIONS

The current data suggested that race did not have a major impact on survival in patients with PCa who deferred primary treatment for clinically nonmetastatic disease.

The impact of health literacy and socioeconomic status on asthma disparities

OBJECTIVE

Racial/ethnic disparities have been well documented in asthma. While socioeconomic status (SES) has been repeatedly implicated as a root cause, the role of limited health literacy has not been extensively studied. The purpose of this study was to examine the independent contributions of SES and health literacy in explaining asthma disparities.

METHODS

A cohort study was conducted in a Chicago-based sample of 353 adults aged 18-40 years with persistent asthma from 2004 to 2007. Health literacy, SES, and asthma outcomes including disease control, quality of life, emergency department visits, and hospitalizations were assessed in person at baseline, and asthma outcomes were measured every 3 months for 2 years by phone. Multivariate models were used to assess racial/ethnic disparities in asthma outcomes and the effect of health literacy and SES on these estimates.

RESULTS

Compared with White participants, African American adults fared significantly worse in all asthma outcomes (p < .05) and Latino participants had lower quality of life (β = -0.47; 95% confidence interval [CI] = -0.79, -0.14; p = .01) and worse asthma control (risk ratio [RR] = 0.63; 95% CI = 0.41, 0.98; p = .04). Differences in SES partially explained these disparities. Health literacy explained an additional 20.2% of differences in quality of life between Latinos and Whites, but differences in hospitalization rates between African American and White adults remained (RR = 2.97; 95% CI = 1.09, 8.12, p = .03).

CONCLUSIONS

Health literacy appears to be an overlooked factor explaining racial and ethnic disparities in asthma. Evidence-based low literacy strategies for patient education and counseling should be included in comprehensive interventions.

How does health literacy affect quality of life among men with newly diagnosed clinically localized prostate cancer? Findings from the North Carolina-Louisiana Prostate Cancer Project (PCaP)

BACKGROUND

Health literacy deficits affect half of the US overall patient population, especially the elderly, and are linked to poor health outcomes among noncancer patients. Yet little is known about how health literacy affects cancer populations. The authors examined the relation between health-related quality of life (HRQOL) and health literacy among men with prostate cancer.

METHODS

Data analysis included 1581 men with newly diagnosed clinically localized prostate cancer from a population-based study, the North Carolina-Louisiana Prostate Cancer Project (PCaP). Participants completed assessment of health literacy using Rapid Estimate of Adult Literacy in Medicine (REALM) and HRQOL using the Short Form-12 General Health Survey (SF12). Bivariate and multivariate regression was used to determine the potential association between REALM and HRQOL, while controlling for sociodemographic and illness-related variables.

RESULTS

Higher health literacy level was significantly associated with better mental well-being (SF12-Mental Component Summary [MCS]; P < .001) and physical well-being (SF12-Physical Component Summary [PCS]; P < .001) in bivariate analyses. After controlling for sociodemographic (age, marital status, race, income, and education) and illness-related factors (types of cancer treatment, tumor aggressiveness, and comorbidities), health literacy remained significantly associated with SF12-MCS scores (P < .05) but not with SF12-PCS scores.

CONCLUSIONS

Among patients with newly diagnosed localized prostate cancer, those with low health literacy levels were more vulnerable to mental distress than those with higher health literacy levels, but physical well-being was no different. These findings suggest that health literacy may be important in patients managing prostate cancer and the effects of treatment, and provide the hypothesis that supportive interventions targeting patients with lower health literacy may improve their HRQOL.

The mechanisms linking health literacy to behavior and health status

OBJECTIVE

To examine the mechanisms linking health literacy to physical activity and self-reported health.

METHODS

From 2005-2007, patients (N = 330) with hypertension were recruited from safety net clinics. Pathanalytic models tested the pathways linking health literacy to physical activity and self-reported health.

RESULTS

There were significant paths from health literacy to knowledge (r = 0.22, P < 0.001), knowledge to self-efficacy (r = 0.13, P < 0.01), self-efficacy to physical activity (r = 0.17, P < 0.01), and physical activity to health status (r = 0.17, P < 0.01).

CONCLUSIONS

Health education interventions should be literacy sensitive and aim to enhance patient health knowledge and self-efficacy to promote self-care behavior and desirable health outcomes.

Applicability of a video intervention to increase informed decision making for prostate-specific antigen testing

PURPOSE

To evaluate the applicability of an evidence-based video intervention to promote informed decision making for prostate cancer screening among African American men with different levels of health literacy.

METHODS

Forty nine African American men participated in interviewer-administered, pretest and posttest interviews between January and March 2008. Health literacy status was assessed with the Test of Functional Health Literacy in Adults. Repeated measures analysis of covariance (ANCOVA), McNemar or binomial distributions were computed to assess pretest and posttest differences in knowledge. Descriptive statistics were produced to describe participants' perceptions of the information presented in the video.

RESULTS

Results indicated that men with functional health literacy had higher mean levels of prostate cancer screening knowledge at baseline than men with inadequate health literacy. The between-group (F2,44= 4.84; p = .013) and within-group (F1,44 = 5.16; p = .028) test results from repeated-measures ANCOVA indicated that preexisting group differences in prostate cancer knowledge had lessened after intervention exposure. Nearly all men rated the information presented in the video as credible (98%), trustworthy (96%), interesting (100%), understandable (94%), and complete (96%).

CONCLUSIONS

Results from this exploratory study suggest that the video intervention is suitable for use with African American men with different health literacy characteristics in 2 counties in the greater Florida panhandle region. More research is recommended to evaluate the impact of the intervention on men's intentions to undergo screening and actual screening behavior.

Racial and ethnic disparities in benign gynecologic conditions and associated surgeries

Common gynecologic conditions and surgeries may vary significantly by race or ethnicity. Uterine fibroid tumors are more prevalent in black women, and black women may have larger, more numerous fibroid tumors that cause worse symptoms and greater myomectomy complications. Some, but not all, studies have found a higher prevalence of endometriosis among Asian women. Race and ethnicity are also associated with hysterectomy rate, route, and complications. Overall, the current literature has significant deficits in the identification of racial and ethnic disparities in the incidence of fibroid tumors, endometriosis, and hysterectomy. Further research is needed to better define racial and ethnic differences in these conditions and to examine the complex mechanisms that may result in associated health disparities.

In search of 'low health literacy': threshold vs. gradient effect of literacy on health status and mortality

Studies have demonstrated significant associations between limited literacy and health outcomes. Yet differences in literacy measurement and the cutoffs used for analysis have made it difficult to fully understand the relationship between literacy and health across the entire spectrum of literacy (i.e., whether the relationship is continuous and graded or whether a threshold exists below which literacy is independently associated with health). To analyze this question, we re-examined the relationship between literacy, baseline physical functioning and mental health, and all-cause mortality for a cohort of 3260 US community-dwelling elderly who were interviewed in 1997 to determine demographics, socioeconomic status, chronic conditions, self-reported physical and mental health (SF-36 subscales), health behaviors, and literacy based upon the Short Test of Functional Health Literacy in Adults (S-TOFHLA). All-cause mortality was determined using data from the US National Death Index through 2003. Seven categories of S-TOFHLA literacy scores were created and used in this analysis instead of the existing three categories identified with the measure. In multivariate analyses, a continuous, graded relationship between literacy and baseline physical functioning was identified. However, participants scoring below the third literacy category had significantly worse mental health compared to the highest literacy category, displaying a notable threshold. Finally, all six literacy categories were significantly associated with greater all-cause mortality risk compared to the highest literacy category, but again there was a marked threshold below the third category at which the adjusted mortality rate significantly increased compared to all other categories. We conclude that the nature of the relationship between literacy and health may vary depending upon the outcome under examination.

Promoting health literacy research to reduce health disparities

Limited health literacy has been linked to worse health outcomes for a range of medical conditions. In addition, limited health literacy is more prevalent among specific racial and ethnic minorities. Although these findings have been widely acknowledged, little systematic research has been conducted to elucidate the role of health literacy in the creation of health disparities or to evaluate the possibility that interventions relating to health literacy may help eliminate health disparities. This paper presents recommendations for a research agenda that is focused on advancing the science for how health literacy research can promote the effort to eliminate health disparities.

Health literacy and its association with the use of information sources and with barriers to information seeking in clinic-based pregnant women

We investigated health literacy and its association with the use of information sources and with barriers to information seeking in clinic-based pregnant women. The Short Test of Functional Health Literacy in Adults (STOFHLA) was used to measure health literacy in 143 English-speaking low-income pregnant women. About 15% of the participants demonstrated low health literacy. Participants with low health literacy were less likely to use the Internet and more likely to have self-efficacy barriers than participants with high health literacy. Interventions to promote information-seeking skills and Internet access are indicated for women with low health literacy.

Literacy and learning in health care

The relationship between literacy and health outcomes are well documented in adult medicine, yet specific causal pathways are not entirely clear. Despite an incomplete understanding of the problem, numerous interventions have already been implemented with variable success. Many of those who proposed earlier strategies assumed the problem to originate from reading difficulties only. Given the timely need for more effective interventions, it is of increasing importance to reconsider the meaning of health literacy to advance our conceptual understanding of the problem and how best to respond. One potentially effective approach might involve recognizing the known associations between a larger set of cognitive and psychosocial abilities with functional literacy skills. Here we review the current health literacy definition and literature and draw on relevant research from the fields of education, cognitive science, and psychology. In this framework, a research agenda is proposed that considers an individual's "health-learning capacity," which refers to the broad constellation of cognitive and psychosocial skills from which patients or family members must draw to effectively promote, protect, and manage their own or a child's health. This new, related concept will lead, ideally, to more effective ways of thinking about health literacy interventions, including the design of health-education materials, instructional strategies, and the delivery of health care services to support patients and families across the life span.

Asthma 1-2-3: a low literacy multimedia tool to educate African American adults about asthma

Asthma 1-2-3 is a newly-developed low-literacy multimedia education tool designed to promote asthma self-care concepts among African American adults. An expert panel (n = 10) informed content development for the tool. The video script and storyboard imagery were shown to 30 African Americans recruited from the American Lung Association, whose reactions and comments guided further revisions. The final version was pilot tested in three diverse community settings in Chicago to determine the efficacy of Asthma 1-2-3 at improving patient understanding of asthma and its symptoms. In all, 130 adults participated in the pilot test. Knowledge scores significantly improved from pretest to posttest following presentation of the developed tool for subjects across all literacy levels (Pretest: Mean = 4.2 [SD = 1.6]; Posttest: M = 6.8 [SD = 2.0], P < 0.001). Symptom pathophysiology concepts were the least understood. Individuals with low literacy had less total knowledge score gains compared to those with marginal and adequate literacy (1.8, 2.6, and 3.2 respectively; P = 0.002). The multimedia tool significantly improved understanding of asthma. Individuals with limited literacy may require additional instruction, repeated viewing, or added tangible cues (i.e. supplementary print materials) to support knowledge retention. In general, feedback from the target population was particularly helpful in the development of the tool and its initial evaluation, and should be considered as a necessary step in the creation of other patient education materials.

Diabetes numeracy: an overlooked factor in understanding racial disparities in glycemic control

OBJECTIVE

Understanding the reasons and eliminating the pervasive health disparities in diabetes is a major research, clinical, and health policy goal. We examined whether health literacy, general numeracy, and diabetes-related numeracy explain the association between African American race and poor glycemic control (A1C) in patients with diabetes.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes (n = 383) were enrolled in a cross-sectional study at primary care and diabetes clinics at three medical centers. Data collected included the following: self-reported race, health literacy, general numeracy, diabetes-related numeracy, A1C, and sociodemographic factors. A series of structural equation models were estimated to explore the interrelations between variables and test for mediation.

RESULTS

In model 1, younger age (r = -0.21, P < 0.001), insulin use (r = 0.27, P < 0.001), greater years with diabetes (r = 0.16, P < 0.01), and African American race (r = 0.12, P < 0.01) were all associated with poorer glycemic control. In model 2, diabetes-related numeracy emerged as a strong predictor of A1C (r = -0.46, P < 0.001), reducing the association between African American and poor glycemic control to nonsignificance (r = 0.10, NS). In model 3, African American race and older age were associated with lower diabetes-related numeracy; younger age, insulin use, more years with diabetes, and lower diabetes-related numeracy were associated with poor glycemic control.

CONCLUSIONS

Diabetes-related numeracy reduced the explanatory power of African American race, such that low diabetes-related numeracy, not African American race, was significantly related to poor glycemic control. Interventions that address numeracy could help to reduce racial disparities in diabetes.

Sexual rehabilitation after localized prostate cancer: current interventions and future directions

Many published articles have documented the impact of prostate-cancer treatment on sexual functioning in men treated for localized disease. Surprisingly, the literature on interventions to rehabilitate men's sexual functioning is much more limited. In this article, we review the sexual-rehabilitation interventions for prostate-cancer patients and identify a number of common themes across interventions. We also identify areas where further research is needed and propose a conceptual model based on psychologic and nursing theories and informed by the published research.