Measuring health literacy in caregivers of children: a comparison of the newest vital sign and S-TOFHLA

Low caregiver health literacy is associated with non-urgent pediatric emergency department use

OBJECTIVE

Caregivers with low health literacy are more likely to overestimate illness severity and have poor adherence with health-promoting behaviors. Our primary objective was to relate caregiver health literacy to the urgency of emergency department (ED) utilization. The secondary objective was to explore the relationship between social and demographic characteristics, health literacy, and urgency of ED use.

METHODS

This sub-study was a descriptive cross-sectional survey with health record review. Data were collected from ten Canadian pediatric EDs. Study variables included demographics, visit details, and the Newest Vital Sign measurement of health literacy. ED visits were classified as urgent or non-urgent based on the resource utilization method.

RESULTS

The response rate was 97.6% (n = 2005). Mean (SD) caregiver age was 37.0 (7.7) years, 74.3% (n = 1950) were mothers, 72.6% (n = 1953) spoke English as a primary language, 51.0% (n = 1946) had a university degree, and 45.1% (n = 1699) had a household income greater than $100,000. The mean (SD) age of the children was 5.9 (5.0) years and 48.1% (n = 1956) were female. 43.7% (n = 1957) of caregivers had low health literacy. Being a caregiver with a child < 2 years old [aOR 1.83 (1.35, 2.48)] and low health literacy [aOR 1.56 (1.18, 2.05)] were associated with greater non-urgent pediatric ED use. Interprovincial variation was evident: Quebec caregivers were less likely to use the pediatric ED for non-urgent presentations compared to Alberta, while those in Nova Scotia, Manitoba, British Columbia, and Ontario were more likely compared to Alberta.

CONCLUSION

Almost half of caregivers presenting to Canadian pediatric EDs have low health literacy, which may limit their ability to make appropriate healthcare decisions for their children. Low caregiver health literacy is a modifiable factor associated with increased non-urgent ED utilization. Efforts to address this may positively influence ED utilization.

Association between Paediatric Complementary and Alternative Medicine Use and Parental Health Literacy, Child Health, and Socio-Economic Variables: A Prospective Study

Complementary and Alternative Medicines (CAMs) constitute products and practices not considered allopathic medicine. CAM use is high in children, but little is known about factors that may influence parents using CAM with their child. This study aimed to determine the variables associated with CAM use in children with a prospective study among children and their parents attending a tertiary care hospital in New Zealand (NZ). Outcomes included current CAM use, parental opinions on CAM, parental health literacy and child well-being. This study was completed by 130 parents (85% female), and the mean child age was 6.7 years. CAM use was reported for 59 (45%) children, the most common being oral supplements and body manipulation. Children were more likely to use CAM if their parent had higher health literacy (p = 0.001), and if they had previously attended the emergency department within 12 months (p = 0.03). There was no association between child well-being and CAM use. Parental opinion of using CAM only if a doctor recommended it was associated with CAM use for their child (p = 0.01). Only 40% of parents disclosed their child's CAM use to the medical team. This study highlights that parental health literacy influences the use of CAM for children in NZ, providing insight for translational research to improve CAM safety and disclosure rates in NZ.

Assessing the health literacy of caregivers in the pediatric intensive care unit: a mixed-methods study

Background

Limited health literacy is associated with increased hospitalizations, emergency visits, health care costs, and mortality. The health literacy levels of caregivers of critically ill children are unknown. This mixed-methods study aims to quantitatively assess the health literacy of caregivers of children admitted to the pediatric intensive care unit (PICU) and qualitatively describe facilitators and barriers to implementing health literacy screening from the provider perspective.

Methods

Caregivers of patients admitted to our large, academic PICU (between August 12, 2022 and March 31, 2023) were approached to complete a survey with the Newest Vital Sign (NVS), which is a validated health literacy screener offered in English and Spanish. We additionally conducted focus groups of interdisciplinary PICU providers to identify factors which may influence implementation of health literacy screening using the Consolidated Framework for Implementation Research (CFIR) framework.

Results

Among 48 surveyed caregivers, 79% demonstrated adequate health literacy using the Newest Vital Sign screener. The majority of caregivers spoke English (96%), were mothers (85%), and identified as White (75%). 83% of caregivers were able to attend rounds at least once and 98% believed attending rounds was helpful. Within the PICU provider focus groups, there were 11 participants (3 attendings, 3 fellows, 2 nurse practitioners, 1 hospitalist, 2 research assistants). Focus group participants described facilitators and barriers to implementation, which were mapped to CFIR domains. Timing of screening and person administering screening were identified as modifiable factors to improve future implementation.

Conclusion

We found the health literacy levels of PICU caregivers in our setting is similar to prior assessments of parental health literacy. Participation in morning rounds was helpful for developing understanding of their child's illness, regardless of health literacy status. Qualitative feedback from providers identified barriers across all CFIR domains, with timing of screening and person administering screening as modifiable factors to improve future implementation.

Assessment Tools for Measuring Health Literacy and Digital Health Literacy in a Hospital Setting: A Scoping Review

Assessment of (digital) health literacy in the hospital can raise staff awareness and facilitate tailored communication, leading to improved health outcomes. Assessment tools should ideally address multiple domains of health literacy, fit to the complex hospital context and have a short administration time, to enable routine assessment. This review aims to create an overview of tools for measuring (digital) health literacy in hospitals. A search in Scopus, PubMed, WoS and CINAHL, following PRISMA guidelines, generated 7252 hits; 251 studies were included in which 44 assessment tools were used. Most tools (57%) were self-reported and 27% reported an administration time of <5 min. Almost all tools addressed the domain 'understanding' (98%), followed by 'access' (52%), 'apply' (50%), 'appraise' (32%), 'numeracy' (18%), and 'digital' (18%). Only four tools were frequently used: the Newest Vital Sign (NVS), the Short Test of Functional Health Literacy for Adults ((S)TOFHLA), the Brief Health Literacy Screener (BHLS), and the Health Literacy Questionnaire (HLQ). While the NVS and BHLS have a low administration time, they cover only two domains. HLQ covers the most domains: access, understanding, appraise, and apply. None of these four most frequently used tools measured digital skills. This review can guide health professionals in choosing an instrument that is feasible in their daily practice, and measures the required domains.

N. S, Clerc P, Carciumaru R, Alqurashi W, Rajagopal M, Kammerer E, Leung J, Wright B, Scott SD. Family caregivers' emotional and communication needs in Canadian pediatric emergency departments

OBJECTIVES

To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details.

STUDY DESIGN

Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit.

RESULTS

This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home.

CONCLUSION

Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Comparison of Newest Vital Sign and Brief Health Literacy Screen scores in a large, urban Hispanic cohort

OBJECTIVE

Prior studies comparing subjective and objective health literacy measures have yielded inconsistent results. Our aim was to examine the concordance between Newest Vital Sign (NVS) and Brief Health Literacy Screen (BHLS) scores in a large cohort of English- and Spanish-speaking urban Hispanic adults.

METHODS

Item means, standard deviations, corrected-item total correlations, Cronbach's alpha, and Spearman correlations and area under receiver operating characteristic (AUROC) curve analysis were used to compare NVS and BHLS items and total scores.

RESULTS

N = 2988 (n = 1259 English; n = 1729 Spanish). Scores on both measures demonstrated good internal consistency (NVS: α = .843 English, .846 Spanish; BHLS: α = .797 English, .846 Spanish) but NVS items had high difficulty; more than half of respondents scored 0. Measures were only weakly correlated (rs = .21, p < .001, English; rs = .19, p < .001, Spanish). The AUROC curves were .606 (English) and .605 (Spanish) for discriminating the lowest NVS scoring category.

CONCLUSION

Subjective health literacy scores were poor predictors of objective scores. Objective scores demonstrated floor effects, precluding discrimination at low levels of the trait continuum.

PRACTICE IMPLICATIONS

Subjective health literacy scores may fail to identify individuals with limited health literacy.

Health literacy of informal caregivers of older adults with dementia: results from a cross-sectional study conducted in Florence (Italy)

AIM

The aim of this study was to measure the prevalence of inadequate health literacy (HL) in a sample of family caregivers of older adults with dementia, and to assess the relationship of HL with characteristics of caregiver and persons with dementia.

METHODS

The study followed a cross-sectional design. Persons with dementia and their family caregivers were enrolled in an outpatients' geriatric memory clinic. For the caregivers, the following information was collected: socio-demographic data, level of HL, cognitive impairment (using the Mini-Cog). For persons with dementia, the following data were collected: socio-demographic data, functional status (using the Basic and Instrumental Activities of Daily Living), cognitive impairment (using the Mini Mental State Evaluation, and the Global Deterioration Scale) behavioral and psychological symptoms associated with dementia (assessed using the Neuropsychiatric Inventory).

RESULTS

A total of 174 person with dementia/caregiver dyads were enrolled. About 45% of the caregivers presented a possibility or a high likelihood of inadequate HL. The percentage of caregivers with inadequate HL was higher among spousal caregivers than in offspring. Female gender, higher age and lower education were independent predictors of low HL. On multiple logistic regression analysis, persons with dementia assisted by caregivers with a high likelihood of limited HL presented higher risk of a more severe disease.

CONCLUSION

The results of this study suggest that the HL of dementia caregivers has to be included in the comprehensive geriatric assessment, to develop an appropriate individualized care plan. Moreover, public health interventions are needed to increase the HL of dementia caregivers.

The impact of health literacy on psychosocial and behavioural outcomes among people at low risk of cardiovascular disease

This study aimed to explore the impact of health literacy on psychosocial and behavioural outcomes for people who were not at high risk of cardiovascular disease receiving a hypothetical blood pressure reading of 135/85 mmHg. We performed a secondary analysis of data from a national sample of Australians aged 40 to 50 years (n = 1318) recruited online. Health literacy was measured using the validated Newest Vital Sign (inadequate: 0-3; adequate: 4-6). Analysed outcomes included: willingness to increase exercise and accept medication; perceived severity; positive and negative affect; illness perceptions and impacts on life and motivation. Participants with inadequate levels of health literacy perceived a blood pressure reading of 135/85 mmHg to be less serious compared to individuals with adequate health literacy (Mean Difference [MD]:0.21; 95%CI 0.03-0.39; p = .024; d = 0.13), and reported less motivation to eat well (MD:0.44; 95%CI 0.31-0.58; p < .001; d = 0.38) and exercise (MD:0.43; 95%CI 0.31-0.58; p < .001; d = 0.36). However, they were more willing to accept medication (MD:0.20; 95%CI 0.07-0.34; p = .004; d = 0.17). Participants with inadequate health literacy also perceived the condition to have fewer negative impacts on aspects of life and work than individuals with adequate health literacy, but reported greater negative emotion and more negative illness perceptions (all p < .001). Tailored communication and behaviour change support may be needed when communicating blood pressure information to people with lower health literacy and not at high risk of cardiovascular disease given the differential impacts on medication (increased willingness) and healthy exercise and diet behaviours (decreased willingness) observed in this study.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Developing performance-based measures of health literacy: A narrative case study and checklist of considerations

Research in health literacy is fundamentally impacted by our ability to adequately assess the construct. Although various measures of health literacy have been developed, there are few reflective discussions of the challenges and learnings from the instrument development process. This is somewhat surprising given that health literacy is a multi-dimensional and contested concept (with inherent measurement challenges), and that there are important practical considerations owing to the fact that people completing health literacy assessments may have lower general literacy (i.e. ability to read and write) and English-language skills. This paper discusses our learnings from developing a performance-based measure of parenting health literacy skills (the Parenting Plus Skills Index). The performance-based instrument is characterised by its grounding in health literacy as asset, with items spanning Nutbeam's functional, communicative and critical health literacy skills, and was designed chiefly to capture improvements resulting from health literacy skills training. This paper elucidates critical junctures in the development process, particularly regarding the conceptualisation and operationalisation of the construct. We also outline our approach to addressing practical measurement issues (e.g. administration time; item difficulty). In summarising these, we offer a 13-item checklist to inform the development of health literacy instruments for other health contexts or health conditions.

Interventions to Improve Health among Reproductive-Age Women of Low Health Literacy: A Systematic Review

Background: Limited or low health literacy (HL) has been associated with poor health outcomes, including inadequate self-caring and preventive behaviors. A few studies have systematically summarized the effect of interventions to improve reproductive health and care in women with insufficient HL. The main objective of the study was to investigate health care promotion interventions and examine their effectiveness on women with inadequate HL through a systematic review of randomized controlled trials (RCT). Methods: RCTs and quasi-experimental studies that assessed HL interventions to improve reproductive health of women with low HL were included. The study protocol was registered with PROSPERO (CRD42020137059). Results: Of the 292 records initially identified, a total of 6 articles were included for review. Five different HL screening tools were used. Four different interventions were included: educational intervention, communication skills, a multimedia interactive tool, and text adaptation to enhance reading comprehension. Not enough research practice has been conducted on the influence of interventions on HL, and thus, it is difficult to implement evidence-based interventions. Conclusions: Interventions aiming to benefit and improve HL should consider the complex web of intersectional determinants that end up shaping the opportunities of women to make optimal decisions regarding their health and care, and which may require attention to much more than clinical or service delivery factors.

Health literacy and its association with adherence in pediatric liver transplant recipients and their parents

OBJECTIVE

Non-adherence to pediatric regimens is a common concern. Low health literacy is correlated with poor outcomes in adults but is understudied in pediatrics. The current project aimed to determine the relationship between health literacy, adherence, and outcomes in pediatric liver transplant recipients. Hypotheses included a) parent and patient health literacy would be positively correlated; and b) low patient and/or parent health literacy would be negatively correlated with adherence and health outcomes.

PATIENTS AND METHODS

Eligible participants were recruited during routine follow-up visits in a pediatric liver transplant clinic. Parents and patients (>13 years old) completed 2 measures of health literacy. Patients ≥18 years completed health literacy measures without corresponding parent surveys. Adherence variables and health outcomes were obtained from medical records.

RESULTS

Seventy-nine patients across two sites completed the study. Variance in classification of health literacy between measures was observed; however, most parents (82%-100%) scored within an "adequate literacy" range. More adolescents scored in lower health literacy ranges relative to the parents. Markers of SES were positively correlated with health literacy. Parent health literacy was negatively associated with biopsy-proven rejection episodes and the number of hospitalizations; however, it was not associated with measures of tacrolimus adherence. There were no relationships observed between parent and adolescent health literacy.

CONCLUSIONS

Health literacy is an important consideration in managing patient care; however, available measures demonstrate variability in capturing the skills of patients. Effective communication strategies may ameliorate admittedly small, but negative, impacts of limited health literacy on outcomes.

Validation of an Australian parenting health literacy skills instrument: The parenting plus skills index

OBJECTIVE

Existing instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills.

METHODS

The PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20-44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500).

RESULTS

Following the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments.

CONCLUSIONS

The PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting.

PRACTICE IMPLICATIONS

The PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions.

Influence of Puerperal Health Literacy on Tobacco Use during Pregnancy among Spanish Women: A Transversal Study

Background: Despite the fact that tobacco use during pregnancy produces adverse perinatal effects, some women continue to smoke. Health literacy (HL) is essential for health outcomes in adults. However, little is known about HL in pregnant women or postpartum women. The study aimed to analyse the relationship between the degree of HL of women during the early puerperium and tobacco use during pregnancy. Methods: A multicentre, descriptive, cross-sectional study was carried out with women in the early puerperium in a region of eastern Spain, between November 2017 and May 2018. Their HL level was obtained using the Newest Vital Sign (NVS) tool. Multivariate logistic models were adjusted to estimate the magnitude of association with tobacco use in pregnancy. Odds ratios (OR) were estimated with a 95% confidence interval. Results: 193 were included in the total. 29.5% (57) of pregnant women smoked tobacco during pregnancy, with a smoking cessation rate of 70.1% (40) while pregnant. 42.0% (81) of pregnant women had inadequate or limited HL. A low level of HL was strongly associated with tobacco use, adjusted by catchment area and age of first pregnancy (LRT p < 0.001; ROC curve = 0.71, 95% CI: 0.64–0.79). Conclusion: A low HL is associated with tobacco consumption during pregnancy. Whether low HL reflects the wide constellation of already-known socioeconomic, political and commercial determinants of tobacco use, or whether incorporating HL support interventions strengthens tobacco cessation activities in pregnancy, warrants further research. Still, it should be considered as essential to understanding the health disparities related to its consumption.

Assessment of health literacy in adolescents with spina bifida and their caregivers: a multi-institutional study

INTRODUCTION

and Objective: Health literacy is defined as the ability to obtain, integrate, and appraise health-related knowledge. It is known to correlate with disparities in clinical outcomes in adults with chronic disease. Patients with spina bifida represent a potentially vulnerable cohort as they often have multiple comorbidities. The authors aimed to characterize health literacy in adolescent patients with spina bifida and their caregivers.

STUDY DESIGN

The Newest Vital Sign (NVS), a validated assessment of health literacy and numeracy, was administered to patients (aged ≥10 years) and caregivers in outpatient pediatric urology and multidisciplinary spina bifida clinics. Subjects not fluent in English or Spanish and those with cognitive delay were excluded. Survey responses and demographic information were analyzed and compared between the spina bifida and control groups.

RESULTS

Three hundred eleven caregivers (caregivers for patients with spina bifida: 185, caregivers for the controls: 126) and 84 adolescents (those with spina bifida: 46, controls: 38) completed the NVS. Although there was no difference in health literacy between caregivers (p = 0.98), adolescents with spina bifida demonstrated lower NVS scores (spina bifida 1 [0-3] vs. control 2 [2-4]; p = 0.02) (Figure). Health literacy of patients with spina bifida and controls increased with age (p = 0.002). Adjusting for age and gender, the odds of having limited literacy were 5.5 times higher in patients with spina bifida than in the controls (p = 0.004). Inadequate caregiver health literacy was associated with a lower education level (p < 0.001).

DISCUSSION

Spina bifida is among the most complex birth defects compatible with life and affects a multitude of systems. Although it is well established that limited health literacy in adults with chronic disease is associated with adverse outcomes, there are considerably fewer data in the pediatric population. The authors found that caregivers of patients with spina bifida exhibited health literacy and numeracy comparable with parents in the control group, despite lower education levels. In contrast, adolescents with spina bifida demonstrated poorer health literacy than the controls. Multidisciplinary care is necessary, given the medical complexity of spina bifida; therefore, impaired understanding of adults' own needs may pose a barrier to successful transition to their care and subsequent outcomes.

CONCLUSIONS

The majority of surveyed caregivers for patients with spina bifida exhibited adequate health literacy, especially those with some college education; however inadequate health literacy was more likely among adolescents with spina bifida when compared with the controls. Screening for health literacy may be useful to assess readiness for transition to more independent self-care among patients with spina bifida.

Health literacy and knowledge of chronic transfusion therapy in adolescents with sickle cell disease and caregivers

BACKGROUND

Patients with sickle cell disease (SCD) may require chronic transfusion therapy (CTT) for prevention of stroke or other complications. Limited health literacy (HL) is common and is associated with poor health-related knowledge and outcomes in chronic disease. We sought to assess HL and transfusion knowledge in patients with SCD on CTT and their caregivers.

METHODS

A cross-sectional study of patients was conducted in outpatient hematology clinics. Forty-five pairs of adolescent patients and caregivers and 20 caregivers of pre-adolescent patients completed the Newest Vital Sign HL assessment and answered questions assessing SCD and transfusion knowledge. Community-level median income and unemployment rates were estimated from Census data. We computed the correlation of HL with knowledge and compared each to Census variables, payor status, educational attainment, and stroke.

RESULTS

HL was inadequate in 22 (34%) caregivers and 31 (69%) adolescents. Adequate caregiver HL was associated with higher educational attainment but not community-level socioeconomics or payor status. Mean knowledge score was lower in adolescents than in caregivers and correlated with age in adolescents (r = 0.42, P = .004). HL correlated with knowledge (r = 0.46, P < .0001). There were no significant correlations of HL or knowledge between adolescents and their caregivers. Neither HL nor knowledge was associated with prior stroke. The greatest knowledge was demonstrated for iron overload and SCD genotype, whereas knowledge gaps existed in alloimmunization, indication for CTT, and SCD curative therapy.

CONCLUSIONS

Enhanced educational resources in transfusion therapy, alloimmunization, and curative therapy are needed for patients with SCD and caregivers of all HL levels.

Health Literacy and Attention to Cigarette Health Warning Labels among Rural Smokers

OBJECTIVES

We evaluated the association of health literacy and attention to the pictorial imagery of 9 health warning labels (HWLs) in a tobacco advertisement among rural US smokers. We hypothesized that lower health literacy would be associated with greater visual attention to pictorial portions of HWLs and evaluated the association between health literacy and recall of advertisement elements.

METHODS

Adult smokers from Appalachian Ohio (N = 180) viewed a pictorial HWL encompassing 20% or 33% of a cigarette advertisement while eye tracking software recorded eye movements toward the advertisement. Health literacy was measured with The Short Test of Functional Health Literacy in Adults.

RESULTS

Generalized linear regression revealed that every one-unit decrease in health literacy increased viewing time of the pictorial portion of the health warning label by 1.3 percentage points. Logistic regression revealed that the odds of recalling elements of the pictorial portion of the health warning label increased 20% for every one-unit increase in health literacy.

CONCLUSIONS

Rural smokers with lower health literacy view pictorial portions of health warning labels longer than those with greater health literacy supporting that health literacy is an important consideration in health communications, including future cigarette warning labels.

Influence of health literacy on acceptance of influenza and pertussis vaccinations: a cross-sectional study among Spanish pregnant women

OBJECTIVES

Immunisations against influenza and Bordetella pertussis infection are recommended to pregnant women in Valencia (Spain), yet vaccination rates remain low. Health literacy (HL) appears as a crucial factor in vaccination decision-making. We explored the relation between HL of pregnant women and decisions to receive influenza and pertussis immunisations.

SETTING

University hospital in Valencia (Spain).

PARTICIPANTS

119 women who gave birth at a hospital in Valencia (Spain) between November 2015 and May 2016. Women in the immediate postpartum period (more than 27 weeks of gestation), between November 2015 and May 2016 were included in the study. Women with impairments, language barriers or illiteracy which prevented completion of the questionnaires, or those who were under 18 years were excluded from enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

HL level; influenza and pertussis immunisation rate; reasons for rejection of vaccination.

RESULTS

119 participants were included (mean age 32.3±5.5 years, 52% primiparous, 95% full-term deliveries). A higher education level was associated with Short Assessment of Health Literacy for Spanish Adults _50 (adjusted R²=0.22, p=0.014) and Newest Vital Sign (adjusted R²=0.258, p=0.001) scores. Depending on the scale, 56%-85% of participants had adequate HL. 52% (62/119) and 94% (112/119) of women received influenza and pertussis immunisation, respectively. Women rejecting influenza vaccine had a higher HL level (measured by SALHSA_50 tool) than those accepting it (Kruskal-Wallis test p=0.022). 24% of women who declined influenza vaccination felt the vaccine was unnecessary, and 23% claimed to have insufficient information.

CONCLUSIONS

Influenza vaccination rate was suboptimal in our study. Women with high HL were more likely to decline immunisation. Information from professionals needs to match patients' HL levels to reduce negative perceptions of vaccination.

Understanding of Information about Medicines Use among Parents of Pre-School Children in Serbia: Parental Pharmacotherapy Literacy Questionnaire (PTHL-SR)

Parental health literacy plays an important role in children&rsquo;s health, Experiences from pharmacy practice show that is necessary to check if parents understand instructions about use of medicines for children. This study aimed to assess pharmacotherapy literacy of parents of pre-school children and to examine association of parental pharmacotherapy literacy level with parent&rsquo;s socio-demographic characteristics. The study was cross-sectional, conducted among parents of pre-school children (1⁻7 years of age), in kindergartens in several municipalities of Belgrade, Serbia, during regular parents meetings, from May to October 2016. Functional health literacy was measured by the Serbian version of the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Parental pharmacotherapy literacy was assessed with newly constructed PTHL-SR questionnaire with good psychometric characteristics (Parental pharmacotherapy literacy questionnaire&mdash;Serbian). Overall, 813 parents participated in the study, mostly females (81.30%), between 30 to 40 years of age (70.85%) with two children (56.70%). Almost all of our study participants (99%) had adequate health literacy as assessed by S-TOFHLA. Mean score on PTHL-SR was 72.83% (standard deviation was 13.37), with better results among females than males (72% of women were in the group of highest PTHL-SR results). Our study showed that many parents (76.5%) knew the appropriate usage of non-prescription medicine for children, 57.2% parents were able to correctly calculate the dose of oral syrup for a child, and only 43.3% were able to interpret non-prescription dosage information written on the package. The majority of parents (61.3%) would make a dosage to child based on age and not on their weight. Every fifth parent with adequate functional health literacy measured by S-TOFHLA test, achieved the lowest results measured by PTHL-SR. Higher performance of the PTHL-SR was significantly correlated with education (p < 0.001), female sex (p < 0.001), married parents and those living in common-law (p < 0.001), older parents (p < 0.05) and parents who have more children (p < 0.05), and are non-smokers (p < 0.05). These results provide evidence that limitations in understanding common information about use of medicines are widespread among parents of pre-school children and encourage efforts for further investigation. PTHL-SR questionnaire may be a useful tool for identification of parents who need more instructions and assistance from healthcare providers, above all in providing better communication, written or spoken at community pharmacy settings.

Parents' pain medication underdosing is associated with more emergency department visits in sickle cell disease

OBJECTIVE

To determine the association between health literacy, medication knowledge, and pain treatment skills with emergency department (ED) use of parents of children with sickle cell disease (SCD).

METHODS

Parents of children 1- to 12-years-old with SCD were enrolled. Health literacy was assessed using the Newest Vital Sign. Parents completed a structured interview assessing knowledge of the dosage and frequency of home pain medications and an applied skills task requiring them to dose a prescribed pain medication. Underdosage was defined by too small a dose (dosage error) or too infrequent a dose (frequency error). The association between medication knowledge and applied skills with ED visits for pain over the past year was evaluated using Poisson regression adjusting for genotype.

RESULTS

One hundred parent/child pairs were included; 50% of parents had low health literacy. Low health literacy was associated with more underdose frequency errors (38% vs. 19%, P = 0.02) on the skills task. On medication knowledge, underdose dosage errors (adjusted incidence rate ratio [aIRR] 2.0, 95% confidence interval [CI] 1.3-3.0) and underdose frequency errors (aIRR, 1.7, 95% CI 1.2-2.6) were associated with a higher rate of ED visits for pain. On the skills task, underdose dosage errors (aIRR 1.6, 95% CI 1.1-2-.4) and underdose frequency errors were associated with more ED visits (aIRR 1.5, 95% CI 1.1-2.1).

CONCLUSIONS

For medication knowledge and skills tasks, children of parents who underdosed pain medication had a higher rate of ED visits for pain. Health literate strategies to improve parents' medication skills may improve pain treatment at home and decrease healthcare utilization.

Why Parents Seek Care for Acute Illness in the Clinic or the ED: The Role of Health Literacy

OBJECTIVE

To explore the decision to seek care and decision-making regarding location of care among parents with low and adequate health literacy.

METHODS

Parents of children 8 years old or younger who presented for 'sick child' visits at a clinic or a nonurgent emergency department (ED) visit (triage level 5) were interviewed. The Newest Vital Sign was used to categorize parental health literacy. Interviewers followed a semistructured interview guide to understand: 1) care-seeking for current illness, and 2) choice of clinic or ED. Themes emerged using a grounded theory process, facilitated by NVivo version 10.0 software (QSR International, Melbourne, Australia). Themes included the experiences of low and adequate health literacy in the clinic as well as in the ED.

RESULTS

Fifty semistructured interviews were completed with parents who brought their child to the ED for a nonurgent visit (n = 30) and clinic parents (n = 20) with 56% possessing low health literacy. Parents with low health literacy were more inclined to overestimate severity of illness and seek care sooner to gain answers about the illness and treatment options, and visit the clinic only when an appointment was available within hours. Parents with adequate health literacy sought reassurance for their ongoing illness management and valued close relationships with their physician, and were willing to wait longer for an appointment. Fever, vomiting, and young child age prompted some parents to seek expedient care regardless of health literacy.

CONCLUSIONS

Caregiving skills (eg, assessing and treating illness, understanding illness severity, and navigating the health care system) in addition to physician-parent relationships and perception of care seem to influence the behavior of parents managing their child's mild acute illness. These factors might be amenable to a future health literacy intervention.

Short Assessment of Health Literacy (SAHL) in Portugal: development and validation of a self-administered tool

The goal of this study was to adapt, improve and validate a short, self-administered health literacy assessment tool for European Portuguese-speaking adults. Health literacy tools are of great importance to health authorities and professionals, as low or inadequate health literacy, that is, a limited capacity to handle health-related information, is associated with higher morbidity and mortality. The 18-item Short Assessment of Health Literacy for Brazilian Portuguese-speaking adults (SAHLPA-18) was adapted into European Portuguese. The European Portuguese tool (SAHLPA-23) includes five additional items. The SAHLPA-23 was tested in a convenience sample of 503 participants from two Portuguese regions. Socio-demographic data, literacy and cognitive indicators were collected. Participants also completed a questionnaire on comprehension of written health materials. Construct validity was assessed through correlations between SAHLPA-23 scores and education, literacy, and cognitive variables and score on the comprehension questionnaire. The psychometric properties of the new tool were compared with those of the SAHLPA-18. The mean SAHLPA-18 and SAHLPA-23 scores were 13.9 (77.2%; SD=2.9) and 18.3 (79.6%; SD=3.8), respectively. Both tools showed adequate reliability (Cronbach’s α>0.7). SAHLPA-23 was more highly correlated with all study variables than SAHLPA-18. Although both instruments displayed acceptable discriminative power, SAHLPA-23 had better accuracy than SAHLPA-18 (DeLong’s method: ΔAUC=0.09, Z=3.36; P<0.001). The SAHLPA-23 is an independent, feasible and innovative tool for estimation of health literacy in the Portuguese adult population.

Health literacy and its correlates in informal caregivers of adults with memory loss

This secondary analysis examined health literacy among informal caregivers of community-dwelling older adults with memory loss and assessed correlates of caregiver health literacy using the Abilities, Skills and Knowledge Model. Caregiver health literacy (n = 91) was assessed by the Newest Vital Sign. Limited health literacy presented in 38.5% caregivers, with significantly low document literacy. Health literacy was associated bivariately with age, education, global cognitive function, executive function, and working memory (all ps < 0.001), as well as medication knowledge (p = 0.015). Hierarchical regression analyses revealed that older age (p = 0.017), and lower global cognitive function (p < 0.001), working memory (p = 0.001), and academic skills (years of education) (p = 0.004), independently predicted lower health literacy (R² = 0.54). Medication knowledge, however, was not found to be an independent predictor in the model. Findings suggest limited health literacy is a potential issue among informal caregivers of adults with memory loss. Appropriate assessment and personalized support are needed for informal caregivers who are at high risk for poor health literacy.

Previous antibiotic-related adverse drug reactions do not reduce expectations for antibiotic treatment of upper respiratory tract infections

BACKGROUND

Patients' expectations may influence prescribers' decisions about antibiotic prescribing for upper respiratory tract infection (URTI). We examined whether a history of an antibiotic related adverse drug reaction (aADR) influenced a person's perception about the safety of antibiotics or their expectation of receiving an antibiotic prescription for an URTI.

METHODS

We developed a questionnaire and surveyed 103 hospital inpatients, 38 of whom (37%) reported past experience of aADR.

RESULTS

Of the 88 participants who reported recent antibiotic use, participants with a history of aADR reported increased perception of harm from their last antibiotic treatment (P<0.05). Overall, 41/103 (40%) participants expected their doctors to prescribe antibiotics to treat an URTI. Participants' perceptions of antibiotic safety or expectation of antibiotic treatment for an URTI did not differ between those who had personal experience of an aADR compared with those with no history of aADR.

CONCLUSIONS

The almost universal belief that antibiotics are safe, beneficial medications, even among people with prior aADR, helps to explain the strong patient expectations for antibiotic treatment in a range of conditions. Educational campaigns about the prescription of antibiotics for viral URTI should include information that the risk of harm far outweighs any potential benefits.

Hemodialysis Access Choice: Impact of Health Literacy

BACKGROUND

Hemodialysis patients need to make decisions about vascular access and diet that they may not fully understand. In this study, we hypothesized that patients with low health literacy are likely to choose a central venous catheter (CVC) and have higher serum potassium (K), serum phosphate (P), and inter-dialysis weight gains (IDWG).

OBJECTIVE

Primarily, the study sought to describe the health literacy of patients treated with hemodialysis in a Canadian tertiary care center. The secondary objective was to describe the association between health literacy and permanent vascular access choice, hyperkalemia, hyperphosphatemia, and IDWG.

METHODS

Adult patients receiving hemodialysis for more than 6 months were included. Health literacy was assessed with the Newest Vital Sign (NVS) test. Vascular access type and reasons for CVC use were determined. Serum K, P, and IDWG were collected retrospectively for 6 months. Student's t test and logistic regression were used to determine the association between health literacy (NVS score < 4 versus ≥ 4) and CVC choice, hyperkalemia, hyperphosphatemia, and high IDWG.

KEY RESULTS

Fifty-six patients were involved. The average NVS score was 2.9. Overall, 66% of the patients had a CVC; one-third had chosen this access themselves. Poor control of K, P, and IDWG was experienced by 27%, 55%, and 36% of patients, respectively. The average NVS score was lower for patients choosing a CVC (p = .001), but not different for those with higher K, P, or IDWG. None of the patients who chose a CVC had adequate health literacy (NVS ≥ 4).

CONCLUSIONS

Patients with low health literacy, who are eligible for both surgically created vascular access (fistula or graft) and CVC, are more likely to refuse fistula/graft creation compared to patients with adequate health literacy. Different educational strategies for such patients may help in appropriate decision-making. [Health Literacy Research and Practice. 2017;1(3):e136-e144.].

PLAIN LANGUAGE SUMMARY

This study suggests that more than one-half of patients who receive hemodialysis may not understand all the information provided by their health care team. Despite a higher risk of complications with a central venous catheter, patients with lower health literacy prefer the catheter over fistula as their blood access for hemodialysis. We need to explore patient education to ensure that information is easy to understand.

A cognitive approach for design of a multimedia informed consent video and website in pediatric research

OBJECTIVE

Poor participant comprehension of research procedures following the conventional face-to-face consent process for biomedical research is common. We describe the development of a multimedia informed consent video and website that incorporates cognitive strategies to enhance comprehension of study related material directed to parents and adolescents.

MATERIALS AND METHODS

A multidisciplinary team was assembled for development of the video and website that included human subjects professionals; psychologist researchers; institutional video and web developers; bioinformaticians and programmers; and parent and adolescent stakeholders. Five learning strategies that included Sensory-Modality view, Coherence, Signaling, Redundancy, and Personalization were integrated into a 15-min video and website material that describes a clinical research trial.

RESULTS

A diverse team collaborated extensively over 15months to design and build a multimedia platform for obtaining parental permission and adolescent assent for participant in as asthma clinical trial. Examples of the learning principles included, having a narrator describe what was being viewed on the video (sensory-modality); eliminating unnecessary text and graphics (coherence); having the initial portion of the video explain the sections of the video to be viewed (signaling); avoiding simultaneous presentation of text and graphics (redundancy); and having a consistent narrator throughout the video (personalization).

DISCUSSION

Existing conventional and multimedia processes for obtaining research informed consent have not actively incorporated basic principles of human cognition and learning in the design and implementation of these processes. The present paper illustrates how this can be achieved, setting the stage for rigorous evaluation of potential benefits such as improved comprehension, satisfaction with the consent process, and completion of research objectives.

CONCLUSION

New consent strategies that have an integrated cognitive approach need to be developed and tested in controlled trials.

Nonurgent and urgent emergency department use during pregnancy: an observational study

BACKGROUND

Emergency department use is common among pregnant women. Nonurgent emergency department use may represent care that would be better provided by an established obstetric provider in an ambulatory setting.

OBJECTIVE

The objective of the study was to identify sociodemographic factors associated with nonurgent emergency department use in pregnancy.

STUDY DESIGN

This is a cross-sectional study of women recruited during their postpartum hospitalization. Data regarding prenatal care and emergency department visits were collected from medical records; participants completed a survey with questions regarding demographics and emergency department use. Urgency of an emergency department visit was prespecified based on a priori criteria abstracted from medical record review. Women with any nonurgent emergency department use were compared with women without nonurgent emergency department use. Logistic regression was performed to identify factors associated with nonurgent emergency department use.

RESULTS

Two hundred thirty-three women participated in this study; 197 (84%) received care in the emergency department during pregnancy. Eighty-three women (35.6%) had at least 1 visit to the emergency department that was nonurgent. In a regression analysis, the increased odds of nonurgent emergency department use was associated with a preferred language other than English (odds ratio, 2.02; 95% confidence interval,1.01-4.05) and lack of private insurance (odds ratio, 5.55; 95% confidence interval, 2.54-12.12). The 2 most common reasons for presentation to the emergency department were concern that there was an emergency (45%) or being referred by a health care provider (36%).

CONCLUSION

Women frequently use the emergency department during pregnancy, including visits for nonurgent indications. Identifying risk factors for nonurgent emergency department use in pregnancy is important for identifying women likely to use the emergency department, including for nonurgent visits, and the development of strategies to decrease nonurgent emergency department utilization in pregnancy.

Comparing the Performance of the S-TOFHLA and NVS Among and Between English and Spanish Speakers

Given the growing body of evidence demonstrating the significant implications of health literacy on a myriad of outcomes, researchers continue to incorporate health literacy metrics in studies. With this proliferation in measurement of health literacy in research, it has become increasingly important to understand how various health literacy tools perform in specific populations. Our objective was to compare the performance of two widely used tests, the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Newest Vital Sign (NVS) among and between a sample of English and Spanish-speaking patients. Adults (N = 402) ages 50-75 years participating in a trial to promote colorectal cancer screening completed in-person interviews which included both measures of health literacy. In the full sample, the tests were moderately correlated (r = 0.69, p < .0001); however, there was a stronger correlation among those completing the test in Spanish (r = 0.83) as compared with English (r = 0.58, p < .0001). English speakers more often were categorized as having adequate literacy by the S-TOFHLA as compared with the NVS, whereas Spanish speakers scored consistently low on both instruments. These findings indicate that the categorization of participants into levels of literacy is likely to vary, depending on whether the NVS or S-TOFHLA is used for assessment, a factor which researchers should be aware of when selecting literacy assessments.

Use of mobile devices and the internet for multimedia informed consent delivery and data entry in a pediatric asthma trial: Study design and rationale

INTRODUCTION

Phase III/IV clinical trials are expensive and time consuming and often suffer from poor enrollment and retention rates. Pediatric trials are particularly difficult because scheduling around the parent, participant and potentially other sibling schedules can be burdensome. We are evaluating using the internet and mobile devices to conduct the consent process and study visits in a streamlined pediatric asthma trial. Our hypothesis is that these study processes will be non-inferior and will be less expensive compared to a traditional pediatric asthma trial.

MATERIALS/METHODS

Parents and participants, aged 12 through 17 years, complete the informed consent process by viewing a multi-media website containing a consent video and study material in the streamlined trial. Participants are provided an iPad with WiFi and EasyOne spirometer for use during FaceTime visits and online twice daily symptom reporting during an 8-week run-in followed by a 12-week study period. Outcomes are compared with participants completing a similarly designed traditional trial comparing the same treatments within the same pediatric health-system. After 8 weeks of open-label Advair 250/50 twice daily, participants in both trial types are randomized to Advair 250/50, Flovent 250, or Advair 100/50 given 1 inhalation twice daily. Study staff track time spent to determine study costs.

RESULTS

Participants have been enrolled in the streamlined and traditional trials and recruitment is ongoing.

CONCLUSIONS

This project will provide important information on both clinical and economic outcomes for a novel method of conducting clinical trials. The results will be broadly applicable to trials of other diseases.