Methodological review: quality of randomized controlled trials in health literacy

Incorporating health literacy principles into the adaptation of a methods motivational interviewing approach for enrolling black adults in a pilot randomized trial

Suboptimal enrollment and retention efforts can compromise the quality of clinical trials. Barriers to enrolling marginalized populations include low awareness/education about clinical trials. Methods-Motivational Interviewing (MMI) is a patient-centered process that integrates education in providing trial information and engages participants in discussions about the trial before enrollment. Though the MMI approach is effective in enhancing trial recruitment and retention, limited studies have incorporated evidence-based health literacy approaches, especially for underrepresented individuals. In this study, prior to the informed consent process, Black adults completed an interactive orientation followed by a small group discussion. The content used health literacy principles including plain language, infographics, and a pictorial roadmap to guide participants about the purpose of a trial, the randomization process, the study objectives, and timeline. Thereafter, two focus groups explored participants' perceptions of the enrollment process. Fifteen participants attended the orientation with 14 enrolled in the trial after the orientation, (93% enrollment rate). Retention was 93% (control) to 100% (intervention) at the end of 6 months. Participants reported positive orientation experiences due to a better understanding of the study information, expectations, and rationale behind randomization. Implementing an adapted MMI approach focused on health literacy principles may improve trial enrollment and retention rates among Black adults.

Health literacy & Chagas disease knowledge: A cross-sectional study in Southern Loja Province, Ecuador

Objective

Health literacy is associated with many patient outcomes. This study sought to determine the association between a person's level of health literacy and their knowledge about Chagas disease.

Methods

A cross-sectional survey was conducted with people living in two counties in rural Loja Province, Ecuador who attended a mobile health clinic. The communities in which the study was conducted are at high risk of Chagas disease and have limited access to both health care and educational resources. The Spanish version of Short Assessment for Health Literacy measured health literacy. The Chagas Disease Knowledge questionnaire measured knowledge of Chagas disease. T-tests and correlational analysis were used to assess associations.

Results

Overall 85 people participated in this study. A majority of the respondents were female (64.1%), and a plurality were married (40.7%) and had education less than secondary (40.7%). The average age of the sample was 44.31 ± 18.85. Health literacy levels and Chagas disease knowledge in the communities were low. About half of people had inadequate health literacy. No association between health literacy and Chagas knowledge was found.

Conclusion

Health literacy levels and Chagas disease knowledge were not found to be correlated. Explanations for the lack of association may include common causes of inadequate investment in Chagas disease education as well as neglect of health systems in rural Ecuador. Efforts to improve both health literacy and Chagas disease knowledge in poorer, rural areas of Ecuador are needed.

Innovation

This is the first study to assess relationships between health literacy and knowledge of Chagas disease in an uninfected population. For novel conditions, relationships between health literacy and disease knowledge should be investigated before communication campaigns are adapted.

Initiating and Maintaining a Lifestyle Program Directed at Persons Living with Severe Mental Illness in a Municipality Care Setting

Lifestyle programs are effective in improving the health of persons living with severe mental illness. However, the implementation of these programs and making them a sustainable part of daily care remain challenging. This qualitative descriptive study aimed to describe how staff worked with and experienced a lifestyle program in a municipality mental health care setting over time. The program intended to support persons living with severe mental illness to overcome health challenges. Data was collected at three time points spanning 7 years. The staff motivated the participants with SMI with severe mental illness to take part in the program, prepared them, and gave them individualized lifestyle support. A key factor of the program's implementation was the staff's interest and engagement in lifestyle questions. According to the staff it was apparent that small efforts such as running the present program could give synergic health effects such as improved mental- and social health. This study shows that it is feasible to conduct this lifestyle program in ordinary care without considerable resources. However, support from management is crucial, as well as the development of guidelines and routines of the work with lifestyle questions.

"A bit of everything": Health literacy interventions in chronic conditions - a systematic review

OBJECTIVE

To systematically evaluate health literacy (HL) interventions in chronic conditions by exploring theoretical perspectives, intervention content and effectiveness.

METHOD

We searched MEDLINE, Cochrane, CINAHL, EMBASE, ERIC, Web of Science and PsycINFO. Standardised systematic review methods were used, and sequences informing our research question were extracted and analysed. The study includes a descriptive summary of the included papers.

RESULTS

We included 39 unique interventions, with diabetes and heart disease as the most targeted chronic conditions. Fifty-four percent of papers included a definition of HL, but the studies showed significant heterogeneity of theoretical underpinnings, modes, measures and content. We identified 23 HL measures, mostly assessing functional HL. The HL interventions were often more complex than the measures indicated. A significant change in HL was found in 28 studies. Study quality was generally poor.

CONCLUSIONS

Interventions optimizing HL appear important to improve health outcomes in chronic conditions. To ensure cumulative knowledge development of this field we need theory-based interventions, consistency in methods and more tailored and comprehensive measures to capture the interventions' complexity.

PRACTICE IMPLICATIONS

A more valid understanding of HL interventions and measurements is needed to reach an agreed understanding of their components and intentions.

Decision-Making Ability: A Missing Link Between Health Literacy, Contextual Factors, and Health

Background:

Health literacy has often been described as an important precondition for good health decisions, healthy behaviors, and health. However, reviews reveal low evidence for intervention effectiveness through health literacy. This result calls for more investigations to be done in the pathway from health literacy to health, considering intermediate outcomes of health literacy.

Objective:

This study explores an important immediate objective of health literacy, namely the decision-making ability (DMA) regarding health issues. The study's hypothesis claims the DMA to be an important mediator between health literacy and health outcomes. Furthermore, the study assumes that the effect of the DMA on different health outcomes is not only contingent on health literacy but also on contextual factors. To test the above hypotheses, six different health literacy dimensions and four health outcomes have been analyzed.

Methods:

Cross-sectional data from the Young Adult Survey Switzerland was used for mediation analyses (N = 4, 569, age, 18 to 25 years, all male). Multiple regression and KHB (Karlson, Holm, and Breen) decomposition analyses were applied to estimate mediation effects between health literacy and health outcomes.

Key Results:

Five of six health literacy dimensions explained the DMA in a linear regression model. The coefficients of the DMA explaining health outcomes were substantially reduced when health literacy items were included into the models (6.1%–20.3%). Furthermore, the associations between health literacy and the health outcomes were fully explained by contextual factors, except in the mental health model.

Conclusions:

The results support the hypothesis that higher health literacy levels do not necessarily lead to better health directly. Rather, health literacy is just one of multiple factors contributing to a higher DMA and, further, to favorable health outcomes. The results of this study call for more investigations in the health decision-making process and the role of contextual factors. [HLRP: Health Literacy Research and Practice. 2022;6(3):e213–e223.]

Plain Language Summary:

The study investigated the ability to make good health decisions while considering health literacy. The results support the intermediate function of the decision-making ability on the path to favorable health outcomes. Furthermore, it is found that the DMA as well as health literacy are highly contingent on contextual factors. The results shed light into the complex decision-making process regarding health issues.

What is the effectiveness of a personalised video story after an online diabetes risk assessment? A Randomised Controlled Trial

Background

Online risk assessment tools for type 2 diabetes communicate risk information to motivate individuals to take actions and reduce their risk if needed. The impact of these tools on follow-up behaviours (e.g., General Practitioner (GP) visits, improvement in health behaviours) is unknown. This study examined effectiveness of a personalised video story and text-based message on GP and health professional visitations and health behaviours, of individuals assessed as ‘high risk’ following completion of the online Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK).

Methods

A Randomised Controlled Trial (conducted between October 2018 and April 2019) included 477 participants with a high score (≥12). The control group received a text-based message (TM) and the intervention group received both the text-based message and a personalised video story (TM+VS) encouraging them to take follow-up action. Participants reported follow-up actions (one- and three months), and physical activity (PA), dietary behaviours and body weight (baseline, one and three months). Generalized Linear Mixed Models and chi-squared tests were used to test differences in outcomes between groups over time.

Results

The intervention was not more effective for the TM+VS group compared to the TM only group (p-values>0.05 for all outcomes). More participants in the TM only group (49.8% compared to 40.0% in the VS+TM group) visited either a GP or health professional (p = 0.18). During the 3-month follow-up: 44.9% of all participants visited a GP (36.7%) and/or other health professional (31.0%). Significant improvements were found between baseline and three months, in both groups for weekly physical activity, daily fruit and vegetable intake and weight status.

Conclusions

Messages provided with online diabetes risk assessment tools to those with high-risk, positively influence GP and health professional visitations and promote short-term improvements in health behaviours that may contribute to an overall reduction in the development of type 2 diabetes.

Trial registration

Australia New Zealand Clinical Trials Registry; ACTRN12619000809134.

Association Between Health Literacy and Work Ability in Employees With Health-Related Risk Factors: A Structural Model

INTRODUCTION

In workplace health promotion (WHP), health literacy and work ability are considered as outcomes of high interest. Therefore, the question arises as to what extent individual health literacy skills have an impact on work ability alongside sociodemographic influences.

OBJECTIVES

This study aimed to examine the associations between a structural model of health literacy as well as sociodemographic context factors and the work ability among employees with health-related risk factors.

MATERIALS AND METHODS

The study was based on baseline data of a workplace-related intervention (158 employees with health-related risk factors, 53.8% women, 48 ± 10 years). Health literacy skills were assessed with Lenartz's Questionnaire (measuring "self-perception", "proactive approach to health", "dealing with health information", "self-control", "self-regulation", and "communication and cooperation"). Work ability was measured by the German Short Form of the Work Ability Index (WAI). As sociodemographic context factors, sex, age, and educational level were assessed. The associations were examined using structural equation modeling with partial least squares (SmartPLS 2.0.M3). Common quality criteria were applied and significance level was set at α = 5%.

RESULTS

Model's reliability, validity, and structure could be validated. Regarding the impact on work ability, "self-regulation" showed a statistically significant direct effect (ß = 0.32, t (∞) = 4.00, p < 0.01, f 2 = 0.09) and "self-perception" had a significant indirect effect (ß = 0.13, t (∞) = 2.53, p < 0.05). The only additional association with work ability was found for age (ß = -0.25, t (∞) = 3.82, p < 0.01, f 2 = 0.04). The WAI score variance was explained to 17.5% by the health literacy skills and to 27.5% considering the additional sociodemographic context factors.

CONCLUSION

According to the structural model of health literacy, in employees with health-related risk factors, a target group-specific WHP approach could be the encouragement of self-regulation and self-perception. However, additional resources and conditions influencing work ability should be considered.

Review of Mendelian Randomization Studies on Endometrial Cancer

Endometrial cancer (EC) is a common gynecological cancer. In some parts of the world, the incidence and mortality of EC are on the rise. Understanding the risk factors of EC is necessary to prevent the occurrence of this disease. Observational studies have revealed the association between certain modifiable environmental risk factors and EC risk. However, due to unmeasured confounding, measurement errors, and reverse causality, observational studies sometimes have limited ability to judge robust causal inferences. In recent years, Mendelian randomization (MR) analysis has received extensive attention, providing valuable insights for cancer-related research, and is expected to identify potential therapeutic interventions. In MR analysis, genetic variation (alleles are randomly assigned during meiosis and are usually independent of environmental or lifestyle factors) is used instead of modifiable exposure to study the relationship between risk factors and disease. Therefore, MR analysis can make causal inference about exposure and disease risk. This review briefly describes the key principles and assumptions of MR analysis; summarizes published MR studies on EC; focuses on the correlation between different risk factors and EC risks; and discusses the application of MR methods in EC research. The results of MR studies on EC showed that type 2 diabetes, uterine fibroids, higher body mass index, higher plasminogen activator inhibitor-1 (PAI-1), higher fasting insulin, early insulin secretion, longer telomere length, higher testosterone and higher plasma cortisol levels are associated with increased risk of EC. In contrast, later age of menarche, higher circulatory tumor necrosis factor, higher low-density lipoprotein cholesterol, and higher sex hormone-binding globulin levels are associated with reduced risk of EC. In general, despite some limitations, MR analysis still provides an effective way to explore the causal relationship between different risk factors and EC.

Intervention Based on Integration of Health Literacy and Health Outcomes in Hypertension “A Systematic Review”

BACKGROUND: Hypertensive patients with low health literacy rarely visit health services, therefore, they have more chances of being hospitalized in comparison with those having a more adequate health literacy. AIM: This article aims to identify intervention based on integration of health literacy and its outcome in hypertensive patients. METHODS: Articles were searched using four bibliographic databases, namely, ProQuest, Science Direct, PubMed, and Google Scholar. PRISMA 2015 is used as a guideline for determining which articles are selected, one of the criteria being published on 2011–2021. RESULTS: A total of 25,264 articles were obtained from the four databases. Seven articles were selected after the extraction and incorporation of the inclusion criteria. The health outcomes of hypertension sufferers after receiving intervention based on integration of health literacy were divided into three groups; medical health outcomes, health literacy skills, and hypertension self-management behavioral. CONCLUSION: An intervention integrated with health literacy and considering the hypertensive patient health literacy in its own will increase the health outcomes of hypertensive patient.

Associations between health-related skills and young adults' work ability within a structural health literacy model

Young adults have a high societal relevance but are still an under-represented target group in health promotion. Health literacy is widely acknowledged as one of the strongest predictors and key determinant of health, so its influence on work ability is of great interest. The purpose of the study was to examine the associations between health-related skills and work ability within the structural model of health literacy of Lenartz, Soellner and colleagues, which explains health behaviour and health through the indirect and direct influence of six 'advanced skills' ('self-perception', 'proactive approach to health', 'dealing with health information', 'self-control', 'self-regulation' and 'communication and cooperation'). The cross-sectional study was based on baseline data of a health literacy promotion intervention (495 vocational school students, 59.0% female, age span 18-25 years). Structural equation modelling with partial least squares was used to examine the associations between the six constructs of the model and the Work Ability Index (WAI). Mean WAI score was 39.7 ± 4.5 (51.1% categorized 'moderate'/'poor'). Five out of six constructs of the model showed a statistically significant indirect or direct effect, respectively, on work ability. The model explained 24.8% of the WAI score variance. Our findings show associations between the health literacy model and the work ability among young employees. In view of demographic change, it is crucial to develop and analyse target group-specific health literacy interventions. The model offers new facets in the modelling of health literacy.

Factors Affecting Rapid Cognitive Decline in Patients with Alzheimer's Disease: A Longitudinal Follow-Up Study

We investigated the preventive and risk factors of rapid cognitive decline in patients with Alzheimer’s disease (AD). Using the Chang Gung Research Database (CGRD), we enrolled patients with AD aged over 65 years between 1 January 2001 and 30 May 2019, and followed up for at least two years. Rapid cognitive decline was defined by a Mini-Mental State Examination (MMSE) score decline of ≥4 in 2 years. A longer prescription of acetylcholinesterase inhibitors (AChEIs) was defined as 22 months based on the median treatment duration of the cohorts. The Cox proportional hazards regression model adjusted for age, sex, medication, and physical comorbidities was used to examine the candidate risk and protective factors. We analyzed data from 3846 patients with AD (1503 men, 2343 women) with a mean age and percentage of females of 77.8 ± 6.2 years and 60.9%, respectively. The mean duration of patients with AD receiving AChEIs was 658.7 ± 21.9 days. In general, 310 patients with AD showed a rapid cognitive decline, accounting for 8.1%. Treatment of a consecutive AChEI prescription for >22 months in patients with AD was a protective factor against rapid cognitive decline (adjusted hazard ratio (aHR) = 0.41, 95% confidence interval (CI) = 0.33–0.52, p < 0.001). Patients with AD aged >85 years (aHR = 0.53, 95% CI = 0.36–0.79, p < 0.01) and aged 75–85 years (aHR = 0.73, 95% CI = 0.57–0.93, p < 0.05) had a significantly lower risk of rapid cognitive decline than those aged 65–75 years. Additionally, patients with mild and moderate AD (clinical dementia rating (CDR = 1, aHR = 1.61, 95% CI = 1.26–2.07, p < 0.001; CDR = 2, aHR = 2.64, 95% CI = 1.90–3.65, p < 0.001) were more likely to have rapid cognitive decline than those with early AD (CDR = 0.5). Sex, medication with different types of AChEIs, and physical comorbidities were not associated with rapid cognitive decline. These findings indicate that it is important to maintain longer consecutive AChEI prescriptions in patients with AD to prevent cognitive decline.

Caregivers' Understanding of Informed Consent in a Randomized Control Trial

There are differences in caregivers' literacy and health literacy levels that may affect their ability to consent to children participating in clinical research trials. This study aimed to explore the effectiveness, and caregivers' understandings, of the process of informed consent that accompanied their child's participation in a dental randomized control trial (RCT). Telephone interviews were conducted with a convenience sample of ten caregivers who each had a child participating in the RCT. Pre-tested closed and open-ended questions were used, and the findings were produced from an inductive analysis of the latter and a descriptive analysis of the former. Participants had limited understanding of the purpose of the RCT and rated the readability of the consent form more highly than they rated their understanding of the research. All felt that informed consent was vital, but some caregivers had not read the consent documents. Some caregivers enrolled their child in the RCT because they trusted the researchers, and the majority wanted to improve dental care for children. The informed consent process was not always effective despite high readability of the informed consent documents. Researchers must consider the health literacy of the study group, and actively engaging with caregivers to achieve meaningful informed consent may be challenging. Future research could explore participants' perspectives of informed consent in populations with low health literacy and assess whether an underlying expectation not to comprehend health-related information may be a barrier to informed consent.

Patient perspectives of nuisance bleeding and adherence to dual antiplatelet therapy: a qualitative study

OBJECTIVE

To understand the experiences of patients with dual antiplatelet therapy (DAPT) and nuisance bleeding, and their perspectives of the impact of nuisance bleeding on medication adherence and information seeking.

METHODS

We conducted focus groups with patients who had undergone percutaneous coronary intervention, coronary artery bypass graft and conservatively managed acute coronary syndrome patients. Two focus groups were with patients at the early stages of treatment (0-3 months), and two with patients coming to the end of treatment (9-12 months). Group discussions were audio recorded, and recordings were transcribed verbatim, anonymised and analysed using framework analysis.

FINDINGS

Nine patients taking DAPT for up to 3 months, and 12 taking DAPT between 9 and 12 months participated in the focus groups. We found that: (1) participants adhered to treatment when they believed DAPT was important to health outcomes; (2) those who experienced nuisance bleeding reported symptoms to be mild and manageable; (3) participants' and their family's understanding of DAPT risks and benefits, and their ability to manage symptoms, influenced perspectives of and experiences with adherence. Factors influencing DAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from hospital.

CONCLUSIONS

Positive attitudes towards adherence were facilitated by knowledge and understanding of DAPT and confidence in dealing with symptoms caused by DAPT, but hindered by lack of opportunities to access relevant, timely and appropriate medication counselling. Education interventions should aim to support medication literacy through family-centred approaches and involve patients and families at all stages of intervention design and evaluation.

Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review

Background

The primary aim of this review was to establish whether health literacy interventions, in adults, are effective for improving health literacy. Two secondary aims assessed the impact of health literacy interventions on health behaviours and whether health literacy interventions have been conducted in cardiovascular patients.

Methods

A systematic review (Prospero registration: CRD42018110772) with no start date running through until April 2020. Eligible studies were conducted in adults and included a pre/post measure of health literacy. Medline, Embase, Eric, PsychINFO, CINAHL, Psychology and Behavioural Science, HMIC, Web of Science, Scopus, Social Care Online, NHS Scotland Journals, Social Policy and Practice, and Global Health were searched. Two thousand one hundred twenty-seven papers were assessed, and 57 full text papers screened to give 22 unique datasets from 23 papers. Risk of bias was assessed regarding randomisation, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting and other biases. Intervention reporting quality was assessed using the TIDieR checklist.

Results

Twenty-two studies were included reporting on 10,997 participants in nine countries. The majority of studies (14/22) were published in 2018 or later. Eight studies (n = 1268 participants) also reported on behavioural outcomes. Health literacy interventions resulted in improvements in at least some aspect of health literacy in 15/22 studies (n = 10,180 participants) and improved behavioural outcomes in 7/8 studies (n = 1209 participants). Only two studies were conducted with cardiovascular patients. All studies were at risk of bias with 18 judged as high risk. In addition, there was poor reporting of intervention content with little explication of the theoretical basis for the interventions.

Conclusions

Health literacy interventions can improve health literacy and can also lead to changes in health behaviours. Health literacy interventions offer a way to improve outcomes for populations most at risk of health inequalities. Health literacy is a developing field with very few interventions using clear theoretical frameworks. Closer links between health literacy and behaviour change theories and frameworks could result in higher quality and more effective interventions.

Prospero registration

Prospero registration: CRD42018110772

Effects of a Classroom Training Program for Promoting Health Literacy Among IT Managers in the Workplace: A Randomized Controlled Trial

OBJECTIVE

IT managers have received limited attention in health literacy research, although they are subject to special professional demands. The aim of this study was to evaluate a training program designed to promote health literacy among managers.

METHODS

A randomized controlled trial with a sample of 171 industry managers from one IT company was conducted. Effects of classroom training on health literacy, psychological well-being, self-rated health, and cortisol awakening response were investigated using pre- (t0), post- (t1), and follow-up (t2) surveys.

RESULTS

The intervention effects (time and group) were not significant for the primary outcome of health literacy. At the second measuring point, psychological well-being and self-rated health significantly decreased, and cortisol awakening response significantly increased.

CONCLUSION

Our study did not show beneficial intervention effects of a training program on promoting health literacy.

Health literacy promotion among young adults: a web-based intervention in German vocational schools

Against the background of an ageing population, the target group of young adults holds strong societal relevance as the future workforce. At the same time, young adults find themselves in a critical phase of life regarding the manifestation of a healthy lifestyle. In this context, young adults' health literacy gains importance. Web-based interventions implemented in educational settings offer the potential for promoting health literacy, although longitudinal studies remain scarce. Within a pre-post cluster randomized controlled trial with 6-month follow-up, this study investigated whether an 8-week web-based intervention in vocational schools (with or without an additional initial face-to-face measure) improves individual competencies within a structural model of health literacy ('self-perception', 'proactive approach to health', 'dealing with health information', 'self-control', 'self-regulation' and 'communication and cooperation'). The control condition was regular school lessons following the curriculum only. A multi-level regression analysis was performed using the control group as reference. None of the interventions showed a significant improvement in any of the dimensions. Significant differences between the intervention and control were obtained for some dimensions, albeit showing reductions. Future research must examine how to build impactful health literacy promotion in educational settings. Investigations into linking digital and face-to-face measures should continue.

The Impact of the Chronic Disease Self-Management Program on Health Literacy: A Pre-Post Study Using a Multi-Dimensional Health Literacy Instrument

This study assessed the impact of the Chronic Disease Self-Management Program (CDSMP) on different domains of health literacy using a pre-post study design. Participants aged over 16 years and with one or more self-reported chronic diseases were recruited for the CDSMP in western Sydney (a highly diverse area of New South Wales, Australia) between October 2014 and September 2018. Health literacy was assessed pre- and immediately post-intervention using the Health Literacy Questionnaire (HLQ), with differences in mean scores for each HLQ domain analysed using paired sample t-tests. A total of 486 participants were recruited into the CDSMP. Of those, 316 (65.0%) completed both pre- and post-intervention surveys and were included in the analysis. The median age of the participants was 68 years, the majority were female (62.5%), and most were born in a country other than Australia (80.6%). There were statistically significant (P < 0.001) improvements across all nine domains of the HLQ. This is the first study evaluating the potential impact of the CDSMP on improving different domains of health literacy amongst a diverse sample of participants with chronic diseases using a multi-dimensional instrument. The absence of a control population in this study warrants caution when interpreting the results.

Effective interventions to improve the health literacy of cancer patients

Health literacy (HL) refers to the cognitive and social abilities that are determinants in the motivation and capacity of the individual to access, understand and use information for the care of one’s own health. In oncology, increased survival, navigation of the healthcare system, the many different forms of treatment and the management of adverse effects/outcomes make HL a critical factor in patient care. The objective of this study is to identify the structure, content and effectiveness of interventions to improve HL in cancer patients.

Skills for Shared Decision-Making: Evaluation of a Health Literacy Program for Consumers with Lower Literacy Levels

Background:

Shared decision-making (SDM) has been found to be significantly and positively associated with improved patient outcomes. For an SDM process to occur, patients require functional, communicative, and critical health literacy (HL) skills.

Objective:

This study aimed to evaluate the impact of a program to improve health literacy skills for SDM in adults with lower literacy.

Methods:

An HL program including an SDM component (HL + SDM) and teaching of the three “AskShareKnow” questions was delivered in adult basic education settings in New South Wales, Australia. The program was evaluated using a partially cluster-randomized controlled trial comparing it to standard language, literacy, and numeracy (LLN) training. We measured the effect of these programs on (1) HL skills for SDM (conceptual knowledge, graphical literacy, health numeracy), (2) types of questions considered important for health decision-making, (3) preferences for control in decision-making, and (4) decisional conflict. We also measured AskShareKnow question recall, use, and evaluation in HL + SDM participants.

Key Results:

There were 308 participants from 28 classes enrolled in the study. Most participants had limited functional HL (71%) and spoke a language other than English at home (60%). In the primary analysis, the HL + SDM program compared with the standard LLN program significantly increased conceptual knowledge (19.1% difference between groups in students achieving the competence threshold; p = .018) and health numeracy (10.9% difference; p = .032), but not graphical literacy (5.8% difference; p = .896). HL + SDM participants were significantly more likely to consider it important to ask questions that would enable SDM compared to standard LLN participants who prioritized nonmedical procedural questions (all p < .01). There was no difference in preferences for control in decision-making or in decisional conflict. Among HL + SDM participants, 79% (n = 85) correctly recalled at least one of the AskShareKnow questions immediately post-intervention, and 35% (n = 29) after 6 months.

Conclusions:

Teaching SDM content increased participants' HL skills for SDM and changed the nature of the questions they would ask health care professionals in a way that would enable shared health decisions. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S58–S74.]

Plain Language Summary:

We developed a health literacy program that included a shared decision-making (SDM) section. The program was delivered in adult basic education classes by trained educators and compared to standard language, literacy, and numeracy training. Teaching SDM content increased participants' health literacy skills for SDM and changed the nature of the questions they would ask health care professionals.

The study design elements employed by researchers in preclinical animal experiments from two research domains and implications for automation of systematic reviews

Systematic reviews are increasingly using data from preclinical animal experiments in evidence networks. Further, there are ever-increasing efforts to automate aspects of the systematic review process. When assessing systematic bias and unit-of-analysis errors in preclinical experiments, it is critical to understand the study design elements employed by investigators. Such information can also inform prioritization of automation efforts that allow the identification of the most common issues. The aim of this study was to identify the design elements used by investigators in preclinical research in order to inform unique aspects of assessment of bias and error in preclinical research. Using 100 preclinical experiments each related to brain trauma and toxicology, we assessed design elements described by the investigators. We evaluated Methods and Materials sections of reports for descriptions of the following design elements: 1) use of comparison group, 2) unit of allocation of the interventions to study units, 3) arrangement of factors, 4) method of factor allocation to study units, 5) concealment of the factors during allocation and outcome assessment, 6) independence of study units, and 7) nature of factors. Many investigators reported using design elements that suggested the potential for unit-of-analysis errors, i.e., descriptions of repeated measurements of the outcome (94/200) and descriptions of potential for pseudo-replication (99/200). Use of complex factor arrangements was common, with 112 experiments using some form of factorial design (complete, incomplete or split-plot-like). In the toxicology dataset, 20 of the 100 experiments appeared to use a split-plot-like design, although no investigators used this term. The common use of repeated measures and factorial designs means understanding bias and error in preclinical experimental design might require greater expertise than simple parallel designs. Similarly, use of complex factor arrangements creates novel challenges for accurate automation of data extraction and bias and error assessment in preclinical experiments.