The role of inadequate health literacy skills in colorectal cancer screening

An Overview of Dentist-Patient Communication in Quality Dental Care

Dentist-patient communication is at the core of providing quality dental care. This study aims to review the importance, challenges, strategies, and training of dentist-patient communication. The World Dental Federation (FDI) emphasizes the importance of effective communication between oral healthcare providers and patients as a critical component of high-quality care. Effective dentist-patient communication allows dentists to accurately and effectively pass on essential medical information to patients. It improves the dentist's efficiency, boosts self-confidence, reduces occupational stress, and minimizes the risks of complaint or litigation. Moreover, it alleviates dental anxiety and fear, helps build trust between dentists and patients, addresses patients' needs and preferences, increases patients' adherence to improved treatment outcomes, and ultimately leads to enhanced patient satisfaction. Nonetheless, it has been widely acknowledged that dentists universally encounter the repercussions arising from suboptimal communication strategies. Time constraints, difficulties in establishing rapport, the oral-health illiteracy of the patients, the poor communication skills of the dentists, dentists' perceptions, and language barriers often hinder dentist-patient communication. Dentists should take the patient-centered approach as a premise and acquire verbal and non-verbal communication skills to overcome these communication barriers. The patient-centered approach comprises the understanding of patients' illness, shared decision-making, and intervention with mindfulness of the patient's own pace. Simple, succinct, and jargon-free language should be used in verbal communication. Proper body postures and gestures are fundamental for showing positive attitudes towards patients. Communication training for dental students should involve a structured pedagogical approach that includes didactic instruction, role-playing exercises, patient interviewing, and ongoing assessments. Key components of effective communication skills training in dental education include motivational interviewing, open-ended questioning, affirmations, reflective listening, and summaries to enhance patient engagement and adherence to treatment plans.

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study

BACKGROUND

How patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer.

METHODS

A prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score.

RESULTS

Overall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036).

CONCLUSION

A significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

'Symptom-free' when inflammatory bowel disease is in remission: Expectations raised by online resources

OBJECTIVES

Up to 60% of patients with inflammatory bowel disease (IBD) experience symptoms when in remission. Qualitative research suggests patients seldom feel they receive adequate explanations for these. This study explores how, and how often, ongoing symptoms during remission are represented on readily searchable patient websites.

METHODS

Bing, Google, and Yahoo were searched for websites providing medical information about IBD. Thematic analysis was used to inductively explore themes around symptoms during quiescent IBD, followed by deductive content analysis to quantify core themes.

RESULTS

Results indicated that remission is commonly defined as "few or no symptoms" and that there is limited information available on symptoms during remission. 55.6% of IBD websites provided a definition of remission based on symptom control only, while 44.4% also incorporated inflammatory control. The few websites that mentioned that symptoms may continue during remission (21.7%) related these to IBS.

CONCLUSIONS

Current website information is predominantly biomedical and fails to adequately explain how symptoms may persist during remission and how IBS and IBD may be linked.

PRACTICE IMPLICATIONS

Lack of explanatory models of symptoms in remission may lead to distress and increase anxiety about symptoms. Clearer explanations of these symptoms are needed.

Impact of Various Risk Factors on the Positive Fecal Immunochemical Test for Colorectal Cancer in the Iranian Population

Background: Colorectal cancer (CRC) is the most prevalent cancer with high mortality worldwide. We aimed to evaluate the incidence of CRC based on the positive fecal immunochemical test (FIT) result in the Iranian population. Methods: The present study was conducted on the health assessment data recorded in the SINA (Integrated Health Information System) in 2018 and 2019 from individuals who had participated in the national program, including asymptomatic people aged 50-69 years or had risk factors of CRC such as family or past personal history of CRC as well as symptomatic individuals, for the early detection and prevention of CRC in Mashhad, Iran. Results: The study participants included 140,463 eligible individuals, of whom 8258 (5.88%) and 145 (2.21%) were positive for FIT and diagnosed with colon cancer, respectively. Unfortunately, only 654 people had undergone colonoscopy. Our results indicated that age, fast food intake (≥two units per day), family history of CRC in first or second-degree relatives, some gastrointestinal diseases such as inflammatory bowel disease (IBD) and CRC, as well as bleeding per anus, constipation, abdominal cramp, and losing body weight were associated with increased risk of positive FIT. However, some other factors, including having a hard job, physical activity, and Iranian nationality (compared to non-Iranians), were associated with a low risk of positive FIT screening tests for CRC. Conclusion: A high number of high-risk persons in Mashhad were positive for the FIT test in 2018-2019, and many of them were diagnosed with CRC, according to the colonoscopy results. Therefore, screening is highly recommended as the first step in the early detection of CRC.

Relationship between health information literacy and health promoting lifestyle among first-degree relatives of patients with colorectal cancer in China: the mediating effect of health belief

Background

History of first-degree relatives with colorectal cancer is one of the most important and common risk factors for colorectal cancer in China. Most chronic diseases, such as malignancies, are preventable by adopting health-promoting behaviors and other approaches. However, the relationships among factors affecting the health-promoting lifestyles of first-degree relatives with colorectal cancer have not been sufficiently studied. This study aimed to test the mediation effects of Health belief in the relationship between health-promoting lifestyle and health information literacy among first-degree relatives with colorectal cancer.

Methods

A cross-sectional descriptive design was conducted using convenience sampling of 856 first-degree relatives of CRC patients attending three tertiary care hospitals in Nanchong and Deyang of China from December 2020 to December 2022. Questionnaires were used to collect data on the participants' demographic information, the colorectal cancer health beliefs, the health promotion lifestyle, and the health information literacy. Data were analyzed with descriptive statistics, one-way ANOVA, Pearson's correlation coefficients, and mediation analysis using SPSS 25.0 program and its macro-program PROCESS.

Results

The findings indicated health information literacy was less, health belief was at the medium level, and performance of health promotion behavior was average for first-degree relatives of colorectal cancer. Whereas first-degree relatives of colorectal cancer health-promotion lifestyle had a positive correlation with health beliefs (r = 0.376, p < 0.01) and health information literacy (r = 0.533, p < 0.01), health beliefs had a positive correlation with health information literacy (r = 0.337, p < 0.01). Health beliefs mediated the positive effect of health information literacy on health-promoting lifestyles (β =0.420, 95% CI, 0.288-0.581), and indirect effects accounted for 14.0% of the total effect.

Conclusion

Health information literacy and health beliefs are key factors associated with a health-promoting lifestyle among first-degree relatives with colorectal cancer. These factors have direct and indirect effects on each other and on health-promoting lifestyles. To enhance health-promoting lifestyles among first-degree relatives with colorectal cancer, interventions that strengthen health beliefs and provide health information literacy should be developed.

Body Image Perception and the Effect of Different Educational Programs on Embarrassment in Patients Undergoing Colonoscopy

PURPOSE

Colonoscopy is recognized as a safe and effective tool for detecting colorectal cancer. However, patients may experience discomfort and embarrassment arising from their body image, with the prejudice that health care professionals will have negative thoughts about their bodies. This study was carried out to determine the effect of the perception of body image and education given with different educational programs on the feeling of embarrassment in patients who were scheduled to undergo colonoscopy.

DESIGN

Quasi-experimental study with pre-test, post-test.

METHODS

The population of this quasi -experimental study with pre-test, post-test, and experimental groups consisted of 184 patients who underwent colonoscopy for the first time at the endoscopy department of a university hospital.

FINDINGS

No statistically significant difference in the mean Colonoscopy Embarrassment Scale (CES) pre-test scores was found between the groups (P > .05). The mean CES post-test scores of the video group were lower than those of the other groups, with a statistically significant difference (P < .05). Comparing the intragroup CES pre-test and post-test mean scores, the mean CES post-test scores were found to be lower in all three groups, with a statistically significant difference between the groups (P < .05). Although a statistically weak negative correlation was found between the body image mean scores and the pre-test CES mean scores of the booklet and video groups, no correlation was observed in the control group.

CONCLUSIONS

The body image perception was found to affect the sense of embarrassment in patients undergoing colonoscopy, and the mean embarrassment scores decreased with planned training programs.

Factors Associated With Dimensions of Patients' Trust in Chiropractic Doctors in the International Medical University Healthcare Chiropractic Center: An Exploratory Study

Objective

The purpose of this study was to investigate the association between patients' sociodemographic factors (age, sex, ethnicity, and education background) and dimensions of patients' trust in chiropractic doctors in Malaysia.

Methods

This cross-sectional study was conducted in the International Medical University Healthcare Chiropractic Center with a total of 302 respondents. Self-administered questionnaires were enclosed in an envelope and passed to participants by the researchers. Descriptive statistics are presented in tables and figures. Each dimension of the patients' trust was compared against the sociodemographic factors. The variables included were sex, age, ethnicity, and education background, along with their dimensions of trust.

Results

There were 106 male respondents (35.1%) and 196 female respondents (64.9%) between 21 and 40 years of age. In all of the trust dimensions, education background was the only statistically significant variable (P < .05).

Conclusion

Several sociodemographic factors were associated highly with the trust dimensions explored. Patients' education background was the only sociodemographic factor to show a statistically significant relationship to all 10 trust dimensions. Sex, age, and ethnicity showed significant associations with some of the trust dimensions explored in this study.

Healthcare Disparities and Colorectal Cancer

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France.

METHODS

We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory.

DISCUSSION

Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening).

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

2020-A01687-32 . Date of registration: 17th November 2020.

Factors influencing chemotherapy knowledge in women with breast cancer

BACKGROUND

Chemotherapy knowledge is linked to managing side effects, reducing exposure to potential infection, and adjusting lifestyle behaviors while going through treatment. However, no research exists regarding the influence of patients' personal attributes on chemotherapy knowledge. Aim The aim of this study was to describe the relationships of health literacy and demographics on chemotherapy knowledge among women with breast cancer undergoing treatment.

METHOD

We used a descriptive, exploratory design with convenience sampling of women with breast cancer receiving intravenous chemotherapy who completed one mandatory education session. Participants completed a demographic questionnaire and three instruments: 1) Rapid Estimate of Adult Literacy - Short Form (REALM-SF); 2) Shortened Test of Functional Health Literacy in Adults (S-TOFHLA); and 3) Leuven Questionnaire on Patient Knowledge of Chemotherapy (L-PaKC). We used univariate linear regression and ANOVA to identify how health literacy and demographics influenced chemotherapy knowledge.

RESULTS

The REALM-SF (p = .022) and S-TOFHLA (p = .023) scores were significantly associated with chemotherapy knowledge. Chemotherapy knowledge scores were affected by marital status (p = .018) and income (p < .001) where married women had significantly higher chemotherapy knowledge scores (M = 92.6, SD = 6.6) than women who were divorced (M = 83.3, SD = 16.7) with a knowledge score difference of -9.3 between the groups (p = .02). Comparisons showed significant differences of chemotherapy knowledge between women with differing income levels.

CONCLUSIONS

This study highlights the relevance of considering patients' health literacy and personal attributes such as marital status and income when teaching about chemotherapy.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis

Background

Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients.

Methods

A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis.

Results

Twenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly.

Conclusion

Based on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors.

PROSPERO registration number

CRD42018115186.

Does Animation Improve Comprehension of Risk Information in Patients with Low Health Literacy? A Randomized Trial

Introduction. Enhanced visual effects, like animation, have the potential to improve comprehension of probabilistic risk information, particularly for those with lower health literacy. We tested the effect of presentation format on comprehension of colorectal cancer (CRC) screening probabilities to identify optimal risk communication strategies. Methods. Participants from a community foodbank and a cancer prevention center were randomized to 1 of 3 CRC screening risk presentations. The presentations used identical content but varied in format: 1) video with animated pictographs, 2) video with static pictographs, and 3) audiobooklet with static pictographs. Participants completed pre- and postpresentation surveys. The primary outcome was knowledge of probability/risk information regarding CRC screening, calculated as total, verbatim, and gist scores. Results. In total, 187 participants completed the study and were included in this analysis. Median age was 58 years (interquartile range [IQR]: 14 years), most participants were women (63%), and almost half had a high school education or less (46%). Approximately one-quarter had inadequate health literacy (Short Test of Functional Health Literacy in Adults marginal/inadequate: 28%; Brief Health Literacy Screener low: 18%), and about half had low numeracy (Subjective Numeracy Scale low: 54%; Graphical Literacy Measure low: 50%). We found no significant differences in total, verbatim, or gist knowledge across presentation formats (all P > 0.05). Discussion. Use of an animated pictograph to communicate risk does not appear to augment or impede knowledge of risk information. Regardless of health literacy level, difficulty understanding pictographs presenting numerical information persists. There may be a benefit to teaching or priming individuals on how to interpret numerical information presented in pictographs before communicating risk using visual methods. Trial Registry: NCT02151032.

Videos improve patient understanding of misunderstood chemotherapy terminology

BACKGROUND

Chemotherapy is the backbone of many cancer therapies; however, the terminology used to describe chemotherapy may be difficult for patients to understand, particularly in underserved populations. Studies have shown that educational videos can improve patient understanding of cancer-related terms. The goal of this study was to identify chemotherapy terms that were difficult for an underserved population to understand and then develop and test educational videos describing these terms.

METHODS

A word bank of 50 difficult-to-understand chemotherapy terms was developed by querying 15 providers and 50 patients at an underserved hospital. Twenty of these terms were then tested with 50 additional patients to determine rates of misunderstanding. Six pilot educational videos describing 6 important terms were created using VideoScribe and then assessed with 50 patients to see if they improved understanding.

RESULTS

Fifteen of the 20 terms tested to establish rates of misunderstanding were misunderstood by more than one third of patients, with 98% unable to define maintenance, 74% unable to define cancer, and 58% unable to define chemotherapy. Patient understanding of all 6 terms improved by at least 20% after watching the videos. Notable improvement was reported for palliative chemotherapy, where before-and-after video understanding increased from 0% to 72%.

CONCLUSION

Chemotherapy, a backbone of cancer treatment, is described with terms that are difficult to understand. Short, animated educational videos can significantly increase patient understanding of chemotherapy terminology.

Analyzing paths from online health information seeking to colorectal cancer screening using health literacy skills frame and cognitive mediation model

OBJECTIVE

To test the hypothesized paths for Online Health Information Seeking (OHIS) behaviors in developing health literacy, leading to colorectal cancer (CRC) screening among Korean Americans (KAs) using Health Literacy Skills Frameworks (HLSF) and Cognitive Mediation Model (CMM).

METHODS

A total of 433 KAs aged 50 through 75 in a metropolitan area in the Southeastern U.S. completed a cross-sectional survey regarding sociodemographics, OHIS behaviors, information overload, health literacy, decisional balance, and CRC screening history. Path analyses were implemented to assess the hypothesized causal models by examining the relationships among these variables.

RESULTS

OHIS was positively associated with information overload and health literacy; information overload was negatively associated with health literacy. Health literacy was positively associated with decisional balance; decisional balance was positively associated with uptake of sigmoidoscopy and colonoscopy.

CONCLUSION

The findings supported both theoretical frameworks, HLSF and CMM, for OHIS to develop health literacy, leading to CRC screening. These findings highlight the significant roles of information overload and attitudes and beliefs about screening in enhancing health literacy and CRC screening among KAs.

PRACTICE IMPLICATIONS

Practice efforts for facilitating CRC screening among medically underserved older KAs should target improving access to and use of OHIS and culturally-tailored health information delivery.

Patient and Healthcare Professionals Perspectives on the Delivery of Exercise Education for Patients With Type 1 Diabetes

Objective: One way of improving the prognosis for the growing numbers of people with type 1 diabetes (T1D) is to increase their frequency of exercise. One known barrier to this is the lack of cohesive support and information from care providers. To better understand the issues around existing support for patients wishing to exercise and inform the design of an education package specifically to facilitate safe exercise we interviewed care providers and patients about the existing provision of support. Research Design and Methods: The study was based within two large UK teaching hospitals where four focus groups were undertaken two consisting of patients diagnosed with T1D who undertook regular exercise, and two with health care providers (HCPs) that were part of the diabetes care team. In all 14 patients and 11 staff were involved. These were complemented by two 1:1 interviews with staff unable to attend group discussions. Results: We found the successful provision of education and advice was influenced by factors relating to the individual patient and their service provider. Patient factors included the type of activity and complexity of the exercise regime, the level of engagement with their condition and care and health literacy. Service-related factors included inconsistent training, a lack of capacity and continuity, and limited coherence of information from across their care team. Conclusions: Any education package developed to support exercise in patients with type 1 diabetes should be offered at a time following diagnosis in accordance with patients' preferences and priorities, contain information on how to manage regular and irregular bouts of exercise. Patients described how they related more closely to the stories of their peers than famous sports stars and one way this can be facilitated is by group delivery. The content and relevance of any supporting materials should be closely considered. Training in the delivery of a novel education package should be made available to staff across the care team to enable them to either deliver the course or increase their confidence in offering salient advice as part of routine care.

CRC Screening Results: Patient Comprehension and Follow-up

BACKGROUND:

Fecal occult blood tests are recommended for colorectal cancer screening, but are only effective if colonoscopy follows positive results. Patients with positive results often do not complete follow-up. This study examined the association between patient comprehension and adherence to colonoscopy after positive FIT (Fecal Immunochemical Test).

METHODS:

Five hundred twenty-two patients completed a telephone questionnaire regarding the FIT and its implications 120 days after a positive result. Patients were asked whether they had the test, received the results, and required follow-up. These questions were used to identify the degree to which patients understood medical information. A participant who answered "no" to any question was defined as having "low comprehension" regarding the FIT, and participants who answered "yes" to all 3 questions, as having "high comprehension".

RESULTS:

Comprehension and colonoscopy adherence were significantly associated. Adherence to colonoscopy was significantly higher among participants with high comprehension, after adjusting for gender, age, education, ethnicity, and socio-economic status.

CONCLUSIONS:

This study demonstrates a link between health comprehension and patient follow-up after positive FIT and contributes to understanding the implications of health comprehension in terms of health promotion. We recommend patients undergoing screening tests receive clear explanations regarding need for follow-up of positive results thus reducing health disparities associated with health comprehension.

Knowledge and social engagement change in intention to be screened for colorectal cancer

OBJECTIVE

Innovative technologies have been used to promote colorectal cancer (CRC) screening among the underserved. However, the impact of these innovative technologies on knowledge and social engagement likelihood as they relate to subsequent intention to be screened across different populations has not been fully explored.

DESIGN

Using a pre-post-test design with an inflatable walk-through colon, we assessed changes in knowledge and social engagement likelihood across populations and their associations with intention to be screened in two community settings. One was a community setting in Washington State (WA); the other, a college campus in New Mexico (NM). Differential effects on knowledge and social engagement likelihood were examined across demographic groups (race/ethnicity, gender, age, education, insurance status, and geographic region). Finally, we assessed if changes in knowledge and social engagement likelihood were associated with CRC screening intention.

RESULTS

NM males had greater gains in CRC knowledge than NM females; in WA, Hispanics, younger, less educated, and uninsured participants had greater gains in knowledge. NM females and younger WA participants were more likely to discuss CRC with their social networks than NM males and older WA participants. In WA, Hispanics and older adults reported greater intention to be screened for CRC. Change in social engagement likelihood, but not knowledge, was associated with intention to be screened.

CONCLUSIONS

The effectiveness of health promotion technologies on knowledge and social engagement may vary across different demographic characteristics. Further, the importance of social engagement likelihood in interacting with intention to be screened was substantiated.

Barriers to Colorectal Cancer Screening in a Racially Diverse Population Served by a Safety-Net Clinic

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, yet screening rates remain low among minority populations. The purpose of the current study was to identify differences in the endorsement of barriers to CRC screening and to evaluate the association between provider recommendation and CRC screening adherence among Hispanic, Pacific Islander and White patients. This study utilized a cross sectional survey design to identify patient-reported barriers to CRC screening. Logistic regression was utilized to evaluate the association between patient demographic characteristics (race/ethnicity, gender, age), having received provider recommendation, and patient awareness of CRC screening. The study sample was comprised of a diverse population (N = 197); 48% Hispanic, 25% White, 10% Pacific Islander, 4% Black and 13% other races/ethnicity. The median age of participants was 58, yet fewer than 30% were up-to-date for CRC screening. The most commonly cited barriers included fear of test results (27.6%), inability to leave work for a CRC screening appointment (26.9%), being unaware of the need for colonoscopy (25.4%), and lack of provider recommendation for CRC screening (24.9%). Only 16.2% of participants reported that a provider had discussed CRC screening options with them. After adjusting for age and gender, Hispanic patients were less likely to report having had a provider discuss CRC screening options compared to White patients (OR = 0.24, 95% CI: 0.09-0.68, p < 0.05). The findings from this study indicate that patient's perceived screening barriers, lack of awareness and a lack of provider communication about CRC screening options may contribute to low screening rates among minority populations.

Validation of the Cancer Health Literacy Test-30 for Populations Without Cancer

Background

Cancer incidence continues to be common and highly consequential for future cancer patients, family members, and other untrained caregivers. Because low health literacy increases the likelihood of poor health outcomes, those with low health literacy would benefit from interventions to improve cancer health literacy.

Objective

Our study was designed to address the need for measuring cancer health literacy in populations without cancer.

Methods

The Cancer Health Literacy Test-30 (CHLT-30) was psychometrically tested on 512 people without a cancer diagnosis.

Key Results

In this population without cancer, the CHLT-30 had strong psychometric properties including unidimensional measurement structure, high reliability, and invariant measurement between gender, race/ethnicity, and educational-attainment groups.

Conclusion

These results support the use of the CHLT-30 to measure cancer health literacy in research studies of family members of people with cancer or the general public. The potential for using the CHLT-30 in clinical practice to assess the need for education for general patient and cancer patient populations is a future direction. [HLRP: Health Literacy Research and Practice. 2018;2(2):e58-e66.].

Plain Language Summary

Psychometric evidence suggests that the CHLT-30, originally developed for cancer patients, can be used to measure cancer health literacy of individuals with no history of cancer as well.

How are health literacy principles incorporated into breast cancer chemotherapy education? A review of the literature

BACKGROUND

Chemotherapy is commonly used in combination with other treatments for breast cancer. However, low adherence to chemotherapy is a growing concern, particularly among breast cancer patients. Side effects such as nausea and vomiting, fatigue, and arthralgia can contribute to reduced adherence. Other factors such as provider communication and limited insurance coverage can affect adherence. Studies have shown that as much as 28% of patients with breast cancer did not continue with their prescribed dose of chemotherapy. Research suggests that chemotherapy education materials can be critical to addressing problems with non-adherence, and may include written materials, verbal instruction, and multimedia programs. Despite this wide variety, the effectiveness and benefit of chemotherapy education hinges on the patients' health literacy. Breast cancer patients with low health literacy may be unclear about chemotherapy or face difficulty adhering to treatment if they do not understand the information provided to them. Thus, this scoping review summarizes the existing research on how health literacy principles are incorporated into breast cancer chemotherapy education materials.

METHODS

Using a combination of keywords (e.g. chemotherapy, education) and Medical subject headings (MeSH) terms (e.g., drug therapy, antineoplastic agents), we searched five databases (1977-2017): CINAHL, PubMed, PsycINFO, Cochrane Library, and Web of Science.

RESULTS

Eight of 4,624 articles met the inclusion criteria. Five articles incorporated health literacy principles (e.g., plain language, maintaining an active voice, using white space) into the development of written materials. Few articles used a theoretical framework to guide education material development (n = 3). Of the three articles that described pilot-testing of educational materials, two used post-tests only and one used a pre/post-test design.

CONCLUSIONS

Findings indicated that limited research exists regarding the use of health literacy principles in chemotherapy education materials. Much of the development of chemotherapy education is not grounded in theory and the application of health literacy principles is limited. Implementing health literacy principles may improve overall comprehension of education thereby increasing adherence.

Barriers and Facilitators to Colorectal Cancer Screening Among Rural Women in Community Clinics by Heath Literacy

BACKGROUND

Rural women lag rural men and urban women in colon cancer (CRC) screening completion.

OBJECTIVE

To identify rural female patients' knowledge, beliefs barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level.

METHODS

This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in south Louisiana. Patients overdue for screening were given a structured interview by a research assistant.

RESULTS

339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p<0.001). Only 25.7% had been given information on CRC testing; those with adequate HL were more likely to have received information (30.1% vs 16.8%; p=0.017). Most women (93.2%) indicated they would want to know if they had CRC, while 72.2% reported a provider had recommended CRC screening. Only 24.9% said a healthcare provider had ever given them an FOBT or that they had ever completed an FOBT (22.7%). There were no differences in women's report of recommendation or completion by HL level.Self-efficacy for completing an FOBT was high; over 90% indicated they could get an FOBT, complete it and mail results to the lab. Level of confidence did not vary by literacy. Three of the four barrier items varied by HL with women with low HL being more likely to fear doing an FOBT because they thought FOBT instructions would be confusing (p=0.002), doing the test would be embarrassing (p=0.025) or messy (p=0.057).

CONCLUSIONS

Rural women are receptive to CRC screening and view FOBTs as effective. Rural community clinics need to provide low cost FOBTs with literacy, gender and culturally appropriate information.

Health Literacy Is an Independent Predictor of Cancer Patients' Hospitalizations

Background

Lower levels of health literacy predict higher hospitalization rates. Hospitalization is expensive and many admissions are potentially avoidable. Research examining the relationship between health literacy and health outcomes for cancer patients is limited, and no published studies to date have focused on hospitalization and health literacy in cancer patients.

Objective

This study examined the ability of health literacy to predict hospitalization of cancer patients.

Methods

This secondary data analysis investigated the relationship between health literacy and hospitalization rates of adult cancer patients in the first 5 years after their diagnosis. The sample included a diverse selection of cancer diagnoses and all stages of cancer were represented. Health literacy was assessed using the Cancer Health Literacy Test 30 (CHLT-30), a psychometrically sound measure of health literacy validated in a cancer patient population. Health literacy's ability to predict the number of times hospitalized, total days spent hospitalized, and number of 30-day readmissions was examined using multivariate negative binomial multiple regression to control for the outcomes and potentially confounding variables.

Key Results

When controlling for potentially confounding variables, a negative relationship was found between health literacy and the number of inpatient hospitalizations (β = -0.041, p = .009) and the total number of days spent hospitalized (β = -0.028, p = .023) independently, whereas the relationship between health literacy and the number of 30-day readmissions failed to reach significance (β = -0.002, p = .903).

Conclusions

Patients with lower health literacy need additional assistance to avoid unplanned hospitalizations. [Health Literacy Research and Practice. 2017;1(4):e153-e162.].

Plain Language Summary

Results from this study found that as cancer patients' health literacy scores decreased, the number of times hospitalized and the total number of days spent in the hospital increased. This relationship was significant when controlling for diagnosis, stage at diagnosis, receipt of chemotherapy, number of comorbidities, death, education, and race. Cancer patients with low health literacy are at a higher risk of being hospitalized.

Misperceptions of Medical Understanding in Low-Literacy Patients: Implications for Cancer Prevention

Background

Patients with limited literacy skills often have difficulty understanding medical information, are less likely to undergo cancer screening, and present with cancer at later stages than patients with better literacy skills. Since primary care physicians are responsible for performing or initiating the majority of cancer screening in the United States, they need to be able to not only identify patients who might not understand medical information but also communicate effectively with them about cancer prevention and screening.

Methods

To determine whether family medicine residents could identify patients who might have difficulty understanding medical information because of limited literacy, we measured the literacy skills of patients in a university-based family medicine clinic using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). After the patients completed their office visits with a physician, we asked family medicine residents to rate the patients’ ability to understand medical information.

Results

Among 140 patients who met with 18 family medicine resident physicians, 24% had limited literacy skills based on testing with the S-TOFHLA. Residents identified only about half of these patients as having poor or below average understanding of medical information.

Conclusions

In many cases, family medicine residents are unable to identify patients who, based on assessment of their literacy skills, are likely to have difficulty understanding medical information. When working with residents, medical educators should promote the habit of taking poor literacy into account when communicating with patients.

Reducing the socioeconomic gradient in uptake of the NHS bowel cancer screening Programme using a simplified supplementary information leaflet: a cluster-randomised trial

BACKGROUND

Uptake of colorectal cancer screening is low in the English NHS Bowel Cancer Screening Programme (BCSP). Participation in screening is strongly associated with socioeconomic status. The aim of this study was to determine whether a supplementary leaflet providing the 'gist' of guaiac-based Faecal Occult Blood test (gFOBt) screening for colorectal cancer could reduce the socioeconomic status (SES) gradient in uptake in the English NHS BCSP.

METHODS

The trial was integrated within routine BCSP operations in November 2012. Using a cluster randomised controlled design all adults aged 59-74 years who were being routinely invited to complete the gFOBt were randomised based on day of invitation. The Index of Multiple Deprivation was used to create SES quintiles. The control group received the standard information booklet ('SI'). The intervention group received the SI booklet and the Gist leaflet ('SI + Gist') which had been designed to help people with lower literacy engage with the invitation. Blinding of hubs was not possible and invited subjects were not made aware of a comparator condition. The primary outcome was the gradient in uptake across IMD quintiles.

RESULTS

In November 2012, 163,525 individuals were allocated to either the 'SI' intervention (n = 79,104) or the 'SI + Gist' group (n = 84,421). Overall uptake was similar between the intervention and control groups (SI: 57.3% and SI + Gist: 57.6%; OR = 1.02, 95% CI: 0.92-1.13, p = 0.77). Uptake was 42.0% (SI) vs. 43.0% (SI + Gist) in the most deprived quintile and 65.6% vs. 65.8% in the least deprived quintile (interaction p = 0.48). The SES gradient in uptake was similar between the study groups within age, gender, hub and screening round sub-groups.

CONCLUSIONS

Providing supplementary simplified information in addition to the standard information booklet did not reduce the SES gradient in uptake in the NHS BCSP. The effectiveness of the Gist leaflet when used alone should be explored in future research.

TRIAL REGISTRATION

ISRCTN74121020 , registered: 17/20/2012.

Explaining time elapsed prior to cancer diagnosis: patients' perspectives

Background

Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients’ prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal.

Methods

This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment.

Results

Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients’ experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization.

Conclusions

This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

An entertainment-education colorectal cancer screening decision aid for African American patients: A randomized controlled trial

BACKGROUND

Colorectal cancer screening rates for African American patients remain suboptimal. Patient decision aids designed with an entertainment-education approach have been shown to improve saliency and foster informed decision making. The purpose of this study was to assess whether an entertainment-education decision aid tailored for African American patients improved patients' decision making, attitudes, intentions, or colorectal cancer screening behavior.

METHODS

Eighty-nine participants were randomized to view 1) a patient decision aid video containing culturally tailored information about colorectal cancer screening options and theory-based support in decision making presented in an entertainment-education format or 2) an attention control video about hypertension that contained similarly detailed information. Participants met with their clinician and then completed follow-up questionnaires assessing their knowledge, decisional conflict, self-advocacy, attitudes, perceived social norms, and intentions. At 3 months, completion of screening was assessed by chart review.

RESULTS

Viewing the culturally tailored decision aid significantly increased African American patients' knowledge of colorectal cancer screening recommendations and options. It also significantly reduced their decisional conflict and improved their self-advocacy. No significant differences were observed in participants' attitudes, norms, or intentions. At three months, 23% of all patients had completed a colonoscopy.

CONCLUSIONS

Designing targeted, engaging patient decision aids for groups that receive suboptimal screening holds promise for improving patient decision making and self-advocacy. Additional research is warranted to investigate the effectiveness of such aids in clinical practices with suboptimal screening rates and on downstream behaviors (such as repeat testing). Cancer 2017;123:1401-1408. © 2016 American Cancer Society.

Changes in Colorectal Cancer Screening Knowledge, Behavior, Beliefs, Self-Efficacy, and Barriers among Community Health Clinic Patients after a Health Literacy Intervention

OBJECTIVE

The objective in this pre- and post-survey assessment was to compare the effectiveness of a health literacy-directed intervention designed to increase knowledge, beliefs, barriers, self-efficacy and behavior associated with CRC screening with FOBT among patients cared for in predominantly rural community clinics and the change in these characteristics over the first 15 months after enrolling in a study designed to assess screening strategies.

METHODS

Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Patients were orally administered a 15-minute survey at enrollment by a clinic research assistant (RA) and at 15 months by phone by a central RA. Participants included 428 community clinic patients aged 50-85 (mean 58.5); the majority (79%) were female, 69% were African American, and 54% had limited health literacy.

RESULTS

There was significant improvement across all groups with the number of patients reporting they had been given information /education on CRC testing (p<.0001), been given an FOBT kit (p<.0001), and completed an FOBT (p<.0001) with significant improvement in having a doctor recommendation in all groups except usual care. Confidence in an FOBT's potential to decrease chances of dying from CRC improved across all groups as well (p<0.002). In addition, patients 'belief that they would get CRC in their lifetime' decreased across all groups post-intervention (p<0.03) as did their worry that they may find out they have CRC (p<0.04).

CONCLUSION

Overall these low income FQHC patients who were not up-to-date with screening had heard of CRC screening, had positive attitudes toward screening and wanted to know if they had cancer. Results demonstrate the value of giving patients a recommendation and a kit; patients in all groups reported significant increases at 15 months in completing CRC screening (>83%) as confirmed by study records.

'That's the doctor's job': Overcoming patient reluctance to be involved in medical decision making

OBJECTIVE

To review the barriers to patient engagement and techniques to increase patients' engagement in their medical decision-making and care.

DISCUSSION

Barriers exist to patient involvement in their decision-making and care. Individual barriers include education, language, and culture/attitudes (e.g., deference to physicians). Contextual barriers include time (lack of) and timing (e.g., lag between test results being available and patient encounter). Clinicians should gauge patients' interest in being involved and their level of current knowledge about their condition and options. Framing information in multiple ways and modalities can enhance understanding, which can empower patients to become more engaged. Tools such as decision aids or audio recording of conversations can help patients remember important information, a requirement for meaningful engagement. Clinicians and researchers should work to create social norms and prompts around patients asking questions and expressing their values. Telehealth and electronic platforms are promising modalities for allowing patients to ask questions on in a non-intimidating atmosphere.

CONCLUSION

Researchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes.

Having cancer in a foreign country

OBJECTIVES

Although immigration and cancer care are two frequently discussed topics in healthcare, the combination of both has seldom been done. Little is known about how immigrant patients experience having cancer in a foreign country. The aim of the study is to gain deeper insight into the meaning of having cancer, in a foreign country and to identify the expectations and experiences of immigrant patients confronted with this disease.

METHODS

Thirty adult non-western immigrant cancer patients were interviewed by means of an in-depth interview technique. The technique of constant comparison, derived from the constructivist grounded theory, was used to analyze the data from the interviews.

RESULTS

Having cancer is a human experience, regardless of one's country of origin. Patients show universal reactions and reaction patterns when confronted with cancer and dealing with cancer treatment. Immigrant patients experience specific obstacles when dealing with cancer, of which the language barrier is the most important. A general lack of accurate basic knowledge about health and disease was found, making certain patients more vulnerable.

CONCLUSIONS AND PRACTICE IMPLICATIONS

When dealing with cancer, immigrant patients are confronted with two major obstacles: a language barrier and a lack of knowledge about health and disease. The implications for a better practice occur on three levels: empowering patients, training healthcare professionals and adapting policy.

Impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen

Background

Colorectal cancer (CRC) screening rates remain low, especially among low-income populations.

Objective

To determine if a CRC screening intervention (video, brochure) improves knowledge about CRC and CRC screening, attitudes toward screening, and intention to complete CRC screening among average-risk adults with different health literacy skills, seeking medical care at a Federally Qualified Health Center (FQHC).

Methods

Average-risk adults (50 years or older) who were not within CRC screening guidelines completed face-to-face pre-and post-intervention interviews that focused on knowledge about CRC and CRC screening, attitudes toward CRC screening, and intention to complete CRC screening.

Results

Of the 270 participants, 64% were women, 72% were black/African American, 86% were not married, 79% had an annual household income of <$20,000, and 57% did not have health insurance. Reading levels by Rapid Estimate of Adult Literacy in Medicine health literacy test were: 3rd grade or lower, 17 participants (6.3%); 4th-6th grade, 27 (10.0%); 7th-8th grade, 101 (37.4 %); and high school, 125 (46.3%). CRC screening knowledge mean score improved, and perceived CRC susceptibility and self-efficacy to complete screening significantly increased, irrespective of health literacy (all P < .01). There were no significant changes in other attitudes or intention to complete screening.

Limitations

The study was conducted in a single FQHC, so the results may not be generalizable to other health centers or populations of low-income and minority patients.

Conclusion

A CRC screening intervention improved CRC screening knowledge and attitudes across levels of health literacy and may be an important strategy for improving CRC screening in the primary care setting.

Funding

National Cancer Institute K07 CA107079 (Ohio State University) and P30 CA016058 (Behavioral Measurement Shared Resource at The Ohio State University).

The community pharmacist's role in cancer screening and prevention

As the Canadian population continues to age, the incidence of cancer is on the rise. To help alleviate the burden malignancy imposes on our health care system, a shift toward early cancer detection is necessary. Pharmacists are well positioned and willing to assume a more active role in cancer surveillance. Patients are receptive to pharmacist involvement and seem to prefer a convenient community pharmacy-based location for screening programs. The community pharmacist's current and potential role in cancer screening and prevention is summarized in this article. A review of screening recommendations and a discussion of opportunities will hopefully inspire pharmacists to consider incorporating malignancy screening initiatives into their practice.

Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education

Background/Method. Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. Results. There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). Conclusion. Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/ knowledge or shared decision-making message.

"It is just another test they want to do": Patient and caregiver understanding of the colonoscopy procedure

OBJECTIVE

Colonoscopy is a complex procedure that requires bowel preparation, sedation, and has the potential for substantial risk. Given this, we investigated colonoscopy patients' perceived and actual understanding of the procedure.

METHODS

Consecutive colonoscopy patients were enrolled and surveyed, with their caregivers, immediately prior to their procedure. Demographics, health literacy, socioeconomic status and perceived risks/benefits were assessed. Thematic analysis was conducted on open-ended responses and a 3-level outcome variable was created to categorize correctness of patients' and caregivers' understanding. Multinomial logistic regression was used to determine predictors of response level.

RESULTS

Patients (N=1821) were 77% White, 60% female, and averaged 54 years old; caregivers were demographically similar. Among patients, bivariate analysis revealed that younger age, minority race, and low income, education, and health literacy were associated with incomplete understanding. Multinomial regression revealed that age, education, health literacy, first-time colonoscopy, and perceived risk-benefit difference discriminated among groups. Bivariate and multinomial results for caregivers were similar.

CONCLUSION

Patients and caregivers varied on information, understanding and misconceptions about colonoscopy. Implications are discussed for inadequate: 1. informed consent, 2. bowel preparation, and 3. emotional preparation for cancer detection or adverse events.

PRACTICE IMPLICATIONS

Attention should be paid to patients' understanding of the purpose, anatomy, and logistics of colonoscopy, preferably prior to bowel preparation.

Understanding Health Literacy and its Impact on Delivering Care to Patients with Inflammatory Bowel Disease

Health literacy (HL) is the extent to which individuals have the capacity to obtain, process, and understand basic health information that is needed to make appropriate health decisions. As adults with inflammatory bowel disease engage in complex health decisions throughout their lives, attention is needed regarding the influence of HL on the lives of people with inflammatory bowel disease. About one-third of adults in the United States have limited HL. Limited HL is a potentially modifiable risk factor that has been associated with barriers to patient-provider communication and worse health outcomes for people with a range of chronic diseases. Gastroenterologists must recognize the role of HL in their practice. Limited HL can affect a patient's ability to understand the purpose of a screening test for colorectal cancer, understand the concept of an asymptomatic yet chronic disease, ask questions in an office visit and engage in shared decision making. Gastroenterologists must approach each patient as potentially having limited HL and use clear communication strategies in all encounters. Currently, there is a lack of training, education, and support for health care providers to meet the needs of patients with limited HL. More research is needed in inflammatory bowel disease to understand the impact of limited health literacy on health outcomes in this population and develop effective systems-based interventions to reduce the health literacy burden on patients.

Thomas N, Yang H, Daniels AH, Born CT. Readability of Trauma-Related Patient Education Materials From the American Academy of Orthopaedic Surgeons

Context:

According to the american medical association (AMA) and the national institutes of health (NIH), the recommended readability of patient education materials should be no greater than a sixth-grade reading level. The online patient education information produced by the american academy of orthopaedic surgeons (AAOS) may be too complicated for some patients to understand. This study evaluated whether the AAOS’s online trauma-related patient education materials meet recommended readability guidelines for medical information.

Evidence Acquisition:

Ninety-nine articles from the “Broken Bones and Injuries” section of the AAOS-produced patient education website, orthoinfo.org, were analyzed for grade level readability using the Flesch-Kincaid formula, a widely-used and validated tool to evaluate the text reading level. Results for each webpage were compared to the AMA/NIH recommended sixth-grade reading level and the average reading level of U.S. adults (eighth-grade).

Results:

The mean (SD) grade level readability for all patient education articles was 8.8 (1.1). All but three of the articles had a readability score above the sixth-grade level. The readability of the articles exceeded this level by an average of 2.8 grade levels (95% confidence interval, 2.6 - 3.0; P < 0.0001). Furthermore, the average readability of the articles exceeded the average reading skill level of U.S. adults (eighth grade) by nearly an entire grade level (95% confidence interval, 0.6-1.0; P < 0.0001).

Conclusions:

The majority of the trauma-related articles from the AAOS patient education website have readability levels that may make comprehension difficult for a substantial portion of the patient population.

Health Literacy as a Social Determinant of Health in Asian American Immigrants: Findings from a Population-Based Survey in California

BACKGROUND

Asian American immigrants have a lower level of health literacy than non-Latino whites, but their level of health literacy and its impact on health outcomes may differ among subgroups.

OBJECTIVE

We investigated the level of health literacy across five subgroups of Asian American immigrants and explored the association between health literacy and self-rated health status and symptoms of depression.

DESIGN

We utilized a cross-sectional survey research design and a population-based sampling strategy using the 2007 California Health Interview Survey (CHIS).

PARTICIPANTS

We sampled 30,615 non-Latino whites and 3,053 Asian American immigrants (1,058 Chinese, 598 Koreans, 534 Filipinos, 416 South Asians, and 447 Vietnamese).

MAIN MEASURES

We used two questions as proxy measures to assess the level of health literacy in non-Latino whites and in both aggregated and disaggregated Asian American immigrant groups. We then investigated the effect of health literacy on two main health outcomes: self-rated health status and depression symptoms.

KEY RESULTS

The level of health literacy varied across the five subgroups of Asian American immigrants. Chinese, Korean, and Vietnamese groups had the lowest levels of health literacy, while Filipinos showed the highest level. Health literacy was positively correlated with health status in Chinese and Korean immigrants, and negatively correlated with depression symptoms in Korean and South Asian immigrants.

CONCLUSION

We found heterogeneity in health literacy among Asian American immigrants and found that health literacy had varying associations with health outcomes. The aggregated Asian American immigrant group results may mask the true health disparities that each Asian American immigrant group faces. Koreans were the only group found to have a significant association between the proxy for health literacy and both health outcomes. Further research is needed to better understand the causes of heterogeneity and to investigate health literacy as a critical determinant of immigrant health.

Decisional stage distribution for colorectal cancer screening among diverse, low-income study participants

Colorectal cancer (CRC) screening uptake among minorities and those with lower incomes is suboptimal. Behavioral interventions specifically tailored to these populations can increase screening rates and save lives. The Precaution Adoption Process Model (PAPM) allows assignment of a decisional stage for adoption of a behavior such as CRC screening. Here, we characterize the PAPM decisional stage distribution among 470 low income, racially and ethnically diverse study participants at intake into a behavioral intervention study designed to increase CRC screening uptake. We staged participants for stool blood test (SBT) and colonoscopy separately and used the highest stage for the two tests as the 'overall' stage for CRC screening. For SBT, sex, language (English versus Spanish) and doctor recommendation were significantly related to PAPM stage for CRC screening. For colonoscopy, language, education level, doctor recommendation and self-efficacy were related to stage. For overall CRC screening stage, all the variables associated with either SBT or colonoscopy, with the exception of language were significant. This study suggests attending to these key variables in designing interventions to promote CRC screening, particularly with respect to medically underserved populations.

Sharing Health Information and Influencing Behavioral Intentions: The Role of Health Literacy, Information Overload, and the Internet in the Diffusion of Healthy Heart Information

Low health literacy remains an extremely common and problematic issue, given that individuals with lower health literacy are more likely to experience health challenges and negative health outcomes. In this study, we use the first three stages of the innovation-decision process found in the theory of diffusion of innovations (Rogers, 2003). We incorporate health literacy into a model explaining how perceived health knowledge, information sharing, attitudes, and behavior are related. Results show that health information sharing explains 33% of the variance in behavioral intentions, indicating that the communicative practice of sharing information can positively impact health outcomes. Further, individuals with high health literacy tend to share less information about heart health than those with lower health literacy. Findings also reveal that perceived heart-health knowledge operates differently than health literacy to predict health outcomes.

Cognitive ability and personality as predictors of participation in a national colorectal cancer screening programme: the English Longitudinal Study of Ageing

BACKGROUND

The English NHS Bowel Cancer Screening Programme has offered biennial faecal occult blood testing to people aged 60-69 years since 2006, and to those aged 60-74 years since 2010. Analysis of the first 2.6 million screening invitations found that 54% of eligible people took up the invitation. The reasons for this low uptake are unclear. We investigated whether participation in screening varies according to cognitive ability and personality.

METHODS

Participants were members of The English Longitudinal Study of Ageing. In 2010-2011, respondents were asked about participation in bowel cancer screening, and cognitive ability and the 'Big Five' personality traits were assessed. Logistic regression was used to examine the cross-sectional relationships between cognitive ability and personality and screening participation in 2681 people aged 60-75 years who were eligible to have been invited to take part in the UK national screening programme for bowel cancer.

RESULTS

In age-adjusted and sex-adjusted analyses, better cognition and higher conscientiousness were associated with increased participation in cancer screening. ORs (95% CIs) per SD increase were 1.10 (1.03 to 1.18) for cognitive ability and 1.10 (1.01 to 1.19) for conscientiousness. After further adjustment for household wealth and health literacy-shown previously to be associated with participation-these associations were attenuated (ORs were 1.07 (1.00 to 1.15) and 1.07 (0.97 to 1.18), respectively).

CONCLUSIONS

We found some indication that better cognitive function and greater conscientiousness may be linked with a slightly increased likelihood of participation in bowel cancer screening. These relationships need investigation in other cohorts of older people.

Low health literacy and cancer screening among Chinese Americans in California: a cross-sectional analysis

OBJECTIVES

Cancer is the leading cause of death among Asian Americans. Chinese Americans comprise the largest Asian American ethnic group. Low health literacy (LHL) is associated with lower cancer screening rates, but this association has not been studied in Chinese Americans. We examined the relationship between LHL and meeting US Preventive Service Task Force (USPSTF) guidelines for cervical, colorectal and breast cancer screening among Chinese Americans.

DESIGN

Observational study of Chinese respondents in the 2007 California Health Interview Survey, a population-based survey. Interview languages included English, Cantonese and Mandarin.

SETTING

California, USA PARTICIPANTS: Chinese respondents in age/gender groupings appropriate for USPSTF cancer screening guidelines (cervical: women ages 21-65, n=632; colorectal: men or women ages 50-75, n=488; and breast: women ages 50-74, n=326).

OUTCOMES

Relationships were tested using multivariable logistic regression models controlling for healthcare access and demographic factors, including limited English proficiency (LEP). The combined effects of having both LHL and LEP were specifically examined. LHL was measured by 2-items on perceived ease-of-use of written medical materials. All study variables were self-reported.

RESULTS

Cancer screening percentages among Chinese Americans were 77.8% for cervical, 50.9% for colorectal (47.9% for women and 54.2% for men), and 85.5% for breast. LHL was associated with lower odds of meeting breast cancer screening guidelines (OR 0.41; 95% CI 0.20 to 0.82). Respondents with both LHL and LEP were significantly less likely to have up-to-date colorectal (OR 0.49; 95% CI 0.25 to 0.97) and breast cancer screening (OR 0.21; 95% CI 0.08 to 0.54) than those with neither health communication barrier. In all multivariable models, having seen a physician in the past year was a significant predictor of an up-to-date screening.

CONCLUSIONS

In Chinese Americans, LHL and LEP were negatively associated with up-to-date breast and colorectal cancer screening, independent of a recent physician visit. Efforts to promote cancer screening among Chinese Americans should consider and address LHL, LEP and physician access barriers.

Effects of Health Literacy and Social Capital on Health Information Behavior

This study aimed to examine whether social capital (bonding and bridging social capital) attenuate the effect of low functional health literacy on health information resources, efficacy, and behaviors. In-person interviews were conducted with 1,000 residents in Seoul, Korea, in 2011. The authors found that respondents' functional health literacy had positive effects on the scope of health information sources and health information self-efficacy but not health information-seeking intention. Respondents' social capital had positive effects on the scope of health information sources, health information efficacy, and health information-seeking intention. The authors found (a) a significant moderation effect of bridging social capital on the relation between health literacy and health information self-efficacy and (b) a moderation effect of bonding social capital on the relation between health literacy and health information-seeking intention.

Validity and reliability of the Japanese version of the Newest Vital Sign: a preliminary study

Health literacy (HL) refers to the ability to obtain, process, and understand basic health information and services, and is thus needed to make appropriate health decisions. The Newest Vital Sign (NVS) is comprised of 6 questions about an ice cream nutrition label and assesses HL numeracy skills. We developed a Japanese version of the NVS (NVS-J) and evaluated the validity and reliability of the NVS-J in patients with chronic pain. The translation of the original NVS into Japanese was achieved as per the published guidelines. An observational study was subsequently performed to evaluate the validity and reliability of the NVS-J in 43 Japanese patients suffering from chronic pain. Factor analysis with promax rotation, using the Kaiser criterion (eigenvalues ≥1.0), and a scree plot revealed that the main component of the NVS-J consists of three determinative factors, and each factor consists of two NVS-J items. The criterion-related validity of the total NVS-J score was significantly correlated with the total score of Ishikawa et al.'s self-rated HL Questionnaire, the clinical global assessment of comprehensive HL level, cognitive function, and the Brinkman index. In addition, Cronbach's coefficient for the total score of the NVS-J was adequate (alpha = 0.72). This study demonstrated that the NVS-J has good validity and reliability. Further, the NVS-J consists of three determinative factors: "basic numeracy ability," "complex numeracy ability," and "serious-minded ability." These three HL abilities comprise a 3-step hierarchical structure. Adequate HL should be promoted in chronic pain patients to enable coping, improve functioning, and increase activities of daily living (ADLs) and quality of life (QOL).

Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing

OBJECTIVE

To determine the association between health literacy and participation in publicly available colorectal cancer (CRC) screening in England using data from the English Longitudinal Study of Ageing (ELSA).

METHODS

ELSA is a population-based study of English adults aged ≥ 50 years. Health literacy, participation in the national CRC screening programme, and covariates were interview-assessed in 2010-11. All those age-eligible for screening from 2006 to 11 were included in the present analysis (n=3087). The association between health literacy and screening was estimated using multivariable-adjusted logistic regression.

RESULTS

73% of participants had adequate health literacy skills. Screening uptake was 58% among those with adequate and 48% among those with limited health literacy skills. Having adequate health literacy was associated with greater odds of CRC screening (multivariable adjusted OR=1.20; 95% CI: 1.00-1.44), independent of other predictors of screening: age (OR=0.92; 95% CI: 0.91-0.94 per one year increase), female sex (OR=1.31; 95% CI: 1.11-1.54), and being in a higher wealth quintile (OR=1.88; 95% CI: 1.43-2.49).

CONCLUSIONS

Limited health literacy is a barrier to participation in England's national, publicly available CRC screening programme. Interventions should include appropriate design of information materials, provision of alternative support, and increased one-on-one interaction with health care professionals.

Assessment of family history of colorectal cancer in primary care: perceptions of first degree relatives of people with colorectal cancer

OBJECTIVE

First degree relatives (FDRs) of someone with colorectal cancer (CRC) are at increased risk of the disease. In this study we examine the factors associated with discussing family history of CRC with a health professional.

METHODS

People with CRC, recruited through the population-based Victorian Cancer Registry in Australia, were asked to refer FDRs to the study. Eight hundred and nineteen FDRs completed a telephone interview.

RESULTS

Thirty-six percent of FDRs recalled ever being asked about their family history of bowel cancer by a health professional. Factors associated with having this discussion were being aged 50-60 years, having a university education, being in the potentially high risk category, being very worried about getting bowel cancer and knowing that family history increases risk through discussions with family, friends or their own education.

CONCLUSION

Despite evidence that doctor endorsement is a key factor in the uptake of CRC screening, our study shows that the majority of FDRs do not recall being asked by a health professional about their family history.

PRACTICE IMPLICATIONS

There is a need to identify the most appropriate method to improve rates of health professional discussion of family history with relatives of CRC patients in order to improve screening rates.

Factors Associated with Informed Decisions and Participation in Bowel Cancer Screening among Adults with Lower Education and Literacy

Background. Making informed decisions about cancer screening involves understanding the benefits and harms in conjunction with personal values. There is little research examining factors associated with informed decision making or participation in screening in the context of a decision aid trial. Objectives. To identify factors associated with informed choice and participation in fecal occult blood testing (FOBT) among lower education populations. Design. Randomized controlled trial of an FOBT decision aid conducted between July and November 2008. Setting. Socioeconomically disadvantaged areas in New South Wales, Australia. Participants. Included 572 adults aged 55 to 64 years with lower education. Measurements. Sociodemographic variables, perceived health literacy, and involvement preferences in decision making were examined to identify predictors of informed choice (knowledge, attitudes, and behavior). Results. Multivariate analysis identified independent predictors of making an informed choice as having higher education (relative risk [RR], 1.49; 95% confidence interval [CI], 1.13–1.95; P = 0.001), receiving the decision aid (RR, 2.88; 95% CI, 1.87–4.44; P < 0.001), and being male (RR, 1.48; 95% CI, 1.11–1.97; P = 0.009). Participants with no confidence in completing forms and poorer self-reported health were less likely to make an informed choice (RR, 0.74; 95% CI, 0.53–1.03; P = 0.05 and RR, 0.57; 95% CI, 0.36–0.89; P = 0.007, respectively). Independent predictors of completing the FOBT were positive screening attitudes, receiving the standard information, preference for making the decision alone, and knowing that screening may lead to false-positive/negative results. Limitations. We did not objectively measure health literacy. Conclusions. Participants with the lowest levels of education had greater difficulties making an informed choice about participation in bowel screening. Alternative methods are needed to support informed decision making among lower education populations.

Effectiveness of a primary care practice intervention for increasing colorectal cancer screening in Appalachian Kentucky

OBJECTIVE

This report describes findings from a randomized controlled trial of an intervention to increase colorectal cancer (CRC) screening in primary care practices in Appalachian Kentucky.

METHODS

Sixty-six primary care practices were randomized to early or delayed intervention groups. The intervention was provided at practices using academic detailing, a method of education where providers receive information on a specific topic through personal contact. Data were collected in cross-sectional surveys of medical records at baseline and six months post-intervention.

RESULTS

A total of 3844 medical records were reviewed at baseline and 3751 at the six-month follow-up. At baselines, colonoscopy was recommended more frequently (43.4%) than any other screening modality, followed by fecal occult blood testing (18.0%), flexible sigmoidoscopy (0.4%), and double-contrast barium enema (0.3%). Rates of documented screening results were higher for all practices at the six-month follow-up for colonoscopy (31.8% vs 29.6%) and fecal occult blood testing (12.2% vs 11.2%). For early intervention practices that recommended screening, colonoscopy rates increased by 15.7% at six months compared to an increase of 2.4% in the delayed intervention practices (p=.01).

CONCLUSIONS

Using academic detailing to reach rural primary care providers with a CRC screening intervention was associated with an increase in colonoscopy.