Patients' perceptions of screening for health literacy: reactions to the newest vital sign

Health literacy and knowledge of female reproduction in undergraduate students

Objective: College students make many important decisions related to sexual health, but little is known about their reproductive health knowledge. The purpose of the study was to examine health literacy and knowledge of female reproduction, contraception, and sexually transmitted infections (STIs) in college students. Participants: Undergraduate students (n = 323) completed a survey in November 2017. Methods: The survey included the Newest Vital Sign (NVS), Knowledge of the Female Body (KFB) scale, contraceptive questions, STI prevention questions, and sexual history questions. Results: NVS and KFB scores were positively correlated (p < .01). Male participants demonstrated significantly lower KFB scores than female participants (p < .001). Transgender participants demonstrated lower health literacy and lower knowledge of basic female reproduction than cisgender participants. Participants demonstrated low knowledge of the menstrual cycle, early physical signs of pregnancy, and certain contraceptives. Conclusions: Undergraduate students have major reproductive knowledge gaps. Healthcare providers need to consider health literacy and knowledge level when educating college students.

Communication Gaps Between Providers and Caregivers of Patients in a Pediatric Emergency Department

Communication gaps between the healthcare team and caregivers of pediatric patients can result in negative consequences. This study aims to identify specific words and phrases used in a pediatric emergency department (ED) that are unclear or confusing to caregivers. Research assistants at the Primary Children’s Hospital recorded caregivers’ responses to the question, “What words or phrases have been used during this visit that are unclear or don’t make sense to you?” Across all steps in the care process, 62 of 220 participants (28.2%) reported unclear words and phrases used by the healthcare team. Responses recorded after the discharge step had the highest proportion of communication problems, followed by the initial evaluation and then the update step (χ² [2, N = 220] = 6.30, P = .043). Themes among responses included ED logistics, signs/symptoms, the diagnostic process, treatment/procedures, general confusion, and language barriers. These results provide feedback to pediatric emergency medicine providers about potential communication gaps and point to a need for further efforts to train providers in the practice of high-quality communication.

A systematic review of instruments to measure health literacy of patients in emergency departments

OBJECTIVES

Knowledge of patient's health literacy (HL) in the emergency department (ED) can facilitate care delivery and reduce poor health outcomes. This systematic review investigates HL measurement instruments used in the ED and their psychometric properties, accuracy in detecting limited HL, and feasibility.

METHODS

We searched in five biomedical databases for studies published between 1990 and January 2021, evaluating HL measurement instruments tested in the ED on internal consistency, criterion validity, diagnostic accuracy, or feasibility. Reviewers screened studies for relevance and assessed methodologic quality with published criteria. Data were synthesized around study and instrument characteristics and outcomes of interest.

RESULTS

Of the 2,376 references screened, seven met our inclusion criteria. Studied instruments varied in objective (n = 5) and subjective (n = 6) measurement of HL skills, and in HL constructs measured. The Brief Health Literacy Screen (BHLS) and the Subjective Numeracy Scale demonstrate acceptable and good internal consistency across studies. None of the instruments perform consistently well on criterion validity. The Rapid Estimate of Adult Literacy in Medicine-Revised and the Newest Vital Sign, both objective tests with short administration times, demonstrate good accuracy in one study with high risk of bias. The BHLS, a short subjective measure, shows moderate accuracy across studies including one with low risk of bias.

CONCLUSIONS

Several short instruments seem valid in measuring HL and accurate in detecting limited HL among ED patients, each with its practical advantages and disadvantages and specific measurement of HL. Additional research is necessary to develop a robust evidence base supporting these instruments.

Hospital pharmacists understanding of available health literacy assessment tools and their perceived barriers for incorporation in patient education - a survey study

BACKGROUND

Patients with low health literacy experience difficulty in understanding their medications leading to worse health outcomes. Pharmacists need to use formal assessment tools to be able to identify these patients, so they can better tailor their patient education. The objective of the study was to characterize hospital pharmacists understanding of health literacy and their use of screening and counselling strategies before and after completion of an educational module and to identify barriers that hospital pharmacists perceive to exist that prevent them from using health literacy tools.

METHODS

Pharmacists in three health authorities were administered a pre-survey and then given access to an online 11 min educational video. The post-survey was distributed 1 month later. Descriptive statistics were used to quantify survey responses with comparisons made between pre and post responses. The main outcome measure was pharmacists' understanding of health literacy and their current practice related to health literacy.

RESULTS

There were 131 respondents for the pre-survey and 39 for the post-survey. In the pre-module survey, 84% of pharmacists felt they understood what health literacy was, but only 53% currently assessed patients for their health literacy status and 40% were aware of what strategies to use in low health literacy patients. Lack of time (74%) was the biggest barrier in assessing patients' health literacy. In the post-module survey, 87% felt they understood what health literacy was and 64% incorporated health literacy status evaluation into their clinical practice. The educational module was helpful to the clinical practice of 74% of respondents.

CONCLUSION

As health literacy can affect a patient's ability to adhere to their medications it is important for pharmacists to assess this in their patients. While pharmacists self-reported a high degree of understanding of health literacy, they are not regularly assessing their patients' health literacy status and are unaware of what strategies to use for low literacy patients.

HPV Misconceptions Among College Students: The Role of Health Literacy

Human papillomavirus (HPV) is currently the most common sexually transmitted disease in the United States, with potentially serious health consequences, including cervical cancer. Young adults are particularly at risk of infection, but many remain unvaccinated. Low health literacy may contribute to poor knowledge of HPV and lack of vaccine uptake, and women living in the Southeastern United States are particularly at risk for lower vaccination rates and cervical cancer screening adherence. Three-hundred-sixty undergraduates at a Southeastern U.S. University completed measures of health literacy, sexual attitudes, and HPV knowledge in 2016. Less than half of both male and female participants had completed an HPV vaccine series, and there were no differences in health literacy scores between participants who had completed a vaccine series and those who had not. Forty subjects were familiar with HPV vaccines but not the virus itself. More than half of these individuals had received at least one dose of an HPV vaccine, highlighting a lack of knowledge regarding the purpose of this vaccine. While health literacy was not related to vaccination status, it was associated with greater knowledge of both HPV and available vaccines. Participants who were familiar with HPV had higher health literacy than participants who were not. College students hold serious misconceptions about HPV that may be redressed through public health education programs to increase health literacy and knowledge. Such public health interventions would potentially increase HPV vaccine uptake, leading to decreased cervical cancer incidence and mortality rates.

Social determinants of health: the how, who, and where screenings are occurring; a systematic review

Screening for social determinants of health allows health care teams to assess and address social factors that influence one's health, mental health, and access to care. These social factors include poverty, health literacy, social support, exposure to trauma, food insecurity, and housing instability. The objective of this study was to examine what screening tools for social determinants of health are being used, in what contexts, and with what populations. Findings suggest that health literacy is the most commonly screened for, followed by trauma history, social support, food insecurity and housing across diverse contexts and populations. Results from this study can be used to inform providers of available screening tools and resources that can be readily utilized in practice.

Universal Measures of Support Are Needed: A Cross-Sectional Study of Health Literacy in Patients with Dupuytren's Disease

BACKGROUND

Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren's contracture and (2) to identify independent predictors of limited health literacy.

METHODS

This cross-sectional study included patients with Dupuytren's disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy.

RESULTS

A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings.

CONCLUSIONS

Limited health literacy is common among patients with Dupuytren's contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.

Development and Validation of an Environmental Health Literacy Assessment Screening Tool for Domestic Well Owners: The Water Environmental Literacy Level Scale (WELLS)

In the U.S., privately owned wells are not subject to any regulatory testing requirements. Well owners must have sufficient environmental health literacy (EHL) to understand and interpret information that contain complex terms and labels to manage their water quality. The objective of this paper is to assess the performance and validity of a new EHL screening tool. The Water Environmental Literacy Level Scale (WELLS) is based on the Newest Vital Sign (NVS) and contains six questions on comprehension, calculations and application of information. Content validity was assessed from expert review. Criterion-related and construct validity were evaluated using an online, convenience sample of adults (n = 869). Percent of correct responses for items ranged from 53% to 96% for NVS and from 41% to 97% for WELLS. Completion time, mean scores, distributions, and internal consistency were equivalent between both scales. Higher scores suggest higher EHL. The scales were moderately correlated (ρ = 0.47, p < 0.001). Kappa agreement was 74%. Bland-Altman plots depicted little mean difference between the scales. Education and income level were positively associated with EHL. WELLS showed criterion-validity with NVS and construct validity with education and income. In practice or research, WELLS could quickly screen individuals for low EHL.

Nursing and allied health professionals' views about using health literacy screening tools and a universal precautions approach to communication with older adults: a qualitative study

Purpose: Health literacy describes individuals' abilities to access, understand and use health information. Lower health literacy is associated with poor health outcomes, is more common among older adults and impacts on the effectiveness of rehabilitation/self-management interventions. This research explored nursing and allied healthcare professionals' views about identifying and responding to older adults' health literacy needs.Methods: Qualitative focus groups were conducted with a purposive sample of 22 UK nursing and AHPs working with older adults. Focus groups were audio-recorded, transcribed verbatim and analyzed using framework approach.Results: Participants used a variety of practices to identify older patients' health literacy levels, but primarily relied on subtle cues. Participants lacked knowledge and confidence in identifying and addressing health literacy needs. Participants expressed concerns about patient reactions and described practical barriers to using recommended health literacy strategies.Conclusions: Participants recognized the importance of addressing patients' health literacy needs, but do not routinely use health literacy strategies, lack confidence and have reservations about recommended health literacy strategies. This impacts on healthcare professionals' abilities to support patients to self-manage and participate in rehabilitation. Health literacy education for health professionals should consider barriers to using health literacy strategies and be tailored to accommodate variation in teams and professions.Implications for rehabilitationRehabilitation professionals need to standardise their practice to health literacy, using strategies which can be easily integrated into routine practice.To meet older adults' health literacy needs, rehabilitation professionals should use clear and accessible tailored communication, build trust, assess understanding and involve patients' social networks.Rehabilitation professionals would benefit from further education regarding health literacy to build their knowledge/confidence and address their concerns about implementing health literacy strategies.Professional education regarding health literacy needs to accommodate variation between individuals and teams.

Health Literacy Among Swedish Lung Transplant Recipients 1 to 5 Years After Transplantation

INTRODUCTION

Understanding medical information and self-management ability is vital for good quality of life among transplant recipients. However, health literacy (HL) has never been investigated among lung transplant recipients.

OBJECTIVE

This study investigated HL among Swedish lung transplant recipients 1 to 5 years after lung transplantation in relation to recovery, fatigue, adherence, cognitive function (CF), and relevant demographic variables.

METHOD

This study was part of a cross-sectional, Swedish multicenter study 1 to 5 years post lung transplantation called Self-Management after Thoracic Transplantation. In total, 117 (57%) of 204 eligible lung recipients due for their yearly follow-up were included; 1 year (n = 35), 2 years (n = 28), 3 years (n = 23), 4 years (n = 20) or 5 years (n = 11) after transplantation. The newest vital sign (NVS) instrument was used to measure the level of HL and contained 6 interview questions. The total scores ranged from 0 to 6 with 0 to 1= inadequate/low, 2 to 3 = marginal, 4 to 6 = adequate/good HL.

RESULTS

Twenty-one percent reported an NVS score of 0 to 3 indicating low or marginal HL and 79% scored 4 to 6 indicating adequate HL. Recipients scoring low or marginal were represented in all 5 years posttransplant, and the majority were not able to work. Health literacy was not related to age, sex, fatigue, adherence, recovery, marital status, or self-reported CF.

DISCUSSION

Health literacy was good among Swedish lung recipients. Providers should be aware that patients with low HL might present at any time posttransplant, and screening will help identify patients who need extra support.

Maternal Attitudes, Normative Beliefs, and Subjective Norms of Mothers of 2- and 3-Year-Old Children

INTRODUCTION

This exploratory study examined maternal attitudes, normative beliefs, subjective norms, and meal selection behaviors of mothers of 2- and 3-year-old children.

METHODS

Guided by the Theory of Reasoned Action, we had mothers complete three surveys, two interviews, and a feeding simulation exercise. Data were analyzed using descriptive and bivariate statistics and multivariate linear regression.

RESULTS

A total of 31 mothers (50% Latino, 34% Black, 46.9% ≤ high school education, 31.3% poor health literacy) of 32 children (37.5% overweight/obese) participated in this study. Maternal normative beliefs (knowledge of U.S. Department of Agriculture recommendations) did not reflect actual U.S. Department of Agriculture recommendations. Collectively, regression models explained 13% (dairy) to 51% (vegetables) of the variance in behavioral intent, with normative belief an independent predictor in all models except grain and dairy.

DISCUSSION

Meal selection behaviors, on average, were predicted by poor knowledge of U.S. Department of Agriculture recommendations. Dietary guidance appropriate to health literacy level should be incorporated into well-child visits.

The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for mis-communication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.

The State of the Science of Health Literacy Measurement

Advancing health literacy (HL) research requires high-quality HL measures. This chapter provides an overview of the state of the science of HL measurement: where the field started, currently is, and should be going. It is divided into eight key sections looking at (1) the history of HL measurement, (2) the relationship between HL definitions and measurement, (3) the HL conceptual domains most and least frequently measured, (4) the methods used to validate HL measures, (5) the characteristics of the participants in the measurement validation studies, (6) the practical considerations related to administering HL measures, (7) the advantages and disadvantages of using objective versus subjective HL measures, and (8) future directions for HL measurement. Based on the material presented in this chapter, the following conclusions can be drawn. First, there is an enormous proliferation of HL measures and this growth presents both opportunities and challenges for the field. Second, to move the field forward, there is an urgent need to better align HL measurement with definitions of HL. Third, some HL domains, such as numeracy, are measured more often than others, such as speaking and listening. Consequently, it is important to think about novel mechanisms to measure HL domains that are rarely measured. Fourth, HL measures are most often developed, validated, and refined using classical measurement approaches. However, strong empirical and practical rationales suggest making an assertive shift toward using modern measurement approaches. Fifth, most HL measures are not well validated for use in minority populations; consequently, future validation studies should be mindful of validation samples. Sixth, HL measures can be administered using multiple modes, most frequently via paper-and-pencil surveys. Identifying which mode of administration is most suitable requires reflecting on the underlying measurement purpose and the characteristics of the participants being measured. These considerations should also be made when deciding between a subjective versus objective HL measure. Cumulatively, this chapter provides tools to help readers select and use the most appropriate measures of HL for their needs. It also provides rationale and strategies for moving the science of HL measurement forward.

Health Literacy and Health Information Technology Adoption: The Potential for a New Digital Divide

Background

Approximately one-half of American adults exhibit low health literacy and thus struggle to find and use health information. Low health literacy is associated with negative outcomes including overall poorer health. Health information technology (HIT) makes health information available directly to patients through electronic tools including patient portals, wearable technology, and mobile apps. The direct availability of this information to patients, however, may be complicated by misunderstanding of HIT privacy and information sharing.

Objective

The purpose of this study was to determine whether health literacy is associated with patients’ use of four types of HIT tools: fitness and nutrition apps, activity trackers, and patient portals. Additionally, we sought to explore whether health literacy is associated with patients’ perceived ease of use and usefulness of these HIT tools, as well as patients’ perceptions of privacy offered by HIT tools and trust in government, media, technology companies, and health care. This study is the first wide-scale investigation of these interrelated concepts.

Methods

Participants were 4974 American adults (n=2102, 42.26% male, n=3146, 63.25% white, average age 43.5, SD 16.7 years). Participants completed the Newest Vital Sign measure of health literacy and indicated their actual use of HIT tools, as well as the perceived ease of use and usefulness of these applications. Participants also answered questions regarding information privacy and institutional trust, as well as demographic items.

Results

Cross-tabulation analysis indicated that adequate versus less than adequate health literacy was significantly associated with use of fitness apps (P=.02), nutrition apps (P<.001), activity trackers (P<.001), and patient portals (P<.001). Additionally, greater health literacy was significantly associated with greater perceived ease of use and perceived usefulness across all HIT tools after controlling for demographics. Regarding privacy perceptions of HIT and institutional trust, patients with greater health literacy often demonstrated decreased privacy perceptions for HIT tools including fitness apps (P<.001) and nutrition apps (P<.001). Health literacy was negatively associated with trust in government (P<.001), media (P<.001), and technology companies (P<.001). Interestingly, health literacy score was positively associated with trust in health care (P=.03).

Conclusions

Patients with low health literacy were less likely to use HIT tools or perceive them as easy or useful, but they perceived information on HIT as private. Given the fast-paced evolution of technology, there is a pressing need to further the understanding of how health literacy is related to HIT app adoption and usage. This will ensure that all users receive the full health benefits from these technological advances, in a manner that protects health information privacy, and that users engage with organizations and providers they trust.

Readiness for Hospital Discharge, Health Literacy, and Social Living Status

Patient characteristics and lack of preparedness are associated with poor outcomes after hospital discharge. Our purpose was to explore the association between patient characteristics and patient- and nurse-completed Readiness for Hospital Discharge Scale (RHDS). We conducted a prospective study of 70 Veterans being discharged from medical and surgical units. Differences in RHDS knowledge subscale scores were found among literacy levels, with lower perceived knowledge reported for those with marginal or inadequate literacy (p = .03). Differences in RHDS expected support subscale scores were also found, with those who were unmarried and/or living alone (p < .001) anticipating less support upon discharge. No other differences were found. Similar differences were found for the RHDS completed by nurses. These findings suggest that the RHDS appears responsive to differences in health literacy and social environment, adding to evidence of its utility as a tool to identify, and plan interventions for, those at risk for readmission.

Utilization of the Newest Vital Sign (NVS) in Practice in the United States

Health literacy refers to the ability of a patient to obtain, communicate, process, and understand basic information related to health and services. It is estimated that the majority of adult Americans may have difficulty understanding health information. In addition, limited health literacy of patients is linked to over $100 billion in health care costs. Measurement of health literacy may aid in improving communication with patients, and thus to improving outcomes and decreasing costs. The Newest Vital Sign (NVS) is a tool that has been used to assess health literacy in a variety of patients. It has been validated against other measures including the Test of Functional Health Literacy in Adults (TOFHLA). Patients are categorized as high likelihood of limited health literacy, possible limited health literacy, or adequate literacy. The NVS has been used in a variety of settings and tested among a wide range of patient groups. The most common setting for use is in primary care, probably due to the relatively quick assessment of health literacy (within 3 minutes). The NVS has been used in Caucasians, African Americans, Hispanics, and several other ethnicities. Assessment with the NVS has been conducted in adult patients across the age continuum, and with several different health conditions, including diabetes, kidney disease, and pain. This article seeks to review the published uses to date and to provide suggestions for potential uses of the NVS.

Brief screening items to identify spanish-speaking adults with limited health literacy and numeracy skills

Background

Limited health literacy (HL) and numeracy have been shown to be associated with a wide array of poor health-related outcomes, knowledge, and behaviors. The purpose of this study was to evaluate the clinical utility of brief HL and numeracy screening items in identifying Spanish-speaking adults’ HL and numeracy skills.

Methods

We studied convenience samples of native Spanish-speaking adults in Columbus, Ohio. A trained research assistant administered sociodemographic items, HL and numeracy screening items, Short Assessment of Health Literacy (SAHL), and Newest Vital Sign (NVS) to participants in Spanish.

Results

Participants (n = 151) averaged 36.8 ± 11.0 years of age and 54.7 % were female. Average SAHL score was 15.7 ± 2.8 (range = 4 to 18), while the average NVS score was 1.7 ± 1.5 (range = 0 to 6). “How confident are you filling out medical forms by yourself?” performed best in detecting limited NVS scores (AUROC = 0.66; 95 % confidence interval [CI] = 0.57–0.75), limited/marginal NVS scores (AUROC = 0.75; 95 % CI = 0.65–0.84), and inadequate SAHL scores (AUROC = 0.69; 95 % CI = 0.58–0.79).

Conclusion

A single HL screening item is useful for quickly estimating HL and numeracy skills in native Spanish-speaking adults.

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.

Health literacy, health information seeking behaviors and internet use among patients attending a private and public clinic in the same geographic area

Despite the growing body of health information available online, patients with limited health literacy may lack either internet access or skills necessary to utilize this information. Nonetheless, patients at all health literacy levels may prefer other primary sources to obtain health information. We conducted a cross-sectional study to measure health literacy of patients attending two clinics in Dallas, TX and determine associations between health literacy, health information access and internet usage before and after controlling for confounders. Patients from both clinics (county N = 265; private N = 233) completed a brief survey which included sociodemographics, internet patterns, confidence in filling out medical forms and a self-administered Newest Vital Sign to measure health literacy. In the county clinic, most patients (61.5 %) were Hispanic, had low income (<$19,000/year), limited education (<11th grade) and a high likelihood or possibility of limited health literacy (68.5 %). In the private clinic, participants were mostly black (40.4 %) or white (38.6 %), had higher incomes (≥$46,000), higher education (technical college or college) and adequate health literacy (75.1 %). The primary source of obtaining health information in both clinics was their health care professional (50.6 % county; 40.1 % private). In multivariate analyses to determine differences by health literacy level, there were no statistically significant differences between patients with limited and adequate health literacy and their primary information source. Regardless of health literacy, patients rely on their health care providers to obtain health information. These results showcase the importance of providers' effective communication with patients to make shared decisions about their health regardless of other factors.

Newest Vital Sign as a proxy for medication adherence in older adults

OBJECTIVE

To assess the utility of the Newest Vital Sign (NVS) as a proxy for medication adherence in community-dwelling older adults.

DESIGN

Descriptive cross-sectional study.

SETTING

12 adult day care centers in the Lisbon metropolitan area, Portugal, between March and May 2009.

PARTICIPANTS

100 white community-dwelling older adults.

INTERVENTION

Participants were administered the NVS, Single Item Literacy Screener (SILS), and self-reported Measure of Adherence to Therapy (MAT).

MAIN OUTCOME MEASURES

Health literacy and medication adherence.

RESULTS

The mean (±SD) age of the respondents was 73.3 ± 7.8 years and 71% were women. The NVS score was 0.81 ± 0.10 (of 6 possible points), and 95% of the respondents scored in the three lowest possible scores, indicating a notable floor effect. Age was found to be inversely correlated with NVS score (P = 0.003). The MAT score was 36.2 ± 4.7 (range 17-42). No statistically significant association between the NVS and level of education (P = 0.059 [Kruskal-Wallis]), gender (P = 0.700 [Mann-Whitney]), SILS (P = 0.167), or MAT (P = 0.379) was identified.

CONCLUSION

The utility of the NVS as a proxy for medication adherence in community-dwelling older adults is limited because of a floor effect that hinders its predictive power for medication adherence.

Accuracy in self-reported health literacy screening: a difference between men and women in Taiwan

OBJECTIVE

Self-reported screening questions are considered as an effective way to identify patients with limited health literacy. Yet research has shown that individuals tend to over-report their reading level. Moreover, the likelihood of over-reporting may differ between gender groups. This study examined if systematic differences exist between men and women in their response to self-reported screening questions.

DESIGN

A national survey in Taiwan with participants selected using a multistage stratified, probability-proportional-to-size sampling strategy.

PARTICIPANTS

A total of 5682 Taiwanese adults aged 18 and older were sampled and recruited. Of those adults, 3491 participated in the survey, resulting in a 62.1% response rate. Both gender groups were equally represented in the final study sample.

MAIN MEASURES

Self-reported health literacy was assessed using two sets of questions that asked how difficult it was for the respondent to understand written health materials and how often the participant needed assistance from others to understand written health materials. The objective level of health literacy was measured using the Mandarin Health Literacy Scale (MHLS).

RESULTS

A significant gender difference was observed among participants who had inadequate health literacy: while women's self-report was in line with the MHLS test result, men had a significant tendency to over-report their comprehension of health information.

CONCLUSIONS

In Taiwan, screening questions are prone to socially desirable response and may underidentify male patients with inadequate health literacy. Development of a brief and easy-to-use health literacy test may be a more effective approach to health literacy screening in clinical settings. Alternatively, clinicians can verify patient comprehension of health information via the 'teach back' or 'show me' technique in order to improve communication and patient care. Research is needed to examine if gender differences in self-report of health literacy exist in other countries.

How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation

BACKGROUND

Low literacy is a significant problem across the developed world. A considerable body of research has reported associations between low literacy and less appropriate access to healthcare services, lower likelihood of self-managing health conditions well, and poorer health outcomes. There is a need to explore the previously neglected perspectives of people with low literacy to help explain how low literacy can lead to poor health, and to consider how to improve the ability of health services to meet their needs.

METHODS

Two stage qualitative study. In-depth individual interviews followed by focus groups to confirm analysis and develop suggestions for service improvements. A purposive sample of 29 adults with English as their first language who had sought help with literacy was recruited from an Adult Learning Centre in the UK.

RESULTS

Over and above the well-documented difficulties that people with low literacy can have with the written information and complex explanations and instructions they encounter as they use health services, the stigma of low literacy had significant negative implications for participants' spoken interactions with healthcare professionals.Participants described various difficulties in consultations, some of which had impacted negatively on their broader healthcare experiences and abilities to self-manage health conditions. Some communication difficulties were apparently perpetuated or exacerbated because participants limited their conversational engagement and used a variety of strategies to cover up their low literacy that could send misleading signals to health professionals. Participants' biographical narratives revealed that the ways in which they managed their low literacy in healthcare settings, as in other social contexts, stemmed from highly negative experiences with literacy-related stigma, usually from their schooldays onwards. They also suggest that literacy-related stigma can significantly undermine mental wellbeing by prompting self-exclusion from social participation and generating a persistent anxiety about revealing literacy difficulties.

CONCLUSION

Low-literacy-related stigma can seriously impair people's spoken interactions with health professionals and their potential to benefit from health services. As policies increasingly emphasise the need for patients' participation, services need to simplify the literacy requirements of service use and health professionals need to offer non-judgemental (universal) literacy-sensitive support to promote positive healthcare experiences and outcomes.

Efficiently assessing patient health literacy: the BHLS instrument

Although health literacy limitations are common among patient populations, no efficient yet comprehensive health literacy assessment tool is available to nurses for use in busy health care settings. This study presents beginning evidence for the validity and reliability of a new health literacy assessment tool, the Brief Health Literacy Screen (BHLS). One hundred patients attending four primary care clinics completed the BHLS and the Test of Functional Health Literacy in Adults (TOFHLA) short form and answered questions about the health literacy tools. Findings indicated significant correlations between BHLS and shortened version of the TOFHLA (S-TOFHLA) scores, with higher correlations between BHLS items addressing written health literacy and the S-TOFHLA. Comparative discrimination findings were significant at BHLS cut point of 18 and S-TOFHLA cut point less than 23. Patients rated the BHLS significantly less difficult to complete than the S-TOFHLA. Results of preliminary testing indicate the BHLS is a potentially efficient, effective, and patient-friendly screening tool for health literacy.

Understanding health literacy measurement through eye tracking

This study used eye-tracking technology to explore how individuals with different levels of health literacy visualize health-related information. The authors recruited 25 university administrative staff (more likely to have adequate health literacy skills) and 25 adults enrolled in an adult literacy program (more likely to have limited health literacy skills). The authors administered the Newest Vital Sign (NVS) health literacy assessment to each participant. The assessment involves having individuals answer questions about a nutrition label while viewing the label. The authors used computerized eye-tracking technology to measure the amount of time each participant spent fixing their view at nutrition label information that was relevant to the questions being asked and the amount of time they spent viewing nonrelevant information. Results showed that lower NVS scores were significantly associated with more time spent on information not relevant for answering the NVS items. This finding suggests that efforts to improve health literacy measurement should include the ability to differentiate not just between individuals who have difficulty interpreting and using health information, but also between those who have difficulty finding relevant information. In addition, this finding suggests that health education material should minimize the inclusion of nonrelevant information.

Time to sign: The relationship between health literacy and signature time

OBJECTIVE

To evaluate the relationship between amount of time taken to sign one's name and health literacy.

METHODS

A prospective, one time assessment was conducted on a convenience sample of 98 patients recruited in an inner-city outpatient internal medicine clinic. The amount of time required to sign (i.e. initiation to completion of writing) was measured by stopwatch. Health literacy was measured with the REALM.

RESULTS

The sample averaged 54.1 (SD 16.2) years of age. Twenty-seven percent had less than high school education and 33% had a terminal general equivalency diploma or high school degree. The time required to sign ranged from 0.91 to 21.3s. Sixty-two percent of the sample had health literacy challenges. Signature time was longest for those with inadequate health literacy (mean 10.0 s), compared with marginal (7.3s) and adequate (4.7s, p ≤ 0.001). Signature time remained significant in a logistic regression model after controlling for education and age (AOR = 0.785, CI = 0.661-0.932).

CONCLUSION

Individuals with signatures completed in six seconds or less were highly likely to display adequate health literacy.

PRACTICE IMPLICATIONS

Signature time may offer a practical and quick approach to health literacy screening in the health care setting.

Improving medication management among at-risk older adults

Low health literacy is common among Medicare recipients and affects their understanding of complex medication regimens. Interventions are needed to improve medication use among older adults, while addressing low health literacy. Community-dwelling older adults in this study were enrolled at an inner-city adult day center. They completed a baseline measure of health literacy, medication self-efficacy, and medication adherence. They were provided with a personalized, illustrated daily medication schedule (PictureRx™). Six weeks later, their medication self-efficacy and adherence were assessed. Among the 20 participants in this pilot project, 70% had high likelihood of limited health literacy and took an average of 13.20 prescription medications. Both self-efficacy and medication adherence increased significantly after provision of the PictureRx cards (p < 0.001 and p < 0.05, respectively). All participants rated the PictureRx cards as very helpful in terms of helping them remember the medication's purpose and dosing. Illustrated daily medication schedules improve medication self-efficacy and adherence among at-risk, community-dwelling older adults.

A Review of Health Literacy: Problem, Tools and Interventions

Health literacy is an important concept that is increasingly being recognised internationally worldwide as a fundamental skill required in maintaining health and accessing the local healthcare system. Not recognising low health literacy can be serious and costly as Singapore's population ages and chronic disease becomes more prevalent. As there are few local studies available, this clinical review highlights the current known prevalence and problem of health literacy in other countries; the assessment tools available; and some useful lessons we can draw from published interventions. This review may be useful in promoting awareness of health literacy, generating interest in this area among clinicians and inspiring more local work into this emerging field.

Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers

OBJECTIVE

The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations.

STUDY DESIGN

The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument.

DATA COLLECTION

Validation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System.

PRINCIPAL FINDINGS

Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p<.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p<.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p<.05) and the English TOFHLA (r=0.68, p<.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy.

CONCLUSIONS

The new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.