Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study

Effectiveness of Pictorial Education Handout on Tracheostomy Care Self-efficacy in Patients With Head and Neck Cancer and Family Caregivers: A Pilot Quasi-Experimental Study

BACKGROUND

Learning and performing tracheostomy care are challenging for laypersons. Effective pictorial patient education handouts are needed for nonprofessional individuals to learn health management skills.

OBJECTIVES

The study aims to (1) evaluate the preliminary efficacy of the pictorial education handout on patients' and family members' self-efficacy in tracheostomy care and (2) identify demographic, psychological, and education-related factors associated with lower self-efficacy on tracheostomy care.

INTERVENTIONS/METHODS

This was a preliminary pilot study with a pretest-posttest design. We recruited a total of 39 participants, including 22 patients with head and neck cancer-related tracheostomy and 17 family caregivers in 2021. All participants received A3-size (297 × 420 mm) pictorial patient education handouts on how to suction and how to clean their tracheostomy at home.

RESULTS

Pictorial education handouts showed a medium to large effect size on self-efficacy in the patient (Cohen D = 0.46) and caregiver participants (Cohen D = 0.78). Participants with higher anxiety were associated with a greater gain in self-efficacy with the pictorial patient education handouts ( r = 0.35, P = .027).

CONCLUSIONS

Pictorial patient education handouts were effective tools for improving patients' and family caregivers' confidence in tracheostomy care, and it is particularly helpful for individuals with high anxiety with tracheostomy.

IMPLICATION FOR PRACTICE

Clinical nurses should use the pictorial education handouts not only to assist patients and family members on learning and practicing tracheostomy care but also to relieve anxiety associated with tracheostomy care at home.

The effect of nurse health literacy interventions on patient health literacy scores in specialty consultations: a quasi-experimental study

BACKGROUND

Patient health literacy (HL) affects health and wellbeing on both individual and population levels. The ability to receive, understand, manage and act upon health information can be positively influenced by nurses' use of HL strategies. This study examined the relationship between nurses' use of a HL checklist (intervention) and before and after patient HL scores, and the effects of frequency and types of strategies used in specialty consultations in Spain.

METHODS

This quasi-experimental, non-randomized study used the HLS19-Q12 to calculate HL scores for 149 patients. Calculations were performed both before and after a nursing intervention that consisted of using a HL checklist. Paired samples t-test assessed the difference between patient HL scores pre- and post-nurse intervention. Frequency analysis and Pearson correlation where used to examine frequencies of nursing HL strategies used and associations with HL scores.

RESULTS

The mean difference between the HLS19-Q12 scores before and after intervention was - 9.94, with a standard deviation of 11.50. There was a statistically significant effect of the intervention on HL score (t = -10.00, p < 0.001). No participant had HL classified as 'inadequate' after the nursing intervention. Verbal teach back method was the most frequent strategy used by nurses, and the use of a computer image was the most frequent visual aid.

CONCLUSIONS

The use of a standardized HL intervention by nurses was shown to have a positive effect on patient general HL scores in specialty consultations in Spain. These results not only suggest that the use of a HL checklist can be an effective HL tool, but also reinforce the potential of nurses to make a positive impact on both individual and population health. Overall, these findings provide data that can be used by health systems, hospitals management, and nurse education programs to adopt strategies to improve patient HL and health outcomes, while potentially lowering costs and ineffective resource utilization related to inadequate HL.

Parental knowledge and attitudes toward food allergies: a cross-sectional study on determinants and educational needs

BACKGROUND

Food allergy (FA) may often lead to fatal consequences if it is treated promptly. Parents of children with FA should have adequate knowledge to improve health outcomes and reduce the associated burden. This study aimed to examine the knowledge and attitudes regarding FA among parents of children with FA.

METHODS

This was a cross-sectional study conducted among parents attending a primary healthcare center using convenience sampling. The minimum sample size of 280 was calculated using an equation based on the local prevalence of FA among children, and was increased to account for missing data. The data were collected using a four-section questionnaire that collected data about the parents and their children and included questions about knowledge and attitudes regarding FA. The knowledge score was calculated by summing the number of correct answers, with a maximum of 15 points. The Mann-Whitney and Kruskal-Wallis tests were used to examine the associations between the knowledge score and other variables. Spearman's correlation was employed to test the correlations between the knowledge score and other variables.

RESULTS

A total of 381 parents completed the questionnaires, of whom 71.9% were mothers and 28.1% were fathers. The prevalence of food allergies was 14.22%. Almost one-third had children who had one or more types of FA (32.8%). Most of those patients had received a professional diagnosis of FA (75.3%). The median knowledge score was 7.0 (IQR = 6-8), with variable proportions of correct answers across and within topics. A higher knowledge score was significantly associated with parenting a child with FA (p = 0.006), comorbid asthma or eczema (p = 0.012), the preference to acquire information from professional health agencies (p < 0.001), and higher educational (p = 0.002) and income (p = 0.001) levels. Moreover, the number of discussions held with a healthcare professional regarding FA was significantly correlated with the knowledge score (r = 0.210, p = 0.019). Online resources were the most commonly reported source of information (65.4%). Parents believed that having a child with FA can cause stress in the family (76.1%) and impact siblings' daily lives (66.7%), while only a minority viewed FA as stigmatizing. Additionally, the majority encouraged governmental spending on FA research (92.9%).

CONCLUSIONS

Parenting a child with FA, comorbid asthma or eczema, number of discussions held with healthcare professionals, and education and income levels were significantly associated with a higher knowledge score. Educational interventions targeting parents should blend emotional regulation, medical information, and management skills to increase knowledge about FA and alleviate associated stress.

Health literacy profiles of medical students in an Australian Doctor of Medicine programme: A cross-sectional study using the Health Literacy Questionnaire

ISSUE ADDRESSED

With the emerging focus on designing health-literate organisations and health care systems, it is essential to understand the health literacy profiles of the medical workforce including medical students, as medical professionals play a key role in within these systems. Medical professionals contribute to good patient health outcomes through enabling access to appropriate health care, provision of quality health information and collaborative shared decision-making, which are fundamental health literacy competencies. The aim of this study is to identify health literacy strengths and weaknesses of medical students enrolled in an Australian Doctor of Medicine programme.

METHODS

Students from all 4 years of an Australian Doctor of Medicine programme were invited to complete an anonymous, online survey in January 2021. Health literacy profiles were identified using the 9-domain, 44-item multi-dimensional Health Literacy Questionnaire, a validated tool which comprehensively evaluates health literacy strengths and weaknesses from diverse perspectives. Demographic characteristics and social attributes were also recorded. The results were compared with Australian Bureau of Statistics data.

RESULTS

Eighty-six participants completed the survey. Most participants were female students (57%) who spoke English at home (88%) with tertiary-educated fathers (60%) and resided in locations associated with high socioeconomic status during adolescence (61%). Males scored significantly higher in three domains which explored health information access and appraisal, and ability to actively engage with health care providers. Students' scores were significantly lower than the Australian general population in Domain 6 (Ability to actively engage with health care providers) and Domain 7 (Navigating the health care system).

CONCLUSIONS

Medical students' health literacy profiles indicate areas of weakness in their ability to engage with health care providers and to navigate the health system. Medical educators will need to create opportunities to address these weaknesses within medical curricula. Gender differences identified in self-rated ability to access and appraise health information requires further exploration. SO WHAT?: Further understanding of health literacy profiles of medical students may influence design of medical school curricula.

Health literacy and household financial loss on malaria treatment for children under five in Ghana: a patients' perspective

BACKGROUND

Inadequate health literacy increases medical costs and leads to poor health outcomes. However, there is a paucity of empirical evidence of such associations in sub-Saharan Africa. This study investigates how the household cost of malaria in children under five in Ghana varies based on different levels of health literacy.

METHODS

A cross-sectional survey involving 1270 caregivers of children under five was conducted. The survey included health literacy questionnaire and several pieces of sociodemographic and behavioural variables.

RESULTS

We created seven caregiver health literacy profiles by scoring nine dimensions. The mean total cost for managing malaria among respondents was US$20.29 per episode. The total household cost for caregivers with high health literacy (Profile 1) (US$24.77) was higher than all other profiles, with the lowest cost (US$17.93) among the low health literacy profile (Profile 6). Compared with Profile 4, caregivers with high health literacy (Profile 1) spent more on managing malaria in children, while those with the lowest health literacy (Profile 7) spent less.

CONCLUSION

The current study presents a snapshot of malaria treatment costs, and argues that low health literacy may lead to increased costs due to possible reinfections from delayed healthcare use. There is a need for longitudinal studies to understand causal relationship between health literacy and household expenses on malaria treatment to inform policy development and interventions.

LAY SUMMARY

This study explores the impact of caregiver health literacy levels on the cost of managing malaria incidents in children under five in Ghana. High health-literate caregivers incurred the highest total household cost at US$24.77, with US$17.93 incurred by lower health-literate caregivers per malaria episode.

Socioeconomic Disparities Associated with Access to Oculofacial Plastic Surgeons: A Cross-Sectional Analysis of US County Demographics

PURPOSE

To compare population demographics with the geographic distribution of oculofacial plastic surgeons (OPSs) in the United States.

DESIGN

A cross-sectional study design was used to investigate demographic differences between counties with 1 or more OPSs and counties with zero OPSs.

PARTICIPANTS

The number of OPSs were identified in each US county using online public databases: American Society of Ophthalmic Plastic and Reconstructive Surgeons and American Academy of Ophthalmology. Counties were categorized into 2 groups: 1 or more OPSs and zero OPSs. Demographic characteristics at the county level were obtained from the 2021 US Census Bureau Population Estimates and the American Community Survey. Cost of living was collected from the 2022 Economic Policy Institute Family Budget Calculator.

MAIN OUTCOME MEASURES

Socioeconomic demographics of the US population as related to geographic OPS distribution.

RESULTS

A total of 1238 OPSs were identified. States with the most OPSs per million were Hawaii (6.2), D.C. (6.0), Connecticut (5.8), Utah (5.1), and Maryland (5.0). Among 3143 counties, 2725 (86.7%) had zero OPSs and 418 (13.3%) had 1 or more OPSs. Counties with 1 or more OPSs had a higher median (standard deviation) household income versus counties with zero OPSs ($72 471 [$19 152] vs. $56 152 [$13 675]; difference $16 319; 95% confidence interval [CI], $14 300-$18 338; P < 0.001). The annual cost of living per person (standard deviation) was higher in counties with 1 or more OPSs versus counties with zero OPSs ($39 238 [$6992] vs. $36 227 [$3516]; difference $3011; 95% CI, $2328-$3694; P < 0.001). Counties with zero OPSs versus counties with 1 or more OPSs had higher proportions of persons with only Medicaid (15.6% vs. 13.6%; difference 2.0%; 95% CI, 1.4%-2.5%; P < 0.001), no health insurance (9.9% vs. 8.0%; difference 1.9%; 95% CI, 1.5%-2.4%; P < 0.001), no household internet access (17.2% vs. 9.6%; difference 7.6%; 95% CI, 7.1%-8.0%; P < 0.001), and higher proportions of persons aged 65 years or older (20.0% vs. 17.0%; difference 3.0%; 95% CI, 2.5%-3.5%; P < 0.001).

CONCLUSIONS

This cross-sectional analysis of all US counties revealed socioeconomic disparities associated with access to OPSs.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

An Introduction to Health Literacy and Social Contexts with Recommendations for Health Professionals and Researchers

Rarely do individuals seek, obtain, and understand health information in a solitary void [...].

Health literacy in orthopaedic lower limb trauma patients: A cross-sectional survey study

INTRODUCTION

The aim of this study was to investigate orthopaedic lower limb trauma patients' comprehension regarding the affected bone, the surgical implant used, and postoperative instructions, and to evaluate the relationship between sociodemographic features and health literacy.

HYPOTHESIS

There is a relationship between health literacy levels, the medical awareness of orthopaedic trauma patients and sociodemographic characteristics.

MATERIAL AND METHODS

The cross-sectional survey study was conducted from June to September 2021 in the orthopaedic clinic of a level 1 trauma centre. The study group consisted of 225 patients with a surgically treated unilateral lower limb fracture. The questionnaire consisted of 3 parts: (1) sociodemographic information, (2) knowledge about ongoing orthopaedic treatment, and (3) 16-item version of The European Health Literacy Survey (HLS-EU-Q16).

RESULTS

Of the patients in the study, 46% were not aware that they were using thromboembolism prophylaxis, and 10% did not use the prophylaxis. More than half of the patients did not know which bone was fractured, three-quarters did not know what type of implant had been used for the fracture fixation, and approximately 90% of the patients did not know their weight-bearing status and the expected healing time after surgery. Inadequacy of HLS-EU-Q16 score with a median of 34.4, (range, 0-50) was 38.7% (n=87).

DISCUSSION

Orthopaedic lower limb trauma patients demonstrated inadequate health literacy with low comprehension of their injuries, surgeries, and discharge schemes. This study's results show the need to promote more effective communication between orthopaedic trauma patients and healthcare providers. Identifying inadequate health literacy in patients and developing appropriate interventions before discharge may help improve outcomes.

LEVEL OF EVIDENCE

II; cross sectional.

Oral Health Strategies: Surveying the Present to Plan the Future of Community-Based Learning

Introduction: Oral health literacy relates to the capacity of individuals to acquire, understand and to act upon oral health information to make appropriate health decisions. This scientific review's main goal is to analyze the strategies that improve oral health literacy within the community, specifically oriented to a community-based learning model focused on the most vulnerable risk groups in society. Materials and Methods: The current review is based on the literature on oral health literacy within community-based learning strategies. The present review selected scientific studies by searching MEDLINE and related databases, such as Web of Science and PUBMED, and by consulting existing bibliographies. Results: Based on the application of the inclusion criteria to the abstracts, 45 publications were retrieved which explicitly dealt with the definitions of oral health literacy, community-based learning, and service learning. Several studies have demonstrated that health consumers with low health literacy fail to understand the available health information. Therefore, innovative oral health literacy strategies should be undertaken. Service learning is an example of an educational approach where the student learns specific soft skills in the classroom and collaborates directly with an agency or institution and engages in reflection activities to deepen their understanding of what is being taught. Conclusions: One of the main strategies used to incorporate the oral health professional in social responsibility and direct contact in the community is through experiencing community-based learning projects. The future graduate must be an educator capable of educating patients in order to themselves acquire high-level skills in oral health literacy.

Navigating Health Literacy and Practices: A Cross-Sectional Study on Nursing Undergraduates in Riyadh, Saudi Arabia

BACKGROUND This study aimed to assess the health literacy (HL) and health practices (HP) among nursing undergraduates at King Saud University in Riyadh, Saudi Arabia. MATERIAL AND METHODS A cross-sectional survey-based study was conducted in 2023 to assess how nursing students perceive HL and HP. HL is the ability of individuals to acquire, interpret, assess, and act on information to promote and maintain good health, while HP involves the application of knowledge and skills. HL was assessed using a total of 16 items, subdivided into 4 domains (understanding, evaluating, accessing, and utilizing health information) while HP was assessed using 11 items on a 5-point Likert scale. RESULTS In this study, 53.9% of the students were found to have poor HP, while 40.9% (n=166) reported moderate HP, and 5.2% (n=21) reported good HP. With regards to HL, 38.9% (n=158) of students were found to have good HL while 52.2% (n=212) reported moderate HL, and 8.9% (n=36) reported poor HL. The findings indicated that there was a relationship between age and HP, indicating that age is a major predictor of HP (P=0.001). Other comparisons, including year of study, income source, marital status, and the prevalence of chronic conditions, were discovered to have a significant relationship (P=0.001) with HP levels. CONCLUSIONS According to these findings, most students reported poor HP, while one-third claimed good HL. Therefore, there is a need to address the factors related to poor HP while also recommending methods to support good HP among students.

Health literacy education at the time of COVID-19: development and piloting of an educational programme for university health professional students in 4 European countries

BACKGROUND

Health literacy has a strong influence on individual health outcomes and the sustainability of healthcare systems. Healthcare professionals often overestimate patients' health literacy levels and lack adequate competencies to address limited health literacy effectively. Therefore, promoting understanding through effective health communication between professionals and citizens is becoming increasingly important. Although health literacy has recently gained more attention, health literacy educational programmes targeting future healthcare professionals are still scarce, especially in Europe. This study describes the piloting process of a pan-European health literacy educational programme and shows how the educational material is being used during time of crisis such as the COVID-19 pandemic.

METHODS

The educational programme was developed through the definition of an educational philosophy and iterative co-creation processes consisting of stakeholders' consultations, material development and pilots with students. The evaluation was carried out in Italy through four pilot tests involving 107 students of health-related degrees. An evaluation questionnaire and a pre-post test were developed and used to collect students' and educators' feedback (quantitative and qualitative) and assess changes in health literacy awareness, respectively. Three additional pilots were organized in Italy and Germany mostly during the COVID-19 pandemic to evaluate the feasibility of the educational programme through online and hybrid learning, respectively.

RESULTS

The pilots received positive feedback from both students and educators. Students were highly satisfied with the courses, reported their relevance for their future profession and appreciated the interactive teaching methods. The pre-post test showed a significant improvement in health literacy awareness after the training. Educators reported the adequacy and flexibility of the training material, the ease of transferability of the content of the lessons into practice, and the validity of the tested options to integrate the educational programme into the curricula.

CONCLUSIONS

Our comprehensive, evidence-based educational programme contributes to addressing the existing challenges in Europe, and its flexibility allows for easy integration in the curricula, through different options, hence supporting a widespread uptake in the European Union and maybe beyond. Health literacy education is a useful tool to improve citizens' access to healthcare information and services, achieve better health outcomes and support healthcare systems' sustainability.

Health Literacy of Caregivers

Caregivers have an important role in supporting the health of individuals who are dependent for cognitive or physical reasons. Health literacy levels of caregivers affect quality of care and health outcomes. The purpose of this descriptive study was to assess health literacy in the caregivers of home care patients. The participants were caregivers aged 18 to 65 (N = 140). Data collected included sociodemographic characteristics, The Lawton Instrumental Activities of Daily Living Scale and The Adult Health Literacy Scale. The mean age of participants in the study was 48 years and 74% were women. The health literacy score was 16.77±3.31. A significant relationship was found between health literacy and education level (p = .000), working status (p = .012), and perception of income (p = .016). Education level was the only predictor of health literacy by logistic regression analysis. Studies aimed at determining health knowledge, skill deficiencies, and education needs of caregivers can provide important information to protect and improve the health of individuals in need of care and increase their quality of life.

The Use of Multidimensional Nomial Logistic Model and Structural Equation Model in the Validation of the 14-Item Health-Literacy Scale in Chinese Patients Living with Type 2 Diabetes

Objective

To evaluate the psychometric properties of the 14-item health literacy scale (HL-14) in patients living with type 2 diabetes mellitus (T2DM) in clinical setting.

Methods

Cross-sectional study using item response theory and structural equation modeling (SEM) for testing the item difficulty and three dimensional-HL configurations was adopted in this study. Chinese patients living with T2DM admitted to endocrinology department of Huadong hospital were evaluated by the HL-14 including communication, functional and critical health literacy from August to December 2021.

Results

The multidimensional random coefficients multinomial logistic model indicated the difficulty settings of the scale are appropriate for the study populations, and differential item functioning was not observed for sex in the study. SEM demonstrated that the three-dimensional configuration of the scale is good in the study population (x2/df=2.698, Comparative Fit Index = 0.965, Root Mean Square Error of Approximation = 0.076, standard residual mean root = 0.042).

Conclusion

The HL-14 scale is a reliable and valid measurement, which can perform equitably across sex in evaluating the health literacy in Chinese patients living with T2DM. Moreover, the scale may help fill the gaps of multidimensional health literacy assessment and rapid screening of health literacy ability for clinical practice.

Prevalence and factors associated with sexual and reproductive health literacy among youth living with HIV in Uganda: a cross-sectional study

BACKGROUND

Adequate sexual and reproductive health literacy (SRHL) among young people has been linked to informed sexual behaviours. Studies on SRHL have largely been conducted among the general adolescent population. Little is known about youth aged 15-24 years living with human immunodeficiency virus (YLHIV). There is a possible lack of SRHL in this population, considering the high rate of teenage pregnancies and unprotected sex reported by YLHIV. This study aimed to assess the prevalence and associated personal and environmental factors for SRHL among YLHIV at a high-volume urban HIV Clinic in Uganda.

METHODS

Through a cross-sectional survey, YLHIV receiving routine HIV care services at Baylor-Uganda HIV Clinic were interviewed using an adapted European Health Literacy Survey (HLS-EU). Using simple random sampling, eligible youth who received HIV care services between August and November 2019 were enrolled in the study. SRHL scores were computed using the HLS-EU index method; and individuals whose scores ranged from 34 to 50 were considered health literate. We used descriptive statistics to determine the prevalence. Potential associated personal and environmental factors (p<0.05) were identified by performing two-step inferential statistics, bivariate analysis and binary logistic regression. Odds ratios were calculated to estimate the likelihood of youth being health literate on sexual and reproductive health (SRH) issues in comparison with the reference categories, and 95% confidence intervals were determined to establish whether the relationships were statistically significant.

RESULTS

Of the 267 YLHIV interviewed at Baylor-Uganda HIV Clinic, 167 (62.5%) were female with a mean age of 18.9 years (SD± 2.8), and the majority (242; 90.6%) were vertically infected with HIV. Only 52 (19.5%) were health literate on SRH issues. At the multivariate level, YLHIV who never had difficulty accessing SRH information were 0.391 times less likely to be health literate on SRH issues than their counterparts with challenges in accessing SRH information (Adjusted Odds Ratio [AOR] = 0.391, 95% CI =0.178 to 0.860; p= 0.019). YLHIV who did not find it easy to access SRH care service points were 2.929 times more likely to be literate in SRH than those who found it easy to access such services (Adjusted Odds Ratio [AOR] = 2.929, 95% CI =1.241 to 6.917; p=0.014). Additionally, YLHIV who did not listen to radio health talks were 2.406 times more likely to be health literate on SRH issues than those who did (AOR = 2.406, 95% CI =1.133 to 5.112; p=0.022).

CONCLUSIONS

SRHL is an unmet need among YLHIV; only 19.5% were health literate on SRH issues. This could complicate the achievement of the UNAIDS sustainable development goal (SDG) of an HIV/AIDS-free generation by 2030 because low health literacy (HL) skills can affect the efficacy of almost all HIV disease prevention and health promotion efforts. Inaccessible SRH care service points and not listening to radio health talks were positively associated with SRHL, while having access to SRH information was negatively associated with SRHL.

Measuring Medication Use, Obstacles, and Knowledge in Individuals With Cirrhosis

BACKGROUND & AIMS

Although patient knowledge is modifiable, there are no widely accepted tools to measure patient understanding during cirrhosis care. We aimed to develop and validate "My Cirrhosis Coach" (MCC), a personalized, self-administered questionnaire to evaluate cirrhosis-related medication use, obstacles, and understanding.

METHODS

Adults with cirrhosis were prospectively enrolled at 3 tertiary centers from July 2016 through July 2020. Psychometrics including confirmatory factor analysis was used to develop and validate a final questionnaire. Content validity was measured via the content validity index and expert performance. Discriminant validity was assessed by comparing scores between groups hypothesized to have varying performance.

RESULTS

The MCC was tested in a diverse cohort (n = 713) with cirrhosis and its complications including ascites (45%) and hepatic encephalopathy (33%) with median Model for End-Stage Liver Disease-Sodium 10 (interquartile range, 9-15). A 6-factor model of the MCC fit the data well (root mean square error of approximation, 0.22; comparative fit index, 0.96; standardized root mean squared residual, 0.104; final domains: Medication Use & Accessibility, Medication Obstacles, Lactulose Use, Diuretic Use, Beta Blocker Use, and Dietary Sodium Use). The MCC had excellent content validity (content validity index, 81%-94%) and accuracy (91%-100%) ratings by experts. Mean domain scores ranged from 1.1 to 2.6 (range, 0-3; 3 indicating better performance). Those with a cirrhosis complication scored higher in the relevant medication domain (ie, diuretic use score in ascites). Compared with outpatients, inpatients scored higher in all knowledge domains except salt use and reported more medication obstacles. Scores differed by income, education level, and having an adult at home.

CONCLUSIONS

In a large, diverse cohort, we validated the MCC, which can serve to standardize medication use and knowledge measurement in clinical practice and education-based studies in cirrhosis.

Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review

A projected rise in patients with complex health needs and a rapidly ageing population will place an increased burden on the healthcare system. Care coordination can bridge potential gaps during care transitions and across the care continuum to facilitate care integration and the delivery of personalised care. Despite having a national strategic vision of improving care integration across different levels of care and community partners, there is no consolidation of evidence specifically on the salient dimensions of care coordination in the Singapore healthcare context. Hence, this scoping review aims to uncover the key themes that facilitate care coordination for patients with chronic conditions in Singapore to be managed in the community while illuminating under-researched areas in care coordination requiring further exploration. The databases searched were PubMed, CINAHL, Scopus, Embase, and Cochrane Library. Results from Google Scholar were also included. Two independent reviewers screened articles in a two-stage screening process based on the Cochrane scoping review guidelines. Recommendation for inclusion was indicated on a three-point scale and rating conflicts were resolved through discussion. Of the 5792 articles identified, 28 were included in the final review. Key cross-cutting themes such as having standards and guidelines for care programmes, forging stronger partnerships across providers, an interoperable information system across care interfaces, strong programme leadership, financial and technical resource availabilities and patient and provider-specific factors emerged. This review also recommends leveraging these themes to align with Singapore's national healthcare vision to contain rising healthcare costs.

The Readability and Accountability of Online Patient Education Materials Related to Common Oculoplastics Diagnoses and Treatments

PURPOSE

To assess the readability and accountability of online patient education materials related to oculoplastic diagnoses and treatments, and to determine the source of information encountered by patients searches.

METHODS

We conducted a Google search for 20 search terms related to common oculoplastic diagnoses and treatments and analyzed the first 10 patient education websites populated for each term. Readability was assessed using four validated measures: Gunning Fog Index, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, and New Dale-Chall Readability. Accountability was assessed using 4 JAMA benchmarks on a scale of 0-4, with one point awarded for each of the following accountability criteria provided on the website: (1) including all authors and their relevant credentials (2) listing references (3) providing disclosures and (4) providing date of last update.

RESULTS

The average grade level of 200 websites analyzed was 10.89, with 29% written at less than the 6^th grade reading level recommended by the American Medical Association. The source of online information was most frequently educational institutions (36%) and private practices (34%), with fewer online patient education materials from national organizations (18%) and crowdsourced websites (12%). There were no significant differences in readability when comparing searches related to oculoplastics diagnoses versus treatments. Websites averaged 0.91 out of a maximum of 4 recommended accountability criteria, reflecting low overall accountability.

CONCLUSIONS

Online education resources encountered by patients are often written at inappropriate reading levels and demonstrate low accountability. Online patient education materials are most frequently maintained by educational institutions and private practices, with fewer articles from national organizations. Revision of online materials may be necessary to improve health literacy among oculoplastic patients.

Health literacy of pregnant women attending antenatal care clinics in Mansoura district, Egypt

BACKGROUND

Health literacy (HL) is an important maternal factor that is involved in the engagement of a mother and her children with health promotion and preventive activities. Studies have found poor HL in large proportions of the population of both developed and developing countries. This study measures the HL of pregnant women and explores its associated factors.

METHODS

A cross-sectional study was conducted on 382 pregnant women attending antenatal care clinics in Mansoura district, Egypt, using an interviewer-administered questionnaire. The Arabic version of the European Health Literacy Survey Questionnaire-short version (HLS-EU-Q16) was used to assess the HL of the participants.

RESULTS

The study showed that 79.8% of studied pregnant women had limited HL (34.5% insufficient HL and 45.3% problematic HL), and only 20.2% of them had sufficient HL. Limited HL was independently predicted by unsatisfactory income (OR = 6.9; 95% confidence interval [CI]: 3.2-15.3; P ≤ 0.05), lower than university education (OR = 5.3; 95% CI: 1.6-17.2; P ≤ 0.05), and having unplanned pregnancy (OR = 3.7; 95% CI: 1.6-8.5; P ≤ 0.05).

CONCLUSION

The majority of pregnant women in this study had limited HL. It was more frequent among women with lower levels of education, insufficient incomes, and unplanned pregnancies. Antenatal care programs should provide services that respond to the HL level and needs of pregnant women.

The development and progress of health literacy in China

Limited health literacy is a serious public health problem. It is strongly associated with increased hospital admissions and readmission, poorer self-management, and health outcomes. It can lead to poor management of chronic disease, lower health care quality, increased mortality, and higher healthcare expenditures. Understanding China's current situation and the progress of health literacy levels are critical to achieving practical solutions for improving population health. This paper intended to provide a concise overview of the key milestones and specific practices in health literacy in China. We summarized the characteristics and changing profile of health literacy from 2008 to 2020 in China. We developed an intervention framework based on social ecosystem theory for improving health literacy in China. Meanwhile, some multi-level actionable recommendations were proposed. The study revealed that China has made progress in improving health literacy in the last decades. Health literacy levels increased from 6.48% of the population in 2008 to 23.15% in 2020. Geographic disparities were substantial. The East performed better health literacy than the Central and West, and cities had higher adequate health literacy than rural areas. Social development index, age, and education level were highly associated with health literacy. A global joint effort to improve health literacy will be required. And we advocate a whole-of-society approach that involves the participation of the entire ecosystem around the targeted population.

Validation of the Short-Test of Functional Health Literacy in Adults for the Samoan Population

BACKGROUND

Health literacy encompasses various levels of communication for an individual, provider, and an organization. Validated and reliable tools have been developed to assess health literacy; however, there is a paucity of tools available to assess health literacy in native languages for indigenous and racial/ethnic minority populations.

OBJECTIVE

This article shares the process taken to translate and evaluate validation and reliability of the Short Test of Functional Health Literacy in Adults for use with the Samoan population.

METHODS

Respondent-driven sampling was used to collect data from 1,543 adults age 45 years and older in American Samoa. A confirmatory factor analysis using a two-factor model for validation was conducted.

KEY RESULTS

The validation results indicated a "good fit" in multiple indices and Cronbach's alpha indicated high internal consistency in both the English and Samoan languages.

CONCLUSIONS

Developing culturally validated and reliable health literacy assessment tools is important to help health care professionals decrease health disparities and address inadequate health literacy in all cultures. [HLRP: Health Literacy Research and Practice. 2022;6(4):e247-e256.] Plain Language Summary: The INSPIRE project studied the Short Test of Functional Health Literacy in Adults (STOFHLA) tested on the American Samoan population age 50 years and older. The results would show if the STOFHLA is a valid tool to measure functional health literacy in American Samoa adults.

Community health literacy outcome measurement practices: A scoping review of recent interventions

Introduction

Evidence suggests that, while a preference for functional Health Literacy (HL) outcome measurement exists, researchers are converging towards more all-encompassing instruments. While this claim is present in the HL field, minimal research has comprehensively explored the state of community HL measurement practices at the direct and proxy level. The almost exclusive focus on direct, as opposed to proxy, community HL measurement indicates a review of progress is needed.

Objective

To identify HL outcome measurement practices for community HL interventions at the direct and proxy level of measurement.

Search Strategy

Medline, PsycINFO, Web of Science, ERIC, Embase, Scopus, CINAHL, ProQuest Dissertations and Theses, Google Scholar and targeted websites were searched.

Inclusion Criteria

Studies were sampled from the general population, included HL as an outcome of interest, involved an intervention aiming to improve HL, were English-text publications and were published ≥2010.

Data Extraction and Synthesis

Study author(s) and publication years, sample characteristics, intervention profiles and direct and proxy instrument and outcome measurement information were extracted. Full-text review retrieved 25 eligible studies.

Main Results

In total, 21 unique direct and 38 unique proxy instruments were extracted. The majority of interventions assessed functional compared to communicative, critical, and other HL domains, with objective instruments more frequently used than subjective or combined objective-subjective types, though more unique subjective HL instruments were extracted overall. The Test of Functional HL in Adults was the most popular instrument, and perceived health, knowledge, behaviors and health intentions were the most frequent proxy outcome measures, with only the Healthy Lifestyle Behavior Scale-II and Patient Activation Measure used across multiple interventions.

Discussion and Conclusions

Direct HL outcome practices endured a unidimensional profile, despite previous suggestions of a convergence towards holistic instruments. This review provides the first overview of proxy HL measurement across community HL interventions, identifying substantial variation in proxy outcome practices.

Patient or Public Contribution

A University-based senior librarian contributed to the development of the search strategy, and reviewed iterations of the strategy until refinement was complete. No further public or patient contribution was made given the review-based nature of the research.

Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration

Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.

Validity and reliability of the Portuguese version of the rapid estimate of adult literacy in dentistry: REALD-29 PT

BACKGROUND

Health literacy is a main factor in health for its improvement, allowing the individuals to have a greater capacity to engage and participate in collective health promotion actions. The evaluation of functional health literacy is essential to determine the ability that each individual has to understand basic health information. The present study aimed to perform the translation and cross-cultural adaptation of the Rapid Estimate of Adult Literacy in Dentistry-30 to the Portuguese language and test the reliability and validity of this version.

METHODS

After translation and cultural adaptation, the instrument was applied to a group of individuals that participate in the program Atividade Senior, developed by the municipality of Viseu, Portugal. The final sample was composed by 206 participants that accepted responding to the translated version of the instrument. Statistical validation was accomplished to complete the process and obtain the final instrument. One question was removed for the creation of the final instrument with 29 questions, therefore being named Rapid Estimate of Adult Literacy in Dentistry-29 PT.

RESULTS

The Rapid Estimate of Adult Literacy in Dentistry-29 PT presented good internal reliability. Cronbach's alpha ranged from 0.89 to 0.90 when words were deleted individually. The analysis of test-retest reliability revealed excellent reproducibility. We can verify that the Rapid Estimate of Adult Literacy in Dentistry-29 PT scale for assessment of oral health literacy among older adults presents an acceptable internal consistency, with a global Cronbach´s alpha of 0.894.

CONCLUSIONS

The new scale can be applied to assess oral health literacy among older Portuguese adults, presenting an acceptable internal consistency and is validated to assess oral health literacy and is crucial in epidemiological studies.

Measuring Health Literacy in Primary Healthcare: Adaptation and Validation of a French-Language Version of the Brief Health Literacy Screening among Patients with Chronic Conditions Seen in Primary Care

Background: The Brief Health Literacy Screening (BHLS) is a short self-report instrument developed to identify patients with inadequate health literacy. This study aimed to translate the BHLS into French Canadian (BHLS-FCv) and to evaluate its psychometric properties among patients with chronic conditions in primary care. Methods: The BHLS was translated into French using the Hawkins and Osborne’s method. Content validity was evaluated through cognitive interviews. A validation study of the BHLS-FCv was conducted in two primary care clinics in the province of Quebec (Canada) among adult patients with chronic conditions. Psychometric properties evaluated included: internal consistency (Cronbach’s alpha); test–retest reliability (intraclass correlation coefficient); and concurrent validity (Spearman’s correlations with the Health Literacy Questionnaire (HLQ)). Results: 178 participants completed the questionnaire at baseline and 47 completed the questionnaire two weeks later over the telephone. The average score was 13.3. Cronbach’s alpha for internal consistency was 0.77. The intraclass correlation coefficient for test–retest reliability was 0.69 (95% confidence interval: 0.45–0.83). Concurrent validity with Spearman’s correlation coefficient with three subscales of HLQ ranged from 0.28 to 0.58. Conclusions: The BHLS-FCv demonstrated acceptable psychometric properties and could be used in a population with chronic conditions in primary care.

Health Information Sources Influencing Health Literacy in Different Social Contexts across Age Groups in Northern Thailand Citizens

Health literacy is an essential social determinant of health and has been associated with positive health outcomes. While many sources of health information are widely available, people of different ages also have diverse social contexts and preferences for health information sources. This study aimed to identify health information sources and socio-demographics influencing health literacy in different social contexts across age groups: 15–29 years (young), 30–59 years (middle-age), and ≥60 years (elderly). We obtained secondary data from a cross-sectional study in northern Thailand from March to August 2019. Multivariate linear regression with age group subgroup analysis was used to determine factors associated with general health literacy by the Thai version of the health literacy questionnaire. Receiving health information from physicians was significantly associated with higher general health literacy in young (β 6.45, 95%CI 0.44–12.45; p = 0.035) and elderly (β 5.18, 95%CI 1.84–8.52; p = 0.002) groups, while receiving health information from health volunteers was significantly associated with a higher general health literacy in the middle-aged (β 2.89, 95%CI 0.38–5.39; p = 0.024) group. Although younger participants showed more frequent access to health information via the media than the other age groups, there were no media sources significantly linked with their general health literacy. Health information from physicians is a vital source of health information.

Scoping review: Influence of cisgender male and female genders on health literacy of the elderly people

This scoping review mapped out the relevant literature, identified gaps and made suggestions on the influence of cisgender on the health literacy (HL) of the elderly people. This scoping review was guided by the PRISMA-ScR checklist. The databases Wiley Online Library™ and Elsevier™ were searched for academic articles published in the English language between February 2011 and February 2021 that met a pre-set criteria of content. The process of selection of sources of evidence based on screening and eligibility of evidence reduced the initially identified 153 sources of evidence in the searched databases to 14 sources of evidence. The content of these 14 sources of evidence was mapped out on a charting table where data was summarised and synthesised individually and collectively by the authors. Repetitive and irrelevant data were deleted. Identified gaps include the lack of extensive exploration of male and female genders alone as a determinant of HL, how gender may be utilised to encourage elderly men and women to apply HL, how different sociocultural and sociodemographic backgrounds of elderly men and women would require separate academic research, the scarcity of social sciences based research and qualitative research methodologies on the subject as well as the use of mixed-methodologies and longitudinal studies. Future research directions were suggested and limitations of this scoping review are addressed in the discussion.

Low health literacy and multiple medications in community-dwelling older adults: a population-based cohort study

OBJECTIVES

Adequate health literacy is important for patients to manage chronic diseases and medications. We examined the association between health literacy and multiple medications in community-dwelling adults aged 50 years and older in England.

DESIGN, SETTINGS AND PARTICIPANTS

We included 6368 community-dwelling people of median age 66 years from the English Longitudinal Study of Ageing. Health literacy was assessed at wave 5 (2010/11) with 4 questions concerning a medication label. Four correct answers were categorised as adequate health literacy, otherwise low. Data on medications were collected at wave 6 (2012/13). To examine the difference in the number of medications between low and adequate health literacy, we used zero-inflated negative binomial regression, estimating odds ratio (OR) for zero medication and incidence rate ratios (IRR) for the number of medications, with 95% CIs. Associations were adjusted for demographic, socioeconomic and health characteristics, smoking and cognitive function. We also stratified the analysis by sex, and age (50-64 and ≥65 years). To be comparable with preceding studies, multinomial regression was fitted using commonly used thresholds of polypharmacy (0 vs 1-4, 5-9, ≥10 medications).

RESULTS

Although low health literacy was associated with a lower likelihood of being medication-free (OR=0.64, 95% CI: 0.45 to 0.91), health literacy was not associated with the number of medications among those at risk for medication (IRR=1.01, 95% CI: 0.96 to 1.05), and this finding did not differ among younger and older age groups or women. Among men, low health literacy showed a weak association (IRR=1.06, 95% CI: 0.99 to 1.14). Multinomial regression models showed graded risks of polypharmacy for low health literacy.

CONCLUSIONS

Although there was no overall association between health literacy and the number of medications, this study does not support the assertion that low health literacy is associated with a notably higher number of medications in men.

Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans

INTRODUCTION

Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period.

MATERIALS AND METHODS

A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records.

RESULTS

Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01).

CONCLUSIONS

In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Do health literacy levels of nursing students change throughout the study programme? A cross-sectional study

OBJECTIVES

The aim of this research was to analyse if the level of health literacy (HL) of nursing students changes throughout the study programme.

DESIGN

A cross-sectional study with anonymous self-reporting was conducted.

PARTICIPANTS/SETTING

329 public university nursing students in Seville, Spain; 243 of the first year and 86 of the fourth.

INTERVENTIONS

The short Spanish version of the Health Literacy Survey Questionnaire-European Union was used to evaluate HL.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportions of the limited level of HL were compared between academic years and the crude and corrected OR were calculated with the Mantel-Haenszel test to evaluate the effect of confusion of the sex variable on the HL level and academic year relationship. A logistic regression model with step-by-step analysis was run, including the independent variables sex, age, marital status, academic year and HL level (limited/sufficient) as the dependent variable.

RESULTS

62.1% of the participants of the first year versus 47.7% of the fourth year had a limited literacy level for a crude OR of 1.5 (95% CI 1.10 to 2.21; p=0.014) and a corrected by sex OR of 1.8 (95% CI 1.10 to 2.96; p=0.026). Only the strata in women had a statistically significant relationship. The logistic regression model ratified that the HL was a function exclusive to the academic year.

CONCLUSION

The HL level of nursing students increases from the first to the fourth academic year, even when controlling for sex. Although the HL level in the fourth academic year was greater than that of the first, both groups had inadequate HL levels. It is hence recommended to implement intervention strategies, which reinforce in the curriculum the knowledge and experiences related with health communication and education to ensure that future professionals improve their HL. Achieving adequate HL is crucial to be able to provide care to patients, their families and the community.

Health Literacy in Surgical Oncology Patients: An Observational Study at a Comprehensive Cancer Center

BACKGROUND

Low health literacy is associated with increased resource use and poorer outcomes in medical and surgical patients with various diseases. This observational study was designed to determine (1) the prevalence of low health literacy among surgical patients with cancer at an NCI-designated Comprehensive Cancer Center (CCC), and (2) associations between health literacy and clinical outcomes.

METHODS

Patients receiving surgery (N=218) for gastrointestinal (60%) or genitourinary cancers (22%) or sarcomas (18%) were recruited during their postsurgical hospitalization. Patients self-reported health literacy using the Brief Health Literacy Screening Tool (BRIEF). Clinical data (length of stay [LoS], postacute care needs, and unplanned presentation for care within 30 days) were abstracted from the electronic medical records 90 days after surgery. Multivariate linear and logistic regressions were used to examine the relationship between health literacy and clinical outcomes, adjusting for potential confounding variables.

RESULTS

Of 218 participants, 31 (14%) showed low health literacy (BRIEF score ≤12). In regression analyses including 212 patients with complete data, low health literacy significantly predicted LoS (β = -1.82; 95% CI, -3.00 to -0.66; P=.002) and postacute care needs (odds ratio [OR], 0.25; 95% CI, 0.07-0.91). However, health literacy was not significantly associated with unplanned presentation for care in the 30 days after surgery (OR, 0.51; 95% CI, 0.20-1.29).

CONCLUSIONS

This study demonstrates the prevalence of low health literacy in a surgical cancer population at a high-volume NCI-designated CCC and its association with important clinical outcomes, including hospital LoS and postacute care needs. Universal screening and patient navigation may be 2 approaches to mitigate the impact of low health literacy on postsurgical outcomes.

Building health literacy system capacity: a framework for health literate systems

The human and social implications of poor health literacy are substantial and wide-ranging. Health literacy represents the personal competencies and organizational structures, resources and commitment that enable people to access, understand, appraise and use information and services in ways that promote and maintain good health. A large-scale societal improvement of health literacy will require political buy-in and a systematic approach to the development of health literacy capacity at all levels. This article builds the case for enhancing health literacy system capacity and presents a framework with eight action areas to accommodate the structural transformation needed at micro, meso and macro levels, including a health literate workforce, health literate organization, health literacy data governance, people-centred services and environments based on user engagement, health literacy leadership, health literacy investments and financial resources, health literacy-informed technology and innovation, and partnerships and inter-sectoral collaboration. Investment in the health literacy system capacity ensures an imperative and systemic effort and transformation which can be multiplied and sustained over time and is resilient towards external trends and events, rather than relying on organizational and individual behavioural change alone. Nevertheless, challenges still remain, e.g. to specify the economic benefits more in detail, develop and integrate data governance systems and go beyond healthcare to engage in health literacy system capacity within a wider societal context.

Validity and reliability of the Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale in patients undergoing bariatric surgery in Sweden: a prospective psychometric evaluation study

OBJECTIVES

The aim was to psychometrically test and evaluate the Swedish functional health literacy scale and the Swedish communicative and critical health literacy scale in patients undergoing bariatric surgery.

DESIGN

A prospective cross-sectional psychometric study.

SETTING

Patients from three bariatric centres in Sweden were consecutively included in this study.

PARTICIPANTS

A total of 704 patients undergoing bariatric surgery filled in the questionnaires preoperatively. Inclusion criteria were scheduled for primary bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) and greater than 17 years, proficiency in Swedish.

PRIMARY AND SECONDARY MEASURES

Psychometric outcomes of the Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale.

RESULTS

There was a higher proportion of females (74.4%, n=523) to males (25.6%, n=180). The mean age was 42 years (SD 11.5). Limited functional health literacy and limited communicative and critical health literacy (including both inadequate and problematic health literacy) was reported in 55% (n=390) and 40% (n=285), respectively. Cronbach alpha for the Swedish Functional Health Literacy scale was α=0.86 and for the Swedish Communicative and Critical Health Literacy scale, α=0.87. Construct validity showed weak to negative correlations between the Swedish Functional Health Literacy scale and income, education and SF-36/RAND36 summary scores. Confirmatory factor analysis showed a one-factor solution for the Swedish Functional Health Literacy scale and a two-factor solution for the Swedish Communicative and Critical Health Literacy scale.

CONCLUSIONS

The Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale are valid and reliable to use for patients undergoing bariatric surgery in a Swedish context. Measuring dimensions of health literacy can be used as a guide for the development of health literacy friendly patient information in patients undergoing bariatric surgery.

Use of the pictorial Sleepiness and Sleep Apnoea Scale in Chinese patients with suspected obstructive sleep apnoea syndrome

Background

Sleep related breathing disorders represent a significant health burden. Being able to stratify patients according to their need for differing types of investigation and predicting the likelihood of obstructive sleep apnoea syndrome (OSAS) is helpful. This study attempts to assess the value of a pictorial Sleepiness and Sleep Apnoea Scale (pSSAS) in this process.

Methods

A total of 126 sequential patients attending a sleep service with suspected OSAS completed the pSSAS, the Epworth Sleepiness Score (ESS), and the Berlin Questionnaire (BQ) prior to full polysomnography.

Results

With Apnoea-hypopnea index (AHI) >15 as the positive diagnostic criterion, the area under the receiver operating characteristic curve (AUC) of the BQ was the highest (0.683), followed by pSSAS and ESS (AUC 0.648 and 0.516, respectively). With AHI >30 as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.696), followed by BQ and ESS (AUC 0.653 and 0.510, respectively). With MiniSO₂ <80% as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.736), followed by BQ and ESS (AUC 0.634 and 0.516, respectively).

Conclusions

This study shows that the pSSAS which was first tested in a European population performs equally well amongst a Chinese population. The pSSAS performed in a similar fashion to the BQ in predicting those likely to have OSAS and was superior at predicting those who have severe OSAS. Because it is a pictorial questionnaire, it has advantages for those who may have reduced health literacy, a problem which is under-recognized in most healthcare systems.

Health Literate Hawai'i: A Blueprint to Empower Health and Wellbeing

Recent studies have identified high rates of chronic disease in Hawai'i's adults and youth. As the state responds to the COVID-19 pandemic and looks beyond it, the prevention and management of chronic diseases are critical for community health and wellbeing. Low health literacy is more common in rural populations, Filipinos, and Pacific Islanders in Hawai'I, older adults, and many other groups with high rates of chronic disease. Promoting health literacy can reduce chronic disease burdens for individuals, families, and communities. Using the framework of the social-ecological model, which is important for visioning effective chronic disease management and prevention, this article provides a blueprint of layers of influence for building a health literate Hawai'I generally and around chronic disease specifically. The article will close with a call to action informed by the National Action Plan to Improve Health Literacy for stakeholders and providers to address health literacy in the state of Hawai'I in organizations, systems, and policy. These actions should address root causes of disease and help build more equitable health outcomes across the state now and in the future.

Liver health literacy and social stigma of liver disease: A general population e-survey

BACKGROUND

Health literacy is increasingly recognized as an essential determinant for the health of the population. Liver patients report perceived stigma to be a considerable problem. Little is however known about liver health literacy in the general population and to what extent liver disease is considered stigmatizing in comparison with other chronic diseases. We aimed to explore these knowledge gaps.

METHODS

We performed an exploratory e-survey in a statistically representative sample of 500 Swedes from the general population. A questionnaire developed for this purpose investigated awareness, attention, knowledge and attitudes towards liver health and compared some aspects with other common health problems.

FINDINGS

Few worry (23%), think (28%), discuss with their doctor (31%) or hear about liver health in the news (19%). Few (18%) had a liver test in the last year and knew (23%) what is considered a normal liver test. More knew what is considered normal blood pressure (89%), blood sugar (74%) and BMI (73%). Few (22%) talk about liver health, mainly (50%) because abuse is presumed. Many (36%) believe that cirrhosis is only caused by alcohol, 31% that the liver produces urine and 21% that you can survive without a liver. Only mental illness (78%) and obesity (74%) were considered more stigmatizing than liver cirrhosis (61%).

INTERPRETATION

The study confirms often held views that liver health receives less attention than many other health areas. Knowledge about liver health is generally poor, and liver cirrhosis carries significant social stigma. Improving public awareness and knowledge about liver health, and thereby ameliorating stigma, should be essential parts of policy objectives and action plans to improve liver health in Europe.

FUNDING

This research was supported by a general grant from the Bengt Ihre Foundation.

Health promotion via Twitter: a case study of three medical centers in the USA

Healthcare institutions including hospitals and clinics are increasingly using social media platforms, such as Twitter, to raise awareness in the community about health and wellness topics. In line with this trend, this study seeks to understand how three leading medical centers in the USA use Twitter to share educational content about medical conditions, treatments, preventive measures and other health-related topics. A sample of tweets posted by Cleveland Clinic, Johns Hopkins Hospital and Mayo Clinic during a 6-month timeframe was collected and thematically analyzed. The first analysis, which focused on eight popular health topics, showed that diet and cancer were consistently the most and diabetes was the least frequently used topics in the tweets. The second analysis, which drew upon the health belief model to understand the educational themes embedded into the tweets, revealed that the three institutions mainly provided general health advice and information in their tweets and paid less attention to causes and consequences of diseases, preventive strategies and patient success stories. Accordingly, it is recommended that healthcare institutions adjust their tweeting activities and align them with society's health education needs. Such revised content strategies can help medical institutions achieve their health promotion goals more effectively.

Health Literacy, Primary Care Health Care Providers, and Communication

BACKGROUND

Decision-makers and health professionals face challenges in providing quality medical services while optimizing diminishing resources. Health literacy is associated with health outcomes and health system costs and influences the way in which communication is managed in the health system.

OBJECTIVE

This study examined the association between the level of health literacy of service providers in the community, their awareness of health literacy, their attitudes toward health literacy promotion, and the way in which they communicate with patients with low health literacy.

METHODS

A cross-sectional analytic study was conducted among 50 physicians and 50 administrative staff members in community clinics of the Maccabi Health Maintenance Organization in Israel.

KEY RESULTS

Significant positive associations were found (p < .05) between the level of health literacy, the attitudes toward health literacy promotion, and the degree to which special communication techniques were used when treating patients with low health literacy. Significant associations were found (p < .01) between the level of awareness, as well as the attitudes toward health literacy promotion and the degree to which communication techniques were applied. Higher health literacy is associated with more favorable attitudes toward health literacy promotion. Additionally, a significant positive association (p < .01) was found between the attitudes toward health literacy promotion and the use of communication techniques. No mediation was found among the research variables.

CONCLUSIONS

To the best of our knowledge, this is the first study that examines health literacy among physicians. The results indicate gaps in the awareness of, and attitudes toward, health literacy among community health care providers, thus suggesting the need for developing and applying guidelines for improving efforts of health system providers regarding health literacy and for applying recommended tools for health communication. [HLRP: Health Literacy Research and Practice. 2021;5(3):e194-e200.] Plain Language Summary: This study examined the link between the health literacy of health care providers (e.g., physicians, service administrators), their awareness and attitudes toward health literacy promotion, and how they communicate with patients with low health literacy. The findings showed significant and positive relationships between these aspects of health literacy as well as gaps in the health care system that need to be addressed.

Associations between Health Literacy and Sociodemographic Factors: A Cross-Sectional Study in Malaysia Utilising the HLS-M-Q18

Health literacy is progressively seen as an indicator to describe a nation's health status. To improve health literacy, countries need to address health inequalities by examining different social demographic factors across the population. This assessment is crucial to identify and evaluate the strengths and limitations of a country in addressing health issues. By addressing these health inequalities, a country would be better informed to take necessary steps to improve the nation's health literacy. This study examines health literacy levels in Malaysia and analyses socio-demographic factors that are associated with health literacy. A cross-sectional survey was carried out using the HLS-M-Q18 instrument, which was validated for the Malaysian population. Multi-stage random sampling strategy was used in this study, utilising several sampling techniques including quota sampling, cluster sampling, and simple random sampling to allow random data collection. A total of 855 respondents were sampled. Our results showed that there were significant associations between health literacy and age, health status, and health problems. Our findings also suggest that lower health literacy levels were associated with the younger generation. This study's findings have provided baseline data on Malaysians' health literacy and provide evidence showing potential areas of intervention.

Effectiveness of pictographs in improving patient education outcomes: a systematic review

The objective of this review was to investigate process of pictograph development and the effectiveness of pictographs in patient education. We conducted searches in Medline/PubMed, CINAHL with full text, PsycInfo, ERIC and Cochrane Library with keywords: (pictograph or pictorial) AND (patient education) NOT (children or adolescent or youth or child or teenagers). After excluding manuscripts that did not meet inclusion criteria, 56 articles were included between the time of the last review on this topic (January 2008) and May 2019. There are 17 descriptive studies, 27 randomized control trial studies, 9 quasi-experimental studies and 2 unique literatures in the systematic review. Major goals of the studies are pictograph development or validation. The majority of manuscripts (n = 48) supported the approach. However, six studies did not find significant differences in the outcome. Differences in patient population, pictograph designs and author-developed outcome measurements made it difficult to compare the findings. There is a lack of evidence on validating information outcome measurements. This review demonstrated that implementing pictographs into patient education is a promising approach for better information understanding and health management. Pictographic interventions need to be carefully developed and validated with both the targeted patient population and the clinical experts.

Estimating the Economic Burden of Low Health Literacy in the Blacktown Community in Sydney, Australia: A Population-Based Study

Evidence shows that inadequate or low health literacy (LHL) levels are significantly associated with economic ramifications at the individual, employer, and health care system levels. Therefore, this study aims to estimate the economic burden of LHL among a culturally and linguistically diverse (CALD) community in Blacktown: a local government area (LGA) in Sydney, Australia. This study is a secondary analysis of cross-sectional data from publicly available datasets, including 2011 and 2016 census data and National Health Survey (NHS) data (2017–2018) from the Australian Bureau of Statistics (ABS), and figures on Disease Expenditure in Australia for 2015–2016 provided by the Australian Institute of Health and Welfare (AIHW). This study found that 20% of Blacktown residents reported low levels of active engagement with health care providers (Domain 6 of the Health Literacy Questionnaire (HLQ)), with 14% reporting a limited understanding of the health information required to take action towards improving health or making health care decisions (Domain 9 of the HLQ). The overall extra/delta cost (direct and indirect health care costs) associated with LHL in the Blacktown LGA was estimated to be between $11,785,528 and $15,432,239 in 2020. This is projected to increase to between $18,922,844 and $24,191,911 in 2030. Additionally, the extra disability-adjusted life year (DALY) value in 2020, for all chronic diseases and age-groups—comprising the extra costs incurred due to years of life lost (YLL) and years lived with disability (YLD)—was estimated at $414,231,335. The findings of our study may enable policymakers to have a deeper understanding of the economic burden of LHL in terms of its impact on the health care system and the production economy.

Challenges and solutions to employing natural language processing and machine learning to measure patients' health literacy and physician writing complexity: The ECLIPPSE study

OBJECTIVE

In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients' health literacy (HL) and physicians' linguistic complexity by employing natural language processing (NLP) techniques and machine learning (ML). We applied these techniques to > 400,000 patients' and physicians' secure messages (SMs) exchanged via an electronic patient portal, developing and validating an automated patient literacy profile (LP) and physician complexity profile (CP). Herein, we describe the challenges faced and the solutions implemented during this innovative endeavor.

MATERIALS AND METHODS

To describe challenges and solutions, we used two data sources: study documents and interviews with study investigators. Over the five years of the project, the team tracked their research process using a combination of Google Docs tools and an online team organization, tracking, and management tool (Asana). In year 5, the team convened a number of times to discuss, categorize, and code primary challenges and solutions.

RESULTS

We identified 23 challenges and associated approaches that emerged from three overarching process domains: (1) Data Mining related to the SM corpus; (2) Analyses using NLP indices on the SM corpus; and (3) Interdisciplinary Collaboration. With respect to Data Mining, problems included cleaning SMs to enable analyses, removing hidden caregiver proxies (e.g., other family members) and Spanish language SMs, and culling SMs to ensure that only patients' primary care physicians were included. With respect to Analyses, critical decisions needed to be made as to which computational linguistic indices and ML approaches should be selected; how to enable the NLP-based linguistic indices tools to run smoothly and to extract meaningful data from a large corpus of medical text; and how to best assess content and predictive validities of both the LP and the CP. With respect to the Interdisciplinary Collaboration, because the research required engagement between clinicians, health services researchers, biomedical informaticians, linguists, and cognitive scientists, continual effort was needed to identify and reconcile differences in scientific terminologies and resolve confusion; arrive at common understanding of tasks that needed to be completed and priorities therein; reach compromises regarding what represents "meaningful findings" in health services vs. cognitive science research; and address constraints regarding potential transportability of the final LP and CP to different health care settings.

DISCUSSION

Our study represents a process evaluation of an innovative research initiative to harness "big linguistic data" to estimate patient HL and physician linguistic complexity. Any of the challenges we identified, if left unaddressed, would have either rendered impossible the effort to generate LPs and CPs, or invalidated analytic results related to the LPs and CPs. Investigators undertaking similar research in HL or using computational linguistic methods to assess patient-clinician exchange will face similar challenges and may find our solutions helpful when designing and executing their health communications research.

The relationship between health literacy and disease specific costs in subjects with chronic obstructive pulmonary disease (COPD)

AIM

In the present study, we aimed to investigate the relationship between health literacy levels and disease specific costs in subjects with chronic obstructive pulmonary disease (COPD) who were staged according to GOLD.

METHODS

This was a descriptive study. The Health Literacy Scale of the European Union was filled out by all of the participants. Costs related to COPD were taken into account.

RESULTS

Compared to health literacy, the total cost of health care and the cost of admission to the emergency room seemed to be higher for subjects with inadequate health literacy levels than for subjects with significant levels of illness (p = .05 and p = .006, respectively). As the number of comorbidities increased, total and emergency department admission costs increased (p < .001 and p = .003, respectively). There was a difference between GOLD stages according to total, pulmonary disease and emergency service costs.

CONCLUSIONS

In this study, it was determined that health literacy is an important factor affecting health expenditures with COPD subjects. With the improvement of health literacy, subjects are expected to reduce the overall cost burden of the disease.

Health literacy levels of British adults: a cross-sectional survey using two domains of the Health Literacy Questionnaire (HLQ)

Background

A person’s health literacy determines whether they are able to make appropriate health decisions and are able to follow treatment instructions. This is important because low health literacy is associated with mortality and extra costs to the healthcare system. Our aim was to describe the health literacy levels of British adults using a nationally representative population survey, and show how health literacy levels vary by population characteristics.

Methods

A population based cross-sectional survey including questions from two domains from the Health Literacy Questionnaire™: 1) Understanding health information well enough to know what to do, and 2) Ability to actively engage with health care providers. Both domains are made up of 5 Likert style questions with 5 levels ranging from ‘cannot do or always difficult’ (1) to ‘always easy’ (5). The survey was conducted by NatCen in Britain (2018) as part of the annual British Social Attitudes survey. We used weighted descriptive analyses and regression to explore the relationship between population characteristics and health literacy. Weighted analyses were used to ensure the sample was representative of the British population.

Results

A total of 2309 responded to the questionnaire. The mean score for ‘understanding information’ was 3.98 (95% CI: 3.94, 4.02) and for ‘ability to engage’ was 3.83 (95% CI: 3.80, 3.87), where 5 is the highest score. 19.4% had some level of difficulty reading and understanding written health information, and 23.2% discussing health concerns with health care providers. The adjusted logistic regression for ‘understanding information’ showed that those with lower health literacy were more likely to be in the most socially deprived quintile (OR 2.500 95% CI: 1.180, 5.296), have a limiting health condition or disability (OR 4.326 95% CI: 2.494, 7.704), and have no educational qualifications (OR 7.588 95% CI: 3.305, 17.422). This was similar for the ‘ability to engage’ domain.

Conclusions

This study described the distribution of health literacy levels for the British population in 2018. Interventions to improve health literacy will best be targeted at those with lower levels of education, those living in the most deprived areas, and those with a limiting health condition or disability.

Evaluating Health Literacy among Adolescent and Young Adult Pregnant Women from a Low-Income Area of Northeast Brazil

Adequate health literacy is important for strong health outcomes during pregnancy, particularly among mothers with high risk of adverse outcomes related to pregnancy and childbirth. Understanding the health literacy of young pregnant women in low-income settings could support strategies to reduce adverse outcomes in this population. This exploratory study assessed the health literacy of young pregnant adolescents and young adults from a rural area in Northeast Brazil and associated factors such as socioeconomic conditions, adequacy of prenatal care, and social support from family and friends. In this cross-sectional study, 41 pregnant adolescents (13–18 years) and 45 pregnant adults (23–28 years) from the Rio Grande do Norte state, Brazil, were assessed regarding health literacy through the Short Assessment of Health Literacy for Portuguese-Speaking Adults (SAHLPA, score from 0–18, inadequate if <15). Income sufficiency, self-perceived school performance, compliance with recommendations for adequate prenatal care, and social support were also assessed. A linear regression analysis was conducted to evaluate the variables associated with the SAHLPA score. Ninety-five percent of the adolescents and 53.3% of the adults (p < 0.001) presented inadequate health literacy. Adolescent age (β − 3.5, p < 0.001), poorer self-perceived school performance (β − 2.8, p < 0.001), and insufficient income for basic needs (β − 2.8, p = 0.014) were associated with worse SAHLPA scores. Adolescent mothers have higher rates of inadequate health literacy in this population. Policies are needed to improve access to health information for young populations from rural low-income areas.

Health literacy and age-related health-care utilisation: a multi-dimensional approach

Inefficient health service utilisation puts pressure on health systems and may cause such negative individual consequences as over-medicalisation or exacerbation of health problems. While previous research has considered the key relevance of health literacy (HL) for efficient use of health services, the results of that research have been somewhat inconclusive. Possible reasons for diverging results of prior research may be grounded in different measurement concepts of HL and the disregarding of age-specific effects. This paper analyses the association between individuals’ HL typology based on a two-dimensional concept and indicators of health service utilisation measured by registered data covering the number of doctor visits and medication costs. Our results confirm a significant interaction effect between age and HL typology. The age-related increase in health service utilisation is strongest for individuals with the combination of high subjective HL but low health-related knowledge, while the smallest increase is for individuals with the constellation of high subjective HL combined with high health-related knowledge. Individuals with specific constellations of HL (that is, individuals with high subjective HL but low health-related knowledge) are associated with reduced service utilisation in younger ages but higher service utilisation in later stages of life, compared to other groups. These results are likely to be attributed to a higher external health-related locus of control and more traditional paternalistic role expectations in such groups.

Prevalence of limited health literacy and its associated factors in patients with type 2 diabetes mellitus in Perak, Malaysia: a cross-sectional study

OBJECTIVE

Limited health literacy in patients with type 2 diabetes mellitus (T2DM) led to poorer diabetes knowledge, less medication adherence and increased healthcare cost. The purpose of this paper was to report the prevalence of limited health literacy in patients with T2DM and to identify factors that are associated with it.

DESIGN

A cross-sectional study was conducted from January to March 2018; data on patients' sociodemographic characteristics, diabetes knowledge, perceived social support and health literacy level were collected. Health literacy level was measured using the European Health Literacy Survey Questionnaire (HLS-EU-Q47).

SETTING

Patients were recruited from four primary care clinics in Perak, Malaysia.

PARTICIPANTS

Adult patients diagnosed with T2DM who attended the study clinics during the study period.

PRIMARY OUTCOME VARIABLE

Patients with HLS-EU-Q47 General Index of ≤33 points were classified as having limited health literacy.

RESULTS

The prevalence of limited health literacy was 65.3% (n=279). In bivariate analysis, patients' ethnicity (p=0.04), highest education level (p<0.001), monthly income (p=0.003), having health insurance (p=0.007), English language fluency (p<0.001), Malay language fluency (p=0.021), attending diabetes education sessions (p<0.001), perceived social support (p<0.001) and diabetes knowledge (p=0.019) were factors associated with limited health literacy. In logistic regression, not being fluent in English was associated with limited health literacy (OR=2.36, 95% CI 1.30 to 4.30) whereas having high perceived social support (OR=0.52, 95% CI 0.40 to 0.69) and having attended diabetes education sessions (OR=0.42, 95% CI 0.27 to 0.68) were associated with adequate health literacy.

CONCLUSION

The prevalence of limited health literacy is high among patients with T2DM in Perak, Malaysia. Strategies to improve health literacy in these patients must consider the influences of English fluency, attendance at diabetes education sessions and social support, and may need to adopt a universal approach to addressing limited health literacy.