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

Barriers to Engagement with Gastrointestinal Health Management

BACKGROUND

Although behavioral interventions have been effective in gastrointestinal (GI) conditions, barriers exist in implementing these interventions into clinical practice. The majority of previously published studies have focused on workforce limitations and have not considered individual and social determinants of health (SDoH) factors that can impact engagement in GI behavioral healthcare.

AIMS

To characterize barriers to engagement in appointment attendance and health management, explore individual and SDoH factors impacting GI behavioral healthcare engagement, and identify barriers that occur more often for patients with SDoH-related vulnerability (low health literacy and/or financial insecurity).

METHODS

A survey was distributed to adult patients who had been seen in Gastroenterology at the Dartmouth-Hitchcock Medical Center from June 2022 to December 2022.

RESULTS

One hundred participants [mean age = 58 years, 57.1% women] completed the survey. SDoH vulnerability was present in 32.3% of the population. For the entire sample, 73% reported at least one barrier to accessing care and 75% reported at least one factor which impacted health management. Those with SDoH vulnerability reported significantly more barriers to attending appointments and to managing health. In addition, they were significantly more likely to endorse physical health problems, difficulty affording medical bills, pain, mobility issues, trauma experiences, significant stress, and difficulty with concentration.

CONCLUSIONS

Patients in a GI clinic reported multiple barriers to accessing care and participating in health management. Innovative, multi-level strategies are needed to address barriers to ensure that all patients are able to obtain quality GI behavioral health services.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Concordance and Discordance Between Patient-reported Remission, Patient-reported Outcomes, and Physician Global Assessment

BACKGROUND

Although validated patient-reported outcome (PRO) measurements can categorize patients with inflammatory bowel disease (IBD) into clinical remission or active disease, patients may have different definitions of remission. The purpose of this study was to compare patient-defined remission to remission based on PRO measures and physician global assessment (PGA) and to understand the clinical and demographic factors associated with disagreements.

METHODS

We retrospectively analyzed 3257 de-identified surveys from 2004 IBD patients who consented to participate in the Crohn's and Colitis Foundation's IBD Qorus Learning Health System between September 2019 and February 2021. We used logistic regression models with generalized estimating equations to analyze the clinical and demographic factors (eg, age, disease duration, health confidence) associated with discordance between patient-defined remission (yes/no) and PRO-defined remission for ulcerative colitis (UC; PRO2: stool frequency, rectal bleeding) and Crohn's disease (CD; PRO-3: average number of liquid stools, abdominal pain, well-being).

RESULTS

Among patients with UC, overall concordance was 79% between patient self-report and PRO2-defined remission and 49% between patient self-report and PGA-defined remission. Among patients with CD, overall concordance was 69% between patient self-report and PRO3-defined remission and 54% between patient self-report and PGA-defined remission. Patients in PRO-defined remission were more likely to report active disease if they had IBD <5 years and low health confidence. Patients with PRO-defined active disease were more likely to report remission if they were not using prednisone and had high health confidence.

CONCLUSION

Discordance exists between how remission is defined by patients, PRO measures, and PGA.

Management of Sleep and Fatigue in Gastrointestinal Patients

Sleep is an essential physiologic process, and unfortunately, people with gastrointestinal (GI) conditions are more likely than people in the general population to experience poor sleep quality, sleep disorders, and fatigue. Herein, we present information on common sleep disorders, fatigue, and data on these problems in various GI populations. We also discuss several treatments for sleep concerns and emerging research on the use of these treatments in GI populations. Cases that illustrate the GI/sleep relationship are presented, in addition to guidance for your own practice and cultural considerations.

Development of inflammatory bowel disease patient education and medical information sheets: serving an unmet need

Inflammatory bowel disease is a chronic gastrointestinal condition that necessitates life‐long healthcare engagement and management. Empowering patients with knowledge is fundamental to enhance health literacy, improve health outcomes and facilitate complex decision‐making regarding medication and potential surgery. A working group was formed to develop concise, comprehensive patient information sheets to meet this unmet need in the Australian setting.

Effects of ethnicity and socioeconomic status on surgical outcomes from inflammatory bowel disease

PURPOSE

Evidence suggests that ethnicity and socioeconomic status of patients with chronic diseases influence their healthcare outcomes. The aim of this study was to assess the impact of these factors on the surgical outcome of patients with inflammatory bowel disease (IBD) over a 15-year period.

METHODS

A retrospective observational study investigated IBD patients operated on at an NHS Trust between 2000-2015, with follow-up data until 2020. Logistic regression models were used to determine the relationship between ethnic minority background and Index of Multiple Deprivation (IMD) on outcomes including requirement for intra-abdominal surgery, permanent stoma, re-do surgery and surgical complications, accounting for age, gender, smoking history and biologic treatment.

RESULTS

There were 1,620 patients (56.7% ulcerative colitis (UC) and 43.3% Crohn's disease (CD)). Median age was 32 years, and 49.6% were female. Patients with an ethnic minority background accounted for 20.6%. Within 5 years of first presentation, 369 patients required intra-abdominal surgery, 95 permanent stomas and 107 re-do surgery. For CD patients, younger age at diagnosis, female patients, those with an ethnic minority background, higher IMD quintile, smoking history and biologic treatment were more likely to have intra-abdominal surgery. Ethnic minority background and higher IMD score were further associated with surgical complications for CD but not UC patients.

CONCLUSION

Ethnic minority status and socioeconomic deprivation were associated with worse surgical outcomes within our cohort of IBD patients. These findings may stimulate discourse regarding the strategic planning of equitable healthcare services.

Health Care Perspectives of Adult Patients with Lower Educational Attainment in Inflammatory Bowel Disease: A Qualitative Study

Patients with lower educational attainment are underrepresented in inflammatory bowel disease (IBD) research. To increase our understanding of the health care perspectives of patients with less than a university degree, semi-structured interviews were conducted among 23 outpatients at the McGill University Health Centre IBD Centre (Montreal, Canada). Thematic analysis was used to analyze the qualitative data. Perspectives focused on communication with health care professionals, access to care, symptoms and treatment, and outside support. Access to an IBD specialist was the most important aspect of care. Good care, kind and receptive staff, and a lengthy delay to diagnosis were frequently reported experiences. IBD specialists, nurses, and family and friends were most helpful in managing disease. Physical and emotional symptoms, reduced social engagement, and medications were difficult aspects of living with IBD. An ideal IBD clinic would provide access to traditional and non-traditional services and assist with obtaining support to help patients engage in social activities, increase affordability of care, and maintain employment. Study findings may be helpful in designing equitable models of health care delivery.

The Process of Developing a Disease Activity Index in Microscopic Colitis

BACKGROUND AND AIMS

Patient-reported outcome measures [PROMs] aim to measure patients' perception of how their disorder influences everyday functioning. The objective of this study was to develop a PROM to assess disease activity in microscopic colitis [MC] fulfilling the requirements of the Food and Drug Administration [FDA].

METHODS

The European Microscopic Colitis Activity Index [E-MCAI] was developed in four steps. [1] A list of symptoms associated with active MC was created by a group of experts in the field. [2] Content validity of the symptoms was performed by experts [n = 14] and patients [n = 79] using the Content Validity Index. [3] Questions and response alternatives were created for each symptom, and validity of the E-MCAI was evaluated with cognitive interviews with patients [n = 7] and by the experts. [4] A pilot postal survey was performed to ensure usability.

RESULTS

Seven of the symptoms related to active MC fulfilled the criteria for content validity and were included in the E-MCAI: stool consistency, stool frequency, stools at night, feel a need to pass more stools shortly after a bowel movement, urgent need to empty the bowel, leakage of stool and abdominal pain. The development and validation process resulted in the current version of the E-MCAI consisting of six questions related to MC.

CONCLUSIONS

The E-MCAI was developed using the methods advocated by the FDA. The evaluation indicates good content validity. Further evaluation will be performed to achieve construct validity, reliability and responsiveness in future cross-sectional and longitudinal studies.

Understanding the surgical experience for Black and White patients with inflammatory bowel disease (IBD): The importance of health literacy

BACKGROUND

Racial/ethnic disparities in outcomes exist for patients with inflammatory bowel disease (IBD) undergoing surgery. The underlying mechanism(s) remain unclear and patient perspectives are needed. We therefore aimed to characterize the surgical experience for Black and White IBD patients using qualitative methods.

METHODS

Patients with IBD who had undergone surgery were recruited to same-race qualitative interviews. Semi-structured interviews explored barriers and facilitators to a positive or negative surgical experience. Transcripts were analyzed with NVivo 12 software.

RESULTS

Six focus groups were conducted that included 10 Black and 17 White IBD participants. The mean age was 44.8 years (SD 13.2), 52% were male and 65% had Crohn's disease. Four themes emerged that most defined the surgical experience: the impact of the IBD diagnosis, the quality of provided information, disease management and the surgery itself. Within these themes, barriers to a positive surgical experience included inadequate personal knowledge of IBD, ineffective written and verbal communication, lack of a support system and complications after surgery. Both groups reported that information was provided inconsistently which led to unclear expectations of surgical outcomes.

CONCLUSIONS

Black and White patients with IBD have varied surgical experiences but all stressed the importance of accurate, trustworthy and understandable health information. These findings highlight the value of providing health literacy-sensitive care in surgery.

Knowledge of 5-aminosalicylic acid nephrotoxicity and adherence to kidney function monitoring of patients with inflammatory bowel disease

BACKGROUND AND AIM

5-Aminosalicylic acid (5-ASA) nephrotoxicity is a rare and idiosyncratic condition in patients with inflammatory bowel disease (IBD), which may lead to end-stage kidney failure. Kidney function monitoring is recommended in clinical practice to prevent this complication. However, no data is available regarding the knowledge and adherence of patients with IBD to this monitoring.

METHODS

As a part of routine practice, patients with IBD under treatment or previously treated with 5-ASA were systematically interviewed about knowledge of 5-ASA nephrotoxicity and adherence to kidney function monitoring. We reported here the experience among the first 103 consecutive patients seen in a French referral center.

RESULTS

A total of 103 patients (93.2% ulcerative colitis, 5.8% Crohn's disease, and 1% unclassified colitis) were analyzed. Among them, 70% were informed about the need for kidney function monitoring, and in most cases, information was provided by their gastroenterologist (94.4%). The adherence rate to monitoring was very high (84.7%). Monitoring consisted of serum creatinine and estimated glomerular filtration rate in most cases (97.2%), while 24-h proteinuria was less frequently used (69.4%). These tests were performed twice or ≥3 times per year by 44.4 and 41.7% of patients, respectively. One case of isolated elevation of proteinuria related to 5-ASA treatment was observed.

CONCLUSION

We reported for the first time that patients with IBD are well informed and adherent to kidney function monitoring of treatment with 5-ASA. The monitoring performed by their treating physician was generally in accordance with current recommendations.

Health Literacy in Multiple Sclerosis patients: A Concept Analysis Using the Evolutionary Method

Introduction: Health literacy is one of the effective factors in health promotion of chronic patients. However, little attention has been paid to it; no exact and clear definition of health literacy has ever been accessible in chronic diseases. This study was conducted with aim of defining and clarifying attributes, antecedents, and consequences of health literacy in multiple sclerosis (MS) patients.

Methods: Rodgers’ evolutionary method of concept analysis was used to clarify the concept of health literacy in MS patients. A literature review was conducted with key terms "multiple sclerosis", "health literacy", "information literacy", "functional health", "health education", "health promotion" and "health behavior". Eight hundred and sixty papers for the period 1980– 2019 were found and finally 23 articles and texts were selected for the analysis. Data analysis was carried out using a thematic analysis.

Results: Health literacy in MS patients is a multidimensional concept with forth attributes: health information evaluation, understand disease and its related issues, reading skills and capacity to use knowledge. Ability to read and comprehend, interacting with health personnel, and interacting with peers as an antecedents and improved self-care, health promotion, medication adherence, and decreased use of health care services to be the consequences of these attributes were found.

Conclusion: The findings can add knowledge about the concept of health literacy in MS patients. Also, health care professionals can use a deeper understanding of the concept of health literacy in providing care plan for MS patients.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans

BACKGROUND

Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy.

METHODS

Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses.

RESULTS

Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels.

CONCLUSIONS

Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Comment on: Low Health Literacy Exists in the Inflammatory Bowel Disease Population and Is Disproportionately Prevalent in Older African Americans

Dos Santos Margues and colleagues found that African Americans with IBD may have more difficulty with understanding and making decisions about health information. We discuss their work and give suggestions on how to create a supportive clinic environment.

Limited Health Literacy Is Associated With Worse Patient-Reported Outcomes in Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) face complex health tasks and decisions. Limited health literacy is a risk factor for poor health outcomes, but this has not been examined in IBD. This study aims to assess the role of health literacy for patients with IBD.

METHODS

We prospectively enrolled adults with IBD receiving care from the Section of Gastroenterology at the Boston Medical Center. In-person, standardized questionnaires were administered to measure health literacy with the Newest Vital Sign, self-efficacy with the Medication Use and Self-Efficacy Scale, quality of life with the 10-question Short Inflammatory Bowel Disease Questionnaire, depression with the Patient-Reported Outcomes Measurement System Short Form, and clinical disease activity for patients with Crohn's disease with the Harvey-Bradshaw Index and for patients with ulcerative colitis with the Simple Clinical Colitis Activity Index (SCCAI). The relationships between health literacy and these variables were subsequently examined.

RESULTS

Of 112 patients invited to participate, 99 enrolled and completed the interview. Limited health literacy was identified in 40% (n = 40) of patients. Patients with limited health literacy reported significantly worse overall health (P = 0.03) and more depressive symptoms (P = 0.01). Of the 56 patients with Crohn's disease, those with adequate health literacy were more likely to be in clinical remission (mean Harvey-Bradshaw Index score < 5), compared with those with limited health literacy (odds ratio, 4.15; 95% confidence interval, 1.37 to 13.45; P = 0.01). There was no significant association between health literacy and clinical disease activity (SCCAI) in patients with ulcerative colitis.

CONCLUSIONS

Limited health literacy is associated with lower ratings of subjective health and depression in IBD and more symptoms of active disease in patients with Crohn's disease.

Innovative Online Educational Portal Improves Disease-Specific Reproductive Knowledge Among Patients With Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is often diagnosed in early adulthood, affecting patients through their reproductive years. Many patients, lacking knowledge about IBD and reproduction, make uninformed decisions. Although patients have turned to the Internet for information, it remains unclear if online resources are effective for improving and retaining IBD-specific reproductive knowledge. We aimed to elucidate if a multimedia vs text-only online educational intervention could improve IBD-specific reproductive knowledge for more than 6 months.

METHODS

We developed a website covering genetics, fertility, surgery, pregnancy, medications, delivery, and postpartum in the context of IBD. Adult IBD patients were randomized into study groups (multimedia or text-only) and provided 60-day access. Participants completed pre-, post-, and 6+ month-postintervention pregnancy knowledge (CCPKnow) questionnaires. Results were compared using nonparametric tests.

RESULTS

Of 111 registered participants, 78 (70.3%) completed pre- and postintervention questionnaires, and 37 (47.4%) subsequently completed the 6+ month questionnaire. Demographics were as follows: median age (interquartile range [IQR]) 29.3 (25.6-32.9) years, Crohn's disease n = 54 (69.2%), females n = 63 (80.3%), of which n = 5 (7.9%) were pregnant and n = 19 (30.2%) had previously been pregnant. The median CCPKnow scores (/17) (IQR) were 8.0 (3.0-10.0) pre-intervention, 16.0 (13.00-17.00) postintervention, and 14.0 (12.0-15.0) 6+ months postintervention. The median within-subject increase in score was 6.5 pre- to postintervention, and 4.0 pre- to 6+ months postintervention (both P < 0.001). The median increase in score (pre- to post-) was 8.0 for the multimedia group and 6.0 for the text-only group (P = 0.216).

CONCLUSIONS

An evidence-based, online educational portal can significantly improve and maintain IBD-specific reproductive patient knowledge for more than 6 months.