More than meets the eye: relationship between low health literacy and poor vision in hospitalized patients

Bridging the gap in health literacy research: The inclusion of individuals with visual impairments

OBJECTIVES

Patient education and health literacy aim to enhance understanding of health and self-care for optimal health outcomes. However, the attention towards populations with visual impairments requiring specialized accommodations for improved health literacy and healthcare access appears to be insufficient METHODS: In an effort to bridge this gap, we conducted a scoping review focusing on health literacy studies undertaken specifically for individuals with visual impairments.

RESULTS

We encapsulate the main findings and constraints of preceding studies and deliberate on the influence of health literacy research for individuals with visual impairments on healthcare inequalities and health disparities.

CONCLUSIONS

A health-literate approach, combined with an accessible healthcare environment, can serve as a catalyst to motivate individuals with visual impairments to actively engage in their self-care practices.

PRACTICE IMPLICATIONS

It is of utmost urgency to develop and validate a health literacy assessment tool for visually impaired individuals, and to utilize it for providing healthcare interventions as well as health education.

The relationship between sensory loss and health literacy in older adults: A systematic review

OBJECTIVES

As sensory loss may impact the ability to receive and apply health information, a relationship between sensory loss and health literacy may exist. The purpose of this systematic review was to explore the relationship between hearing, vision and dual sensory loss and health literacy in older adults.

METHODS

Studies examining the relationship between sensory loss and health literacy in older adult populations using a validated health literacy instrument were included. The search was conducted in the CINAHL, PubMed, Scopus, AgeLine and REHABdata databases in May-June 2021.

RESULTS

Nine studies were included. Findings revealed a positive association between hearing and vision loss and low health literacy.

DISCUSSION

This review highlights a relationship between hearing and vision loss and low health literacy. The small number of studies and overall heterogeneity of study methods limits strength of this evidence. Individuals with sensory loss may benefit from additional clinician support in receiving and applying health information.

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Evaluating the Need to Address Digital Literacy Among Hospitalized Patients: Cross-Sectional Observational Study

Background

Technology is a potentially powerful tool to assist patients with transitions of care during and after hospitalization. Patients with low health literacy who are predisposed to poor health outcomes are particularly poised to benefit from such interventions. However, this population may lack the ability to effectively engage with technology. Although prior research studied the role of health literacy in technology access/use among outpatients, hospitalized patient populations have not been investigated in this context. Further, with the rapid uptake of technology, access may no longer be pertinent, and differences in technological capabilities may drive the current digital divide. Thus, characterizing the digital literacy of hospitalized patients across health literacy levels is paramount.

Objective

We sought to determine the relationship between health literacy level and technological access, use, and capability among hospitalized patients.

Methods

Adult inpatients completed a technology survey that asked about technology access/use and online capabilities as part of an ongoing quality of care study. Participants’ health literacy level was assessed utilizing the 3-question Brief Health Literacy Screen. Descriptive statistics, bivariate chi-squared analyses, and multivariate logistic regression analyses (adjusting for age, race, gender, and education level) were performed. Using Bonferroni correction for the 18 tests, the threshold P value for significance was <.003.

Results

Among 502 enrolled participants, the mean age was 51 years, 71.3% (358/502) were African American, half (265/502, 52.8%) were female, and half (253/502, 50.4%) had at least some college education. Over one-third (191/502, 38.0%) of participants had low health literacy. The majority of participants owned devices (owned a smartphone: 116/173, 67.1% low health literacy versus 235/300, 78.3% adequate health literacy, P=.007) and had used the Internet previously (143/189, 75.7% low health literacy versus 281/309, 90.9% adequate health literacy, P<.001). Participants with low health literacy were more likely to report needing help performing online tasks (133/189, 70.4% low health literacy versus 135/303, 44.6% adequate health literacy, P<.001). In the multivariate analysis, when adjusting for age, race, gender, and education level, we found that low health literacy was not significantly associated with a lower likelihood of owning smartphones (OR: 0.8, 95% CI 0.5-1.4; P=.52) or using the internet ever (OR: 0.5, 95% CI 0.2-0.9; P=.02). However, low health literacy remained significantly associated with a higher likelihood of needing help performing any online task (OR: 2.2, 95% CI 1.3-3.6; P=.002).

Conclusions

The majority of participants with low health literacy had access to technological devices and had used the internet previously, but they were unable to perform online tasks without assistance. The barriers patients face in using online health information and other health information technology may be more related to online capabilities rather than to technology access. When designing and implementing technological tools for hospitalized patients, it is important to ensure that patients across digital literacy levels can both understand and use them.

The Mediating Role of the Patient Health Engagement Model on the Relationship Between Patient Perceived Autonomy Supportive Healthcare Climate and Health Literacy Skills

Individuals with low health literacy (HL) are known to have poorer health outcomes and to have higher mortality rates compared to individuals with higher HL; hence, the improvement of HL is a key outcome in modern healthcare systems. Healthcare providers are therefore asked to support patients in becoming more and more engaged in their healthcare, thus augmenting their literacy skills. Our main hypothesis is that the well-known relationship between patients’ perceived autonomy supportive healthcare climate and HL skills is mediated by the Patient Health Engagement Model (PHE-model) which describes the patients’ progressive maturation of a psychological readiness to become active players in their healthcare. The purpose of this study was to formulate a hypothetical structural equation model (SEM) linking an autonomy-supportive healthcare climate to PHE-model and HL. A cross-sectional survey design was employed involving 1007 Italian chronic patients. The hypothetical model was tested using SEM to verify the hypothesized mediation of the PHE-model between autonomy-supportive healthcare climate and HL. Results show that the theoretical model has a good fit indexes and that PHE-model fully mediates the relationship between autonomy-supportive healthcare climate and HL. This finding suggests healthcare systems to implement a new paradigm where patients are supported to play an autonomous role in their own healthcare.

Effectiveness of Virtual vs In-Person Inhaler Education for Hospitalized Patients With Obstructive Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Many patients who are hospitalized cannot use inhalers correctly, yet education for their use is often not provided. To address the need for an effective intervention feasible for wide-scale implementation, a virtual teach-to-goal intervention was developed to provide tailored patient-directed education using adaptive learning technology.

OBJECTIVE

To assess whether the virtual teach-to-goal intervention is noninferior to an in-person teach-to-goal intervention for improving inhaler technique.

DESIGN, SETTING, AND PARTICIPANTS

An equivalence and noninferiority randomized clinical trial took place from January 13, 2016, through September 20, 2017, with analyses conducted between October 25, 2017, and September 23, 2019. Adult inpatients with asthma or chronic obstructive pulmonary disease (COPD) admitted to general inpatient wards were eligible. Enrolled participants were randomized to virtual (n = 61) or in-person (n = 60) educational interventions. Investigators and research assistants were masked to interventions. Initial enrollment, study assessments, and delivery of the educational intervention occurred in the hospital; participants returned at 30 days for a follow-up research visit.

INTERVENTIONS

Virtual education was a module delivered via handheld tablet with self-assessment questions before demonstration, narrated video demonstration of the correct technique, and self-assessment questions after demonstration; up to 3 rounds were repeated as needed. In-person education participants received iterative rounds of inhaler technique assessment and education by trained staff.

MAIN OUTCOMES AND MEASURES

Noninferiority testing of whether virtual vs in-person education achieved an equal percentage with correct inhaler technique after education (>9 of 12 steps correct) against an a priori noninferiority limit of -10%; logistic regression models were used to adjust for differences in baseline technique and health literacy.

RESULTS

Among 118 participants (59 in each group), most were black (114 [97%]) and female (76 [64%]), with a mean (SD) age of 54.5 (13.0) years. Correct technique increased similarly before vs after education in virtual (67%; range, 2%-69%) and in-person (66%; range, 17% to 83%) groups, although the difference after intervention exceeded the noninferiority limit (-14%; 95% CI lower bound, -26%). When adjusting for baseline inhaler technique, the difference was equivalent to the noninferiority limit (-10%; 95% CI lower bound, -22%).

CONCLUSIONS AND RELEVANCE

The findings suggest that patient-directed virtual education similarly improved the percentage of participants with correct technique compared with in-person education. Future work should confirm whether virtual teach-to-goal education is noninferior to in-person education and whether it is associated with long-term skills retention, medication adherence, and improved health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02611531.

Inpatient vision screening: A needs assessment

Insufficient vision is a common but under-recognized risk factor among hospitalized patients that affects patient safety and self-care. Nurses may be ideal providers to screen inpatients’ vision, but little is known regarding their knowledge of inpatient vision, screening skills, and willingness to serve as screeners. We conducted a pilot, prospective, qualitative, and quantitative interview study and enrolled 25 consenting registered nurses. Descriptive statistics were employed to analyze discrete questionnaire items and responses to qualitative open-ended items. Forty-eight percent (12/25) of nurses believed that vision problems were “moderately common,” half (13/25) did not know how to administer vision screenings, and three-quarters (19/25) had never administered screenings. Half of nurses (12/25) believed vision screening would be feasible, though over half (14/25) believed physicians should conduct the screening. This study underscores the necessity and positive support for inpatient vision screening; however, while nurses play a critical role, an inter-professional approach should be explored.

Health Literacy and Hospital Length of Stay: An Inpatient Cohort Study

BACKGROUND

Associations between low health literacy (HL) and adverse health outcomes have been well documented in the outpatient setting; however, few studies have examined associations between low HL and in-hospital outcomes.

OBJECTIVE

To compare hospital length of stay (LOS) among patients with low HL and those with adequate HL.

DESIGN

Hospital-based cohort study.

SETTING

Academic urban tertiary-care hospital.

PATIENTS

Hospitalized general medicine patients.

MEASUREMENTS

We measured HL using the Brief Health Literacy Screen. Severity of illness and LOS were obtained from administrative data. Multivariable linear regression controlling for illness severity and sociodemographic variables was employed to measure the association between HL and LOS.

RESULTS

Among 5540 participants, 20% (1104/5540) had low HL. Participants with low HL had a longer average LOS (6.0 vs 5.4 days, P < 0.001). Low HL was associated with an 11.1% longer LOS (95% confidence interval [CI], 6.1%-16.1%; P < 0.001) in multivariate analysis. This effect was significantly modified by gender (P = 0.02). Low HL was associated with a 17.8% longer LOS among men (95% CI, 10.0%-25.7%; P < 0.001), but only a 7.7% longer LOS among women (95% CI, 1.9%-13.5%; P = 0.009).

CONCLUSIONS

In this single-center cohort study, low HL was associated with a longer hospital LOS. The findings suggest that the adverse effects of low HL may extend into the inpatient setting, indicating that targeted interventions may be needed for patients with low HL. Further work is needed to explore these negative consequences and potential mitigating factors.

Health Literacy Not Associated with Chronic Kidney Disease Awareness

Background:

Patient awareness of their chronic kidney disease (CKD) and health literacy (HL) are both important for adherence to therapies that slow CKD progression and to reduce risk of complications. Little is known about the association between HL and CKD awareness.

Objective:

We sought to determine if patient HL is associated with CKD awareness.

Methods:

We conducted a cross-sectional study of general medicine inpatients at an urban academic medical center discharged between June 2011 and July 2013 with CKD, defined as having at least one CKD International Classification of Diseases, ninth revision code (585.0–585.9), among their first 20 admission diagnoses. Logistic regression was used to analyze the influence of HL, demographic, clinical, and health care use covariates on the likelihood of patients' CKD awareness. Our primary outcome was patient awareness of their CKD, defined as correct patient self-report of “kidney problems.” We used the Brief Health Literacy Screen, a three-item verbal questionnaire, to assess HL.

Key Results:

Among 1,308 patients with CKD, awareness of CKD was 33%, and 48% had adequate HL. However, CKD awareness was not associated with HL even among patients with stage 4 or 5 CKD. In multivariable logistic regression, greater awareness was associated with being a woman, younger than age 50 years, married, White, having hypertension, and having a higher CKD stage (all p < .05). In stratified analyses, patients with hypertension had greater CKD awareness, regardless of HL or diabetes status (p < .05).

Conclusions:

Among hospitalized patients with CKD, both CKD awareness and HL are low and inadequate. Surprisingly, patients' knowledge of their CKD diagnosis was not related to patients' HL. Patients with hypertension who young, white, or married may be receiving or retaining more education related to CKD. More work is needed on how to effectively communicate CKD diagnosis to prevent widening health disparities. [Health Literacy Research and Practice. 2017;1(3):e117–e127.]

Plain Language Summary:

We studied whether patients with low health literacy also had low awareness of their chronic kidney disease (CKD). Hospitalized patients with CKD were asked three questions about their health literacy and whether they had “kidney problems.” Overall CKD awareness and health literacy were low, but a low score on one did not predict a low score on the other.

Screening Hospitalized Patients for Low Health Literacy: Beyond the REALM of Possibility?

As patient-centered education efforts increase, assessing health literacy (HL) becomes more salient. The verbal Brief Health Literacy Screen (BHLS) may have clinical and feasibility advantages over written tools, including the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and Short Test of Functional Health Literacy in Adults (S-TOFHLA); however, the BHLS's utility among inpatients remains unresolved. Hospitalized adults were enrolled; HL was assessed using three tools. Categorical comparisons used chi-square; area under the receiver operating characteristic curve was calculated (reference: REALM-R). The prevalence of low HL among participants ( n = 260) was higher for the BHLS than S-TOFHLA (29% vs. 17%, p < .001) and higher for the REALM-R than both the BHLS (44% vs. 29%, p = .004) and S-TOFHLA (44% vs. 17%, p < .001). The areas under the receiver operating characteristic curve were .58 for BHLS and .66 for S-TOFHLA. The different prevalence of low HL among the participants based on each tool likely reflects the complexity of measuring HL and differing domains captured by each tool. The BHLS can be considered a viable inpatient HL screening tool, given its increased feasibility and verbal administration.

Postdischarge Falls and Readmissions: Associations with Insufficient Vision and Low Health Literacy among Hospitalized Seniors

The role of patient-level risk factors such as insufficient vision has been understudied. Because insufficient vision may interfere with health literacy assessments, the full impact of low health literacy among older patients with impaired vision is unknown. We sought to determine whether senior inpatients' insufficient vision and low health literacy are associated with adverse outcomes postdischarge, specifically falls and readmissions. We conducted an observational study of adult medicine inpatients at an urban hospital. Visual acuity and health literacy were screened at bedside. Outcomes data were collected by telephone 30 days postdischarge. Among 1,900 participants, 1,244 (65%) were reached postdischarge; 44% had insufficient vision and 43% had low health literacy. Insufficient vision was associated with postdischarge falls among participants ≥65 years (adjusted odds ratio [AOR] 3.38, 95% confidence interval [CI] 1.42-8.05), but not among participants <65 years (AOR 1.44, 95% CI 0.89-2.32). Low health literacy was associated with readmissions among participants ≥65 years (AOR 3.15, 95% CI 1.77-5.61), but not among participants <65 years (AOR 0.78, 95% CI 0.56-1.09). The results suggest the need to implement screening for older inpatients' vision and health literacy. Developing effective interventions to reduce these risks is critical given national priorities to reduce falls and readmissions.

Development of the Health Literacy Assessment Scale for Adolescents (HAS-A)

BACKGROUND

Health literacy has been found to be a crucial component of successful communication and navigation in health care. Various tools have been developed to measure health literacy skills, but few have been developed specifically for adolescents, and most require in-person administration. This study sought to develop a self-report health literacy scale for adolescents to assess four key health literacy domains: the ability to obtain, communicate, understand, and process health information.

METHODS

We collected data from 272 youth aged 12-19 recruited from a pediatrics clinic (37%) and the community (63%). We administered the Rapid Estimate of Adolescent Literacy in Medicine-Teen, Newest Vital Sign, and three surveys, and used factor analysis to identify scale items.

RESULTS

Using multiple health literacy assessments, it was clear that many teens struggle with low health literacy skills. When identifying items that can be used as self-report items in future research, factor analysis identified three subscales; a 5-item communication scale (alpha = 0.77), a 4-item confusion scale (alpha = 0.73), and a 6-item functional health literacy scale (alpha = 0.76). The scales performed reasonably well when compared with validation items.

CONCLUSIONS

Self-report items can be used to assess health literacy skills for adolescents when in-person administration is not possible or feasible. Such items will allow for greater study of how health literacy impacts communication in not only health care settings, but for all levels of health communication. The tool will also allow researchers to better understand how adolescent health literacy is related to a variety of health outcomes. Further testing of these scales with different populations is warranted.

Insights into inpatients with poor vision: A high value proposition

BACKGROUND

Vision impairment is an under-recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low-cost ($8 and up) nonprescription "readers" may be a simple, high-value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision.

METHODS

From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ(2) tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116).

DISCUSSION

Among an easily identified subgroup of inpatients with poor vision, low-cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high-value care related to patients' vision.