Health literacy and patient outcomes in chronic kidney disease: a systematic review

Evaluating the role of technology in disseminating education to patients with chronic kidney disease

The optimal management of chronic kidney disease (CKD) requires lifestyle changes and adherence to long-term medications. Knowledge is a component of health literacy and is needed for self-management. Limited health literacy can lead to negative outcomes, such as adverse clinical events and mortality.1

Social Deprivation and Incidence of Pediatric Kidney Failure in France

Introduction

Approximately 8 per million children and young adults aged < 20 years initiate kidney replacement therapy (KRT) per year in France. We hypothesize that social deprivation could be a determinant of childhood-onset kidney failure. The objective of this study was to estimate the incidence of pediatric KRT in France according to the level of social deprivation.

Methods

All patients < 20 years who initiated KRT from 2010 to 2015 in metropolitan France were included. Data were collected from the comprehensive French registry of KRT French Renal Epidemiology and Information network (REIN). We used a validated ecological index to assess social deprivation, the 2011 French version of the European Deprivation Index (EDI). We estimated the age standardized incidence rates according to the quintiles of EDI using direct standardization and incidence rate ratio using Poisson regression.

Results

We included 672 children with kidney failure (58.6% males, 30.7% with glomerular or vascular disease, 43.3% starting KRT between 11 and 17 years). 38.8% were from the most deprived areas (quintile 5 of EDI). The age standardized incidence rate increased with quintile of EDI, from 5.45 (95% confidence interval [CI] = 4.25-6.64) per million children per year in the least deprived quintile to 8.46 (95% CI = 7.41-9.51) in the most deprived quintile of EDI (incidence rates ratio Q5 vs. Q1 1.53-fold; 95% CI = 1.18-2.01).

Conclusion

This study showed that even in a country with a universal health care system, there is a strong association between the incidence of pediatric KRT and social deprivation showing that social health inequalities appear from KRT initiation. This study highlights the need to look further into social inequalities in the earliest stage of chronic kidney disease (CKD).

Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care.

Role of health literacy profiles in fluid management of individuals receiving haemodialysis: A cross-sectional study

AIMS

To identify health literacy profiles in individuals receiving haemodialysis and to explore how these profiles interact with individuals' self-efficacy, engagement with traditional dietary habits, self-reported fluid restriction and relative-interdialytic weight gain.

DESIGN

A cross-sectional study engaging nephrology departments from four hospitals in Guangdong Province, China.

METHODS

A sample of 433 individuals receiving haemodialysis participated between December 2018 and July 2019. We assessed health literacy, self-efficacy and self-reported fluid restriction using the Health Literacy Questionnaire, the Fluid Self-efficacy Scale and the Fluid Adherence Subscale, respectively. Traditional dietary habits, including daily tea drinking, soup drinking and preserved food consumption, were measured using three yes/no questions. Relative-interdialytic weight gain was calculated by dividing the mean interdialytic weight gain (from three recent intervals) by dry weight. Latent profile analysis and structural equation modelling were performed.

RESULTS

Three health literacy profiles were identified: low, moderate and high. Compared to those in the low health literacy profile, individuals in high and moderate health literacy profiles demonstrated an indirect association with reduced relative-interdialytic weight gain. This reduction can be attributed to their higher self-efficacy levels, decreased reliance on dietary habits and higher self-reported fluid restrictions.

CONCLUSIONS

Most participants exhibited either low or moderate levels of health literacy. Improving health literacy has the potential to promote self-efficacy and foster effective fluid restriction, ultimately leading to a reduction in relative-interdialytic weight gain in individuals receiving haemodialysis.

IMPACT

This study reveals heterogeneity in health literacy levels among individuals receiving haemodialysis and illuminates the connections between an individual's entire spectrum of health literacy and fluid management. These findings provide valuable insights for developing person-centred fluid management interventions, especially for individuals with diverse cultural dietary backgrounds within the haemodialysis population.

REPORTING METHOD

We adhered to the STROBE guideline.

PATIENT OR PUBLIC CONTRIBUTION

Patients were included only for collecting their data.

Impact of Health Literacy on Patient-Reported Outcomes in Benign Gynecology: A Systematic Review

The objective of this study was to systematically review the relationship between low health literacy and patient-reported outcomes in patients with benign gynecologic conditions. In this specific population, we also sought to determine the current reported prevalence of low health literacy, examine demographic characteristics that may be related to low health literacy, and collate any health literacy interventions described in the literature. A systematic search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, The Cochrane Library, Web of Science, PubMed, and clinicaltrials.gov was performed on July 12, 2021, and repeated on October 13, 2023, for terms related to health literacy, specific health literacy measures, and benign gynecologic conditions. There were language or publication period restrictions. Inclusion required primary literature to report associations between health literacy and patient-reported outcomes, using validated tools to quantitatively measure each, in adult women with benign gynecologic conditions. Title screening, abstract screening, and full-text review were conducted with Covidence software (Melbourne, Australia) assisting with the review process. Of the 18,701 studies returned using our search strategy, 25 were selected for full-text review. Of these, no studies met inclusion criteria and reported an association between health literacy and patient-reported outcomes. This study identified a large gap in the literature. Future work should be directed at evaluating the association between health literacy and patient-reported outcomes in benign gynecology to inform patient-centered interventions and care provision.

Health-literacy, self-efficacy and health-outcomes of patients undergoing haemodialysis: Mediating role of self-management

BACKGROUND

Health literacy, self-efficacy and self-management are known to influence health-related well-being. However, the precise influence of self-management, health literacy and self-efficacy on health outcomes in Asian countries is under-researched.

OBJECTIVES

To examine the impact of health literacy and self-efficacy (independent variables) and self-management (mediator) on patients' health outcomes (dependent variable).

DESIGN

An observational, cross-sectional design was conducted between 1 March 2022 and 31 August 2022.

PARTICIPANTS

Outpatients receiving haemodialysis (n = 200) at a Taiwanese medical centre were assessed.

MEASUREMENTS

The survey included demographic questions and standardised scales: the 3-item Brief Health Literacy Screen, the 8-item Perceived Kidney/Dialysis Self-Management Scale as a measure of self-efficacy, and the 20-item Haemodialyses Self-Management Instrument. Health outcomes were responses on the 12-item Short-Form Health Survey version 2 and clinical blood results from the past 3 months.

RESULTS

Participants aged over 60 exhibited common comorbidities, with 34% showing low health literacy. Biochemical markers (e.g., haemoglobin and albumin) significantly correlated with physical and mental health scores. Mediating coefficients revealed that self-management significantly influenced associations between health outcomes, health literacy (β = 0.31; p < 0.01), and self-efficacy (β = 0.19; p < 0.01).

IMPLICATIONS FOR PRACTICE

Self-management can modify the overall influence of health literacy and self-efficacy on patients' quality of physical and emotional health. When managing a chronic condition, 'knowing' how to self-manage does not always result in 'doing so' by the patient. Continuous monitoring and promoting self-management behaviours and support by nurses are crucial to enhance health outcomes.

Generative artificial intelligence chatbots may provide appropriate informational responses to common vascular surgery questions by patients

OBJECTIVES

Generative artificial intelligence (AI) has emerged as a promising tool to engage with patients. The objective of this study was to assess the quality of AI responses to common patient questions regarding vascular surgery disease processes.

METHODS

OpenAI's ChatGPT-3.5 and Google Bard were queried with 24 mock patient questions spanning seven vascular surgery disease domains. Six experienced vascular surgery faculty at a tertiary academic center independently graded AI responses on their accuracy (rated 1-4 from completely inaccurate to completely accurate), completeness (rated 1-4 from totally incomplete to totally complete), and appropriateness (binary). Responses were also evaluated with three readability scales.

RESULTS

ChatGPT responses were rated, on average, more accurate than Bard responses (3.08 ± 0.33 vs 2.82 ± 0.40, p < .01). ChatGPT responses were scored, on average, more complete than Bard responses (2.98 ± 0.34 vs 2.62 ± 0.36, p < .01). Most ChatGPT responses (75.0%, n = 18) and almost half of Bard responses (45.8%, n = 11) were unanimously deemed appropriate. Almost one-third of Bard responses (29.2%, n = 7) were deemed inappropriate by at least two reviewers (29.2%), and two Bard responses (8.4%) were considered inappropriate by the majority. The mean Flesch Reading Ease, Flesch-Kincaid Grade Level, and Gunning Fog Index of ChatGPT responses were 29.4 ± 10.8, 14.5 ± 2.2, and 17.7 ± 3.1, respectively, indicating that responses were readable with a post-secondary education. Bard's mean readability scores were 58.9 ± 10.5, 8.2 ± 1.7, and 11.0 ± 2.0, respectively, indicating that responses were readable with a high-school education (p < .0001 for three metrics). ChatGPT's mean response length (332 ± 79 words) was higher than Bard's mean response length (183 ± 53 words, p < .001). There was no difference in the accuracy, completeness, readability, or response length of ChatGPT or Bard between disease domains (p > .05 for all analyses).

CONCLUSIONS

AI offers a novel means of educating patients that avoids the inundation of information from "Dr Google" and the time barriers of physician-patient encounters. ChatGPT provides largely valid, though imperfect, responses to myriad patient questions at the expense of readability. While Bard responses are more readable and concise, their quality is poorer. Further research is warranted to better understand failure points for large language models in vascular surgery patient education.

Testing a Digital Health App for Patients With Alcohol-Associated Liver Disease: Mixed Methods Usability Study

BACKGROUND

Alcohol-associated liver disease (ALD) is increasingly common and associated with serious and costly health consequences. Cessation of drinking can improve ALD morbidity and mortality; however, support for cessation is not routinely offered to those diagnosed with ALD, and continued drinking or resumption of drinking after diagnosis is common. Mobile health (mHealth) has the potential to offer convenient and scalable support for alcohol cessation to those diagnosed with ALD, but mHealth interventions for alcohol cessation have not been designed for or evaluated in a population with ALD.

OBJECTIVE

This study aims to understand how individuals with ALD would perceive and use an mHealth tool for alcohol cessation and to gather their perspectives on potential refinements to the tool that would allow it to better meet their needs.

METHODS

We interviewed 11 individuals who attended clinic visits related to their ALD to elicit their needs related to support for alcohol cessation and views on how mHealth could be applied. After completing initial interviews (pre), participants were provided with access to an mHealth app designed for alcohol cessation, which they used for 1 month. Afterward, they were interviewed again (post) to give feedback on their experiences, including aspects of the app that met their needs and potential refinements. We applied a mixed methods approach, including a qualitative analysis to identify major themes from the interview transcripts and descriptive analyses of use of the app over 1 month.

RESULTS

First, we found that a diagnosis of ALD is perceived as a motivator to quit drinking but that patients had difficulty processing the overwhelming amount of information about ALD they received and finding resources for cessation of alcohol use. Second, we found that the app was perceived as usable and useful for supporting drinking recovery, with patients responding favorably to the self-tracking and motivational components of the app. Finally, patients identified areas in which the app could be adapted to meet the needs of patients with ALD, such as providing information on the medical implications of an ALD diagnosis and how to care for their liver as well as connecting individuals with ALD to one another via a peer-to-peer support forum. Rates of app use were high and sustained across the entire study, with participants using the app a little more than half the days during the study on average and with 100% (11/11) of participants logging in each week.

CONCLUSIONS

Our results highlight the need for convenient access to resources for alcohol cessation after ALD diagnosis and support the potential of an mHealth approach to integrate recovery support into care for ALD. Our findings also highlight the ways the alcohol cessation app should be modified to address ALD-specific concerns.

A Policy Call to Address Rare Kidney Disease in Health Care Plans

Despite a large number of people globally being affected by rare kidney diseases, research support and health care policy programs usually focus on the management of the broad spectrum of CKD without particular attention to rare causes that would require a targeted approach for proper cure. Hence, specific curative approaches for rare kidney diseases are scarce, and these diseases are not treated optimally, with implications on the patients' health and quality of life, on the cost for the health care system, and society. There is therefore a need for rare kidney diseases and their mechanisms to receive the appropriate scientific, political, and policy attention to develop specific corrective approaches. A wide range of policies are required to address the various challenges that target care for rare kidney diseases, including the need to increase awareness, improve and accelerate diagnosis, support and implement therapeutic advances, and inform the management of the diseases. In this article, we provide specific policy recommendations to address the challenges hindering the provision of targeted care for rare kidney diseases, focusing on awareness and prioritization, diagnosis, management, and therapeutic innovation. In combination, the recommendations provide a holistic approach aiming for all aspects of rare kidney disease care to improve health outcomes, reduce the economic effect, and deliver benefits to society. Greater commitment from all the key stakeholders is now needed, and a central role should be assigned to patients with rare kidney disease to partner in the design and implementation of potential solutions.

Health inequities in dialysis care: A scoping review

MAIN PROBLEM

We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care.

METHODS

Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed.

RESULTS

In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified.

CONCLUSIONS

Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.

Association between health literacy and dysphagia in the community-dwelling older population: a cross-sectional study

BACKGROUND

Dysphagia, or swallowing disorders, has become a growing concern due to the aging population, and health literacy plays a crucial role in active aging. However, the relationship between them remains unclear.

AIMS

To investigate the association between health literacy and dysphagia among community-dwelling older adults in China.

METHODS

A survey was conducted on 4462 older adults aged 65 and above in a community in Yiwu City, China, from May 2021 to January 2022. Swallowing problems were assessed using a 30 ml water swallowing test (WST) and the Eating Assessment Tool-10 questionnaire (EAT-10). The participants' health literacy was evaluated using the Chinese Health Literacy Scale (CHLS). Logistic regression and t tests were employed to measure the association between them.

RESULTS

The prevalence of dysphagia was 5.70% and 7.85% as determined by EAT-10 and 30 ml-WST, respectively. The health literacy level of community-dwelling older adults was 24.4 ± 4.93 (9-45). Participants with dysphagia exhibited lower levels of health literacy (p < 0.05). The logistic regression model demonstrated an inverse association between health literacy and dysphagia (OR = 0.94, 95%CI = 0.91-0.96 for EAT-10, and OR = 0.93, 95%CI = 0.92-0.95 for WST). Moreover, this association remained significant even after adjusting for covariates.

DISCUSSION

Older adults with dysphagia have lower levels of health literacy, particularly in terms of their ability to seek medical advice, acquire and evaluate medical information, and access social support resources.

CONCLUSIONS

Health literacy is associated with dysphagia among community-dwelling older adults. Effective interventions should be implemented to provide support in terms of both medical services and social support for this population.

The Shift from Individual to Organizational Health Literacy: Implications for Kidney Healthcare Leaders and Clinicians

BACKGROUND

As a social determinant of health, health literacy has a vital role in the management of chronic disease management, including chronic kidney disease (CKD).

SUMMARY

To be able to manage their condition, patients with CKD need to be able to assess, comprehend, appraise, and utilize complex health-related information. Those patients are much more likely to understand and use health information appropriately, if it addresses their personal needs related to language, culture, educational background, and socioeconomic status. One aspect of health literacy, organizational health literacy (OHL), relates to the degree with which health organizations justifiably empower patients to locate, understand, and utilize health information and facilities to inform their decision-making and health behaviours. With increasing evidence-based about OHL as a way to improve healthcare, it is a new concept for kidney clinicians.

KEY MESSAGES

As producers of health-related information, the multidisciplinary kidney healthcare team have a responsibility to meet the needs of those in their care, as such, priority should be given to implementation of OHL initiatives. Through enhancing the clarity of information, OHL initiatives may provide a game plan for person-centred care for those with CKD.

The Effectiveness of Improving Infectious Disease-Specific Health Literacy Among Residents: WeChat-Based Health Education Intervention Program

BACKGROUND

Infectious disease-specific health literacy (IDSHL) has become an important determinant of infectious disease incidence. It can not only reduce the incidence of re-emerging infectious diseases, but also effectively prevent the emergence of new infectious diseases such as COVID-19. WeChat, as a new media, has been proven to greatly reduce the chance of infectious diseases spreading from person to person, especially in case of respiratory infections. However, there is currently no concrete health education invention program to improve IDSHL using a WeChat public account.

OBJECTIVE

The aims of this study were as follows: (1) to determine the IDSHL of the population in Zhejiang, China; (2) to develop a health education program for the improvement of IDSHL using a WeChat public account; and (3) to evaluate the effectiveness of the health education program that was implemented in the prevention of infectious disease outbreaks.

METHODS

We used a standardized questionnaire, which consisted of 28 closed-ended questions, to measure the level and score of IDSHL before and after intervention. A multiple-stage stratified random sampling technique was used to select study participants from Zhejiang province in China, who were further divided randomly into 2 groups: the intervention and control groups. From July 2014 to January 2015, a WeChat-based health education intervention program was carried out on the intervention group. Standard descriptive statistics and chi-square and t tests were conducted to analyze the data.

RESULTS

A total of 3001 residents participated in the baseline survey of this study. At baseline, participant IDSHL rates were 73.29% and 72.12% for the intervention and control groups, respectively (Χ21=0.5; P=.50). After 7 months of intervention, 9.90% (297/3001) of participants dropped out of the study. Of the lost participants, 119 were from the intervention group and 178 were from the control group. There were significant differences between follow-up and lost participants with respect to age (P=.04), marital status (P=.02) and occupations (P=.002). After intervention, the intervention group scores in the different domains were higher than those in the control group (infectious disease-related knowledge, prevention, management, or treatment, identification of pathogens and infection sources, and cognitive ability). There were significant improvements in the IDSHL of participants in both the intervention and control groups (Χ21=135.9; P<.001 vs Χ21=9.1; P=.003), and there was a greater change in the IDSHL among the intervention group participants than among the control group participants (1230/1359, 90.51% vs 1038/1359, 77.17%).

CONCLUSIONS

The health education intervention program using a WeChat public account proved to be an effective, feasible, and well-accepted means to improve the IDSHL of the general population. In the future, this health education intervention program can be used as a reference for prevention and treatment of infectious diseases.

Exploring health literacy in patients with chronic diseases in Chongqing, China: a cross-sectional study

OBJECTIVES

Personal health literacy is the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others. Health literacy levels remain low, despite the many measures that have been taken to improve it. In addition, the number of patients with chronic diseases is increasing. Our study aimed to explore the different aspects and factors influencing health literacy among patients with chronic diseases in Chongqing, China.

DESIGN

Cross-sectional study.

SETTING AND PATIENTS

This study was conducted in Chongqing using the 2018 National Questionnaire on Health Literacy of Residents administered to 27 336 patients with chronic diseases.

OUTCOME MEASURES

The prevalence and factors of health literacy in patients with chronic diseases.

RESULTS

Among the patients who participated in the study (n=27 336), 51.3% were males. Only 21.6% of the patients with chronic diseases had adequate health literacy (questionnaire score was equal to or exceeded 80% of the total questionnaire score). Patients with chronic diseases aged 25-34 years (OR=1.18, 95% CI 1.02 to 1.36) and 35-44 years (OR=1.18, 95 % CI 1.03 to 1.35) had higher health literacy than patients aged 65-69 years. Patients from rural areas had higher health literacy levels than those from urban areas (OR=0.92, 95% CI 0.86 to 1.00). Furthermore, married patients had lower health literacy than unmarried patients (OR=0.88, 95% CI 0.80 to 0.97). Patients who were illiterate or slightly literate (OR=0.10, 95% CI 0.08 to 0.12) had lower health literacy than patients who were in junior college or had a bachelor's degree or above. In addition, non-farmers had higher health literacy levels than farmers (OR=1.18, 95% CI 1.08 to 1.28). In terms of inadequate health literacy, patients who self-rated themselves as healthy had higher health literacy than those who self-rated as unhealthy (OR=1.80, 95% CI 1.33 to 2.43).

CONCLUSIONS

The health literacy of patients with chronic conditions remains at a low level and varies significantly with their demographic and social characteristics. These findings indicate that targeted interventions may be useful to improve health literacy in patients with chronic conditions in China.

Organizational Health Literacy and Health Among New York State Medicaid Members

BACKGROUND

The definition of health literacy has recently expanded beyond the idea of individual skills to include the system and environment the individual interacts with to receive care, known as organizational health literacy (OHL). However, neither the prevalence of OHL nor the impact of OHL on individuals' perceptions of their health and healthcare have been examined in New York's Medicaid managed care population.

OBJECTIVE

This study aimed to estimate the prevalence of organizational health literacy in the New York State (NYS) Medicaid Managed Care (MMC) program.

METHODS

A brief measure to assess organizational health literacy was developed from responses to two questions in the 2018 NYS Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Generalized Estimating Equation models were developed to analyze the association between organizational health literacy and three aspects of perceptions of health and health care, controlling for demographic differences and clustering effects from health insurance plans. Missing data were handled using multiple imputation.

KEY RESULTS

Among 3,598 members included in the study, 20% of the MMC members reported inadequate organizational health literacy. These members were more likely to be older, less educated, from racial and ethnic minority groups, and less fluent with English. They are more likely to have poorer self-reported health (odds ratio [OR] 1.49), lower perceived access to health care (OR 6.97), and lower satisfaction with their health care (OR 6.49) than members who did not report inadequate organizational health literacy.

CONCLUSIONS

Our results suggest that a proportion of the NYS MMC population faces inadequate organizational health literacy, which can present a barrier to health care access and result in patients having a significantly poorer health care experience. Using an existing data source that is part of existing data collection allows for routine assessment of organizational health literacy, which can help inform health plans about areas for potential improvement. [HLRP: Health Literacy Research and Practice. 2023;7(3):e154-e164.].

Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: a systematic review

INTRODUCTION

Low health literacy is widely reported in people with chronic kidney disease (CKD) and has been associated with reduced disease self-management, poor health outcomes, increased mortality and poorer quality of life. However, these associations are still not well understood.

METHODS

Electronic-based systematic searches were performed to identify studies examining associations between health literacy and self-management behaviours and/or health outcomes in patients with CKD. A tabular and narrative synthesis of the data was performed. Meta-analysis was not appropriate due to the heterogeneity of study designs and methods.

RESULTS

Searches identified 48 studies that met the inclusion criteria. A total of 41 published articles, six conference abstracts, and one thesis were included. Of the 48 studies, 11 were cohort and 37 were cross-sectional. In total there were 25,671 patients; 16,952 from cohort studies. Median study sample size was 159 (IQR 92-275). Study quality was high (5), moderate (24) and poor (19). Thirteen measures of health literacy were used. Despite the limitations of the available evidence, there appear to be consistent relationships between higher health literacy and favourable self-management behaviours for patients with CKD. Definitive relationships between health literacy and patient outcomes are far less clear and remain incompletely understood.

DISCUSSION

Conclusive evidence describing a causal link between health literacy and patient outcomes remains limited, but for many outcomes, a consistent association is described. In addition to associations with mortality, hospitalisation and clinical events, there were consistent associations between health literacy and favourable self-management behaviours which could support the development of patient education aimed at improving health literacy.

Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus

Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.

Health Literacy and Anxiety Among Hemodialysis Patients During the Coronavirus Disease Pandemic

Background and Purpose

The COVID-19 pandemic can cause psychological distress, and hemodialysis patients with chronic kidney disease may be particularly vulnerable. The aim of this study is to investigate anxiety levels among patients undergoing hemodialysis during the COVID-19 pandemic and to explore the relationship between health literacy and anxiety.

Methods

This study recruited 149 hemodialysis patients from two hospitals between July 16th and July 31st, 2021. Patient data were collected using questionnaires on general characteristics, health literacy, generalized anxiety, and coronavirus disease-related anxiety. We used the Coronavirus Anxiety Scale (CAS) and the Korean version of the Generalized Anxiety Disorder (GAD) scale to evaluate the anxiety symptoms of the patients. Statistical analyses were performed using descriptive statistics, t-test, Mann-Whitney U-test, one-way ANOVA, Kruskal-Walli's test and Spearman's rank correlation.

Results

The results showed that health literacy increased with decreasing age and increasing educational level among patients who source health information from the internet and among patients without comorbidities. Patients with comorbidities showed high levels of general anxiety. Patients who search for health information for ≥1 hour had high levels of coronavirus disease-related anxiety. Both CAS and GAD showed a significant negative correlation with the sub-domains of health literacy, except for critical health literacy.

Conclusion

The results of this study highlight the need for a follow-up study on whether health literacy programs will reduce the anxiety levels of patients undergoing hemodialysis during infectious disease outbreaks. In addition, provision of social support for patients with comorbidity is essential for reducing their anxiety levels during disease outbreaks.

Relationship between health literacy and COVID-19 knowledge: A cross-sectional study

Background

Health literacy (HL) is a protective factor for some chronic diseases. However, its role in the Coronavirus Disease 2019 (COVID-19) pandemic has not been clarified. This study aims to explore the association between HL and COVID-19 knowledge among residents in Ningbo.

Methods

A total of 6,336 residents aged 15-69 years in Ningbo were selected by multi-stage stratified random sampling method. The "Health Literacy Questionnaire of Chinese Citizens (2020)" was used to evaluate the relationship between COVID-19 knowledge and HL. Chi-square test, Mann-Whitney U test and logistic regression were used to analyze the data.

Results

The HL and COVID-19 knowledge levels of Ningbo residents were 24.8% and 15.7%, respectively. After adjusting for confounding factors, people with adequate HL were the more likely to have adequate COVID-19 knowledge compared with those with limited HL (OR = 3.473, 95% CI = 2.974-4.057, P <0.001). Compared with the limited HL group, the adequate HL group had a higher rate of COVID-19 knowledge, a more positive attitude, and a more active behavior.

Conclusion

COVID-19 knowledge is significantly associated with HL. Improving HL may influence people's knowledge about COVID-19, thereby changing people's behaviors, and finally combating the pandemic.

Implementation of health literacy training for clinicians in a federally qualified health center

Objective

The objective of this quality improvement project was to evaluate the effectiveness of a succinct health literacy training for providers at a demanding federally qualified health center.

Methods

One group, pretest-posttest design was used to measure for a change in knowledge regarding the effects of limited health literacy, a change in self-reported measure of routine screening for limited health literacy and a change in self-reported utilization of patient-centered communication techniques.

Results

The average percentage of correct responses on the Health Literacy Knowledge Check showed significant improvement from 23.6% (SD = 18.1%) to 63.9% (SD = 25.3%), p < .001. There were no significant changes in median responses at pre- and post-intervention for self-reported use of screening and communication techniques (all p > .05).

Conclusion

This brief training was effective at improving participants' knowledge of health literacy but did not improve use of recommended communication techniques or screening for health literacy. The results suggest that emphasizing a universal precautions approach to health literacy may be more effective with participants who work in high-volume clinics.

Practice implications

For high-volume clinics, a brief training may improve participants' knowledge but does not increase use of actual communication techniques based on self-report.

Low Health Literacy Is Associated with Poorer Physical and Mental Health-Related Quality of Life in Dialysed Patients

Health-related quality of life (HRQoL) is an important health indicator in chronic diseases like kidney diseases. Health literacy (HL) may strongly affect HRQoL, but evidence is scarce. Therefore, we assessed the associations of HL with HRQoL in dialysed patients. We performed a cross-sectional study in 20 dialysis clinics across Slovakia (n = 542 patients, mean age = 63.6 years, males = 60.7%). We assessed the association of categorised HL (low, moderate, high) with the SF36 physical component score (PCS) and mental component score (MCS) using generalised linear models adjusted for age, gender, education, and comorbidity (Charlson Comorbidity Index, CCI). We found significant associations of HL with PCS and MCS in dialysed patients, adjusted for age, gender, education, and CCI. Low-HL patients had a lower PCS (B = -3.27, 95%-confidence interval, CI: -5.76/-0.79) and MCS (B = -6.05, 95%-CI: -8.82/-3.29) than high-HL patients. Moderate-HL patients had a lower MCS (B = -4.26, 95%-CI: -6.83/-1.69) than high-HL patients. HL is associated with physical and mental HRQoL; this indicates that dialysed patients with lower HL deserve specific attention and tailored care to have their HRQoL increased.

Health literacy in chronic kidney disease patients: association with self-reported presence of acquaintance with kidney disease, disease burden and frequent contact with health care provider

BACKGROUND

Limited data suggest that health literacy (HL) is associated with kidney functions and clinical outcomes in patients with non-dialysis chronic kidney disease (CKD). We aimed to identify factors associated with the level of HL in a CKD population that has not been studied previously.

METHODS

Patients with stage I-V (non-dialysis) CKD according to the Kidney Disease Outcomes Quality Initiative classification were enrolled in the study from two tertiary healthcare centers. Data were collected cross-sectionally using the European Health Literacy Survey (HLS-EU).

RESULTS

Data of 208 participants were analyzed. HLS-EU scores had the highest correlations with age (r = - 0.494, p = 0.0001) and education (r = 0.476, p = 0.0001). Estimated glomerular filtration rate (e-GFR) was significantly correlated with HLS-EU score (r = 0.186, p = 0.01). Presence of a self-reported acquaintance with any kind of kidney disease was associated with higher HL. On the other hand, participants with multiple comorbidities, and therefore with more frequent contact with the health system, had lower HL than those without such frequent contact. Similarly, those with a high disease burden had lower HL than those without. HLS-EU scores were also significantly associated with gender, marital status, occupational status, self-perception of health, restriction of daily activities, participation in social activities, place of residence, blood pressure, body mass index, and serum parathyroid hormone and albumin levels.

CONCLUSION

Low HL is prevalent among CKD patients and is associated with e-GFR. Presence of an acquaintance with any kind of kidney disease is positively associated with HL. Presence of multiple comorbidities might be a limiting factor for the improvement of HL, which might also be expected to improve as a result of frequent contact with healthcare providers.

Kidney Health for All: Bridging the Gap in Kidney Health Education and Literacy

The high burden of kidney disease, global disparities in kidney care, and poor outcomes of kidney failure bring a concomitant growing burden to persons affected, their families, and carers, and the community at large. Health literacy is the degree to which persons and organizations have or equitably enable individuals to have the ability to find, understand, and use information and services to make informed health-related decisions and actions for themselves and others. Rather than viewing health literacy as a patient-deficit, improving health literacy largely rests with health care providers communicating and educating effectively in codesigned partnership with those with kidney disease. For kidney policy makers, health literacy provides the imperative to shift organizations to a culture that places the person at the center of health care. The growing capability of and access to technology provides new opportunities to enhance education and awareness of kidney disease for all stakeholders. Advances in telecommunication, including social media platforms, can be leveraged to enhance persons' and providers' education; The World Kidney Day declares 2022 as the year of "Kidney Health for All" to promote global teamwork in advancing strategies in bridging the gap in kidney health education and literacy. Kidney organizations should work toward shifting the patient-deficit health literacy narrative to that of being the responsibility of health care providers and health policy makers. By engaging in and supporting kidney health-centered policy-making, community health planning, and health literacy approaches for all, the kidney communities strive to prevent kidney diseases and enable living well with kidney disease.

Kidney Health for All: Bridging the Gap in Kidney Health Education and Literacy

The high burden of kidney disease, global disparities in kidney care, and poor outcomes of kidney failure bring a concomitant growing burden to persons affected, their families, and carers, and the community at large. Health literacy is the degree to which persons and organizations have or equitably enable individuals to have the ability to find, understand, and use information and services to make informed health-related decisions and actions for themselves and others. Rather than viewing health literacy as a patient deficit, improving health literacy largely rests with health care providers communicating and educating effectively in codesigned partnership with those with kidney disease. For kidney policy makers, health literacy provides the imperative to shift organizations to a culture that places the person at the center of health care. The growing capability of and access to technology provides new opportunities to enhance education and awareness of kidney disease for all stakeholders. Advances in telecommunication, including social media platforms, can be leveraged to enhance persons' and providers' education; The World Kidney Day declares 2022 as the year of "Kidney Health for All" to promote global teamwork in advancing strategies in bridging the gap in kidney health education and literacy. Kidney organizations should work toward shifting the patient-deficit health literacy narrative to that of being the responsibility of health care providers and health policy makers. By engaging in and supporting kidney health-centered policy making, community health planning, and health literacy approaches for all, the kidney communities strive to prevent kidney diseases and enable living well with kidney disease.

Acceptability of Plant-Based Diets for People with Chronic Kidney Disease: Perspectives of Renal Dietitians

The purpose of this study was to explore the perspective of renal dietitians regarding plant-based diets for chronic kidney disease (CKD) management and evaluate the acceptability of a hypothetical plant-based dietary prescription aiming for the consumption of 30 unique plant foods per week. This study used an exploratory mixed methods design. Forty-six renal dietitians participated in either an online survey (n = 35) or an in-depth interview (n = 11). Dietitians perceived that plant-based diets could address multiple clinical concerns relevant to CKD. Forty percent of survey respondents reported the hypothetical dietary prescription was realistic for people with CKD, 34.3% were unsure, and 25.7% perceived it as unrealistic. Strengths of the hypothetical prescription included shifting the focus to whole foods and using practical resources like recipes. Limited staffing, time, and follow-up opportunities with patients, as well as differing nutrition philosophies were the most commonly reported challenges to implementation; while a supportive multidisciplinary team was identified as an important enabler. To increase patient acceptance of plant-based dietary approaches, education about plant food benefits was recommended, as was implementing small, incremental dietary changes. Successful implementation of plant-based diets is perceived to require frequent patient contact and ongoing education and support by a dietitian. Buy-in from the multidisciplinary team was also considered imperative.

The Role of Health Literacy in Health Behavior, Health Service Use, Health Outcomes, and Empowerment in Pediatric Patients with Chronic Disease: A Systematic Review

About 8% of all children and adolescents worldwide are affected by chronic diseases. Managing chronic conditions requires pediatric patients to be health literate. The purpose of this review is to examine the existing evidence on the links between health literacy and its outcomes proposed by the model by Sørensen et al. in chronically ill pediatric patients. Four electronic databases (PubMed, Scopus, CINAHL, PsycINFO) were searched to identify pertinent articles published up to November 2021. The search was conducted independently by two researchers and restricted to observational studies. Of 11,137 initial results, 11 articles met eligibility criteria. Overall, 6 studies identified a significant association between health literacy and one of the considered outcomes. Regarding health behavior, none of the studies on adherence found significant associations with health literacy. The results in terms of health service use were inconclusive. Regarding health outcomes, health literacy did not affect most physiological parameters, but it significantly improved health-related quality of life. Overall, evidence remains inconclusive but suggests that health literacy is associated with self-efficacy, health-related quality of life, and health service use in pediatric patients. Further research should be undertaken to strengthen the evidence.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.

Health-Related Quality of Life Profiles in Dialyzed Patients With Varying Health Literacy. A Cross-Sectional Study on Slovak Haemodialyzed Population

Objectives: Chronic kidney disease (CKD) strongly affects patients’ health-related quality of life (HRQoL), mostly in the advanced stages of CKD. Health literacy (HL) may affect this association, in particular for some aspects of HRQoL. The aim of this study is to compare the profiles of HRQoL in dialyzed patients with varying HL.

Methods: We obtained data on HL using the Health Literacy Questionnaire (HLQ) and on HRQoL using the Kidney Disease Quality of Life – Short Form (KDQoL-SF 1.3) in a multicentre cross-sectional study in 20 dialysis clinics in Slovakia (n = 542; mean age = 63.6 years; males: 60.7%). We compared HRQoL for three HL groups using ANOVA and the Kruskal-Wallis test.

Results: Patients with low HL reported worse HRQoL than patients with moderate and high HL. The greatest differences between HL groups were found in the scales Effect of kidney disease, Cognitive function, Quality of social interaction, Social support, Dialysis staff encouragement, Patient satisfaction, Physical functioning, Pain, Emotional well-being and Social function. p-values in all cases were <0.001.

Conclusion: Patients with low HL have a worse HRQoL in several domains than patients with a higher HL. Increasing HL capacities and better supporting patients with low HL should thus be given priority to support their HRQoL and at least maintain its level.

Two aspects of health literacy and their importance for the use of health-promotion measures by teachers in the school setting

Purpose

Teachers are exposed to many stressors. Compared to other occupational groups, they are more frequently affected by psychosomatic complaints. In recent decades, numerous prevention and intervention measures for promoting health have been developed and implemented for this target group. However, it remains unclear how the uptake of health-promotion measures (HPMs) by teachers can be increased in order to prevent stress-related disorders. This paper examines two facets of health literacy—health awareness and health value—in terms of their importance in both the take-up and intended take-up of HPMs.

Design/methodology/approach

In the 2017/2018 school year, data were collected by paper and pencil from a representative sample of 830 teachers across all school types in the German State of Brandenburg.

Findings

Teachers who place great value on their own health show significantly higher levels of take-up and intended take-up of HPMs. The findings regarding health awareness are more heterogeneous. Further associations were found with age and psychosocial stress.

Originality/value

While there has been growing academic interest in developing HPMs for teachers, there has been relatively little focus on the factors that may influence the implementation and uptake of these measures. The paper contributes to addressing this gap by shedding light on the relevance of two facets of health literacy. Strengthening the perceived importance of health could be a starting point for increasing the use of HPMs by teachers and thus improving their health.

Research on Influencing Factors and Dimensions of Health Literacy in Different Age Groups: Before and After the COVID-19 Era in Chongqing, China

Background: Understanding the levels of health literacy among different groups is essential for better public health interventions targeting specific subgroups of the population. Additionally, this article explores the prevalence and influencing factors of the health literacy levels of different age groups during the COVID-19 epidemic. Methods: Multistage stratified cluster random sampling and the Probability Proportion to Size (PPS) method were used to select permanent residents aged 15-69 in Chongqing (54,706) for the questionnaire survey. The survey period is from July 2019 and July 2020. Single-factor analysis and logistic regression models were used to study the relationship between demographics, socioeconomic factors, other independent covariates, and health literacy. Results: The health literacy levels of residents declined with age, and there were significant differences in health literacy levels between age groups (χ² = 3332.884, P < 0.05). As far as the factors affecting health literacy level are concerned, high education and high income are the protective factors for health literacy level for residents of all ages. For adolescents (OR = 1.383, 95% CI: 1.217-1.571), young adults (OR = 1.232, 95% CI = 1.117-1.358), and middle-aged people (OR = 1.096, 95% CI = 1.017-1.182), residence in rural areas was a protective factor. In terms of the dimensions of health literacy, in particular, elderly health literacy in 2020 in Scientific Health Concepts, Safety and First Aid, Basic Medical Care decreased significantly compared with 2019. Conclusions: For adolescents, young adults, middle-aged people, to solve the problem of urban and rural health quality gap, we should not only use the geographical division, but also consider the social population and socio-economic differences. For the elderly, the following four dimensions of health literacy need to be paid more attention than those of other age: Basic Knowledge and Concepts, Scientific Health Concepts, Safety and First Aid, and Basic Medical Care. A lack of knowledge on the prevention and treatment of chronic diseases is the main reason for the recent decline in health literacy. And the health literacy among residents in major public health emergencies is needed.

Missing In-Center Hemodialysis Sessions among Patients with End Stage Renal Disease in Banda Aceh, Indonesia

Indonesian universal health coverage was implemented in 2013 and hemodialysis services became universally accessible, yet few studies have examined patient adherence to hemodialysis schedules. We examined the rates of missed in-center hemodialysis sessions in Banda Aceh and the factors associated with non-attendance. This cross-sectional questionnaire survey included 193 patients receiving in-center hemodialysis. Approximately 28% of the patients missed ≥ 1 hemodialysis session in the month prior to the questionnaire’s administration. About 65% reported attending religious activities as the reason for missing hemodialysis. The level of health literacy was generally low with a mean score of 14.38 out of 26 (55.3%). Multivariate logistic regression analyses showed that patients with educational levels higher than elementary school were less likely to miss hemodialysis sessions. Participants who performed more self-care behaviors had lower odds of missing hemodialysis sessions. Every unit increase in the health literacy score was associated with increased odds of missing hemodialysis sessions. Emphasizing the importance of attending hemodialysis sessions and modifying hemodialysis schedules based on patients’ needs is essential. Patients who miss hemodialysis sessions should be reminded of all self-care behaviors. Health literacy among hemodialysis patients should be improved, with emphasis on patient safety, advanced knowledge, and critical health literacy.

Stakeholder-Guided Development of Dialysis Vascular Access Education Materials

Background

Initiating hemodialysis via an arteriovenous (AV) access is considered best practice for most patients. Despite the well-recognized advantages of AV access, 80% of US patients start hemodialysis with a catheter. Limited patient knowledge about vascular access, among other factors, may play a role in this high rate. We used iterative stakeholder input to develop novel, mixed media vascular access education materials and evaluated their preliminary acceptability.

Methods

We conducted preliminary focus groups and interviews with key stakeholders to assess patient vascular access understanding and elicit perspectives on existing education materials. We then used stakeholder input to inform initial development and iterative updates to the content and design of an animated video and complementary brochure. Video development (scripting, storyboarding, animation) was guided by an evidence-based framework and two health behavior change models. We assessed acceptability of the completed materials with patients and medical providers/personnel via interviews.

Results

Overall, 105 stakeholders participated in education materials development and review (80 patients/care partners, 25 medical providers/personnel). Preliminary qualitative work included 52 patients/care partners and 16 providers/personnel; video development included 28 patients/care partners and nine providers/personnel. The video script, storyboards, and animation underwent 14, four, and nine stakeholder-guided iterations, respectively. Responsive changes included aesthetic modifications, technical updates, and content additions (e.g., HD circuit, access self-monitoring, enhanced patient testimonials). The final 18-minute video and complementary brochure define vascular access types, describe care processes, outline potential complications, and address common patient concerns. Interviews with 28 patients/care partners and nine providers/personnel from diverse geographic regions revealed preliminary acceptability of, and enthusiasm for, the materials by patients and providers.

Conclusions

In collaboration with key stakeholders, we developed mixed media vascular access education materials that were well-received by patients and providers. Preliminary findings suggest that the materials are promising to improve vascular access understanding among patients.

Risk factors for poorer health literacy in patients with liver cirrhosis

BACKGROUND

Health literacy is a concept that refers to patients' ability to manage their disease and the health system's ability to guarantee access to services. There is evidence that health literacy impacts the health outcomes of patients with chronic diseases, but detailed information on this topic in patients with liver cirrhosis is scarce. It was the aim of this study to identify risk factors for poorer health literacy in patients with liver cirrhosis.

METHODS

89 patients with liver cirrhosis were enrolled in this study and health literacy was measured using the Health Literacy Questionnaire (HLQ). Covert hepatic encephalopathy (CHE) was diagnosed clinically according to the West-Haven Criteria (HE grade 1) and the PHES (minimal HE). Depressive symptoms were assessed using the Hamilton Depression Rating Scale (HDRS). Based on the nine subscales of the HLQ, risk factors for poor health literacy were identified using linear regression models.

RESULTS

Normalized HLQ scores ranged between 65-76%, while appraisal of health information had lowest score (65%) and ability to actively engage with healthcare providers had highest score (76%). Multivariable regression analyses revealed an association of poorer health literacy and liver function as determined by MELD score and complications of liver cirrhosis such as a history of ascites or CHE. Additionally, we identified modifiable or preventable factors such as depressive symptoms, a history of falls, and active smoking as risk factors for poorer health literacy.

CONCLUSION

Multiple factors seem to impact on health literacy in patients with liver cirrhosis. Addressing modifiable and preventable factors may improve health literacy.

Accompanying Patients Aged 65 or Over: How Companions' Health Literacy Affects Value Co-Creation During Medical Encounters

Objectives: The recent health crisis has led to a tightening of visitor policies during medical consultations. This work studies the relationship between the companion's health literacy (functional, interactive, and critical) and the companion's co-creation of value (co-production and value in use). Methods: Six hypotheses are tested by means of a sample of companions of chronically ill patients over the age of 65, using structural equation modeling. Results: Functional literacy does not predict the co-creation of value through either of its dimensions (co-production and value in use). Interactive literacy has a positive influence on co-production and a negative influence on value in use. Critical literacy only positively influences value in use. Discussion: Merely understanding the health information is not sufficient for the companion to be recognized as a collaborator or "ally" of the doctor. It is necessary to encourage the companion's communication and critical evaluation skills.

Application of the eHealth Literacy Model in Digital Health Interventions: Scoping Review

BACKGROUND

Digital health interventions (DHIs) are increasingly being adopted globally to address various public health issues. DHIs can be categorized according to four main types of technology: mobile based, web based, telehealth, and electronic health records. In 2006, Norman and Skinner introduced the eHealth literacy model, encompassing six domains of skills and abilities (basic, health, information, scientific, media, and computer) needed to effectively understand, process, and act on health-related information. Little is known about whether these domains are assessed or accounted for in DHIs.

OBJECTIVE

This study aims to explore how DHIs assess and evaluate the eHealth literacy model, describe which health conditions are addressed, and which technologies are used.

METHODS

We conducted a scoping review of the literature on DHIs, based on randomized controlled trial design and reporting the assessment of any domain of the eHealth literacy model. MEDLINE, CINAHL, Embase, and Cochrane Library were searched. A duplicate selection and data extraction process was performed; we charted the results according to the country of origin, health condition, technology used, and eHealth literacy domain.

RESULTS

We identified 131 unique DHIs conducted in 26 different countries between 2001 and 2020. Most DHIs were conducted in English-speaking countries (n=81, 61.8%), delivered via the web (n=68, 51.9%), and addressed issues related to noncommunicable diseases (n=57, 43.5%) or mental health (n=26, 19.8%). None of the interventions assessed all six domains of the eHealth literacy model. Most studies focused on the domain of health literacy (n=96, 73.2%), followed by digital (n=19, 14.5%), basic and media (n=4, 3%), and information and scientific literacy (n=1, 0.7%). Of the 131 studies, 7 (5.3%) studies covered both health and digital literacy.

CONCLUSIONS

Although many selected DHIs assessed health or digital literacy, no studies comprehensively evaluated all domains of the eHealth literacy model; this evidence might be overlooking important factors that can mediate or moderate the effects of these interventions. Future DHIs should comprehensively assess the eHealth literacy model while developing or evaluating interventions to understand how and why interventions can be effective.

Low Health Literacy is Associated with the Onset of CKD during the Life Course

BACKGROUND

Health literacy, the ability to deal with information related to one's health, is a predictor of health outcomes in CKD. However, research has not explored whether low health literacy predicts the onset of CKD.

METHODS

We used data from participants of Lifelines, a prospective population-based cohort study of individuals living in The Netherlands, to assess the share of individuals with low health literacy by eGFR category, whether low health literacy is associated with CKD onset in the general population and in the subgroup of older adults, and whether established CKD risk factors mediate this association.

RESULTS

In the total sample of 93,885 adults (mean follow-up 3.9 years), low health literacy was more likely among individuals in worse eGFR categories, increasing from 26.4% in eGFR category 1 to 50.0% in category 5 (P=0.02). Low health literacy, compared with adequate health literacy, was associated with the onset of CKD in the total sample (3.0% versus 2.1%) and in the subgroup of older adults (13.4% versus 11.3%), with odds ratios (ORs) of 1.44 (95% confidence interval (95% CI), 1.31 to 1.59) and 1.21 (95% CI, 1.04 to 1.41), respectively. After adjustment for sex, age, education, and income, health literacy was associated with CKD onset only in older adults (OR, 1.25; 95% CI, 1.04 to 1.50). This association was mediated by hypertension and high body mass index (BMI) in the crude model, but only by BMI after adjustment (with BMI explaining 18.8% of the association).

CONCLUSIONS

Low health literacy is a risk factor for CKD onset among older adults, which suggests that CKD prevention might benefit from strategies to address low health literacy.

A Validation Study of the Korean Version of the Nurses' Patient Education Questionnaire

This study aimed to investigate the internal consistency reliability and construct validity of the Korean version of the Nurses’ Patient Education Questionnaire. An accurate assessment of nurses’ perceived patient education competency is required, and these needs assessment results can provide the evidence for designing a continuing education to empower and equip nurses with optimal competency for patient education. A cross-sectional study was used to which a convenience sample of 262 hemodialysis unit nurses in the Republic of Korea. In the exploratory factor analysis, the questionnaire consisted of 26 items belonging to seven factors: (1) nurse belief and knowledge; (2) documentation of patient education activities; (3) collegial teamwork; (4) educational environment; (5) interdisciplinary cooperation; (6) education foundation; and (7) health care organization, all of which accounted for 70.2% of the variance. The internal consistency reliability was 0.91 for the overall scale and each factor at 0.70 to 0.77. The questionnaire provides a valid and reliable instrument to assess nurses’ patient education competency.

Inpatient rehabilitation facility discharge destination among younger adults with traumatic brain injury: differences by race and ethnicity

OBJECTIVE

: To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care.

DESIGN

Secondary analysis using Uniform Data System for Medical Rehabilitation data.

METHODS

: Patients (N = 99,614) diagnosed with TBI, age 18-64, admitted for IRF care between 2002 and 2018. Logistic regression was used to analyze data.

OUTCOME

: Discharge destination (home/community vs. subacute settings).

RESULTS

: Most younger adults (age 18-64) with TBI were discharged home (89.24%) after IRF care vs. subacute (10.76%). Of those discharged home, 63.16% were white, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR = 1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR = 1.10; 95% CI: 1.00, 1.21] (vs. White) had higher odds of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. white). Predictors of discharge destination for groups stratified by race/ethnicity varied.

CONCLUSIONS

: Younger patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. white) were more likely to go home vs. subacute. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

Predictors of kidney function recovery among incident ESRD patients

Background

ESRD is considered an irreversible loss of renal function, yet some patients will recover kidney function sufficiently to come off dialysis. Potentially modifiable predictors of kidney recovery, such as dialysis prescription, have not been fully examined.

Methods

Retrospective cohort study using United States Renal Data System (USRDS) data to identify incident hemodialysis (HD) patients between 2012 and 2016, the first 4 years for which dialysis treatment data is available. The primary outcome was kidney recovery within 1 year of ESRD and HD initiation, defined by a specific recovery code and survival off dialysis for at least 30 days. Patient and treatment characteristics were compared between those that recovered versus those that remained dialysis-dependent. A time-dependent survival model was used to identify independent predictors of kidney recovery.

Results

During the study period, there were 372,387 incident HD patients with available data, among whom 16,930 (4.5%) recovered to dialysis-independence. Compared to non-recovery, a higher proportion of patients with kidney recovery were of white race, and non-Hispanic ethnicity. Both groups had a similar age distribution. Patients with an acute kidney injury diagnosis as primary cause of ESRD were most likely to recover, but the most common ESRD diagnosis among recovering patients was type 2 diabetes (29.8% of recovery cases). Higher eGFR and lower albumin at ESRD initiation were associated with increased likelihood of recovery. When examining HD ultrafiltration rate (UFR), each quintile above the first quintile was associated with a progressively lower likelihood of recovery (HR 0.45, 95% CI 0.43–0.48 for highest versus lowest quintile, p < 0.001).

Conclusions

We identified non-modifiable and potentially modifiable factors associated with kidney recovery which may assist clinicians in counseling and monitoring incident ESRD patients with a greater chance to gain dialysis-independence. Clinical trials are warranted to examine the impact of dialysis prescription on subsequent kidney function recovery.

The concept of justifiable healthcare and how big data can help us to achieve it

Over the last decades, the face of health care has changed dramatically, with big improvements in what is technically feasible. However, there are indicators that the current approach to evaluating evidence in health care is not holistic and hence in the long run, health care will not be sustainable. New conceptual and normative frameworks for the evaluation of health care need to be developed and investigated. The current paper presents a novel framework of justifiable health care and explores how the use of artificial intelligence and big data can contribute to achieving the goals of this framework.

Social Support, Sense of Coherence, and Self-Management among Hemodialysis Patients

Self-management is essential for patients who require regular hemodialysis treatment. This study aimed to explore the relationships between social support, sense of coherence (SOC), and self-management in hemodialysis patients and to examine whether SOC plays a mediating role. In a cross-sectional study, 402 hemodialysis patients from four tertiary hospitals were recruited. Data were analyzed using structural equation modeling. Social support, SOC, and self-management were significantly correlated with each other. The proposed model provided a good fit to the data. Social support had a direct effect on self-management and SOC, partially mediated the effect of social support on self-management (β = 0.248, p = 0.001). Social support and SOC explained 69% of the variance in self-management. Our findings indicate that health care providers can enhance social support with an emphasis on strengthening SOC strategies to better improve self-management in hemodialysis patients.

Health literacy impacts self-management, quality of life and fear of recurrence in head and neck cancer survivors

PURPOSE

Little is known about whether health literacy is associated with affects certain key outcomes in head and neck cancer (HNC) survivors. We investigated (i) the socio-demographic and clinical profile of health literacy and (ii) associations among between health literacy and self-management behaviours, health-related quality of life (HRQL) and fear of recurrence (FoR) in HNC survivors.

METHODS

A population-based survey was conducted in Ireland. Health literacy was assessed using a validated single-item question. Socio-demographic, clinical and psychosocial outcome variables (FoR, self-management behaviours, HRQL) were collected. Multivariable linear regression was performed to estimate associations between health literacy and each psychosocial outcome.

RESULTS

Three hundred ninety-five (50%) individuals responded to the survey. Inadequate health literacy was evident among 47% of the sample. In adjusted models, HNC survivors with inadequate health literacy had significantly lower levels of self-management behaviours in the domains of health-directed behaviour, positive and active engagement in life, self-monitoring and insight, constructive attitudes and approaches and skills and technique acquisition. Inadequate health literacy was independently associated with lower functional well-being and HNC disease-specific HRQL. FoR was also significantly higher among those with inadequate health literacy.

CONCLUSIONS

HNC survivors with inadequate health literacy have lower levels of self-management behaviours, lower functional HRQL and increased FoR compared to those with adequate health literacy.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians, healthcare providers and those developing interventions should consider how inadequate health literacy among HNC survivors might affect post-treatment outcomes when developing services and providing support for this group.

Health literacy, preventive COVID 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban Jodhpur, Rajasthan

BACKGROUND AND AIMS

Potential role of health literacy in determining adherence to COVID-19 preventive behavior, pharmacological, and lifestyle management among diagnosed patients of chronic diseases during nationwide lockdown is inadequately investigated.

METHODS

A cross-sectional study was conducted from May-August 2020 among diagnosed patients of chronic diseases residing in a COVID-19 hotspot of urban Jodhpur, Rajasthan, and availing health services from primary care facility. Telephonic interviews of participants were conducted to determine their health literacy using HLS-EU-Q47 questionnaire, adherence to COVID-19 preventive behaviour as per World Health Organization recommendations, and compliance to prescribed pharmacological and physical activity recommendations for chronic disease.

RESULTS

All the 605 diagnosed patients of chronic diseases availing services from primary care facility were contacted for the study, yielding response rate of 68% with 412 agreeing to participate. Insufficient health literacy was observed for 65.8% participants. Only about half of participants had scored above median for COVID-19 awareness (55.1%) and preventive behavior (45.1%). Health literacy was observed to be significant predictor of COVID-19 awareness [aOR: 3.53 (95% CI: 1.81-6.88)]; COVID-19 preventive behavior [aOR: 2.06, 95%CI; 1.14-3.69] and compliance to pharmacological management [aOR: 3.05; 95% CI: 1.47-6.35] but not for physical activity.

CONCLUSION

COVID-19 awareness, preventive behavior, and compliance to pharmacological management is associated with health literacy among patients of chronic disease availing services from primary health facility. Focusing on health literacy could thus be an essential strategic intervention yielding long term benefits.

How to tackle health literacy problems in chronic kidney disease patients? A systematic review to identify promising intervention targets and strategies

BACKGROUND

Limited health literacy (LHL) is associated with multiple adverse health outcomes in chronic kidney disease (CKD). Interventions are needed to improve this situation, but evidence on intervention targets and strategies is lacking. This systematic review aims to identify potential targets and strategies by summarizing the evidence on: (i) patient- and system-level factors potentially mediating the relation between LHL and health outcomes; and (ii) the effectiveness of health literacy interventions customized to CKD patients.

METHODS

We performed a systematic review of peer-reviewed research articles in Medline, Embase and Web of Science, 2009-19. We assessed the quality of the studies and conducted a best-evidence synthesis.

RESULTS

We identified 860 publications and included 48 studies. Most studies were of low quality (n = 26) and focused on dialysis and transplantation (n = 38). We found strong evidence for an association of LHL with smoking and having a suboptimal transplantation process. Evidence was weak for associations between LHL and a variety of factors related to self-care management (n = 25), utilization of care (n = 23), patient-provider interaction (n = 8) and social context (n = 5). Six interventions were aimed at improving knowledge, decision-making and health behaviours, but evidence for their effectiveness was weak.

CONCLUSIONS

Study heterogeneity, low quality and focus on kidney failure largely impede the identification of intervention targets and strategies for LHL. More and higher quality studies in earlier CKD stages are needed to unravel how LHL leads to worse health outcomes, and to identify targets and strategies to prevent disease deterioration. Healthcare organizations need to develop and evaluate efforts to support LHL patients.

Predialysis Care Trajectories of Patients With ESKD Starting Dialysis in Emergency in France

Introduction

Emergency dialysis start (EDS) is frequent for patients with chronic kidney disease (CKD). To improve CKD management, new trajectory-based care policies are currently being introduced both in France and in the United States. This study describes the different types of predialysis care trajectories and factors associated with EDS.

Methods

Adults patients who started dialysis in France in 2015 were included. Individual clinical and health care consumption data were retrieved from the French national end-stage kidney disease (ESKD) registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Hierarchical Clustering on Principal Component was used to identify groups of patients with the same health care consumption profile during the 2 years before dialysis start. Logistic regression analysis was used to identify factors associated with EDS.

Results

Among the 8856 patients included in the analysis, 2681 (30.3%) had EDS. The Hierarchical Clustering on Principal Component identified six types of predialysis care trajectories in which EDS rate ranged from 13.8% to 61.8%. After adjustment for the patients’ characteristics, less frequent or lack of follow-up with a nephrologist was associated with higher risk of EDS (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.17–1.50 and OR: 1.83; 95% CI: 1.58–2.12), but not follow-up with a general practitioner.

Conclusions

The care trajectories during the 2 years before dialysis start were heterogeneous and patients with a lesser or lack of follow-up with a nephrologist were more likely to start dialysis in emergency, regardless of the frequency of follow-up by a general practitioner (GP). New CKD policies should include actions to strengthen CKD screening and referral to nephrologists.

Comparison of health literacy profile of patients with end-stage kidney disease on dialysis versus non-dialysis chronic kidney disease and the influencing factors: a cross-sectional study

OBJECTIVES

Lower health literacy (HL) is associated with poor outcomes in patients with kidney disease. Since HL matches the patient's competencies with the complexities of the care package, the level of HL sufficient in earlier stages of chronic kidney disease (CKD) may be inadequate for patients with end-stage kidney disease (ESKD) on dialysis. We aimed to analyse the HL profile of patients with ESKD and non-dialysis CKD and examine if there were significant associations with covariates which could be targeted to address HL deficits, thereby improving patient outcomes.

DESIGN AND SETTING

Cross-sectional study of patients with CKD and ESKD from a single Australian health district.

METHODS

We assessed the HL profile of 114 patients with CKD and 109 patients with ESKD using a 44-item multidomain Health Literacy Questionnaire (HLQ) and examined its association with demographic factors (age, gender, race), smoking, income, education, comorbidities, carer status, cognitive function and depression. Using multivariable logistic regression models, HL profiles of patients with CKD and ESKD were evaluated after adjusting for covariates.

RESULTS

Patients with ESKD had similar demographics and educational levels compared with patients with CKD. ESKD had significantly higher frequency of vascular disease, cognitive impairment and depression. Patients with ESKD had better HL scores for the social support domain (37.1% vs 19.5% in higher HLQ4 tertile, p=0.004), whereas all other HL domains including engagement with healthcare providers were comparable to CKD. Depression was independently associated with nearly all of the HL domains (HLQ1: OR 2.6, p=0.030; HLQ2: OR 7.9, p=<0.001; HLQ3: OR 7.6, p<0.001; HLQ4: OR 3.5, p=0.010; HLQ5: OR 8.9, p=0.001; HLQ6: OR 3.9, p=0.002; HLQ7: OR 4.8, p=0.001; HLQ8: OR 5.3, p=0.001) and education with HL domains relevant to processing health-related information (HLQ8: OR 2.6, p=0.008; HLQ9: OR 2.5, p=0.006).

CONCLUSIONS

Despite very frequent interactions with health systems, patients with ESKD on dialysis did not have higher HL in engagement with health providers and most other HL domains, compared with patients with CKD. Strategies promoting patient-provider engagement and managing depression which strongly associates with lower HL may address the impact of HL deficits and favourably modify clinical outcomes in renal patients.

Does Depression and Anxiety Mediate the Relation between Limited Health Literacy and Diet Non-Adherence?

Limited health literacy (HL), depression and anxiety are common in dialyzed patients and affect health outcomes and self-management. We explored whether depression and anxiety mediate the association of HL with diet non-adherence (DN-A) in dialyzed patients. We performed a cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; mean age: 63.6 years; males: 60.7%). Hierarchical cluster analysis was performed to create three HL groups. Logistic regression adjusted for age, gender and education was used to explore whether depression and anxiety mediate the association of HL with DN-A. Patients in the moderate HL group were more likely to be non-adherent to diet (OR (Odds Ratio)/95% CI: 2.19/1.21-3.99) than patients in the high HL group. Patients in the low HL and moderate HL group more likely reported depression or anxiety. Patients reporting depression (OR/95% CI: 1.94/1.26-2.98) or anxiety (OR/95% CI: 1.81/1.22-2.69) were more likely to be non-adherent with diet. Adjustment for depression reduced the association between moderate HL and DN-A by 19.5%. Adjustment for anxiety reduced the association between moderate HL and DN-A by 11.8%. Anxiety and depression partly mediated the association of HL with DN-A. More attention should be paid to treating patients' psychological distress to ensure adequate adherence with recommended diet.

Fact-finding survey on health literacy among Japanese predialysis chronic kidney disease patients: a multi-institutional cross-sectional study

BACKGROUND

Low health literacy (HL) has been associated with poor chronic disease management and adverse outcomes. However, reports on HL in predialysis chronic kidney disease (CKD) patients are limited in Japan.

METHODS

From August 2019 to February 2020, the European Health Literacy Survey (Japanese version) and a patient background survey (highest level of education, income, social activities, and exercise habit) were conducted on adult predialysis CKD patients. We compared clinical parameters in two groups according to the average HL score of a healthy Japanese population. In addition, a median value of 42 items was used as a cutoff for extracting CKD patient background factors associated with HL since HLS-EU-Q47 included five items related to physical activity and exercise.

RESULTS

Valid responses were received from 200 patients. Median general HL index was 25.2 points. The high-HL group (≥ 25.3 points) showed a low proportion of male (56.7% vs. 70.9%, p = 0.038), high social activities (69.1% vs. 48.5%, p = 0.003), and high exercise habit (36.1% vs. 13.6%, p < 0.001). In the multivariate analysis, social activity [OR (95% CI); 2.12 (1.16-3.89), p = 0.015] and exercise habit [OR (95% CI); 2.39 (1.16-4.90), p = 0.018] were extracted as the only significant variable.

CONCLUSIONS

HL in Japanese predialysis CKD patients was associated with high social activity and exercise habit.

Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review

Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.