Beyond Reading and Understanding: Health Literacy as the Capacity to Act

Impact of a transformative health literacy model for Thai older adults with hypertension

BACKGROUND

Hypertension is the important risk factor for cause disability and death, particularly if there is a loss of self-care knowledge. Health literacy encompasses the comprehension and awareness of health-related information, which is beneficial for managing the health of older adults with hypertension. Therefore, the objective of this study was to examine the impact of a transformative health literacy model to develop the health literacy levels among Thai senior citizen with hypertension.

METHOD

This research employed an experiment. Thirty-six participants engaged in the transformative health literacy model. The instrument is the health literacy in hypertension scale, which had acceptable reliability and validity.

RESULTS

The study revealed that the level of health literacy in the post-test and follow-up phases of the experimental group who received the health literacy promotion model was significantly higher than the pre-test level of health literacy at a significance level of 0.05.

CONCLUSION

The study outcomes create a new pathway to enhancements of health literacy in Thai older adults with hypertension.

Patient online access to general practice medical records: A qualitative study on patients' needs and expectations

BACKGROUND

Patient online access to medical records is assumed to foster patient empowerment and advance patient-centred healthcare. Since July 2020, patients in the Netherlands have been legally entitled to electronically access their medical record in general practice. Experience from pioneering countries has shown that despite high patient interest, user rates often remain low. How to best support implementation depends on individual needs and expectations of patient populations, which are as yet unknown in the Dutch context.

OBJECTIVE

To understand Dutch patients' needs and expectations with regard to online access to their medical record in general practice.

METHOD

Twenty participants completed semi-structured individual interviews via video or telephone call. Transcripts of interviews underwent template analysis combining deductive and inductive coding using Atlas.ti software.

RESULTS

Patients' needs and expectations ranged across three overlapping areas: (i) prerequisites for getting online access; (ii) using online access; and (iii) the impact on interaction with healthcare providers. Patients expected benefits from online access such as better overview, empowerment and improved communication with their general practitioner but identified needs regarding technological difficulties, data privacy and complex medical language in their record.

CONCLUSION

The concerns and obstacles participants identified point towards the need for organisational changes in general practice, for example, adjusted documentation practices, and the key role of the general practitioner and staff in promoting and facilitating online access.

IMPLICATIONS

Implementation strategies addressing needs identified in this study may help to unlock the full potential of online access to achieve desired outcomes of patient involvement and satisfaction.

Occupational Health Literacy Scale development and validation in Italy: a pilot study

OBJECTIVES

This study aimed to adapt and validate the Occupational Health Literacy Scale (OHLS) for the Italian workforce, assessing its psychometric properties and ensuring its relevance and applicability within this specific cultural setting.

STUDY DESIGN

Validation process by observational and descriptive study.

METHODS

Initially, two members of the research team independently translated the original OHLS into Italian. Subsequent comparisons and syntheses of these translations produced a unified Italian document. To ensure translation accuracy, this document was then retranslated back into English. An expert committee with specialized knowledge in occupational safety and health evaluated the retranslations to finalize the Italian version. This version underwent a preliminary test using a pilot group, followed by anonymous administration to a sample of 398 workers.

RESULTS

The adaptation of the OHLS into Italian demonstrated outstanding psychometric characteristics. The scale exhibited an excellent model fit and strong internal consistency. Furthermore, the factorial structures were congruent with theoretical expectations, underscoring the scale's robust construct validity.

CONCLUSIONS

The Italian version of the OHLS has been validated as a reliable and effective instrument for quantifying occupational health literacy among Italian workers. This tool's demonstrated validity and reliability suggest its potential for broader application in promoting occupational health awareness and interventions within Italian-speaking populations.

Patient online access to medical records in general practice: Perceived effects after one year follow-up

OBJECTIVE

Online access to medical records is expected to foster patient empowerment and patient-centred healthcare. However, data on actual experienced effects remain limited. We aimed to examine the development of effects patients perceive from online access.

METHODS

A nationwide online survey (N = 1769) evaluated Dutch patients' use of online access and beliefs about its effects on 16 outcomes at baseline and one-year follow-up. Analyses of Variance (ANOVA) were used to examine within-person belief changes across three user groups: patients who 1) used online access before the study, 2) started use during the study, and 3) did not use it at all.

RESULTS

There was a small decline in five beliefs around online access facilitating patient empowerment and participation in participants who started using online access during the study compared to at least one other user group. Most changes in beliefs did not differ between groups.

CONCLUSION

No evidence of benefits from online access was found. The findings might indicate inadequacies in the current system of online access. Possibly, the benefits of online access are contingent upon portal improvements and changes in documentation practices.

PRACTICE IMPLICATION

Records need to be easily accessible and comprehensible for patients. Consultation practices should enable patient participation.

When Positive is Negative: Health Literacy Barriers to Patient Access to Clinical Laboratory Test Results

BACKGROUND

Health literacy is a multidimensional set of skills (e.g., narrative, numeracy, digital, medication) that patients need to access and understand health information timely and accurately to make evidence-based informed decisions.

CONTENT

Multiple barriers prevent patients from effectively interacting with health information. The most salient barriers are poor overall health literacy skills and linguistic proficiency in English. As patients prefer direct access to laboratory test results, especially those of routine tests, contextualization and provider-directed interpretation of results are required to foster shared decision-making to address their healthcare issues and improve health outcomes.

SUMMARY

The use of systematic approaches that account for poor health literacy skills and include culturally and linguistically appropriate planning and availability of resources is warranted at individual and population health levels (e.g., human-centered design of patient portals).

The Shift from Individual to Organizational Health Literacy: Implications for Kidney Healthcare Leaders and Clinicians

BACKGROUND

As a social determinant of health, health literacy has a vital role in the management of chronic disease management, including chronic kidney disease (CKD).

SUMMARY

To be able to manage their condition, patients with CKD need to be able to assess, comprehend, appraise, and utilize complex health-related information. Those patients are much more likely to understand and use health information appropriately, if it addresses their personal needs related to language, culture, educational background, and socioeconomic status. One aspect of health literacy, organizational health literacy (OHL), relates to the degree with which health organizations justifiably empower patients to locate, understand, and utilize health information and facilities to inform their decision-making and health behaviours. With increasing evidence-based about OHL as a way to improve healthcare, it is a new concept for kidney clinicians.

KEY MESSAGES

As producers of health-related information, the multidisciplinary kidney healthcare team have a responsibility to meet the needs of those in their care, as such, priority should be given to implementation of OHL initiatives. Through enhancing the clarity of information, OHL initiatives may provide a game plan for person-centred care for those with CKD.

Testing a single item screener to support family doctors in identifying patients with limited health literacy: convergent validity of the SILS and the HLS-EU-Q16

BACKGROUND

Low health literacy (HL) is associated with reduced disease self-management skills, worse health outcomes, an increased number of hospitalizations, more frequent use of the emergency room and less utilization of preventive services. To support patients with low HL it is crucial to identify affected patients. HL is a multidimensional construct, which covers different skills and abilities to make informed health decisions. Validated brief screening tools to assess health-literacy-related skills or abilities in primary care settings are currently not available in German. This study aimed to validate a single item screener developed in the US for the German primary care setting.

METHODS

Our study used cross-sectional data from a survey among mainly chronically ill patients (n = 346) conducted in family practices in the state of North Rhine-Westphalia. We explored the convergent validity between a single item literacy screener (SILS) and the HLS-EU-Q16. The SILS measures functional HL by asking patients about their need for help when reading information materials. The HLS-EU-Q16 is a multidimensional HL measure frequently used for research purposes in Germany. Associations between the two instruments were examined using Spearman's correlations and regression analyses. The diagnostic performance of the SILS relative to the HLS-EU-Q16 was assessed using receiver operator curves (ROC).

RESULTS

The SILS had a statistically significant correlation with the HLS-EU-Q16 (Spearman ρ: 0.35) and explained 26% of its total variance. Stratified analyses of the convergent validity between both instruments by age, sex, migration background, education level and chronic disease status showed moderate statistically significant correlations in all subgroups (range: 0.223 to 0.428). With an area under the curve of 0.66, the receiver operator curve indicated a satisfactory diagnostic performance of the SILS relative to the HLS-EU-Q16.

CONCLUSIONS

The SILS provided an acceptable initial assessment of HL limitations among a heterogeneous population of mainly chronically ill patients in a primary care setting. With only one item, the SILS can be a short and effective tool for routine use in primary care and specialized care settings. Future research should test the SILS in other populations and pilot applications of the SILS in routine care.

The Effects of Online Access to General Practice Medical Records Perceived by Patients: Longitudinal Survey Study

BACKGROUND

Patient online access to medical records is assumed to facilitate patient empowerment and advance patient-centered health care. However, to date, the actual effects of online access to medical records perceived by patients and other outcomes are insufficiently empirically tested.

OBJECTIVE

This study aimed to investigate the effects of online access to medical records on patient empowerment, informed decision-making, and the patient-provider relationship perceived by patients.

METHODS

A nationwide, 2-wave, longitudinal survey study was conducted among Dutch adults (N=2402). Linear regression analyses were performed. In model 1, the perceived effects of online access to medical records (measured at T1 [first measurement; July 2021]) on 16 outcomes (measured at T2 [second measurement; January 2022]), which were associated with the use of online access to general practice medical records in previous research, were investigated. Model 2 included sociodemographic factors and patient characteristics as confounders.

RESULTS

Users indicated more strongly than nonusers that online access to medical records would increase their participation in health care, improve the relationship with their general practitioner, and support informed decision-making. These results were robust when adjusted for the influence of confounders. Effect sizes were very small, with unstandardized regression coefficients (B) ranging between -0.39 and 0.28. Higher digital and health literacy were associated with higher ratings of almost all effects.

CONCLUSIONS

Online access to medical records has the potential to empower patients and foster informed decision-making among patients. The effects in this study were small but might grow over time. Other factors, such as the attitude of general practitioners toward online access to medical records, might moderate these effects. The results indicate that the potential benefits of online access to medical records might be unevenly distributed. We suggest future exploration of the conditions under which online access to medical records can improve health care system functioning and efficiency without increasing health inequality.

The Effect of Health Literacy on Health-Related Quality of Life Among Saudi Women With Chronic Diseases

BACKGROUND

Women have unique health concerns in the context of chronic illness. Although health literacy has been linked to health-related quality of life, the pathway by which some factors mediate this relationship has not been well examined among Saudi women with chronic disease.

PURPOSE

This study was designed to examine the relationship between health literacy and health-related quality of life and determine the mediating roles of healthy lifestyle and patient-centered care in explaining this relationship.

METHODS

A cross-sectional study was used. A random sample of 20 primary healthcare centers in Saudi Arabia was selected. A convenience sample of 300 women diagnosed with a chronic illness was recruited from these centers. Structural equation modeling was used to test the proposed relationships.

RESULTS

Controlling for women's age and education, the hypothesized model adequately fit the data. Health literacy and its dimensions were found to positively and directly affect both patient-centered care (β = 0.614, B = 0.189, p < .001) and healthy lifestyle behaviors (β = 0.550, B = 1.211, p < .001). Furthermore, both patient-centered care (β = 0.390, B = 1.301, p < .001) and healthy lifestyle behaviors (β = 0.322, B = 0.150, p < .001) were found to positively and directly affect health-related quality of life, whereas health literacy had significant, direct (β = 0.285, B = 0.292, p < .001) and indirect (β = 0.417, B = 0.428, p < .001) effects on health-related quality of life through patient-centered care and healthy lifestyle behaviors.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Special consideration should be given to health literacy, patient-centered care, and healthy lifestyle behaviors to enhance health-related quality of life in women with chronic illness. Gender-specific health services and interventions are needed to improve women's health literacy.

Behavior Guidance during the Covid-19 Pandemic: Health Literacy as a Weapon against the Virus

Portugal was hit by COVID-19 on the 2^nd of March 2020. For almost two months, the country was confined due to the declaration of the emergency state. The confinement was always conveyed by the media, who clearly guided citizens toward preventive behaviors and so became a means of fighting this pandemic by helping the country stay home. Several authors recognize the importance of health communication and health literacy in fighting COVID-19. In a public health crisis like this, media are important actors in the promotion of health and prevention of disease, and they can have a central role in behavior change. To further understand how the media guided citizens toward preventive behaviors we applied a questionnaire survey to Portuguese journalists. More than 90% assumed citizens' behavior guidance. Journalists' perceptions about their work reflect a true concern with the promotion of health literacy, and their assumption of a public service mission was crucial in people's adherence to confinement. Health literacy achieved its maximum during this confinement period, not only because these were extraordinary times but also because Portuguese journalists had an exemplar behavior.

Development and implementation of a community health literacy hub, 'Health Kiosk'-A grassroots innovation

Being health literate is important to get sufficient health information, to navigate the health system, to access appropriate care and to be able to self-manage health. As such it is a key determinant of health. There is a need for innovative measures to improve health literacy among people living in socioeconomically vulnerable circumstances. Literature shows that this innovation needs to: have "low-threshold access" to health resources in a community-based, outreaching way; be adapted to the needs of the target group; provide reliable and understandable health information adapted to the target population, and support people in developing confidence to act on that knowledge. In response to this need, this article describes-guided by the principles underpinning the Integrated Community Care (ICC) framework-the development and implementation process of a grassroots innovation, namely "Health Kiosk" in a socioeconomically vulnerable area in the northern part of a Belgian city. To be able to focus on the core activity of the Health Kiosk-i.e., stimulating healthy living and health literacy-community building and considering the spatial environment of the neighborhood formed a fundamental basis. Several core ingredients of the Health Kiosk are important to stimulate health literacy among socioeconomically vulnerable groups, namely: (1) working in a community-based, outreaching way; (2) providing accessible health information and support to act on that knowledge; and (3) working in a flexible and independent way to adapt to local needs. As such, the Health Kiosk forms a community health literacy hub with low-threshold access for people living in socioeconomically vulnerable circumstances.

Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey

Health literacy (HL) is a competence to find, understand, appraise, and apply health information and is necessary to maneuver the health system successfully. People with low HL are, e.g., under the risk of poor quality and safety of care. Previous research has shown that low HL is more prevalent among, e.g., people with lower social status, lower educational level, and among the elderly. In Germany, people with substitutive private health insurance (PHI) account for 11% of the population and tend to have a higher level of education and social status, but in-detail assessments of their HL are missing so far. Therefore, this study aimed to investigate the HL of PHI insureds in Germany, and to analyze their assessment of the health system according to their HL level. In 2018, 20,000 PHI insureds were invited to participate in a survey, which contained the HLS-EU-Q16, and items covering patient characteristics and the World Health Organization health systems framework goals (e.g., access, quality, safety, responsiveness). Low HL was found for 46.2% of respondents and was more prevalent, e.g., among men and insureds with a low subjective social status. The health system performance was perceived poorer by respondents with low HL. Future initiatives to strengthen health systems should focus on promoting HL.

Engaging health professions students in community-based service learning through the design of a needs assessment survey

Background: Interprofessional student participation in community-based service learning projects is critically important for the preparation of future health professionals to care for underserved and vulnerable populations. Oftentimes, there is a disconnect between existing community services and the actual needs of individuals being served, such as those experiencing homelessness. A best practice of launching a new service learning project is to begin with a needs assessment. This study describes the stepwise approach taken to guide students launching a new street medicine program in developing and administering a needs assessment survey and is generalizable to other student-led service learning outreaches. Methods: We conducted a needs assessment from April-June 2018 on 144 unsheltered homeless individuals in metro Phoenix, Arizona. The 16-question survey investigated perceptions of priority needs, sources of medical care, health literacy, and health status. Survey results were analyzed using Wilcoxon Rank Sum Test, chi-squared analysis, and multivariable logistic regression. Results: Most respondents (91.6%) identified food as a top need. The majority (64.1%) utilized emergency departments as their primary source of care, and 40.1% reported suboptimal health. Suboptimal health was more likely to be reported in those who expressed transportation (OR 3.03, 95% CI: 1.30-7.07) as a top priority need. Health illiteracy (OR 3.68, 95% CI: 0.76-17.9) was associated with suboptimal health, as was obtaining care at an Emergency Department (OR 2.05, 95% CI: 0.81-5.25). Conclusions: Pairing healthcare with meals and other primary needs may be an effective strategy to increase service utilization by this population. Future needs assessments should consider implementing open-ended questions to better assess the holistic needs of study populations and match community partner organization services with these needs. Needs assessments provide an opportunity for health professional students to learn about social needs and more effectively connect patients with services from community agencies and healthcare organizations.

Chronic Obstructive Pulmonary Disease and Social Determinants of Health: A Case of Marginalization in Rural Appalachia

Chronic obstructive pulmonary disease remains a challenging epidemic across the United States. This serious illness impacts nearly twice as many individuals in the rural area compared with urban counterparts. As the disease progresses, the symptom burden and needs of the patient and caregivers escalate. Access gaps to services, such as hospice and palliative care, and the social determinants of health found in Appalachia may lead to marginalization and social injustice. Defined as the condition of being peripheralized based upon one's social margins of identity, associations, and/or environment, marginalization impacts health outcomes and quality of life. This article explores the triple threat of marginalization for patients with chronic obstructive pulmonary disease living in rural Appalachia. By recognizing marginalization and designing initiatives to reduce the impact, hospice and palliative care nurses serve as advocates and leaders to influence systemic change through partnerships with key policymakers and legislators.

Internists’ ambivalence toward their role in health counseling and promotion: A qualitative study on the internists’ beliefs and attitudes

Crucial to its success is that physicians enhance their competence in Lifestyle Medicine and take on their role as Health Advocates in Health Counseling and Promotion (HC&P). However, studies on patients’ views of lifestyle counseling in clinical practice demonstrate that many patients neither perceived a need to adopt a healthy lifestyle nor having had any discussion with their physician about their lifestyle. This study is part of a participatory action research project focusing on identifying areas of improvement for health promotion in the practice of internists. Within this project, we interviewed 28 internists from six different subspecialties of an academic medical center in the Netherlands. This study aims to gain insight into how internists understand their role in HC&P by a qualitative analysis of their beliefs and attitudes in the interview data. Participants claimed that promoting a healthy lifestyle is important. However, they also reflected a whole system of beliefs that led to an ambivalent attitude toward their role in HC&P. We demonstrate that little belief in the success of HC&P nurtured ambivalence about the internists’ role and their tasks and responsibilities. Ambivalence appeared to be reinforced by beliefs about the ability and motivation of patients, the internists’ motivational skills, and the patient-doctor relationship, and by barriers such as lack of time and collaboration with General Practitioners. When participants viewed HC&P as a part of their treatment and believed patients were motivated, they were less ambivalent about their role in HC&P. Based on our data we developed a conceptual framework that may inform the development of the competences of the Health Advocate role of internists in education and practice.

The importance of health literacy for self-management: A scoping review of reviews

OBJECTIVES

Self-management of chronic diseases is rather complex, especially for patients with limited health literacy. In this review, we aim to disentangle the specific difficulties patients with limited health literacy face in relation to self-management and their associated needs with respect to self-management support.

METHODS

We performed a literature search in five databases. We used a broad definition of health literacy and self-management was categorized into four types of activities: medical management, changing lifestyle, communicating and navigating through the health care system and coping. Included reviews described the relationship between health literacy and different domains of self-management and were published after 2010.

RESULTS

A total of 28 reviews were included. Some clear difficulties of patients with limited health literacy emerged, predominantly in the area of medical management (especially adherence), communication and knowledge. Other associations between health literacy and self-management were inconclusive. Barriers from the patients' perspective described mainly medical management and the communication and navigation of the health care system.

DISCUSSION

Patients with limited health literacy experience difficulties with specific domains of self-management. For a better understanding of the relationship between health literacy and self-management, a broader conceptualization of health literacy is warranted, including both cognitive and behavioural aspects.

Preference for shared decision-making among Arabic-speaking people with chronic diseases: a cross-sectional study

OBJECTIVES

To assess Arabic-speaking patients' preference for involvement in decision-making in the United Arab Emirates (UAE) and characterise people who preferred involvement in decision-making.

DESIGN

Cross-sectional quantitative study. The conduct and reporting of this research complied with Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cross-sectional studies.

SETTING

Participants were recruited from outpatient clinics of 10 major hospitals in four cities in the UAE: Abu Dhabi, Dubai, Sharjah and Umm al Quwain.

PARTICIPANTS

Adult patients with at least one chronic disease completed a cross-sectional survey consisting of 37 items in six sections measuring variables that may influence preferred involvement in decision-making. These included health literacy, health status, unanswered questions about care and satisfaction with treatment decisions. Bivariate and multivariate analyses were performed to determine the predictors of patients' preferred involvement in decision-making.

RESULTS

A total of 516 participants completed the survey. One-in-four participants preferred shared decision-making. Preferred involvement in decision-making was more frequent among women, not married, unemployed, people who rarely/never had unanswered questions and participants with anxiety/depression symptoms. After adjustment, not being married (OR=1.634; 95% CI 1.049 to 2.544) remained as a predictor of preferred involvement in decision-making, while having unanswered questions (OR=0.612; 95% CI 0.393 to 0.954) and problems in self-care were predictors of a preference for paternalistic decision-making (OR=0.423; 95% CI 0.181 to 0.993).

CONCLUSIONS

Contrary to the results from Western countries, this study showed that a majority of Arabic-speaking patients with chronic diseases preferred a paternalistic decision-making model. At the same time, some subgroups of Arabic-speaking people (eg, women, unemployed patients) had a higher preference for participation in decision-making. Physicians' support and changes in healthcare systems are required to foster Arabic-speaking patients' involvement in treatment decision-making process.

Information Needs of People With Limited Health Literacy Regarding a New "Opt-Out" Organ Donation System: A Qualitative Study in the Netherlands

Background: In the Netherlands, new legislation on organ donation was implemented, based on a “opt-out” consent system, which means that all adults are presumed to consent for organ donation, unless they actively register their decision not to donate. A public information campaign preceded the law change. In the Netherlands, 29% of the population has limited health literacy (LHL). The aim of the study was to gain insight in the information needs of Dutch citizens with LHL regarding organ donation and the new legislation, as well as in their preferred information channels.

Methods: A qualitative study was performed; 30 people participated in four focus groups and six individual interviews. Transcripts were coded, interviews were thematically analysed.

Results: People with LHL need specific information to make an informed decision on organ donation. Relevant topics: 1) choice options, 2) eligibility, 3) role of partner and/or family, 4) impact on quality of care, and 5) process of organ donation. Information should be easy to understand.

Conclusion: Current standard materials are too difficult and abstract. People with LHL require personal support to tailor general information to their personal situation, and practical help to actually register their choice. Suggestions on how to improve information is provided.

Assessing the experience of person-centred coordinated care of people with chronic conditions in the Netherlands: Validation of the Dutch P3CEQ

BACKGROUND

Countries are adapting their health and social care systems to better meet the needs of growing populations with (multiple) chronic conditions. To guide this process, assessment of the 'patient experience' is becoming increasingly important. For this purpose, the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) was developed in the United Kingdom, and translated into several languages.

AIM

This study aimed to assess the internal and construct validity of the Dutch P3CEQ to capture the experience of person-centred coordinated care of people with chronic conditions in the Netherlands.

PARTICIPANTS AND METHODS

Adults with chronic conditions (N = 1098) completed the Dutch P3CEQ, measures of health literacy and patient activation, and reported the use and perceived quality of care services. Data analysis included Principal Component and reliability analysis (internal validity), analysis of variance and Student's T-tests (construct validity).

RESULTS

The two-component structure found was pretty much the same as in the UK validation study. Sociodemographic correlates also resembled those found in the United Kingdom. Women, persons who were less educated, less health-literate or less activated experienced less person-centred coordinated care. P3CEQ scores correlated positively with general practitioner performance scores and quality ratings of the total care received.

CONCLUSION

The Dutch P3CEQ is a valid instrument to assess the experience of person-centred coordinated care among people with chronic conditions in the Netherlands. Awareness of inequity and more attention to communication skills in professional training are needed to ensure that care professionals better recognize the needs of women, lower educated or less health-literate persons, and improve their experiences of care.

PATIENT CONTRIBUTION

The P3CEQ has been developed in collaboration with a range of stakeholders. Eighteen persons with (multiple) chronic conditions participated as patient representatives and codesign experts in (four) codesign workshops. Other patient representatives participated in cognitive testing of the English-language instrument. The usability of the P3CEQ to capture the experience of person-centred coordinated care of older persons has been examined by interviewing 228 older European service users, including 13 living in the Netherlands, as part of the SUSTAIN project. More than a thousand persons with chronic conditions participated in the validation study of the Dutch P3CEQ.

Use of Physiotherapy Prior to Total Knee Arthroplasty—Results of the Prospective FInGK Study

Background: Data regarding physiotherapy (PT) utilization prior to total knee arthroplasty (TKA) are insufficient. Therefore, this study aims to examine which percentage of patients receive PT within 12 months prior to TKA and which factors are associated with its use. Methods: Consecutive patients (≥18 years) undergoing primary or revision TKA in a German university hospital were recruited. A questionnaire including information on PT utilization, demography, and socioeconomics was collected one day prior to surgery and linked to medical hospital records. Multivariable logistic regression was conducted to determine variables associated with the use of PT. Results: A total of 241 out of 283 (85%) patients participated (60% female; mean age: 68.4 years). Overall, 41% received PT at least once during 12 months prior to TKA, women more frequently than men (48% vs. 29%). Although high disease burden was associated with increased utilization, about one in two in this condition did not receive PT. Multivariable logistic regression showed that age 75+ years, low education level, and moderate-to-severe depressive symptoms were associated with decreased PT utilization. Conclusions: We found low use of recommended PT management in patients prior to TKA. This potential underuse was even higher in some vulnerable subgroups, indicating inequalities. Prescribers as well as patients should integrate PT more consistently into osteoarthritis management.

Relevant associations between alexithymia and health-literacy in persons with psoriasis

OBJECTIVE

To explore possible associations between alexithymia and health literacy (HL) in persons with psoriasis.

METHODS

We conducted a cross-sectional study, including 825 persons with moderate to severe psoriasis, using the Toronto Alexithymia Scale, and the Health Literacy Questionnaire. Descriptive statistics compare HL means between alexithymic and not alexithymic participants. Associations between alexithymia and HL are analyzed using a linear multiple regression model.

RESULTS

Twenty-six percent of the participants were characterized as alexithymic, and 26.8% had borderline alexithymia. Higher alexithymia scores were associated with lower education, biological medicines, and more comorbidities, together with lower self-efficacy. The HL domains with the strongest associations with alexithymia were those focusing on managing and getting support for health, as well as the ability to find health information.

CONCLUSION

A more elevated alexithymia score is associated with lower HL. Further studies of these associations may contribute to a more comprehensive perspective of psoriasis. To know a patient's alexithymia level and HL needs may guide health care personnel's understanding of possible associations between health status, clinical presentation, behavior, and response to treatment.

Preferences and Experiences of People with Chronic Illness in Using Different Sources of Health Information: Results of a Mixed-Methods Study

Background: People with chronic illness are particularly dependent on adequate health literacy (HL), but often report difficulties in accessing, understanding, appraising, and applying health information. To strengthen the HL of people with chronic illness, in-depth knowledge about how they deal with health information is crucial. Methods: To this end, quantitative data from the Second Health Literacy Survey Germany (HLS-GER 2) and qualitative data from seven focus group discussions were used to examine the interest in health information, preferred sources of information as well as experiences and challenges with information management among people with chronic illness. Results: The results show that people with chronic illness have a great interest in health information and use very different sources of health information, preferring personal information from physicians most. The results also point to several challenges in health information management that seem to be influenced by the illness duration as well as by the experiences made with the respective sources. Conclusions: Overall, the study provides important starting points for intervention development for the provision and communication of health-related information, but also to research on health information behavior and HL.

Determination of Health Literacy in Different Generations

BACKGROUND

The development of health literacy (HL) is critical in reducing lifestyle-related diseases. The purpose of this study was to determine levels of HL and related variables among members of Generations X and Z.

METHODS

This study was a descriptive survey conducted in the city of Antalya, Turkey. Participants were 350 Generation Z students and 150 Generation X parents. We created a personal data form for both students and parents, and used the Secondary Education HL Scale and Adult HL Scale for data collection.

RESULTS

The average HL score of Generation Z was 20.98 ± 6.19 and that of Generation X 17.38 ± 3.54. The HL levels of 75% of the Generation Z were low to marginal and those of 33.1% of the Generation X were below average.

CONCLUSIONS

More than half of the Generation Z students and about one-third of Generation X parents were found to have low HL. Health professionals and nurses can give direction to the different generations to improve overall HL.

The Relationship between Health Literacy Dimensions and Perceived Risk of Cardiovascular Disease in Middle-Aged Iranian Women

Background:

The purpose of the study was to investigate the relationship between health literacy dimensions and the perceived risk of cardiovascular disease in middle-aged Iranian women.

Materials and Methods:

This is a descriptive-correlational study in which 280 women aged 40–60 years were investigated by random cluster sampling out of seven health centers in Yazd city in 2018. Data collection tools included predesigned demographic information from a standard Health Literacy for Iranian Adults (HELIA), and a standard perceived susceptibility and perceived risk components of the preventive behaviors of cardiovascular disease questionnaire. The data were analyzed using one-way ANOVA, independent t-test, Kruskal-Wallis, and Mann Whitney tests.

Results:

A significant relationship was identified between demographic information and health literacy (p < 0.001). The mean (SD) scores of the perceived risk of cardiovascular disease and health literacy appeared to be 30.71 (5.10) and 35.62 (15.32), respectively. The perceived risk of cardiovascular disease in the participants turned out to be significantly correlated with the accessibility dimension of health literacy (r = 0.31, p < 0.001), but it failed to have any significant relationship with demographic information, especially obesity.

Conclusions:

As there is a significant relationship between health literacy and perceived risk of cardiovascular disease, hence increasing the health literacy of middle-aged women, especially in persons with high body mass index through the media and health centers, considered as an important source of health information, can be an appropriate task to augment the perceived risk of cardiovascular diseases.

Challenging the association between health literacy and health: the role of conversion factors

Previous studies have found substantial correlations between health literacy and various health outcomes. However, the role of social and personal factors in those links remains understudied. Applying a moderation approach, we assume that these factors function as conversion factors on the associations between health literacy and health outcomes. Consequently, we test if associations between health literacy and health outcomes are stronger among young male adults who score high in conversion factors compared to those who score low. Cross-sectional data from the Young Adult Survey Switzerland were used for the analyses (n = 9339, age = 18-25). Multiple logistic regression analyses were applied to estimate associations between health literacy and health. Moderator analyses with three conversion factors and five health outcomes were conducted. For each health outcome at least one conversion factor moderated the association between health literacy and health according to the hypothesis. Although strength and form of the moderation effect differ across analyses, generally stronger associations were found among groups with beneficial social or personal factors. The present findings support the hypothesis that conversion factors play a crucial role in the associations between health literacy and health. The findings, thus, point towards a potential risk of linear health literacy approaches that assume equal benefits from increased health literacy. Individuals with beneficial social and personal factors (those already privileged) may enjoy greater health benefits from interventions improving health literacy.

Effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to breast cancer genetic testing

Background

There is an underuse of genetic testing in breast cancer patients with a lower level of education, limited health literacy or a migrant background. We aimed to study the effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to genetic testing.

Methods

We conducted a multicenter study in a quasi-experimental pre-post (intervention) design. The intervention consisted of an online module and a group training for surgical oncologists and specialized nurses in three regions in the Netherlands. Six months pre- and 12 months post intervention, clinical geneticists completed a checklist with socio-demographic characteristics including the level of health literacy of each referred patient. We conducted univariate and logistic regression analysis to evaluate the effect of the training program on disparities in referral to genetic testing.

Results

In total, 3179 checklists were completed, of which 1695 were from hospital referrals. No significant differences were found in educational level, level of health literacy and migrant background of patients referred for genetic testing by healthcare professionals working in trained hospitals before (n = 795) and after (n = 409) the intervention. The mean age of patients referred by healthcare professionals from trained hospitals was significantly lower after the intervention (52.0 vs. 49.8, P = 0.003).

Conclusion

The results of our study suggest that the health literacy training program did not decrease disparities in referral to genetic testing. Future research in a more controlled design is needed to better understand how socio-demographic factors influence referral to breast cancer genetic testing and what other factors might contribute.

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Study on the effect of a health literacy training on access to breast cancer genetic testing.

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Background characteristics of breast cancer patients pre- and post-intervention are compared.

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Mean age of patients referred by trained hospitals was significantly lower after intervention.

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The health literacy training did not decrease disparities in referral to genetic testing.

COVID-19, a tale of two pandemics: novel coronavirus and fake news messaging

The emergence of COVID-19, caused by novel Coronavirus SARS-CoV-2, became a pandemic in just 10 weeks. Without effective medications or vaccines available, authorities turned toward mitigation measures such as use of face masks, school's closings, shelter-in-place, telework and social distancing. People found refuge on the internet and social media apps; however, there was a proliferation of instant messaging containing hoaxed, deliberate misleading information: fake news messaging (FNM). The aim of this study was to assess FNM through content analysis and to discriminate them in a proposed taxonomy structure. A sample of convenience of messages, memes, tweets or cartoons in several languages was selected from the most popular social media outlets, i.e. Facebook, WhatsApp, Twitter etc. More than 300 FNM were identified. Descriptive statistics were used for highlighting potential relationships between variables. Content analysis determined that FNM could be divided into Health- and non-health-related types. There are several sub-types considering, but not limited to, religious beliefs, politics, economy, nutrition, behaviors, prevention of the infection, the origin of the disease and conspiracy theories. The parallel FNM pandemic affected the response from an already debilitated public health system through the confusion created in the community and the erosion in the credibility of genuine media. Public health practitioners had to face people's unpredictable behaviors, panic, tensions with the communities and, in some cases, a hostile climate toward frontline workers. Public health practitioners must adjust ongoing and future health promotion and education interventions including plans to neutralize fake news messages.

Patient-Reported Outcome Measures in Voice: An Updated Readability Analysis

PURPOSE

The purpose of this study was to investigate whether voice-related patient-reported outcome measures (PROMs) developed and validated since 2011 meet the recommendation by health literacy experts that such materials be written at a fifth-to-sixth grade reading level.

METHOD

A readability analysis of eight voice-related PROMs was conducted. Readability formulas utilized were the Coleman-Liau index, Flesch-Kincaid reading ease, FORCAST, simple measure of Gobbledygook index, and Gunning-Fog score.

RESULT

Three-fourths of the PROMs exceeded the recommended fifth- to sixth-grade reading level.

CONCLUSION

Although awareness of health literacy has grown, voice-related PROMs continue to be developed without full consideration of their reading grade level. Researchers should consider revising or developing PROMs with consideration to reading grade level as well as other features to enhance readability.

The impact of health literacy on beliefs about medication in a Dutch medication-using population

PURPOSE

Medication beliefs are likely contingent on aspects of health literacy: knowledge, motivation, and competences to access, understand, appraise, and apply health information. An association between medication beliefs and health literacy is expected as they both influence self-management. The aim of this study was to examine the association between health literacy and the beliefs about overuse and harmful effects of medication and to examine modifying effects of age, gender, and number of medications on this association.

METHODS

The data were collected using the online "Medication panel" of the Dutch Institute for Rational Use of Medicine. A linear regression model was used to examine the association between health literacy and beliefs about medication and the modifying effects of age, gender, and number of medications on this association.

RESULTS

Respondents with a lower level of health literacy had more concerns about overuse (β adj.= -.174, p<.001) and harmful (β adj.= -.189, p<.001) effects of medication. This study found no modifying effects.

CONCLUSIONS

A lower health literacy level is associated with more concerns about the overuse and harmful effects of medication. The results of this study suggest that extra attention should be given to persons with low health literacy level by healthcare professionals, to decrease their concerns about overuse and harmful effects, and improve adherence to self-management behavior.

Towards a comprehensive, person-centred assessment of health literacy: translation, cultural adaptation and psychometric test of the Dutch Health Literacy Questionnaire

Background

Many health literacy instruments focus on reading skills, numeracy and/or information processing aspects only. In the Netherlands, as in other countries, the need for a comprehensive, person-centred measure of health literacy was observed and consequently the decision was made to translate the Health Literacy Questionnaire (HLQ) into Dutch. The HLQ has nine health literacy domains covering people’s experiences and skills. This research sought to translate, culturally adapt and psychometrically test the HLQ.

Methods

The translation and adaptation was done using a systematic approach with forward translation guided by item intents, blind back translation, and a consensus meeting with the developer. The Dutch version of the HLQ was applied in a sample of non-hospitalized, chronically ill patients. Descriptive statistics were generated to describe mean, standard deviation and floor and ceiling effects for all items. A Confirmatory Factor Analysis (CFA) model was fitted to the data. Scores on the nine domains of the HLQ were compared across demographic and illness characteristics as a form of known-groups validity. Psychometric analyses included Cronbach’s alpha, item-rest and item-remainder correlations.

Results

Using CFA, the Dutch HLQ psychometric structure was found to strongly align with the hypothesised (original) nine independent domains of the English version. The nine scales were found to be highly reliable (all scales had alpha between 0.83 and 0.94). Six of the nine HLQ-scales had items that show ceiling-effects. There were no ceiling effects present at the scale level. Scores on the scales of the HLQ differed according to demographic and illness characteristics: people who were older, lower educated and living alone and patients with multiple chronic diseases generally scored lower.

Conclusions

The Dutch version of the HLQ is a robust and reliable instrument that measures nine different domains of health literacy. The questionnaire was tested in a sample of chronically ill patients, and should be further tested in the general population as well as in different disease groups. The HLQ is a major addition to currently available instruments in the Netherlands, since it measures health literacy from a multi-dimensional perspective and builds on patients’ experiences and skills.

Health Literacy and Preventive Behaviors Modify the Association between Pre-Existing Health Conditions and Suspected COVID-19 Symptoms: A Multi-Institutional Survey

People with pre-existing health conditions (PEHC) are vulnerable to viral infection while health literacy (HL) and preventive behaviors (PB) have been shown to benefit people during the COVID-19 pandemic. The aim of this study was to examine the association between PEHC and suspected COVID-19 symptoms (S-COVID-19-S), and to investigate the modification effect of HL and PB. A cross-sectional study was conducted on 8291 participants visiting outpatient departments at 18 hospitals and health centers across Vietnam from 14 February to 31 May 2020. Data were collected regarding participant's characteristics, HL, PB, PEHC, and S-COVID-19-S. Regression models were used for analyzing the associations. Results showed that people with PEHC had a 3.38 times higher likelihood of having S-COVID-19-S (odds ratio, OR, 3.38; 95% confidence interval, 95% CI, 3.01, 3.79; p < 0.001). In comparison to participants without PEHC and with the lowest HL score, those with PEHC and one HL score increment had a 7% lower likelihood of having S-COVID-19-S (OR, 0.93; 95% CI, 0.92, 0.94; p < 0.001). In comparison to participants without PEHC and not adhering to mask wearing, those with PEHC and adhering to mask wearing had a 77% lower likelihood of having S-COVID-19-S (OR, 0.23; 95% CI, 0.16, 0.32; p < 0.001). Higher HL and adherence to mask wearing can protect people from having S-COVID-19-S, especially in those with PEHC.

Gesundheitskompetenz von Menschen mit chronischer Erkrankung in Deutschland

Hintergrund Menschen mit chronischen Erkrankungen (MmcE) sind mit vielfältigen Anforderungen der Krankheitsbewältigung und der Versorgungsnutzung konfrontiert. Entsprechend hoch ist ihr Bedarf an Information und auch an Gesundheitskompetenz (GK). Während das Thema international seit längerem die Aufmerksamkeit der Forschung findet, fehlen für Deutschland bislang Untersuchungen zur GK von MmcE.

Ziel und Methode Ziel der vorliegenden Analyse ist es, die GK von MmcE in Deutschland vertiefend zu analysieren. Dazu wurden Querschnittsdaten von insgesamt 499 MmcE des deutschen Gesundheitskompetenzsurveys (HLS-GER) genutzt. Die GK wurde mit dem European Health Literacy Survey Questionnaire (HLS-EU-Q 47) erfasst. Potenzielle Unterschiede bei der Verteilung von GK wurden nach Geschlecht, Alter, Sozialstatus, finanzielle Ressourcen, Bildungsniveau und literale Fähigkeiten (gemessen mit dem Newest Vital Sign (NVS)) und krankheitsbezogenen Merkmalen (Krankheitsanzahl und -dauer) mittels Chi-Quadrat Test geprüft. Ebenso wurde der Einfluss dieser Faktoren auf GK bei MmcE mittels multipler logistischer Regression untersucht.

Ergebnisse 72,7% der MmcE weisen eine geringe GK auf. Dabei variiert die GK stark nach den untersuchten Bereichen Krankheitsbewältigung/-versorgung, Prävention und Gesundheitsförderung. Ein niedriger Sozialstatus (Odds Ratio (OR): 4,4 [1, 8; 10, 7]), geringe finanzielle Ressourcen (OR: 2,0 [1,2; 3,1]), limitierte literale Fähigkeiten (OR: 2,7 [1,4; 5,0]) sowie ein mittleres Bildungsniveau (OR: 0,5 [0,3; 0,9]) sind in der multiplen logistischen Regression mit geringer Gesundheitskompetenz assoziiert. Krankheitsanzahl und -dauer zeigen keinen signifikanten Zusammenhang mit geringer GK.

Schlussfolgerung Die Analyse liefert erste Erkenntnisse für Deutschland, die künftig der Vertiefung bedürfen. Sie liefern aber schon jetzt wichtige Hinweise für die Interventionsentwicklung. Erforderlich ist es, zielgruppenspezifische Interventionen zur Stärkung der persönlichen GK von MmcE zu entwickeln, die sich speziell an chronisch Erkrankte mit niedrigem Sozialstatus, geringen finanziellen Ressourcen und eingeschränkter Literalität richten. Um Stigmatisierungen zu vermeiden, ist es wichtig, dass Interventionen zugleich auf die Reduktion bestehender Anforderungen in der Lebensumwelt zielen und die Suche, Aneignung und Verarbeitung von Information erleichtern und damit zur Verringerung von Ungleichheiten beitragen.

Low Health Literacy Is Associated With Frailty and Reduced Likelihood of Liver Transplant Listing: A Prospective Cohort Study

The effect of low health literacy (HL) on outcomes in end-stage liver disease (ESLD) is largely unknown. The association of low HL on clinical outcomes was investigated in a prospective cohort of outpatients with ESLD undergoing liver transplantation (LT) evaluation. From 2014 to 2017, 276 patients underwent LT evaluation with assessments of liver disease severity, medical and psychosocial comorbidities, physical frailty, and malnutrition. Literacy was measured with the Newest Vital Sign, a brief validated assessment. Multivariate models assessed relationships between HL and clinical outcomes adjusting for clinical and psychosocial variables. The median Model for End-Stage Liver Disease-sodium score of the study sample was 15 (interquartile range, 11-19), 71 (25.7%) of candidates were frail, 117 (42.4%) had malnutrition, 151 (54.7%) had hepatic encephalopathy, 104 (37.7%) had low HL, and 85 (39.2%) had marginal or poor social support. Adjusting for education level, socioeconomic factors, and severity of illness, low HL was independently associated with physical frailty (adjusted odds ratio [aOR], 3.59; 95% confidence interval [CI], 1.50-8.59; P = 0.004) and not being wait-listed (aOR 1.96; 95% CI, 1.03-3.75; P = 0.04). Strong social support attenuated the relationship between low HL and not being wait-listed (aOR, 1.58; 95% CI, 0.74-3.36; P = 0.24). Low HL is common and a largely unrecognized risk factor for poor health outcomes among patients with ESLD. Patient-oriented infrastructure and support are needed at the health system level to ensure all patients can successfully navigate the complex process of LT evaluation and wait-listing.

Empowering parents for human immunodeficiency virus prevention: Health and sex education at home

BACKGROUND

Improving health literacy amongst human immunodeficiency virus (HIV)-positive mothers could strengthen child and adolescent HIV prevention. The Amagugu intervention included health literacy materials to strengthen maternal communication and has demonstrated success in low-resource HIV-endemic settings.

OBJECTIVES

Our aims were to (1) evaluate whether Amagugu materials improved health literacy leading to changes in parental behaviour towards communicating on topics such as HIV, health behaviours and sex education, and (2) explore what additional information and materials mothers would find helpful.

METHOD

The Amagugu evaluation included 281 HIV-positive mothers and their HIV-uninfected children (6-10 years). Process evaluation data from exit interviews were analysed using content analysis and logistic regression techniques.

RESULTS

Of 281 mothers, 276 (98.0%) requested more educational storybooks: 99 (35.2%) on moral development/future aspirations, 92 (32.7%) on general health, safety and health promotion, and 67 (23.8%) on HIV and disease management. Compared to baseline, mothers reported that the materials increased discussion on the risks of bullying from friends (150; 53.4%), teacher problems (142; 50.5%), physical abuse (147; 52.3%) and sexual abuse (126; 44.8%). Most mothers used the 'HIV Body Map' for health (274; 97.5%) and sex education (267; 95.0%). The use of a low-cost doll was reported to enhance mother-child communication by increasing mother-child play (264; 94.3%) and maternal attentiveness to the child's feelings (262; 93.6%).

CONCLUSION

Parent-led health education in the home seems feasible, acceptable and effective and should be capitalised on in HIV prevention strategies. Further testing in controlled studies is recommended.

Medication self-management support for people with diabetes and low health literacy: A needs assessment

INTRODUCTION

An adequate level of health literacy is regarded as a prerequisite for adequate medication self-management. Low health literacy skills are relatively more common in people with Diabetes Mellitus type 2. The aim of this study was to explore the needs regarding medication self-management of people with type 2 diabetes and low (functional, communicative and critical) health literacy, and their preferences for medication self-management support.

MATERIALS AND METHODS

A two-stage qualitative needs assessment study was performed using in-depth individual interviews and focus groups.

RESULTS

The participants preferred to be supported with reliable and easily understandable information, adequate interactive communication with health care professionals and fellow people with diabetes and tools for medication self-management support.

DISCUSSION

Future interventions should be created in co-creation with people with low health literacy and fulfill the expressed needs on information, communication and tools to improve self-management.

The Relationship between Health Literacy, Quality of Life, and Subjective Health: Results of a Cross-Sectional Study in a Rural Region in Germany

Low health literacy is associated with poorer health and quality of life. An open question is whether a regional integrated healthcare system whose management strives to enable and empower its members with regard to health issues can contribute to a higher level of health literacy in the population. Against this background, in a cross-sectional study we surveyed a random selection of members of an integrated healthcare system in southwestern Germany (n = 180). The standardized questionnaire included, inter alia, questions on health literacy and subjective health. In this sample we wanted to (1) determine the proportion of respondents with sufficient health literacy and (2) investigate whether the association between health literacy and quality of life and subjective health status-as found in other studies-can be replicated. In our sample a health literacy score could be calculated in 126 subjects (70%). A sufficient level of health literacy was detected in 62% of respondents. Confirming the findings of a meta-analysis based on international studies, we found moderate correlations between health literacy and quality of life (r = 0.41) and health literacy and subjective health status (r = 0.40); these correlations hardly decreased when we controlled for various sociodemographic characteristics. As the proportion of respondents with sufficient health literacy was higher in our sample than in comparable studies conducted in Germany, we may hypothesize that an integrated healthcare system like the one we surveyed could have contributed to increased health literacy in the population. Thus, it could be worthwhile to investigate this research question with a more rigorous study design and a larger sample.

Usability of the Turkish Translation of the Dutch Talking Touch Screen Questionnaire for Physical Therapy Patients With a Turkish Background: Qualitative Study

Background

The Turkish translation of the Dutch Talking Touch Screen Questionnaire (TTSQ) has been developed to help physical therapy patients with a Turkish background in the Netherlands to autonomously elucidate their health problems and impairments and set treatment goals, regardless of their level of health literacy.

Objective

The aim of this study was to evaluate the usability of the Turkish TTSQ for physical therapy patients with a Turkish background with diverse levels of health literacy and experience in using mobile technology.

Methods

The qualitative Three-Step Test-Interview method was carried out to gain insight into the usability of the Turkish TTSQ. A total of 10 physical therapy patients participated. The interview data were analyzed using a thematic content analysis approach aimed at determining the accuracy and completeness with which participants completed the questionnaire (effectiveness), the time it took participants to complete the questionnaire (efficiency), and the extent to which the participants were satisfied with the ease of use of the questionnaire (satisfaction). The problems encountered by the participants in this study were given a severity rating, which was used to provide a rough estimate of the need for additional usability improvements.

Results

No participant in this study was able to complete the questionnaire without encountering at least one usability problem. A total of 17 different kinds of problems were found. On the basis of their severity score, 3 problems that should be addressed during future development of the tool were “Not using the navigation function of the photo gallery in Question 4 causing the participant to not see all presented response items;” “Touching the text underneath a photo in Question 4 to select an activity instead of touching the photo itself, causing the activity not to be selected;” and “Pushing too hard or tapping too softly on the touch screen causing the touch screen to not respond.” The data on efficiency within this study were not valid and are, therefore, not reported in this study. No participant was completely satisfied or dissatisfied with the overall ease of use of the Turkish TTSQ. Two participants with no prior experience of using tablet computers felt that, regardless of what kinds of improvement might be made, it would just be too difficult for them to learn to work with the device.

Conclusions

As with the Dutch TTSQ, the Turkish TTSQ needs improvement before it can be released. The results of this study confirm the conclusion of the Dutch TTSQ study that participants with low levels of education and little experience in using mobile technology are less able to operate the TTSQ effectively. Using a Dutch speaking interviewer and Turkish interpreter has had a negative effect on data collection in this study.

Health Literacy is Associated with Health Behaviors in Students from Vocational Education and Training Schools: A Danish Population-Based Survey

Health literacy has been identified as an important and changeable intermediary determinant of health equity. Vocational education and training (VET) schools are a relevant setting for health behavior interventions seeking to diminish health inequities because many VET students come from low socio-economic status backgrounds. This study examines VET students’ health literacy and its association with health behavior based on a cross-sectional survey among 6119 students from 58 VET schools in Denmark in 2019. Two scales from the Health Literacy Questionnaire was used to assess domains of health literacy. Data were analyzed using Anova and logistic regression. The study population consisted of 43.4% female, and mean age was 24.2 years (range 15.8–64.0). The health literacy domain ‘Actively managing my health’ mean was 2.51, SD 0.66, and ‘Appraisal of health information’ mean was 2.37, SD 0.65. For both domains, being female, older age, attending the VET educational program Care-health-pedagogy, and higher self-rated health were associated with higher scale scores. In the adjusted analyses, lower scale scores were associated with less frequent breakfast, daily smoking, high-risk alcohol behavior and moderate-to-low physical activity. Our results show that low health literacy is associated with unhealthy behaviors in this population. Our results support and inform health literacy research and practice in educational institutions and services.

Health Literacy among People in Cardiac Rehabilitation: Associations with Participation and Health-Related Quality of Life in the Heart Skills Study in Denmark

Health literacy (HL) is a dynamic determinant of health and a promising target of health equity interventions in noncommunicable disease prevention. Among people referred to a cardiac rehabilitation program, we examined the associations between (1) HL and participation in cardiac rehabilitation and (2) HL and health-related quality of life (HRQoL). Using a cross-sectional design, we invited 193 people referred to cardiac rehabilitation in Randers Municipal Rehabilitation Unit, Denmark, to respond to a questionnaire in 2017. Of these, 150 people responded (77.7%). HL was measured using the nine scales of the Health Literacy Questionnaire (HLQ), while HRQoL was measured using the Short Form Health Survey 12 (version 2) (SF-12). The mean age of respondents was 67.0 years; 71.3% of the sample were men. Nonrespondents had significantly lower educational attainment and more often lived alone than respondents. Using multiple regression analyses, we found no significant associations between HL and participation in cardiac rehabilitation. There were significant positive associations between several aspects of HL and physical and mental HRQoL. HL could be a factor of interest in initiatives aimed at improving participation and outcomes of cardiac rehabilitation.

Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study

OBJECTIVE

Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found.

METHODS

This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m²).

RESULTS

There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95-0.99), male (OR 0.33, 0.25-0.45), and who lacked post-secondary education (OR 0.70, 0.53-0.93).

CONCLUSION

In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

Associations between disease education, self-management support, and health literacy in psoriasis

BACKGROUND

Patients' ability to perform self-management may be compromised if they are unable to fully comprehend their diagnosis and treatments. Weaknesses in health literacy (HL) pose a considerable health concern and may negatively influence SM, as well as interactions with health care professionals (HCP) and peers.

OBJECTIVES

To investigate possible associations between comprehensive HL and psoriasis education from HCPs in a cohort of patients with psoriasis. Another aim was to examine essential sources for psoriasis information and how these are evaluated.

METHODS

Cross-sectional questionnaire data, including the comprehensive Health Literacy Questionnaire (HLQ) from 825 patients with psoriasis who had participated in Climate Helio Therapy (CHT).

RESULTS

Participants having received HCP education scored significantly better in all HLQ scales compared to participants who did not receive such education (Cohen's effect size: 0.24 to 0.44). The CHT program, peers, and dermatologists were the most important sources of psoriasis information. People having participated more than once in CHT presented better HL scores and also higher self-management (skill and technique acquisition) and more psoriasis knowledge (effect-size: 0.75).

CONCLUSIONS

Psoriasis education by HCP seems important for HL and psoriasis knowledge. Patients may need multiple approaches and repetitions over time to be health literate and effective self-managers.