The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study

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.

Effectiveness and implementation of mPATH™-CRC: a mobile health system for colorectal cancer screening

BACKGROUND

Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates.

METHODS

The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a "high touch" evidence-based implementation strategy with a "low touch" implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50-74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the "high touch" and "low touch" implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation).

DISCUSSION

This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.

Preferences for Colorectal Cancer Screening Modalities Among the General Population in Saudi Arabia

BACKGROUND

Colorectal cancer (CRC) could be a leading explanation for cancer-related death. Numerous studies have shown the benefit of early screening for colorectal cancer in reducing mortality. Screening for colorectal cancer is a rational and cost-effective strategy for reducing the incidence of colorectal cancer and related mortality. Despite endorsement by academic and healthcare organizations, patient awareness and compliance with screening are low, partly due to patient-related barriers to screening.

AIM

This study aimed to explore the preferred screening method for colorectal cancer in Saudi Arabia in general.

METHODS

This is a cross-sectional study conducted among the Saudi adult population from September 2021 through February 2022. A self-developed questionnaire was distributed among the population using an online platform. Data were tabulated in Google Forms, and all statistical analyses were performed using SPSS version 26 (IBM Corp., Armonk, NY).

RESULTS

During this study, data from 10,781 participants were analyzed. Among them, the most preferred screening modality for colorectal cancer was the stool fecal immunochemical test (41.7%) and the most suitable (33.5%). The most commonly mentioned qualities that influenced choosing a particular screening test were "how the test was performed" (50.4%).

CONCLUSION

Because the stool fecal immunochemical test is the most preferred screening modality for colorectal cancer, this study could serve as a database to aid in the implementation of a colorectal cancer screening program that meets the preferences of the general population of Saudi Arabia.

Impact of genomic literacy components on genetic testing decision-making in the general Japanese population in the 20s and 30s

In promoting genomic medicine, genomic literacy, which is the public's ability to acquire and utilize the knowledge and skills related to genetics and genomes, requires urgent improvement. This study determined how the three components of genomic literacy (genetic/genomic knowledge, health numeracy, and interactive and critical health literacy) are associated with risk and benefit perception for genetic testing and decision-making related to genetic testing. Using an online questionnaire, we surveyed genetic/genomic knowledge, health numeracy, interactive and critical health literacy, risk and benefit perception of genetic testing, and intention toward genetic testing of 857 Japanese citizens (aged 20-39). A vignette was created to measure the intention toward genetic testing, and respondents were asked about their willingness to undergo genetic testing and to share the results with their partners and children. The path analysis, which was done by creating a path diagram revealing the relationship of the three components with risk and benefit perception, revealed that genetic and genomic knowledge and interactive and critical health literacy affected the respondents' intention to undergo genetic testing via recognition of the benefits of such testing. Further, it was suggested that health numeracy affects benefit perception through risk perception toward genetic testing. However, the goodness of fit of this model for the intention of conveying positive results to partners and children was relatively low, thus indicating that the hypothetical model needs to be reexamined.

COLORECTAL CANCER: ASSOCIATION BETWEEN SOCIODEMOGRAPHIC VARIABLES AND THE ADHERENCE TO CANCER SCREENING

BACKGROUND

Colorectal cancer (CRC) is a worldwide health problem whose control depends on public policy establishment and effective prevention and screening programs. In Brazil, there are few studies related to adherence to screening methods.

AIMS

The aim of this study was to evaluate the association between demographic and socioeconomic to adherence to CRC screening with fecal immunochemical test (FIT) among average-risk individuals for CRC.

METHODS

In this prospective cross-sectional study, conducted between March 2015 and April 2016, 1,254 asymptomatic individuals aged 50-75 years, participating in a hospital screening campaign in Brazil, were invited to participate in the study.

RESULTS

The adherence rate to FIT was 55.6% (697/1,254). In the multivariable logistic regression analysis, patients aged 60-75 years (odds ratio (OR)=1.30; 95% confidence interval (CI): 1.02-1.66; p=0.03), religious belief (OR=2.04; 95% CI: 1.34-3.11; p<0.01), previous fecal occult blood test (OR=2.07; 95% CI: 1.55-2.76; p<0.01), and full/part-time working status (OR=0.66; 95% CI: 0.49-0.89; p<0.01) were independently associated with adherence to CRC screening.

CONCLUSION

The results of the present study highlight the importance of considering the labor aspects when implementing screening programs, suggesting that campaigns conducted in the workplace and repeated over the years may be more effective.

Impact of Health Care-Associated Cost Concerns on Mammography Utilization: Cross-Sectional Survey Results From the National Health Interview Survey

PURPOSE

Health care-related cost concerns and financial toxicity are increasingly recognized barriers along the breast cancer care continuum. The purpose of this study was to evaluate the association between patient-reported cost concerns and screening mammography utilization.

METHODS

Survey participants aged 40 to 74 years from the 2018 National Health Interview Survey without personal history of breast cancer were included (response rate: 64%). Respondents were queried if they had experienced specific access-related health care barriers. Multiple variable logistic regression analyses were performed to evaluate the association between barriers to care and patient-reported screening mammography utilization.

RESULTS

Of survey respondents, 7,511 women were included. Of this group, 68.9% reported receiving a screening mammogram within the last 2 years and 52.2% reported receiving a screening mammogram within the last year. Of all survey respondents, 48.4% reported worry paying medical bills. Patients who reported worry about paying medical bills (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.76-0.97; P = .01), challenges affording dental care (OR 0.65; 95% CI: 0.54-0.77; P < .01), and challenges affording eyeglasses (OR 0.67; 95% CI: 0.54-0.84; P < .01) were less likely to report screening mammography use than their respective counterparts. Patients who skipped medication doses (OR 0.69; 95% CI: 0.52-0.91; P < .01), took less medication, (OR 0.63; 95% CI: 0.48-0.82; P < .01), and delayed filling prescriptions (OR 0.71; 95% CI: 0.56-0.90; P < .01) to save money were also less likely to report receiving mammography screening.

CONCLUSION

Patient-reported cost-related barriers are associated with decreased utilization of routine mammography.

The association between adherence to cancer screening programs and health literacy: A systematic review and meta-analysis

The effectiveness of a cancer screening program relies on its adherence rate. Health literacy (HL) has been investigated among the factors that could influence such participation, but the findings are not always consistent. The aim of this meta-analysis was to summarize the evidence between having an adequate level of HL (AHL) and adherence to cancer screening programs. PubMed, Scopus, and Web of Science were searched. Cross-sectional studies, conducted in any country, that provided raw data, unadjusted or adjusted odds ratio (OR) on the associations of interest were included. The quality of the studies was assessed with the Newcastle-Ottawa Scale. Inverse-variance random effects methods were used to produce pooled ORs and their associated confidence interval (CI) stratified by time interval (e.g., undergoing screening in the last period, or at least once during lifetime) for each cancer type, considering unadjusted and adjusted estimates separately. A sensitivity analysis was performed for those studies providing more estimates. Overall, 15 articles of average-to-good quality were pooled. We found a significant association between AHL and higher screening participation for breast, cervical and colorectal cancer, independently of other factors, both overall (N = 7, aOR = 1.73; 95% CI: 1.27-2.36; N = 3, aOR = 1.64; 95% CI: 1.30-2.09; and N = 5, aOR = 1.25, 95% CI: 1.12-1.39, respectively) and in most time-stratified analyses. The sensitivity analyses confirmed these results. Health literacy seems to be critical for an effective cancer prevention. Given the high prevalence of illiterate people across the world, a long-term action plan is needed.

Filipinos' attitudes, barriers, and enablers on colorectal cancer screening: Insights from a qualitative research study

BACKGROUND

Filipinos have lower colorectal cancer (CRC) screening rates and worse outcomes versus non-Hispanic Whites. As Filipinos are understudied on how they perceive CRC screening, we conducted focus groups examining their attitudes, enablers, and barriers to screening.

METHODS

In August and September 2021, we recruited Filipinos aged 40-75 years to participate in an online focus group. Filipinos who received care at an academic medical center or were members of Filipino community organizations in Los Angeles, CA, were sent emails inviting them to participate. We used a semi-structured interview guide for the focus groups and audio recordings were transcribed and analyzed using an inductive coding approach. Codes were generated from the qualitative data, sorted, classified into themes and subthemes, and illustrated with verbatim quotes.

RESULTS

We conducted four online focus groups with 16 Filipinos. As for enablers for CRC screening, participants mentioned the importance having a doctor's recommendation. Participants reported the following barriers: potential out-of-pocket costs (the Philippines healthcare system is largely cash-based); fatalistic beliefs; reactive approach to health; lack of awareness in the community on CRC screening. Suggested solutions for improving CRC screening uptake in the community included: providing information on screening benefits, what to expect from each test (e.g., steps involved, accuracy), and financial considerations; participation by Filipino celebrities and doctors in media campaigns.

CONCLUSION

Our study highlights Filipinos' perceptions on CRC screening. These data can support investigators, health systems, public health agencies, and community organizations in developing culturally tailored, sustainable interventions to address CRC screening disparities among Filipinos.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

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

Patient-Reported Barriers Are Associated With Receipt of Hepatocellular Carcinoma Surveillance in a Multicenter Cohort of Patients With Cirrhosis

BACKGROUND

More than 20% of patients with cirrhosis do not receive semi-annual hepatocellular carcinoma (HCC) surveillance as recommended. Few studies have evaluated the effects of patient-level factors on surveillance receipt.

METHODS

We administered a telephone survey to a large cohort of patients with cirrhosis from 3 health systems (a tertiary care referral center, a safety-net health system, and Veterans Affairs) to characterize patient knowledge, attitudes, and perceived barriers of HCC surveillance. Multinomial logistic regression was performed to identify factors associated with HCC surveillance receipt (semi-annual and annual vs none) during the 12-month period preceding survey administration.

RESULTS

Of 2871 patients approached, 1020 (35.5%) completed the survey. Patients had high levels of concern about developing HCC and high levels of knowledge about HCC. However, patients had knowledge deficits, including believing surveillance was unnecessary when physical examination and laboratory results were normal. Nearly half of patients reported barriers to surveillance, including costs (28.9%), difficulty scheduling (24.1%), and transportation (17.8%). In the year before the survey, 745 patients (73.1%) received 1 or more surveillance examination; 281 received on-schedule, semi-annual surveillance and 464 received annual surveillance. Semi-annual HCC surveillance (vs none) was significantly associated with receipt of hepatology subspecialty care (odds ratio, 30.1; 95% CI, 17.5-51.8) and inversely associated with patient-reported barriers (odds ratio, 0.62; 95% CI, 0.41-0.94). Patterns of associations comparing annual vs no surveillance were similar although the magnitude of effects were reduced.

CONCLUSIONS

Patient-reported barriers such as knowledge deficits, costs, difficulty scheduling, and transportation are significantly associated with less frequent receipt of HCC surveillance, indicating a need for patient-centered interventions, such as patient navigation.

Relationship between Degree of Exercise Participation and Active Aging among Older Adults

Government departments and scholars have focused on promoting health care for older adults in response to population aging and the annual increase in the number of older adults. Old age does not necessarily involve rapid health decline, fragility, or senility. Therefore, active aging among older adults has become a major consideration worldwide. The effect of exercise participation and social support on active aging warrants investigation. This study proposes a conceptual model for understanding the effects of exercise participation and social support on active aging among older adults. Exercise participation, social support, and health literacy were integrated to hypothesize a theoretical model of active aging among older adults. Furthermore, the moderating role of health literacy in the relationship between exercise participation, social support, and active aging was analyzed. Questionnaires were administered to respondents from Northern Taiwan during face-to-face interviews. Of the 1,800 distributed questionnaires, 1,586 completed questionnaires were received (response rate = 88.1%). The data collected were analyzed using structural equation modeling. The results indicated that exercise participation (β = 0.163, $p=0.000$ ), social support (β = 0.384, $p=0.000$ ), and health literacy (β = 0.360, $p=0.000$ ) had significant positive effects on active aging. Health literacy did not moderate the effects of exercise participation and social support on active aging among older adults (β = −0.054, $p=0.197$ and 0.061, $p=0.066$ ). The current results confirm that social support has a considerable effect on active aging, which could be used as a reference for future proposals targeted at relevant institutions and older adults.

What can be done to encourage women from Black, Asian and minority ethnic backgrounds to attend breast screening? A qualitative synthesis of barriers and facilitators

OBJECTIVE

The objective of the study is to identify the barriers to UK Black, Asian and Minority Ethnic (BAME) women attending breast screening and subsequently, support the growing evidence base providing solutions to the public health problem of ethnic variation within screening attendance.

STUDY DESIGN

A systematic review and thematic analysis of UK-based, qualitative studies concerning BAME women.

METHODS

The methodology of this review is based on Cochrane guidelines. A search strategy was applied to Embase, PubMed and Medline. Predefined inclusion and exclusion criteria yielded 8 final articles which were appraised and thematically analysed.

RESULTS

The main findings of the review revealed three overarching themes: knowledge-related, access-related and cultural-related factors. The emphasis of the importance of knowledge was highlighted by all studies identifying a lack of knowledge as a key barrier to screening attendance.

CONCLUSIONS

BAME women have disproportionally lower breast screening attendance and a lack of knowledge is an essential barrier to overcome when addressing this health inequality.

Relationship between health literacy and quality of colonoscopy bowel preparation

BACKGROUND/AIMS

There are a variety of factors that affect the quality of colonoscopy bowel preparations, although the relationship between the level of health literacy (HL) and the quality of bowel preparations has yet to be clarified. The present study evaluated the effect of HL on the quality of bowel preparation prior to a colonoscopy.

MATERIALS AND METHODS

The data of 150 patients who underwent a colonoscopy for colorectal cancer screening and in whom the quality of bowel preparation was scored during the colonoscopy were recorded prospectively. The European Health Literacy Survey Questionnaire (HLS-EU-Q47) was used to evaluate HL prior to the colonoscopy, and the Boston bowel preparation scale was used to evaluate the quality of the bowel preparation during the colonoscopy. The demographic characteristics of the patients, the presence of comorbidities, socioeconomic characteristics (marital status, income level, and educational level), HLS-EU-Q47 questionnaire, and Boston bowel preparation scale scores were recorded and evaluated.

RESULTS

A significant linear relationship was identified between the general HL index score, the cleanliness of the colonic segments (right, transverse, and left colon) and the total Boston bowel preparation scale score (p=0.013, p=0.010, p=0.008, p=0.001, respectively). In a HL subgroup analysis, a significant linear relationship was noted between disease prevention and health promotion index, the cleanliness of the colonic segments (right, transverse, and left colon), and the total Boston bowel preparation scale score. It was observed that an increase in the health care index resulted in an increase in the cleanliness of the relevant colonic segments and the total Boston bowel preparation scale score. No relationship was found between the right, transverse, and left colon and the total Boston bowel preparation scale scores and gender, age, Body Mass Index (BMI), comorbidity, marital status, level of income, or educational level.

CONCLUSION

The level of HL affects the quality of colonoscopy bowel preparations.

Health Literacy and Physical Activity: A Systematic Review

BACKGROUND

The importance of health literacy (HL) in health promotion is increasingly clear and acknowledged globally, especially when addressing noncommunicable diseases. This paper aimed to collect and summarize all current data from observational studies generating evidence of the association between HL and physical activity (PA) and to analyze intervention studies on the promotion of PA to ascertain whether HL moderates the efficacy of such intervention.

METHODS

A comprehensive systematic literature search of observational studies investigating the association between HL and PA was performed. Intervention studies on the promotion of PA that also measured the HL levels of participants and its effect on the outcome of the intervention were also identified.

RESULTS

Of the 22 studies included in this review, 18 found a significant positive association between high HL and high levels of PA. The only intervention study among them indicated that HL was not a significant moderator of the intervention's effectiveness.

CONCLUSION

HL can enable individuals to make deliberate choices about their PA and thus contribute to preventing many chronic noncommunicable diseases. That said, low levels of HL do not seem to influence the efficacy of health promotion interventions.

Association between health literacy and dietary intake of sugar, fat and salt: a systematic review

Objectives:

To collect and summarise all current data from observational studies, generating evidence of the association between health literacy (HL) and the dietary intake of sugar, salt and fat, to analyse intervention studies on the promotion of an appropriate dietary intake of the above-mentioned nutrients and to ascertain whether HL moderates the efficacy of such intervention.

Design:

A systematic literature search of analytical observational studies on the association between HL and dietary intake of sugar, salt and fat was performed in Medline and Scopus databases. Intervention studies on the promotion of healthy nutrition that concerned the intake of sugar, salt and fat were also assessed.

Results:

Of the eight observational studies included in this review, five investigated dietary intake of sugar, one focused on salt, one assessed sugar and salt and one analysed the fat intake. The results of the five studies assessing sugar were mixed: three found an association between low levels of HL and a high sugar intake, one found this association only for boys and two found no evidence of any association. The two studies assessing salt and the one assessing fat found no evidence of any association with HL. One intervention study on the sugar intake concluded that HL was not a significant moderator of the intervention’s effectiveness.

Conclusion:

No evidence of any association between HL and salt and fat intake emerged, while for sugar, the results are mixed. More work is needed to better understand the moderating effects of HL on the outcomes of health promotion interventions.

Examining Potential Usability and Health Beliefs Among Young Adults Using a Conversational Agent for HPV Vaccine Counseling

The human papillomavirus (HPV) vaccine is the most effective way to prevent HPV-related cancers. Integrating provider vaccine counseling is crucial to improving HPV vaccine completion rates. Automating the counseling experience through a conversational agent could help improve HPV vaccine coverage and reduce the burden of vaccine counseling for providers. In a previous study, we tested a simulated conversational agent that provided HPV vaccine counseling for parents using the Wizard of OZ protocol. In the current study, we assessed the conversational agent among young college adults (n=24), a population that may have missed the HPV vaccine during their adolescence when vaccination is recommended. We also administered surveys for system and voice usability, and for health beliefs concerning the HPV vaccine. Participants perceived the agent to have high usability that is slightly better or equivalent to other voice interactive interfaces, and there is some evidence that the agent impacted their beliefs concerning the harms, uncertainty, and risk denials for the HPV vaccine. Overall, this study demonstrates the potential for conversational agents to be an impactful tool for health promotion endeavors.

The association between health literacy and colorectal cancer screening uptake in a publicly funded screening program in Denmark: Cross-sectional study

There are multiple reasons for not participating in colorectal cancer screening, but the role of health literacy in screening uptake is not well understood. The aims of this study were to determine the association between health literacy and colorectal cancer screening uptake and to explore whether socioeconomic and -demographic characteristics and worry and attitude variables modify this association. In a cross-sectional study, 10,030 53-74-year-old randomly selected citizens resident in Central Denmark Region received a questionnaire assessing health literacy using the European Health Literacy Survey Short Scale 16-item. Data on colorectal cancer screening uptake were obtained from the Danish Colorectal Cancer Screening database, and socioeconomic and -demographic data were linked from Statistics Denmark. The response rate was 71% (n = 7142). Odds ratio (OR) for uptake was 1.06 (95% confidence interval (CI): 0.96, 1.19) for problematic health literacy and 1.00 (95% CI: 0.87, 1.16) for inadequate health literacy, when using adequate health literacy as the reference value. The association was not modified by socioeconomic or -demographic characteristics, worry or attitude. No association was found between health literacy and colorectal cancer screening uptake. Future research needs to clarify which dimensions of health literacy may predict screening uptake and how it is best measured.

Adding value to remote monitoring: Co-design of a health literacy intervention for older people with chronic disease delivered by telehealth - The telehealth literacy project

OBJECTIVE

To co-design, test and evaluate a health literacy, chronic disease self-management and social support intervention for older people delivered by group videoconferencing into the home.

METHOD

The Telehealth Literacy Project (THLP) was a mixed methods, quasi-experimental, non-randomised trial nested within a telehealth remote monitoring study. An intervention group (n = 52) participated in five, weekly videoconference group meetings lasting for 1.5 h and a control group (n = 60) received remote monitoring only. Outcomes were measured using the nine-scale Health Literacy Questionnaire (HLQ) and two scales of the Health Education Impact Questionnaire (heiQ). Semi-structured interviews and focus group data were thematically analysed.

RESULT

At 3 month follow-up, univariate analysis identified small effects in the intervention group only, with improved health literacy behaviours (five HLQ scales) and self-management skills (two heiQ scales). ANOVA of HLQ scales indicated no significant differences between the two groups over time indicating a contributing effect of the remote monitoring project. Intervention participants reported improved perception of companionship, emotional and informational support.

CONCLUSION

The THLP delivered with telemonitoring indicates potential to improve social support and some health literacy factors in older people.

PRACTICE IMPLICATIONS

Patient education can be delivered by group videoconferencing.

Decision-making styles in the context of colorectal cancer screening

BACKGROUND

Our study examined the use of decision-making styles, as identified by Scott and Bruce (1995) (i.e. differentiating between a rational, intuitive, dependent, avoidant and spontaneous decision-making style), within the context of colorectal cancer (CRC) screening participation. In the field of cancer screening, informed decision-making is considered important, which follows the Rational Decision model. Subsequently, gaining more insight into decision-making styles being used in real life, could improve support to people when making their screening decision. In addition, we examined whether the decision-making style that people used was associated with their experienced decisional conflict.

METHODS

An online survey was carried out among a sample of first-time CRC screening invitees (1282 respondents, response rate 49%). We assessed people's decision-making styles, CRC screening participation, education level, self-reported health literacy, and decisional conflict, and examined the possible associations between them.

RESULTS

In our study, people who had to decide about CRC screening scored high on using both a rational and intuitive decision-making style. Respondents scoring higher on using a spontaneous or dependent decision-making style were more likely to have participated in CRC screening, while respondents scoring higher on using an avoidant decision-making style were more likely not to have participated in CRC screening. However, differences were small. Generally, people in our study experienced low decisional conflict.

CONCLUSION

Our eligible CRC screening population scored high on using both a rational and intuitive decision-making style. To optimise support to people, public education materials could be appealing more to the intuitive processes at hand. That being said, the current education materials aimed at informed/rational decision-making do not necessarily seem to create a problem, as people generally experienced low decisional conflict. Possible concerns regarding the use of a spontaneous, dependent or avoidant decision-making style could be that these styles might be contributing to less informed decisions. However, it is relevant to consider that the found differences are small and that any possible concern applies to a relatively small group of people.

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans

OBJECTIVES

Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans.

METHODS

Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics.

RESULTS

Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2).

CONCLUSION

Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels.

PRACTICE IMPLICATIONS

Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.

Randomised controlled trial of an intervention to improve parental knowledge and management practices of fever

BACKGROUND

We know that parents require resources which can assist them to improve fever knowledge and management practices. The purpose of this study, using an RCT, was to examine the effectiveness of an information leaflet at increasing parental knowledge of fever, specifically temperature definition.

METHODS

A prospective, multi-centre, randomised, two-parallel arm, controlled trial with blinded outcome ascertainment was conducted. Parents presenting at purposively selected healthcare facilities who had a child aged ≤5 years of age were invited to participate. An information leaflet for use in the trial was designed based on previous studies with parents. Parents in the intervention arm read an information leaflet on fever and management of fever in children, completed a short questionnaire at Time 1 (T1) and again 2 weeks after randomisation at Time 2 (T2). Parents in the control arm did not receive the fever information leaflet but completed the same questionnaire as the intervention arm at T1 and againat T2. The primary outcome was the correct definition of fever (higher than ≥38 °C).

RESULTS

A total of 100 parents participated in the study at T1. A greater proportion of the intervention group (76%) than the control group (28%) selected the correct temperature (≥38 °C) at T1. 76% of the intervention arm correctly identified "higher than ≥38°C" as the temperature at which a fever is said to be present compared to 28% of the control arm. After 2 weeks, there was an increase of 6% of parents in the intervention arm (increase to 82.4%) who gave the correct temperature compared to just a 2.8% increase in the control arm (increase to 30.8%). Univariate logistic regression showed that parents in the intervention arm were significantly more likely to give the correct answer at both time-points (T1: OR 8.1; CI 95% 3.3-19.9: p < 0.01; T2: OR 10.5; CI 95% 3.4-32.0: p < 0.01).

CONCLUSIONS

Our RCT of this simple educational intervention has been shown to improve parental understanding of fever knowledge and correct management strategies. Education interventions providing simple, clear information is a key step to decreasing parental mismanagement of fever and febrile illness in children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02903342, September 16, 2016, Retrospectively registered.

Previous Use of Mammography as a Proxy for General Health Checks in Association with Better Outcomes after Major Surgeries

Although previous studies have shown that health checks may improve several risk factors for chronic diseases, the effect of preoperative health checks on postoperative recovery in surgical patients remains unknown. We aimed to investigate the association between preoperative use of mammography and the risk of perioperative complications. We conducted a matched cohort study of 152,411 patients aged ≥47 years who received mammography screening and later underwent major surgery from 2008 to 2013. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 152,411 controls who underwent surgery but were not screened were selected. We collected patients’ characteristics and medical conditions from claims data of Taiwan’s National Health Insurance. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative complications and in-hospital mortality associated with mammography screening. Patients receiving mammography prior to major surgery had significantly lower risks of perioperative complications, including pneumonia, septicemia, acute renal failure, stroke, urinary tract infection, deep wound infection, acute myocardial infarction, intensive care unit stay, and 30 day in-hospital mortality (OR 0.45, 95% CI 0.38–0.53). The association was consistent across each stratum of age, number of hospitalizations, emergency visits, and comorbidities. In conclusion, preoperative use of mammography was strongly associated with fewer perioperative complications and less in-hospital mortality after major surgeries. The evidence provided by this study justifies the implementation of preoperative health checks in clinical practice.

Poor Health Literacy and Medication Burden Are Significant Predictors for Inadequate Bowel Preparation in an Urban Tertiary Care Setting

GOALS

The goal of this study was to identify factors impacting the quality of bowel preparation in an urban tertiary care setting.

BACKGROUND

Inadequate bowel preparation is encountered in 17% to 32% of colonoscopies performed in the United States. Suboptimal colonic visualization reduces the yield of screening colonoscopies and increases healthcare costs because of longer procedure times and aborted procedures.

STUDY

We performed a cross-sectional survey in patients undergoing outpatient colonoscopy within the Johns Hopkins Health System. A Boston Bowel Preparation Score (BBPS) score of <5 was considered inadequate. Fisher's exact, χ tests and univariate and multivariate binary logistic regression were performed to assess the strength of the association for selected factors with a BBPS<5.

RESULTS

In total, 467 patients (76.3% response rate) completed the survey between August 2017 and October 2017. The median BBPS score was 7, and 81.4% of patients had an adequate bowel preparation (BBPS≥5). There was significant association between bowel preparation adequacy and level of education, health literacy, functional status, income, and medication burden. When adjusted for other factors, poor confidence in filling forms (OR, 24.1; P<0.001), multiple daily prescription medications (OR, 12.49; P=0.02) and poor functional status (OR, 2.82; P=0.03) had the highest odds of predicting inadequate bowel preparation.

CONCLUSIONS

Inadequate bowel preparation is a significant problem accounting for reduced yield of screening and increased health care costs. Poor health literacy, functional status, and number of daily medications are significant factors predicting inadequate bowel preparation in the tertiary care setting.

HPV Misconceptions Among College Students: The Role of Health Literacy

Human papillomavirus (HPV) is currently the most common sexually transmitted disease in the United States, with potentially serious health consequences, including cervical cancer. Young adults are particularly at risk of infection, but many remain unvaccinated. Low health literacy may contribute to poor knowledge of HPV and lack of vaccine uptake, and women living in the Southeastern United States are particularly at risk for lower vaccination rates and cervical cancer screening adherence. Three-hundred-sixty undergraduates at a Southeastern U.S. University completed measures of health literacy, sexual attitudes, and HPV knowledge in 2016. Less than half of both male and female participants had completed an HPV vaccine series, and there were no differences in health literacy scores between participants who had completed a vaccine series and those who had not. Forty subjects were familiar with HPV vaccines but not the virus itself. More than half of these individuals had received at least one dose of an HPV vaccine, highlighting a lack of knowledge regarding the purpose of this vaccine. While health literacy was not related to vaccination status, it was associated with greater knowledge of both HPV and available vaccines. Participants who were familiar with HPV had higher health literacy than participants who were not. College students hold serious misconceptions about HPV that may be redressed through public health education programs to increase health literacy and knowledge. Such public health interventions would potentially increase HPV vaccine uptake, leading to decreased cervical cancer incidence and mortality rates.

General practitioners' predictions of their own patients' health literacy: a cross-sectional study in Belgium

OBJECTIVES

To support patients in their disease management, providing information that is adjusted to patients' knowledge and ability to process health information (ie, health literacy) is crucial. To ensure effective health communication, general practitioners (GPs) should be able to identify people with limited health literacy. To this end, (dis)agreement between patients' health literacy and GPs' estimations thereof was examined. Also, characteristics impacting health literacy (dis)agreement were studied.

DESIGN

Cross-sectional survey of general practice patients and GPs undertaken in 2016-17.

SETTING

Forty-one general practices in two Dutch-speaking provinces in Belgium.

PARTICIPANTS

Patients (18 years of age and older) visiting general practices. Patients were excluded when having severe impairments (physical, mental, sensory).

MAIN OUTCOME MEASURES

Patients' health literacy was assessed with 16-item European Health Literacy Survey Questionnaire. GPs indicated estimations on patients' health literacy using a simple scale (inadequate; problematic; adequate). (Dis)agreement between patients' health literacy and GPs' estimations thereof (GPs' estimations being equal to/higher/lower than patients' health literacy) was measured using Kappa statistics. The impact of patient and GP characteristics, including duration of GP-patient relationships, on this (dis)agreement was examined using generalised linear logit model.

RESULTS

Health literacy of patients (n=1375) was inadequate (n=201; 14.6%), problematic (n=299; 21.7%), adequate (n=875; 63.6%). GPs overestimated the proportion patients with adequate health literacy: adequate (n=1241; 90.3%), problematic (n=130; 9.5%) and inadequate (n=4; 0.3%). Overall, GPs' correct; over-/underestimations of health literacy occurred for, respectively, 60.9%; 34.2%; 4.9% patients, resulting in a slight agreement (κ=0.033). The likelihood for GPs to over-/underestimate patients' health literacy increases with decreasing educational level of patients; and decreasing number of years patients have been consulting with their GP.

CONCLUSIONS

Intuitively assessing health literacy is difficult. Patients' education, the duration of GP-patient relationships and GPs' gender impact GPs' perceptions of patients' health literacy.

Low Health Literacy Is Associated With Risk of Developing Type 2 Diabetes in a Nonclinical Population

PURPOSE

The purpose of this study was to examine associations among risk of type 2 diabetes (T2D), health literacy levels, and sociodemographic characteristics in a nonclinical adult population to assist in the development of effective T2D prevention programs.

METHODS

The Health Literacy Questionnaire and Australian Type 2 Diabetes Risk Assessment Tool were included in an online survey. Participants were a random sample of adults residing in each Australian state and territory. Data were analyzed with descriptive statistics and multinomial logistic regression.

RESULTS

A total of 1279 Australian adults participated (52% female; mean ± SD age, 61 ± 12 years). Most were at medium (42.4%) or high (46.9%) risk of developing T2D. The lowest health literacy scores were found for the domains "critical appraisal of health information" and "navigating the health care system." After controlling for covariates, participants at the highest risk of developing T2D were significantly more likely to be unemployed, have ≥1 chronic conditions, or have a mental health condition. Furthermore, they were significantly more likely to develop T2D if they scored low in 1 of the following health literacy domains: critical appraisal of health information, navigating the health care system, actively managing health, social support, and health care provider support.

CONCLUSIONS

Health literacy was associated with increased risk for developing T2D and should therefore be part of diabetes prevention initiatives. Specifically, new health promotion initiatives need to help people develop skills required to critically appraise health information and navigate the health care system. Health practitioners and educators should ensure that health information developed for consumers is uncomplicated and easily understood.

Knowledge, attitudes, and worries among different health literacy groups before receiving first invitation to colorectal cancer screening: Cross-sectional study

Background

Colorectal cancer screening uptake is associated with knowledge, attitudes and worries about screening. People with higher levels of health literacy usually have higher screening-related knowledge, but its association with attitudes and worries is sparsely described.The aim of this study was to describe knowledge, attitudes, and worries about colorectal cancer screening among unscreened citizens, and to estimate the association between these and health literacy.

Methods

In a cross-sectional study 10,030 53-74 year-old Central Denmark Region citizens received a questionnaire assessing knowledge, attitudes, worry and health literacy. Socioeconomic and -demographic data were linked from Statistics Denmark after data collection.

Results

In total, 7142 (71.2%) questionnaires were completed. A good general level of knowledge was observed (4.91 and 5.13 out of 7 for men and women, respectively). Citizens tended to be positive towards screening (21.4 and 21.3 on a 4-28 range scale for men and women respectively), and showed low levels of worries (8.8 and 9.09 on a 3-15 range scale for men and women respectively). Knowledge decreased and worries increased with lower levels of health literacy. Further, attitudes tended to be more positive with higher levels of health literacy.

Conclusions

In general, citizens tend to have good knowledge, positive attitudes and few worries about colorectal cancer screening. People with lower health literacy could benefit from targeted interventions that address knowledge and worries about screening to support informed decision making.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents

Purpose

Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake.

Methods

A convenience sample of 58 participants, aged 35–65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening.

Findings

Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening.

Conclusions

Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

Association between maternal literacy and child vaccination in Ethiopia and southeastern India and the moderating role of health workers: a multilevel regression analysis of the Young Lives study

BACKGROUND

Child vaccination coverage in low- and middle-income countries is still far from complete, mainly among marginalized people such as children with illiterate mothers.

OBJECTIVE

This study aims to examine the association between maternal literacy and immunization status of children in Ethiopia and southeastern India (Andhra Pradesh and Telangana) and test whether state-run health centers and community health workers moderate that association.

METHODS

This study is based on cross-sectional data from samples of children in Ethiopia and India, collected as part of round 2 within the Young Lives study (2006). Multilevel logistic regression was conducted to estimate the association between maternal literacy and the completion of four kinds of child vaccinations. We further tested for cross-level interactions between state-run health centers or community health workers and maternal literacy. Estimates were adjusted for several individual- and household-level demographic and socioeconomic factors.

RESULTS

Literate mothers were more likely to complete all four kinds of vaccinations for their children compared to illiterate mothers in Ethiopia (Odds Ratio (OR)=4.84, Confidence Interval (CI)=1.75-13.36). Presence of a health center was positively associated with completed vaccinations in India only (OR = 6.60, CI = 1.57-27.70). A cross-level interaction between community health workers and maternal literacy on the vaccination completion status of children was significant in Ethiopia only (OR = 0.29, CI = 0.09-0.96).

CONCLUSIONS

Our findings suggest that increased availability of community health workers may reduce the child vaccination gap for illiterate mothers, depending on the country context.

CRC Screening Results: Patient Comprehension and Follow-up

BACKGROUND:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Questionnaire Validation of Colorectal Cancer Literacy Scale among Thai People in Northeastern Thailand

Background: Colorectal cancer is an important public health problem worldwide. Although progress in screening and treatment has considerably improved the prognosis in the developed world, in developing countries colorectal cancer mortality rate remains relatively high. Colorectal cancer screening literacy is an important initial step in overcoming this problem. Development of a validated assessment instrument is therefore important for implementation of appropriate health education programs to facilitate early detection. Objectives: This study focused on generation and validation of a colorectal cancer screening literacy scale for Thai people in northeastern Thailand. Methods: This methodological study was carried out in two phases: (1) literature reviews and semi-structured interviews were used to select items, then the content and face validity were checked; and (2) a confirmatory factor analysis (CFA) was conducted to test construct validity and reliability. A self-administered questionnaire was used to collect data from Thai people aged 50- 65 in June 2017. Results: For the total of 400 participants who responded (response rate 100 %), the age ranged from 50 to 65 years old (mean = 57.3, SD = 4.616). The colorectal cancer screening literacy scale was designed to include 6 domains and it was shown to have good internal consistency, and CFA demonstrated the model to fit data adequately (Chi-squared/degree of freedom = 1.079, p = 0.061, CFI = 1.00, GFI = 0.93, AGFI = 0.91, RMSEA = 0.014 and SRMR = 0.036). The final version of its, consisting of 57 items across the 6 domains covering key aspects of colorectal cancer screening literacy, demonstrated good psychometric properties for this population. Conclusions: Use of the colorectal cancer screening literacy scale in Thai people could lead to improved educational programs for optimizing colorectal cancer screening.

Is Awareness Enough to Bring Patients to Colorectal Screening?

Background

The aim of the study was to assess the awareness of colorectal cancer (CRC) patients about CRC screening methods and to investigate the relationship between awareness, socio-demographic characteristics and the stage in which patients with CRC are diagnosed.

Methods

The observational cross-sectional study included 275 CRC patients admitted between 2014 and 2016 to two surgical clinics from Tîrgu Mureş, Romania. Study variables were collected via face-to-face interview and from patients’ observation sheets.

Results

Only 41.5% of the patients heard about cancer screening and 6.5% about specific CRC screening methods. Mass-media was the major source of information (85.1%) followed to a much lesser extent (14.9%) by family, friends, and colleagues. Health professionals did not contribute at all to informing patients about screening methods. Awareness about screening methods was statistically associated with the patients’ residence, age, and educational achievement, but not with the stage of CRC.

Conclusion

The level of awareness of CRC screening methods was very low among the CRC patients included in the study but it could not predict the stage in which malignancy was diagnosed, suggesting that awareness alone is not enough to bring patients to undergo early CDC screening procedures.

Is Awareness Enough to Bring Patients to Colorectal Screening?

Background

The aim of the study was to assess the awareness of colorectal cancer (CRC) patients about CRC screening methods and to investigate the relationship between awareness, socio-demographic characteristics and the stage in which patients with CRC are diagnosed.

Methods

The observational cross-sectional study included 275 CRC patients admitted between 2014 and 2016 to two surgical clinics from Tîrgu Mureş, Romania. Study variables were collected via face-to-face interview and from patients' observation sheets.

Results

Only 41.5% of the patients heard about cancer screening and 6.5% about specific CRC screening methods. Mass-media was the major source of information (85.1%) followed to a much lesser extent (14.9%) by family, friends, and colleagues. Health professionals did not contribute at all to informing patients about screening methods. Awareness about screening methods was statistically associated with the patients' residence, age, and educational achievement, but not with the stage of CRC.

Conclusion

The level of awareness of CRC screening methods was very low among the CRC patients included in the study but it could not predict the stage in which malignancy was diagnosed, suggesting that awareness alone is not enough to bring patients to undergo early CDC screening procedures.

Cervical Cancer Knowledge, Self-Efficacy, and Health Literacy Levels of Married Women

The purpose of this descriptive and relational study is to investigate the relationship between cervical cancer knowledge and self-efficacy and health literacy levels of married women aged 18-65 years. The study sample consisted of 400 married women (18-65 years old) who presented to a family health center. Independent variables were sociodemographic characteristics; dependent variables were cancer knowledge, self-efficacy, and health literacy level. Of the participants, 67% had a Pap smear. The participants' median knowledge score was 13 (min-max = 1-21). As the age increased, so did the knowledge score (p = 0.001). The secondary school graduates had the lowest knowledge level (p = 0.009). The participants' self-efficacy level was moderate (83.18 ± 7.70). As the educational status increased, so did their self-efficacy. Of the participants, 55.2% had a health literacy level of 7th-8th grade. The health literacy level was lower among the literate, primary school graduate, and advanced-age participants (p = 0.000). Increases in the self-efficacy and health literacy levels of the participants positively affected their knowledge status. The participants' cervical cancer and Pap smear screening knowledge levels increased as their self-efficacy levels increased. The literate or primary school graduate participants had the self-efficacy and health literacy levels.

A Cross-Sectional Assessment of Literacy and Awareness, Attitudes, and Beliefs About Colorectal Cancer and Its Screening in Riyadh Region

This study aims to explore the association between functional health literacy and awareness for, beliefs, and attitudes of patients with colorectal cancer (CRC) and CRC screening test in Riyadh, Saudi Arabia. A total of 256 participants from two different tertiary level hospitals in Riyadh, Saudi Arabia were recruited in this study. The participants were interviewed by a trained researcher between October and December 2015. All respondents answered a three-part questionnaire which included demographic data, questions related to CRC awareness, attitude, behaviour, and short Test of Functional Health Literacy in Adults (STOFHLA). More than half of the participants had an inadequate awareness of functional health literacy skills (FHLS), 16.4 % had marginal of FHLS awareness and 17.6 % had adequate awareness about FHLS as assessed by the STOFHLA. Overall, the majority of the participants in both marginal and adequate aware groups showed a limited awareness about colorectal cancer screening and testing. A significant association was found on awareness of the patients about frequencies that they should have been tested for colorectal cancer and functional health literacy. No significant association was found between functional health literacy as assessed by STOFHLA and concerns of Faecal Occult Blood Test (FOBT) (p = 0.384) and sigmoidoscopy or colonoscopy might cause embarrassment (p = 0.089), harm (p = 0.917), and pain (p = 0.849). The present study revealed a low level of health literacy among Saudi adults in Riyadh region. Although the level of literacy was low, the bigger concern is that of the poor awareness and beliefs of Saudi adults about CRC and CRC screening.

Colorectal cancer beliefs, knowledge, and screening among Filipino, Hmong, and Korean Americans

BACKGROUND

To the authors' knowledge, there are few studies to date regarding colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, who are reported to have lower CRC screening rates compared with white individuals. The current study was performed to assess knowledge and beliefs regarding the causes of CRC, its prevention, and factors associated with CRC screening among 3 Asian American groups.

METHODS

The authors conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, California), and Korean (Los Angeles, California) Americans aged 50 to 75 years who were sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening.

RESULTS

The sample of 981 participants was 78.3% female and 73.8% reported limited proficiency in English. Few of the participants were aware that age (17.7%) or family history (36.3%) were risk factors for CRC; 6.2% believed fate caused CRC. Only 46.4% of participants knew that screening prevented CRC (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; P<.001). Approximately two-thirds of participants reported ever having undergone CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; P<.001) and 48.6% were up to date for screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; P<.001). Factors found to be significantly associated with ever screening were being Korean (compared with Filipino), having a family history of CRC, having health insurance or a regular source of health care, and knowing that a fatty diet caused CRC. Believing that fate caused CRC and that praying prevented it were found to be negatively associated with ever screening. Factors associated with being up to date for CRC screening included being born in the United States, having a family history of CRC, and having access to health care.

CONCLUSIONS

Knowledge regarding the causes of CRC and its prevention among Filipino, Hmong, and Korean individuals is low. However, health care access, not knowledge or beliefs, was found to be a key determinant of CRC screening. Cancer 2018;124:1552-9. © 2018 American Cancer Society.

Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services

Background: Despite recently expanded access to health insurance, consumers still face barriers to using their coverage to obtain needed health care. Objective: To examine the characteristics of those who delay or avoid health care due to costs. Methods: Participants were recruited via Amazon MTurk and completed a survey assessing demographic characteristics, financial toxicity, health care minimizer-maximizer tendencies, health insurance knowledge, numeracy, delaying/avoiding any care, and delaying/avoiding six common health care services (three preventive and three nonpreventive services). Validated measures were used when available. Delay/avoidance behaviors were categorized into delaying/avoiding any care, preventive care, and nonpreventive care. Logistic regression models examined 1) financial toxicity, 2) minimizer-maximizer tendencies, 3) numeracy, 4) health insurance knowledge, and 5) knowledge of preventive care coverage separately on three forms of delay/avoidance behaviors, controlling for chronic conditions, insurance status, and/or income where appropriate. Results: Of 518 respondents, 470 did not fail attention-check questions and were used in analyses. Forty-five percent of respondents reported delaying/avoiding care due to cost. Multivariable analyses found that financial toxicity was related to delaying/avoiding any care (odds ratio [OR] = 0.884, P < 0.001), preventive care (OR = 0.906, P < 0.001), and nonpreventive care (OR = 0.901, P < 0.001). A tendency to minimize seeking health care (OR = 0.734, P < 0.001) and lower subjective numeracy (OR = 0.794, P = 0.023) were related to delaying/avoiding any care. General health insurance knowledge (OR = 0.989, P = 0.023) and knowledge of preventive care coverage (OR = 0.422, P < 0.001) were related to delaying/avoiding preventive care. Conclusions: Many people delay or avoid health care due to costs, even when insured. Results suggest that there may be different reasons individuals delay or avoid preventive and nonpreventive care. Findings may inform interventions to educate consumers and support discussions about health care costs to facilitate appropriate health care utilization.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health Literacy Is an Independent Predictor of Cancer Patients' Hospitalizations

Background

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

Objective

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

Methods

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

Key Results

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

Conclusions

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

Plain Language Summary

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

Survey of health literacy level and related influencing factors in military college students in Chongqing, China: A cross-sectional analysis

Health literacy (HL) has become an important public health issue and is receiving growing attention. However, the HL levels of military college students in China have never been analyzed. This study aimed to investigate the HL and related associate factors in military college students in Chongqing, China. Data was obtained with the “Chinese Citizen Health Literacy Questionnaire (2012 edition)” from 3183 military college students aged 16–28 years at Chongqing in December 2015. A total score of ≥80 points determined adequate HL, and HL level was defined as the proportion of students who had adequate HL out of the total number of participants. Multiple logistic regression analysis with a stepwise forward likelihood ratio (LR) method was used to determine the effects of sociodemographic characteristics, health-related behaviors, and family-related factors on HL level. The mean score of HL was 68.56, and the HL level of military college students was 21.05%; the overall knowledge rate was 71.33%. The independent factors that were associated with HL level were years in college, educational system, time playing online games, annual household income and father's education level. Senior (odds ratio [OR] = 1.229, 95% confidence interval [CI] 1.018∼1.484), undergraduate (OR = 1.509, 95% CI 1.151∼1.978), time played games more than 5 hours each week (OR = 0.638, 95% CI 0.486∼0.837), annual household incomes more than 50,000 yuan (OR = 1.231, 95% CI 1.027∼1.476) and father's education level (high school: OR = 2.327, 95% CI 1.186∼4.565; university: OR = 2.450, 95% CI 1.244∼4.825), were independently associated with higher HL level. HL levels of military college students in Chongqing need to be improved across the board. Our data suggests that special emphasis should be placed on students in junior and those in the specialist educational system. School departments may also benefit from incorporating health literacy into their curricula and helping students manage the time they spend playing online games.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Structural properties and psychometric improvements of the Health Literacy Questionnaire in a Slovak population

OBJECTIVES

Health literacy is an important determinant of health and health equity and therefore requires robust measurement. The aim was to examine the psychometric properties of the Slovak version of the Health Literacy Questionnaire (HLQ) including revised wording of response categories.

METHODS

A cross-sectional survey of the general Slovak adult population (N = 360, mean age 39) was conducted with the HLQ following its translation and cultural adaptation. Psychometric tests (confirmatory factor analysis, Cronbach's alpha, composite reliability) and association (linear regression, ANOVA) with sociodemographic variables were undertaken. The performance of alternative version of response options were explored with the Mann-Whittney U test and item response theory.

RESULTS

A highly restrictive nine-factor confirmatory factor analysis showed acceptable fit [χ ²WLSMV = 1684 (df  = 866), p < 0.0001; CFI = 0.943, TLI = 0.938, RMSEA = 0.051, WRMR = 1.297] and reliability was acceptable (range 0.73-0.84). The revised response categories had a better distribution with lower average scores in three domains, compared with the original, and improved item information curves.

CONCLUSIONS

The nine HLQ scales are robust, providing a fine-grained assessment of health literacy. The revised response options improve psychometric properties and are recommended for future studies.

Accessibility of standardized information of a national colorectal cancer screening program for low health literate screening invitees: A mixed method study

OBJECTIVE

To explore the accessibility of standardized printed information materials of the national Dutch colorectal cancer screening program among low health literate screening invitees and to assess the effect of the information on their knowledge about colorectal cancer and the screening program.

METHODS

Linguistic tools were used to analyze the text and design characteristics. The accessibility, comprehensibility and relevance of the information materials were explored in interviews and in observations (n=25). The effect of the information on knowledge was assessed in an online survey (n=127).

RESULTS

The materials employed a simple text and design. However, respondents expressed problems with the amount of information, and the difference between screening and diagnostic follow-up. Knowledge significantly increased in 10 out of 16 items after reading the information but remained low for colorectal cancer risk, sensitivity of testing, and the voluntariness of colorectal cancer screening.

CONCLUSION

Despite intelligible linguistic and design characteristics, screening invitees with low health literacy had problems in accessing, comprehending and applying standard information materials on colorectal cancer screening, and lacked essential knowledge for informed decision-making about participation.

PRACTICE IMPLICATIONS

To enable equal access to informed decision-making, information strategies need to be adjusted to the skills of low health literate screening invitees.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Colon Cancer among Older Saudis: Awareness of Risk Factors and Early Signs, and Perceived Barriers to Screening

BACKGROUND

Colon cancer screening (CRCS) uptake is markedly affected by public awareness of the disease. This study was conducted to assess levels of knowledge of CRC, to explore the pattern of CRCS uptake and identify possible barriers to screening among Saudis older than 50 years of age and primary care providers (PCPs) in Al Hassa region, Saudi Arabia.

MATERIALS AND METHODS

This cross-sectional study was conducted in randomly selected primary health care (PHC) centers, 884 Saudis and 39 PCPs being enrolled for data collection. Structured interviews were conducted to obtain information regarding socio-demographic characteristics, personal information relevant to CRC, awareness about early signs/symptoms and risk factors, and barriers to CRCS. Also, a self- administered data collection form was used to assess barriers to CRCS from the physicians' perspectives.

RESULTS

More than 66% of participants were lacking knowledge about CRC. Participants with higher educational levels, having ever heard about CRC, and having relatives with CRC had a significantly higher awareness of the disease. The rate of reported CRCS was low (8.6%). After conducting a logistic regression analysis, it was observed that female gender (OR=0.28; 95% CI=0.14-0.57; P=0.001), being unmarried (OR=0.11; 95% CI=0.10-0.23; P=0.001), lower levels of education (OR=0.36; 95% CI=0.16-0.82; P=0.015), and having no relatives with CRC (OR=0.30; 95% CI=0.17-0.56; P=0.001) were significantly associated with a lower CRCS uptake. There was a significant difference between most of the perceived barriers to CRCS and gender. Exploratory factor analysis showed that personal fear (especially fear of the screening results and shyness) was the major factor that hindered CRCS with high loading Eigen value of 2.951, explaining 34.8% of the barriers of the included sample toward utilization of CRCS, followed by lack of awareness of both person and providers (high Eigen value of 2.132, and explaining 23.7% of the barriers). The most frequently cited barriers to CRCS from the physicians' perspectives were lack of public awareness, lack of symptoms and signs, and fear of painful procedures.

CONCLUSIONS

Poor levels of knowledge about CRC were found among older Saudis attending PHC centers in Al Hassa, Saudi Arabia. It is crucial to implement an organized national screening program in Saudi Arabia to increase public awareness.

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

Background

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

Objective

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

Methods

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

Results

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

Limitations

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

Conclusion

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

Funding

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

Randomized Trial of a Computerized Touch Screen Decision Aid to Increase Acceptance of Colonoscopy Screening in an African American Population with Limited Literacy

The goal of this study was to assess the effectiveness of a touch screen decision aid to increase acceptance of colonoscopy screening among African American patients with low literacy, developed and tailored using perceptual mapping methods grounded in Illness Self-Regulation and Information-Communication Theories. The pilot randomized controlled trial investigated the effects of a theory-based intervention on patients' acceptance of screening, including their perceptions of educational value, feelings about colonoscopy, likelihood to undergo screening, and decisional conflict about colonoscopy screening. Sixty-one African American patients with low literacy, aged 50-70 years, with no history of colonoscopy, were randomly assigned to receive a computerized touch screen decision aid (CDA; n = 33) or a literacy appropriate print tool (PT; n = 28) immediately before a primary care appointment in an urban, university-affiliated general internal medicine clinic. Patients rated the CDA significantly higher than the PT on all indicators of acceptance, including the helpfulness of the information for making a screening decision, and reported positive feelings about colonoscopy, greater likelihood to be screened, and lower decisional conflict. Results showed that a touch screen decision tool is acceptable to African American patients with low iteracy and, by increasing intent to screen, may increase rates of colonoscopy screening.

Feasibility of conducting a web-based survey of patient-reported outcomes and rehabilitation progress

Background

Web-based surveys provide an efficient means to track clinical outcomes over time without the use of clinician time for additional paperwork. Our purpose was to determine the feasibility of utilizing web-based surveys to capture rehabilitation compliance and clinical outcomes among postoperative orthopedic patients. The study hypotheses were that (a) recruitment rate would be high (>90%), (b) patients receiving surveys every two weeks would demonstrate higher response rates than patients that receive surveys every four weeks, and (c) response rates would decrease over time.

Methods

The study deaign involved a longitudinal cohort. Surgical knee patients were recruited for study participation during their first post-operative visit (n = 59, 34.9 ± 12.0 years of age). Patients with Internet access, an available email address and willingness to participate were counter-balanced into groups to receive surveys either every two or four weeks for 24 weeks post-surgery. The surveys included questions related to rehabilitation and questions from standard patient-reported outcome measures. Outcome measures included recruitment rate (participants consented/patients approached), eligibility (participants with email/participants consented), willingness (willing participants/participants eligible), and response rate (percentage of surveys completed by willing participants).

Results

Fifty-nine patients were approached regarding participation. Recruitment rate was 98% (n = 58). Eligibility was 95% (n = 55), and willingness was 91% (n = 50). The average response rate was 42% across both groups. There was no difference in the median response rates between the two-week (50%, range 0–100%) and four-week groups (33%, range 0–100%; p = 0.55).

Conclusions

Although patients report being willing and able to participate in a web-based survey, response rates failed to exceed 50% in both the two-week and four-week groups. Furthermore, response rates began to decrease after the first three months postoperatively. Therefore, supplementary data collection procedures may be necessary to meet established research quality standards.