Cost effectiveness of a computer-delivered intervention to improve HIV medication adherence

A systematic review of the theory of planned behaviour interventions for chronic diseases in low health-literacy settings

Background

Due to their chronicity, prolonged morbidity, and high mortality, chronic respiratory diseases (CRDs) pose a huge burden of disease globally, primarily among low- and middle-income countries. Most of these diseases can be controlled by early diagnosis and treatment, correct practice of medications, regular follow-up, and avoidance of risk factors, which involves a change in health behaviour among patients. The theory of planned behaviour (TPB) has been proven to be effective and has been used increasingly as a behavioural framework for designing and evaluating behaviour change interventions, although most such studies were on affluent populations and from the global north. We aimed to collate evidence of TPB-based behavioural interventions in low health literacy settings for its effectiveness and feasibility by conducting a systematic review (SR).

Methods

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines in conducting and reporting this study. We selected interventional studies using at least two constructs of TPB for behaviour change in chronic disease patients and conducted in LMICs, used the PICO framework, and exported the retrieved studies through the Endnote software. We evaluated the studies using the Risk of Bias (RoB) 2 and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tools.

Results

We retrieved and reviewed the titles and abstracts 4281 titles and abstracts, identifying 186 articles for further detailed screening. Eleven studies met the criteria for a standardised independent full-text screening by two authors and four were selected for narrative synthesis. All studies were from urban settings, with established feasibility and fidelity; all interventions were effective in changing health behaviour and TPB constructs and provided structured education to participants in the intervention group (either face-to-face and through group education). Three studies had some concerns/moderate risk of bias and one had high risk of bias.

Conclusions

All studies demonstrated effectiveness, feasibility, and fidelity of TPB interventions in LMIC settings, although most were of moderate quality. Further studies should gather definitive evidence and prove their feasibility and utility in LMICs.

Registration

PROSPERO CRD42018104890.

Cost-Effectiveness of Anti-retroviral Adherence Interventions for People Living with HIV: A Systematic Review of Decision Analytical Models

BACKGROUND

Although safe and effective anti-retrovirals (ARVs) are readily available, non-adherence to ARVs is highly prevalent among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. This systematic review aimed to review and appraise the decision analytical economic models developed to assess ARV adherence-improvement interventions.

METHODS

The review protocol was registered on PROSPERO (CRD42022270039), and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant studies were identified through searches in six generic and specialized bibliographic databases, i.e. PubMed, Embase, NHS Economic Evaluation Database, PsycINFO, Health Economic Evaluations Database, tufts CEA registry and EconLit, from their inception to 23 October 2022. The cost-effectiveness of adherence interventions is represented by the incremental cost-effectiveness ratio (ICER). The quality of studies was assessed using the quality of the health economics studies (QHES) instrument. Data were narratively synthesized in the form of tables and texts. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis.

RESULTS

Fifteen studies, mostly conducted in North America (8/15 studies), were included in the review. The time horizon ranged from a year to a lifetime. Ten out of 15 studies used a micro-simulation, 4/15 studies employed Markov and 1/15 employed a dynamic model. The most commonly used interventions reported include technology based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15) and others that involved multi-component interventions (5/15). In 1/15 studies, interventions gained higher quality-adjusted life years (QALYs) with cost savings. The interventions in 14/15 studies were more effective but at a higher cost, and the overall ICER was well below the acceptable threshold mentioned in each study, indicating the interventions could potentially be implemented after careful interpretation. The studies were graded as high quality (13/15) or fair quality (2/15), with some methodological inconsistencies reported.

CONCLUSION

Counselling and smartphone-based interventions are cost-effective, and they have the potential to reduce the chronic adherence problem significantly. The quality of decision models can be improved by addressing inconsistencies in model selection, data inputs incorporated into models and uncertainty assessment methods.

A mobile app for chronic disease self-management for individuals with low health literacy: A multisite randomized controlled clinical trial

Objective

The purpose of this study was to evaluate the effects of a mobile app designed to improve chronic disease self-management in older adult patients with low health literacy and who had at least one chronic health condition, and to assess the impact of delivering information at different levels of reading difficulty.

Methods

A randomized controlled trial was completed at two sites. Individuals 40 years of age and older screened for low health literacy who had at least one chronic health condition were randomly assigned to a tailored information multimedia app with text at one of three grade levels. Four primary outcomes were assessed: patient activation, chronic disease self-efficacy, health-related quality of life, and medication adherence.

Results

All groups showed overall increases in activation, self-efficacy, and health-related quality of life, but no change in medication adherence. No between-group differences were observed.

Conclusions

The mobile app was effective in increasing participants' levels of several psychosocial variables, but reading difficulty level was not significantly related to outcomes.Registered at clinicaltrials.gov NCT02922439.

Creating a Tailored Info App to Promote Self-Management Skills in Persons with Chronic Health Conditions: Development Strategies and User Experience

Persons with chronic health conditions, such as heart disease, diabetes, hypertension, and others, often experience self-management problems that are not disease specific. These include disrupted sleep, pain, memory issues, and challenges in working with healthcare providers. These patients may benefit from information and skill development for these problems, but simply providing them information in brief sessions during clinical appointments or in handouts or pamphlets may not have a substantial impact on their behavior. Providing information tailored to persons' needs and individual characteristics has a greater impact on patients' behavior and may increase these persons' abilities to manage their health. Creating tailored information for each person, however, is labor intensive, making it difficult to use in everyday clinical practice. Computer-based tailoring is an alternative, allowing automated tailoring of information presented to patients based on their interactions with a computer app. The purpose of this article is to describe our process in developing a series of modules for chronic disease self-management for persons 40 years of age or older with one or more chronic health conditions.

Development of a computerized intervention to improve health literacy in older Hispanics with type 2 diabetes using a pharmacist supervised comprehensive medication management

Objective

The primary objective was to develop a computerized culturally adapted health literacy intervention for older Hispanics with type 2 diabetes (T2D). Secondary objectives were to assess the usability and acceptability of the intervention by older Hispanics with T2D and clinical pharmacists providing comprehensive medication management (CMM).

Materials and methods

The study occurred in three phases. During phase I, an integration approach (i.e., quantitative assessments, qualitative interviews) was used to develop the intervention and ensure cultural suitability. In phase II, the intervention was translated to Spanish and modified based on data obtained in phase I. During phase III, the intervention was tested for usability/acceptability.

Results

Thirty participants (25 older Hispanics with T2D, 5 clinical pharmacists) were included in the study. Five major themes emerged from qualitative interviews and were included in the intervention: 1) financial considerations, 2) polypharmacy, 3) social/family support, 4) access to medication/information, and 5) loneliness/sadness. Participants felt the computerized intervention developed was easy to use, culturally appropriate, and relevant to their needs. Pharmacists agreed the computerized intervention streamlined patient counseling, offered a tailored approach when conducting CMM, and could save them time.

Conclusion

The ability to offer individualized patient counseling based on information gathered from the computerized intervention allows for precision counseling. Future studies are needed to determine the effectiveness of the developed computerized intervention on adherence and health outcomes.

Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH

OBJECTIVES

Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information.

METHODS

Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness.

RESULTS

Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use.

CONCLUSIONS

Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.

Cost-effectiveness of a Medical Care Coordination Program for People With HIV in Los Angeles County

Background

The Los Angeles County (LAC) Division of HIV and STD Programs implemented a medical care coordination (MCC) program to address the medical and psychosocial service needs of people with HIV (PWH) at risk for poor health outcomes.

Methods

Our objective was to evaluate the impact and cost-effectiveness of the MCC program. Using the CEPAC-US model populated with clinical characteristics and costs observed from the MCC program, we projected lifetime clinical and economic outcomes for a cohort of high-risk PWH under 2 strategies: (1) No MCC and (2) a 2-year MCC program. The cohort was stratified by acuity using social and clinical characteristics. Baseline viral suppression was 33% in both strategies; 2-year suppression was 33% with No MCC and 57% with MCC. The program cost $2700/person/year. Model outcomes included quality-adjusted life expectancy, lifetime medical costs, and cost-effectiveness. The cost-effectiveness threshold for the incremental cost-effectiveness ratio (ICER) was $100 000/quality-adjusted life-year (QALY).

Results

With MCC, life expectancy increased from 10.07 to 10.94 QALYs, and costs increased from $311 300 to $335 100 compared with No MCC (ICER, $27 400/QALY). ICERs for high/severe, moderate, and low acuity were $30 500/QALY, $25 200/QALY, and $77 400/QALY. In sensitivity analysis, MCC remained cost-effective if 2-year viral suppression was ≥39% even if MCC costs increased 3-fold.

Conclusions

The LAC MCC program improved survival and was cost-effective. Similar programs should be considered in other settings to improve outcomes for high-risk PWH.

What are the barriers and challenges faced by adolescents when searching for sexual health information on the internet? Implications for policy and practice from a qualitative study

OBJECTIVES

As sexual health information is increasingly presented digitally, and adolescents are increasingly seeking sexual health information on the internet, it is important to explore the challenges presented by this developing source of information provision. This study examined the key barriers and challenges faced by young people when accessing and using sexual health information online.

METHODS

A novel qualitative approach was used which combined paired interviews with real-time online activities. A purposive sample of 49 young people aged between 16 and 19 years and diverse in terms of gender, sexuality, religion and socio-demographic background were recruited from areas across Scotland. Data analysis comprised framework analysis of conversational data (including pair interactions), descriptive analysis of observational data, and data integration.

RESULTS

This study highlighted practical and socio-cultural barriers to engagement with online sexual health content. Key practical barriers included difficulty filtering overabundant content; limited awareness of specific, relevant, trusted online sources; difficulties in finding locally relevant information about services; and difficulties in navigating large organisations' websites. Key socio-cultural barriers included fear of being observed; wariness about engaging with visual and auditory content; concern about unintentionally accessing sexually explicit content; and reticence to access sexual health information on social networking platforms or through smartphone applications. These practical and socio-cultural barriers restricted access to information and influenced searching practices.

CONCLUSION

This study provides insights into some of the key barriers faced by young people in accessing and engaging with sexual health information and support online. Reducing such challenges is essential. We highlight the need for sexual health information providers and intervention developers to produce online information that is accurate and accessible; to increase awareness of and promote reliable, accessible sources; and to be sensitive to young people's concerns about 'being seen' accessing sexual health information regarding audio-visual content and platform choice.

A mixed analysis approach to elucidate the multiple chronic condition experience of English- and Spanish-speaking older adults

Background

Having multiple chronic conditions (MCCs) is the most common health condition in older adults. The management of each condition presents many challenges. A key factor in patients’ ability to manage their own health care is their level of health literacy.

Purpose

The purpose of this mixed analysis study was to elucidate the experience of older adults living with MCCs and identify associations among the experiences to determine targets for future mobile health (mHealth) interventions focused on MCCs and health literacy.

Participants and methods

Using the Abilities, Skills, and Knowledge Model as a framework, semi-structured interviews were completed with 25 older adults in English and Spanish. Interviews were analyzed using inductive thematic analysis and hierarchical cluster analysis.

Results

The main themes from these results included 1) Reflections of chronic disease; 2) Emotional aspects of chronic disease; 3) Physical barriers to well-being; 4) Quality-of-care factors; and 5) Cognitive strategies for self-management. Qualitative results highlighted the importance of a multi-targeted approach to chronic disease self-management (CDSM). Cluster analysis identified associations within the qualitative data, revealing the importance of the subthemes related to coping with pain and the impact of the patient–provider relationship on treatment adherence.

Conclusion

Results support the utility of mHealth interventions to improve health literacy and promote CDSM.

Enhancing the Impact of Mobile Health Literacy Interventions to Reduce Health Disparities

Health literacy is a key factor in health outcomes that should be considered when creating mobile health promotion apps. In this paper, we detail our work over the past 10 years in developing the theory and practice of targeting the content of mobile apps at a level appropriate for the intended audience. We include a review of our theory of health literacy as expertise, the ASK model, and integrate it with the Theory of Planned Behavior. We then provide data that support both the model and its use. More recently, we have developed a predictive analytic model that uses demographic information and patient performance on a 10-item screening measure to determine patient level of health literacy at a high level of accuracy. The predictive model will enable apps to automatically provide content to users at an appropriate level of health literacy. This strategy, along with other aspects of tailoring, will allow apps to be more personally relevant to users, enhancing their effects in promoting health behavior change.

Cost Analysis of Implementing a Video-Based eHealth Intervention for HIV-Positive Gay, Bisexual, and Other Men Who Have Sex With Men

Clinician-delivered HIV prevention interventions are common and often effective but have small reach, particularly in remote, rural, or sparsely populated areas. Electronic health (eHealth) interventions may be an efficient alternative to providing HIV prevention to geographically dispersed or traditionally hard-to-reach populations, though eHealth interventions tend to have high start-up costs. We present cost data from a video-based eHealth intervention, Sex Positive!, among 1,208 U.S. gay, bisexual, and other men who have sex with men living with HIV. Specifically, we provide estimates for the cost of the intervention, overall, and per participant based on funding amounts. The total average cost per participant was $1,021. Sensitivity analyses demonstrated that reaching more participants would greatly reduce the average cost per participant. Findings indicate that the cost per person engaged in an eHealth HIV intervention is consistent with previous studies, and that further scaling up would greatly reduce the cost while increasing reach.

Challenges in the Evaluation of Interventions to Improve Engagement Along the HIV Care Continuum in the United States: A Systematic Review

In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. 'Linkage' studies utilized 11 different outcome definitions, while 'retention' studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework.

A Mobile App for Chronic Disease Self-Management: Protocol for a Randomized Controlled Trial

BACKGROUND

Health literacy is a critically important skill that helps people become active participants in their health care. Multiple studies in the United States and across the world have documented the association of health literacy with multiple health outcomes. In particular, the elderly and many members of minority groups have been shown to have low levels of health literacy; the same groups are disproportionately affected by chronic illnesses. These twin burdens affect the people most in need of the skills and knowledge required for coping with chronic illnesses. Chronic disease self-management (CDSM) is a logical target for a general health literacy intervention. In an approach that spans across specific diseases, CDSM targets problems and skills needed to cope with issues such as fatigue, pain, stress, depression, sleep disturbance, and treatment adherence. In a previous study, we showed that a computer-delivered tailored information intervention targeting health literacy could improve treatment and adherence and be cost effective, but it is not clear that this same strategy will be effective in persons with low health literacy and multiple chronic conditions.

OBJECTIVE

The purpose of this study is to develop a computer-delivered mobile intervention that will provide individuals with chronic conditions the necessary information to cope with their conditions.

METHODS

In this project, we will complete a qualitative study on the status and needs of individuals with more than one chronic condition. Results of this study will be used to develop a mobile tailored information app that will address self-management challenges in the areas of pain, sleep, fatigue, depression, anger, stress, memory problems, and treatment adherence. The impact of the intervention on patient quality of life, patient-provider relationships, health literacy, and patient activation will be assessed. We will also explore the extent to which health literacy mediates important outcomes, such as health-related quality of life and health service utilization.

RESULTS

We are currently completing the preliminary qualitative and usability studies that will inform the content and design of the intervention. We anticipate that the intervention will be complete in 2017, and the clinical trial of its efficacy will also commence in 2017.

CONCLUSIONS

Results will provide evidence on the usefulness of a mobile tailored information app for improving health literacy, patient activation, health-related quality of life, and self-reported health in patients with multiple chronic conditions.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02922439; https://clinicaltrials.gov/ct2/show/NCT02922439 (Archived by WebCite at http://www.webcitation.org/6pTiqDAyN).

Cost-effectiveness analysis along the continuum of HIV care: how can we optimize the effect of HIV treatment as prevention programs?

The cascade of HIV care has been proposed as a useful tool to monitor health system performance across the key stages of HIV care delivery to reduce morbidity, mortality, and HIV transmission, the focal points of HIV Treatment as Prevention campaigns. Interventions to improve the cascade at its various stages may vary substantially in their ability to deliver health value per amount expended. In order to meet global antiretroviral treatment access targets, there is an urgent need to maximize the value of health spending by prioritizing cost-effective interventions. We executed a literature review on economic evaluations of interventions to improve specific stages of the cascade of HIV care. In total, 33 articles met the criteria for inclusion in the review, 22 (67 %) of which were published within the last 5 years. Nonetheless, substantial gaps in our knowledge remain, particularly for interventions to improve linkage and retention in HIV care in developed and developing-world settings and generalized and concentrated epidemics. We make the case here that the attention of scientists and policymakers needs to turn to the development, implementation, and rigorous evaluation of interventions to improve the various stages of the cascade of HIV care.

Virtual intervention to support self-management of antiretroviral therapy among people living with HIV

Background

Living with human immunodeficiency virus (HIV) necessitates long-term health care follow-up, particularly with respect to antiretroviral therapy (ART) management. Taking advantage of the enormous possibilities afforded by information and communication technologies (ICT), we developed a virtual nursing intervention (VIH-TAVIE) intended to empower HIV patients to manage their ART and their symptoms optimally. ICT interventions hold great promise across the entire continuum of HIV patient care but further research is needed to properly evaluate their effectiveness.

Objective

The objective of the study was to compare the effectiveness of two types of follow-up—traditional and virtual—in terms of promoting ART adherence among HIV patients.

Methods

A quasi-experimental study was conducted. Participants were 179 HIV patients on ART for at least 6 months, of which 99 were recruited at a site offering virtual follow-up and 80 at another site offering only traditional follow-up. The primary outcome was medication adherence and the secondary outcomes were the following cognitive and affective variables: self-efficacy, attitude toward medication intake, symptom-related discomfort, stress, and social support. These were evaluated by self-administered questionnaire at baseline (T0), and 3 (T3) and 6 months (T6) later.

Results

On average, participants had been living with HIV for 14 years and had been on ART for 11 years. The groups were highly heterogeneous, differing on a number of sociodemographic dimensions: education, income, marital status, employment status, and living arrangements. Adherence at baseline was high, reaching 80% (59/74) in the traditional follow-up group and 84% (81/97) in the virtual follow-up group. A generalized estimating equations (GEE) analysis was run, controlling for sociodemographic characteristics at baseline. A time effect was detected indicating that both groups improved in adherence over time but did not differ in this regard. Improvement at 6 months was significantly greater than at 3 months in both groups. Analysis of variance revealed no significant group-by-time interaction effect on any of the secondary outcomes. A time effect was observed for the two kinds of follow-ups; both groups improved on symptom-related discomfort and social support.

Conclusions

Results showed that both interventions improved adherence to ART. Thus, the two kinds of follow-up can be used to promote treatment adherence among HIV patients on ART.

Development of a culturally appropriate computer-delivered tailored Internet-based health literacy intervention for Spanish-dominant Hispanics living with HIV

BACKGROUND

Low health literacy is associated with poor medication adherence in persons with human immunodeficiency virus (HIV), which can lead to poor health outcomes. As linguistic minorities, Spanish-dominant Hispanics (SDH) face challenges such as difficulties in obtaining and understanding accurate information about HIV and its treatment. Traditional health educational methods (e.g., pamphlets, talking) may not be as effective as delivering through alternate venues. Technology-based health information interventions have the potential for being readily available on desktop computers or over the Internet. The purpose of this research was to adapt a theoretically-based computer application (initially developed for English-speaking HIV-positive persons) that will provide linguistically and culturally appropriate tailored health education to Spanish-dominant Hispanics with HIV (HIV + SDH).

METHODS

A mixed methods approach using quantitative and qualitative interviews with 25 HIV + SDH and 5 key informants guided by the Information-Motivation-Behavioral (IMB) Skills model was used to investigate cultural factors influencing medication adherence in HIV + SDH. We used a triangulation approach to identify major themes within cultural contexts relevant to understanding factors related to motivation to adhere to treatment. From this data we adapted an automated computer-based health literacy intervention to be delivered in Spanish.

RESULTS

Culture-specific motivational factors for treatment adherence in HIV + SDH persons that emerged from the data were stigma, familismo (family), mood, and social support. Using this data, we developed a culturally and linguistically adapted a tailored intervention that provides information about HIV infection, treatment, and medication related problem solving skills (proven effective in English-speaking populations) that can be delivered using touch-screen computers, tablets, and smartphones to be tested in a future study.

CONCLUSION

Using a theoretically-grounded Internet-based eHealth education intervention that builds on knowledge and also targets core cultural determinants of adherence may prove a highly effective approach to improve health literacy and medication decision-making in this group.

Negative and positive beliefs related to mood and health

OBJECTIVES

To observe whether elderly patients' positive and negative beliefs about efforts improving or maintaining health are related to health and mood.

METHODS

We developed a brief scale to assess these beliefs. Factor analysis was used to evaluate its dimensions; the extent to which the scale's dimensions mediate the relationship between mood and self-reported health was explored.

RESULTS

Analyses show that the scale reflects a general factor as well as 2 subscales that evaluate distinct but related positive and negative dimensions. The scale was not related to race, sex, or education, but showed modest relations to age. Scales were significantly related to mood, health status, and health-related quality of life.

CONCLUSIONS

Both negative and positive beliefs mediated the relation between depression and self-reported health.

Health literacy: impact on the health of HIV-infected individuals

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

Commentary: demonstrating cost-effectiveness in pediatric psychology

OBJECTIVE

Changes in the health care system and payment plans will likely require pediatric psychologists to illustrate the impact of their services. Cost-effectiveness analyses are one method of demonstrating the potential economic benefits of our services but are rarely used by pediatric psychologists.

METHOD

A hypothetical cost-effectiveness analysis was conducted, comparing the costs and outcomes between a behavioral adherence intervention and no intervention for youth with acute lymphoblastic leukemia.

RESULTS

Results illustrate how pediatric psychologists can use cost-effectiveness analyses to demonstrate the economic impact of their work.

CONCLUSIONS

Efforts to conduct economic analyses could allow pediatric psychologists to advocate for their services. Implications and future directions are discussed.

Development and initial validation of a computer-administered health literacy assessment in Spanish and English: FLIGHT/VIDAS

Current measures of health literacy have been criticized on a number of grounds, including use of a limited range of content, development on small and atypical patient groups, and poor psychometric characteristics. In this paper, we report the development and preliminary validation of a new computer-administered and -scored health literacy measure addressing these limitations. Items in the measure reflect a wide range of content related to health promotion and maintenance as well as care for diseases. The development process has focused on creating a measure that will be useful in both Spanish and English, while not requiring substantial time for clinician training and individual administration and scoring. The items incorporate several formats, including questions based on brief videos, which allow for the assessment of listening comprehension and the skills related to obtaining information on the Internet. In this paper, we report the interim analyses detailing the initial development and pilot testing of the items (phase 1 of the project) in groups of Spanish and English speakers. We then describe phase 2, which included a second round of testing of the items, in new groups of Spanish and English speakers, and evaluation of the new measure’s reliability and validity in relation to other measures. Data are presented that show that four scales (general health literacy, numeracy, conceptual knowledge, and listening comprehension), developed through a process of item and factor analyses, have significant relations to existing measures of health literacy.