Health Literacy in Older Latinos With Heart Failure: A Systematic Review

Concept analysis of "Insufficient health literacy" in older adults and refinement of a diagnosis proposal

PURPOSE

This study aims to conduct a thorough analysis of the concept of insufficient health literacy (IHL) in older adults and to refine a nursing diagnosis proposal while considering the specific characteristics of this demographic.

METHODS

A comprehensive concept analysis was undertaken using Walker & Avant's method as a framework.

FINDINGS

A systematic search across seventeen databases yielded 29 relevant studies for inclusion. Through analysis, we identified 15 antecedents, 3 attributes, and 7 consequents associated with IHL in older adults.

CONCLUSIONS

The concept analysis brought clarity to the understanding of IHL within older adults, facilitating the refinement of a diagnosis proposal. This process was instrumental in establishing a diagnostic structure that accounts for the unique needs and challenges faced by older adults.

IMPLICATIONS FOR NURSING PRACTICE

The structured diagnosis derived from the concept analysis provides a solid theoretical foundation for nurses specializing in Gerontology. By tailoring care interventions to address the specific requirements of older adults, this framework enhances the quality of nursing practice and contributes to improved patient outcomes in geriatric care settings.

The Situation-Specific Theory of Heart Failure Self-care: An Update on the Problem, Person, and Environmental Factors Influencing Heart Failure Self-care

Many studies of heart failure (HF) self-care have been conducted since the last update of the situation-specific theory of HF self-care.

OBJECTIVE

The aim of this study was to describe the manner in which characteristics of the problem, person, and environment interact to influence decisions about self-care made by adults with chronic HF.

METHODS

This study is a theoretical update. Literature on the influence of the problem, person, and environment on HF self-care is summarized.

RESULTS

Consistent with naturalistic decision making, the interaction of the problem, person, and environment creates a situation in which a self-care decision is needed. Problem factors influencing decisions about HF self-care include specific conditions such as cognitive impairment, diabetes mellitus, sleep disorders, depression, and symptoms. Comorbid conditions make HF self-care difficult for a variety of reasons. Person factors influencing HF self-care include age, knowledge, skill, health literacy, attitudes, perceived control, values, social norms, cultural beliefs, habits, motivation, activation, self-efficacy, and coping. Environmental factors include weather, crime, violence, access to the Internet, the built environment, social support, and public policy.

CONCLUSIONS

A robust body of knowledge has accumulated on the person-related factors influencing HF self-care. More research on the contribution of problem-related factors to HF self-care is needed because very few people have only HF and no other chronic conditions. The research on environment-related factors is particularly sparse. Seven new propositions are included in this update. We strongly encourage investigators to consider the interactions of problem, person, and environmental factors affecting self-care decisions in future studies.

The importance of health literacy for self-management: A scoping review of reviews

OBJECTIVES

Self-management of chronic diseases is rather complex, especially for patients with limited health literacy. In this review, we aim to disentangle the specific difficulties patients with limited health literacy face in relation to self-management and their associated needs with respect to self-management support.

METHODS

We performed a literature search in five databases. We used a broad definition of health literacy and self-management was categorized into four types of activities: medical management, changing lifestyle, communicating and navigating through the health care system and coping. Included reviews described the relationship between health literacy and different domains of self-management and were published after 2010.

RESULTS

A total of 28 reviews were included. Some clear difficulties of patients with limited health literacy emerged, predominantly in the area of medical management (especially adherence), communication and knowledge. Other associations between health literacy and self-management were inconclusive. Barriers from the patients' perspective described mainly medical management and the communication and navigation of the health care system.

DISCUSSION

Patients with limited health literacy experience difficulties with specific domains of self-management. For a better understanding of the relationship between health literacy and self-management, a broader conceptualization of health literacy is warranted, including both cognitive and behavioural aspects.

Challenges Facing Heart Failure Patients With Limited English Proficiency: A Qualitative Analysis Leveraging Interpreters' Perspectives

BACKGROUND

Limited English proficiency (LEP) heart failure (HF) patients experience worse HF outcomes, including higher readmission rates and emergency department visits. To elucidate the challenges this population faces, the authors interviewed interpreters to identify gaps in care quality and ways to improve care for LEP HF patients.

OBJECTIVES

The authors sought to understand the challenges facing HF patients with LEP using medical interpreters' perspectives.

METHODS

The authors conducted a qualitative study using semistructured interviews with interpreters working at an academic medical center. All interpreters employed by the medical center were eligible to participate. Interviews were analyzed using thematic analysis.

RESULTS

The authors interviewed 20 interpreters from 9 languages (mean age: 48 ± 14.3 years; mean experience: 16.3 ± 10.6 years). Two themes regarding the challenges of care delivery to LEP HF patients emerged: 1) LEP patients often had a limited understanding of HF etiology, prognosis, and treatment options, and interpreters cited difficulty explaining HF given the complexity of the subject; and 2) practical steps to improve the discharge process for LEP HF patients. Integrating interpreters into both the inpatient and outpatient HF teams was a strongly supported intervention. Additionally, conducting pre-encounter huddles, providing the interpreter service phone number at the time of discharge, involving family members when appropriate, and considering nutrition referrals were all important steps highlighted by interpreters.

CONCLUSIONS

This study illuminates challenges that LEP HF patients face and provides potential solutions to improve care for this vulnerable group. Integrating interpreters as part of the HF team and designing practical discharge plans for LEP HF patients could reduce current disparities.

Health Literacy and Outcomes Among Patients With Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this study was to determine if health literacy is associated with mortality, hospitalizations, or emergency department (ED) visits among patients living with heart failure (HF).

BACKGROUND

Growing evidence suggests an association between health literacy and health-related outcomes in patients with HF.

METHODS

We searched Embase, MEDLINE, PsycINFO, and EBSCO CINAHL from inception through January 1, 2019, with the help of a medical librarian. Eligible studies evaluated health literacy among patients with HF and assessed mortality, hospitalizations, and ED visits for all causes with no exclusion by time, geography, or language. Two reviewers independently selected studies, extracted data, and assessed the methodological quality of the identified studies.

RESULTS

We included 15 studies, 11 with an overall high methodological quality. Among the observational studies, an average of 24% of patients had inadequate or marginal health literacy. Inadequate health literacy was associated with higher unadjusted risk for mortality (risk ratio [RR]: 1.67; 95% confidence interval [CI]: 1.18 to 2.36), hospitalizations (RR: 1.19; 95% CI: 1.09 to 1.29), and ED visits (RR: 1.17; 95% CI: 1.03 to 1.32). When the adjusted measurements were combined, inadequate health literacy remained statistically associated with mortality (RR: 1.41; 95% CI: 1.06 to 1.88) and hospitalizations (RR: 1.12; 95% CI: 1.01 to 1.25). Among the 4 interventional studies, 2 effectively improved outcomes among patients with inadequate health literacy.

CONCLUSIONS

In this study, the estimated prevalence of inadequate health literacy was high, and inadequate health literacy was associated with increased risk of death and hospitalizations. These findings have important clinical and public health implications and warrant measurement of health literacy and deployment of interventions to improve outcomes.

The role of health literacy, depression, disease knowledge, and self-efficacy in self-care among adults with heart failure: An updated model

BACKGROUND

Patients with inadequate health literacy and heart failure face high healthcare costs, more hospitalizations, and greater mortality. To address these negative consequences, patients need to improve heart failure self-care. Multiple factors may influence self-care, but the exact model by which they do so is not fully understood.

OBJECTIVES

The objective of this study was to examine a model exploring the contribution of health literacy, depression, disease knowledge, and self-efficacy to the performance of heart failure self-care.

METHODS

Using a cross-sectional design, patients were recruited from a heart failure clinic and completed validated assessments of their cognition, health literacy, depression, knowledge, self-efficacy and self-care. Patients were separated into two groups according to their health literacy level: inadequate/marginal and adequate. Differences between groups were assessed with an independent t-test. Hypothesized paths and mediated relationships were estimated and tested using observed variable path analysis.

RESULTS

Participants (n = 100) were mainly male (67%), white (93%), and at least had a high school education (85%). Health literacy was associated with disease knowledge (path coefficient=0.346, p = 0.002), depression was negatively associated with self-efficacy (path coefficient=-0.211, p = 0.037), self-efficacy was positively associated with self-care (path coefficient=0.402, p<0.0005), and there was evidence that self-efficacy mediated the link between depression and self-care. There was no evidence of: mediation of the link between health literacy and self-care by knowledge or self-efficacy; positive associations between knowledge and self-efficacy or self-care; or mediation of the disease knowledge and self-care relationship by self-efficacy. Further, depression was associated with self-care indirectly rather than also directly as hypothesized.

CONCLUSIONS

Self-efficacy and depression are associated with heart failure self-care. Data generated from the model suggest that healthcare professionals should actively engage all patients to gain self-efficacy and address depression to positively affect heart failure self-care.

Gender Differences in the Associations Between Health Literacy and Medication Adherence in Hypertension: A Population-Based Survey in Heris County, Iran

Objective

We examined the gender-based associations of health literacy (HL) with self-reported medication adherence (MEDA) among patients with primary hypertension (pHTN).

Patients and Methods

The subjects were recruited from the general population through all health centers of the Heris county, east Azarbaijan. They were to be adults (30+ years age), with pHTN of any stage, of any gender, and without comorbid illness. All underwent detailed face-to-face interview. We used valid questionnaires for HL and MEDA. Hierarchical regression was done to establish the association between MEDA, socio-demographic variables, and nine HL domains by gender. Other statistical procedures were also done.

Results

A total of 300 (48.6% males, mean age: 56.7±9.3) subjects participated; 43.0% were uneducated, 73.0% had moderate socioeconomic status, 68.0% had poor HL, and 7.0% maintained high adherence. Men were better in reading skills (p=0.002), and accessing (p=0.01) and using (p=0.02) health information, but women were better in health knowledge (p=0.004). The average regression estimate (±standard deviation) between HL and MEDA was 0.37±0.09, lower among men (0.361±0.11) than women (0.396±0.08), p=0.003. Upon hierarchical regression, the association between HL and MEDA was significant for communication and decision-making skills alone among both men (34.5%) and women (40.6%), individually.

Conclusion

HL had substantial association with MEDA among those with HTN, for both men and women, particularly the communication and decision-making. With considerations on gender differences, this association should be confirmed through interventional studies to help make HL a formal mitigating strategy for MEDA and other public health goals.

Literacy critical to heart failure management: a scoping review

Heart failure is a complex clinical syndrome most commonly encountered among older adults. This complex clinical syndrome is associated with poor health outcomes such as frequent admissions and mortality. These adverse outcomes are commonly associated with poor self-care and lower health literacy. Literacy is a combination of knowledge and skills and often reflected by appropriate interaction with the community, while health literacy is the cognitive and social skills reflected by accessing and comprehending health information and making appropriate health decisions. These decisions are common and challenging to patients with heart failure. Poor outcomes are said to be reduced by adequate self-care, which is associated with health literacy among heart failure patients. Better self-care was also shown to be associated with self-efficacy and self-confidence that were in turn associated with health literacy. Hence, enhancing health literacy among patient with heart failure is critical to enable them to increase control over their disease by better understanding and participating in health care, while being empowered to take part in designing health care services and even tailoring research to serve their needs and consequently improve outcome at the individual and community level. In clinical practice, assessing health literacy, measuring health literacy, and identifying patients at risk of low nutrition literacy is important to enhance health literacy and health outcomes. Hence, developing reliable and valid methods and tools for assessment and developing tailored and targeted interventions is of critical importance.

The relationship between health literacy and perceived shared decision making in patients with breast cancer

OBJECTIVES

We explored the relationship between patient-perceived shared decision making (SDM) and three domains of health literacy (HL) in patients with breast cancer.

METHODS

In this cross-sectional study, we prospectively recruited a convenience sample of 511 breast cancer patients from 3 hospitals in Taiwan. Patients completed questionnaires about HL and perceived SDM in a recent consultation. Sequential regressions, controlling for International Classification of Functioning, Disability and Health (ICF)-related factors) were conducted. Interactions of each HL domain with age or education were also assessed for the relationship with perceived SDM.

RESULTS

Higher scores in the HL domains of healthcare and disease prevention, but lower scores in the health promotion domain, were significantly associated with a higher perceived level of SDM after controlling for ICF-related factors (R² = 33.44%). The association of SDM with two domains of HL varied with age, while the relationship between the 3 HL domains and SDM differed across education levels.

CONCLUSION

Each HL domain was significantly associated with perceived SDM after controlling for the ICF-related factors and across different age- and education-stratifications.

PRACTICE IMPLICATIONS

Clinicians should be cognizant of patients' HL levels and incorporate HL best practices into consultations and interactions with patients with breast cancer to facilitate SDM.

Health literacy and health outcomes in hypertension: An integrative review

OBJECTIVE

The aim of this study was to summarize the evidence of health literacy and health outcomes in hypertensive patients.

METHODS

Articles published in English were searched from six databases: MEDLINE, CINAHL, Embase, ERIC, psycINFO, and SCOPUS. The articles published up to September 2017 were included.

RESULTS

Nineteen publications were included in the review. There was quality and consistent evidence that hypertensive patients with lower literacy had poorer knowledge. There was inconsistent evidence to show the relationship between health literacy and clinical outcomes, of systolic and diastolic blood pressure, and blood pressure control; behavioral outcomes, of self-care, self-efficacy, adherence; patient-physician interactions outcomes, of patient-physician communication, patient trust, involvement in decision making and other outcomes.

CONCLUSION

The person with low health literacy is likely to have poor knowledge of hypertension. However, there is insufficient evidence to suggest that health literacy is associated with outcomes of hypertension independently.

A Cardiovascular Health Intervention for Spanish Speakers: The Health Literacy and ESL Curriculum

Spanish speakers in the United States are in need of effective interventions that address both cardiovascular disease (CVD) and health literacy. However, the literature lacks interventions that have used and evaluated a strategies that focus on both, particularly at the community level. The aim of this study was to explore the effect of a health literacy curriculum on cardiovascular health behavior among Spanish speaking adults. It used a randomized controlled pre-posttest design. Participants included Hispanic adults with a low-to-intermediate level of English proficiency. The intervention group received the health literacy and English as a second language (ESL) Curriculum with CVD specific content, while the control group received a conventional ESL curriculum. Tools included the Spanish Cardiovascular Health Questionnaire (CSC), the test of functional health literacy in adults (TOFHLA), and the Combined English Language Skills Assessment. Analysis of change scores included independent sample t test and multiple linear regression. A total of 155 participants completed the study. There was a significant greater improvement for the intervention group in change of CSC score from pretest to posttest (P = 0.049) compared to controls. The study also found significantly improved TOFHLA (P = 0.011), however it did not find a relationship between changes in CVD behavior and health literacy or English proficiency. The Health Literacy and ESL Curriculum constitutes a valuable resource for addressing the cardiovascular health, literacy, and language needs of Spanish-speaking adults. Interventions that take a multilevel education and health approach may be more effective in addressing the needs of immigrants. Research should further explore the interactions between CVD behavior, health literacy, and English proficiency.

Factors Related to Self-Care in Heart Failure Patients According to the Middle-Range Theory of Self-Care of Chronic Illness: a Literature Update

Purpose of the Review

As described in the theory of self-care in chronic illness, there is a wide range of factors that can influence self-care behavior. The purpose of this paper is to summarize the recent heart failure literature on these related factors in order to provide an overview on which factors might be suitable to be considered to make self-care interventions more successful.

Recent Findings

Recent studies in heart failure patients confirm that factors described in the theory of self-care of chronic illness are relevant for heart failure patients.

Summary

Experiences and skills, motivation, habits, cultural beliefs and values, functional and cognitive abilities, confidence, and support and access to care are all important to consider when developing or improving interventions for patients with heart failure and their families. Additional personal and contextual factors that might influence self-care need to be explored and included in future studies and theory development efforts.